The Standardized Cesarean Section

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Back in June 2019, we did an episode on The Evidence-Based Cesarean Section. Back then, we talked a bit about incision types, infection practices, and some in surgical technique. In the November 2020 Green Journal, two of our podcast guests - Dr. Josh Dalhke and Dr. Jeff Sperling, in addition to their coauthors - make the case for standardizing cesarean delivery technique.

The text is definitely worth a read, as it’s a succinct review of the most current literature. Some of the practices you may employ already; others you may be surprised by! We talk a bit more with these two authors about the recommendations, what was most surprising, and what things are to come.

This checklist comes from the article, and is definitely worth discussing at your institutions. We’ll let the podcast speak for itself otherwise.

Dahlke et. al, O&G, Nov. 2020 — hyperlink above

Preventing the Primary Cesarean, Part II

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We’re re-visiting an old episode of ours on preventing the primary cesarean, with some more and differently focused information. We heard some great feedback from our last episode so we’re incorporating some of that here! This time around, we want to focus some more on how to promote normal labor and physiological birth! 

Let’s start off with talking about shared decision-making. This is a framework for taking situations with various individuals with different sets of knowledge, belief systems, and priorities and coming together to form a mutually satisfying plan to get everyone where they want to go. ACOG CO 587 reviews this in part, stating SDM can increase patient engagement and reduce risk with resultant improved outcomes, satisfaction, and treatment adherence.

Shared decision making can take the form of a variety of tools in prenatal care and on the labor floor:

  1. Partograms - allowing patients to see where they are in their labor course compared to others.

  2. Birth plans - providers and patients can come together early in their course of the pregnancy to identify patient goals and desires for their labor. Also allows recognition of some goals/desires may not be feasible due to the patient’s individual risk factors, pregnancy complications, etc. 

  3. Patient education resources - we love www.birthtools.org, but there’s a number that exist (and some probably specific to your institution) that can help set expectations for the birthing process.

In identifying a patient’s desires in labor, one of the most common questions has to do with analgesia. Prental care is an excellent time to discuss both pharmacologic and non-pharmacologic options for coping. While epidurals are common in the USA, continuous labor support is another option for coping and also has been shown to reduce cesarean rates in trials. It can take on many forms, and be administered by anyone a laboring person trusts:

  1. Physical support - positioning, use of touch, application of cold and heat and control of environment.

  2. Emotional support - being present with the laboring woman, use of distraction.

  3. Instructional/informational support - assistance with relaxation and breathing, using effective communication techniques.

  4. Advocacy labor support - building trust, providing security and giving laboring women control.

Nutrition and hydration during labor is another common sticking point. It is very common for nutritional deprivation at NPO or clear liquid diets to occur in labor. This is for ostensibly, a good reason: fear of aspiration of stomach contents in the event for need for general anesthesia, or for vomiting due to decreased GI motility. However, a Cochrane review demonstrated no statistical difference in maternal or newborn outcomes related to type of birth or Apgar scores at five minutes. Nutritional deprivation provided no benefit or harm, and so evidence does not support nutritional deprivation. This review further stated that nutritional deprivation can cause maternal distress, unbalanced nutritional status, and increased pain in labor.

What about our original fear of aspiration? Current studies don’t show that nutritional deprivation ensure low stomach residue or acidity. When combined with decreased use of general anesthesia in modern obstetrics, concern for aspiration risk does not provide sound basis for implementation of withholding food or fluid from women in labor.

Next, let’s review the benefits of collaborative care models:

Labor is a team sport that contains the woman, her support person/people, her nurse, and provider (midwife/obstetrician/family practitioner). It shares the workload for this 24 hour in house care, providing a variety of perspectives on the case, in a mutually respectful environment. Now certainly, there are challenges to what sounds so harmonious: interdisciplinary mistrust, inconsistent communication, variable skill sets, scheduling logistics, hospital structure, to name a few. However, we know that this is evidence based! Studies where there have been 24 hour laborists and strip review and collaboration have led to significant decrease in NTSV rate. Why does it work? Well, it likely promotes consideration of alternative options, with experts of multiple perspectives and skill level.

Lastly, systems-based and structural design challenges may also contribute to cesarean. This work is nascent, but check out the awesome work by the folks at Ariadne Labs’ Delivery Decisions Initiative to learn more.

The Evidence-Based Cesarean Section

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Today we go through the steps of cesarean delivery from an evidence basis. We hope this helps everyone from the new interns starting up in just a few weeks to senior residents thinking more about their technique and teaching. The essential article on this from AJOG in 2013 can be found here. However, there have been a number of other articles and talks since, including one regularly given at the ACOG Annual Meeting (check out the 2017 edition by Dr. Strand here), that you all may be aware of and that we encourage you to check out.

One of the more challenging things to relay in the podcast is incisional technique, particularly comparing the traditional Pfannenstiel technique to newer techniques such as Joel-Cohen or Misgav-Ladach. We summarize the differences in those techniques here:

(C) CREOGs Over Coffee (2019)

What’s the difference in these skin incisions?

  • Pfannenstiel: traditionally taught as a curved incision made two finger breadths above the symphysis pubis, with the mid portion of the incision generally within the superior-most aspect of the pubic hair.

  • Joel-Cohen: a straight incision made 3cm below the imaginary line that connects the ASIS on either side. Ultimately this is slightly higher than the Pfannenstiel.

  • Maylard: curved incision made 5-8 cm obove the pubic symphysis. The rectus fascia and muscle are cut transversely, and the inferior epigastric arteries must be ligated.

  • Cherney: using the same skin incision as a Pfannenstiel, but then blunt dissection is used to identify the rectus muscle tendons at their insertion to the public symphysis. They are cut 1-2 cm above their insertion point. On closure, the muscles should be reattached to the anterior rectus sheath, as reattaching to the pubic symphysis may serve as a nidus for osteomyelitis.