Classical CS

Question 1

Indications for classical CS

Answer 1

• Poorly developed lower segment when more than normal intrauterine manipulation is anticipated i.e. extremely preterm breech; back down transverse lie.
• Lower segment pathology e.g. large fibroid, anterior placenta previa or accreta
• Densely adherent bladder
• Postmortem delivery
• Delivery of very large fetus e.g. anomalous, extreme macrosomia where there is high risk of transverse incision extension or T/J incision may be required to extract fetus.

Question 2

How would you consent a woman for a classical CS?

Answer 2

Risks unique to classical CS:

• Increased risk of uterine rupture cf. normal CS, elective CS recommended for future pregnancies.
• Increased risk of placenta praevia and accreta
• HMB

Risks for all CS:

• Bleeding
• Infection
• Intra-abdominal injury
• Blood clots
• Implications for future pregnancies: scar rupture, placenta previa, accreta

Question 3

Outline how you would perform a classical CS

Answer 3

Routine entry until uterus.
Check for rotation of uterus and correct.
Vertical incision in centre of uterus extending up into upper segment.
Delivery baby; breech extraction often easiest.
Oxytocics, deliver placenta and check uterine cavity empty.
Closure of uterotomy in three layers using 1-monocryl or vicryl. Ask assistant to reapproximate incision to reduce tension on incision and preven tearing.
First layer: inner myometrium with continuous suture.
Second layer: mid-portion of myometrium with continuous suture. Leave 1 cm of outer myometrium open.
Third layer: continuous baseball stitch to invert the edges of incision. Baseball stitch is a continuous unlocked stitch where the needle is driven through the cut edge of the myometrium to exit the serosa a few millimetres from the incision for each bite.
Routine closure for rest of CS.