My name is Deepa Ilangovan and I'm a third-year medical student at William Carey College of Osteopathic Medicine and I'll be your moderator for this evening. Dr. Cox-Padota is an OBGYN with a focus on clinical practice, education, and women's health care. She's the OBGYN Residency Site Director at McNeil Hospital under Loyola University Health System and serves as an Assistant Clinical Clerkship Director at Loyola Stritch School of Medicine. Dr. Cox-Padota also teaches as an adjunct faculty member at Midwestern University's Chicago College of Osteopathic Medicine. Her work includes regional presentations on topics like maternal mortality and contraception at events such as the Illinois Osteopathic Medical Society and the Ward E. Perrin DO Clinical Refresher Course. She has received recognition in teaching, including Loyola Wolf's and Kettle Teacher Award in 2023. Dr. Cox-Padota has led research projects, including a quality improvement initiative to promote COVID-19 vaccination among pregnant patients and a study on IVF success rates based on ovarian response. Her affiliations include the AOA and the American College of OBGYN. She currently serves as a board examiner for the American Board of Osteopathic Obstetricians and Gynecologists. For disclosure purposes, Dr. Cox-Padota has no financial relationships with an ineligible company to disclose. And with that, Dr. Cox-Padota, the screen is yours. Great. Thank you so much. Just to make sure I'm still sharing my screen here. Okay. Everyone can see my slides? Yep, we can see them. All right. Fantastic. All right. So that was a very nice introduction. Thank you, Deepa. I appreciate it. So yeah, I work at McNeil Hospital as the site director for the OB-GYN residents there. I'm predominantly an OB-GYN hospitalist. I do have a one-day-a-week resident clinic, but most of the time I am in the hospital with the residents managing labor and delivery and the gyne consults and emergency department consults. So one thing we actually talk about a lot, we go through some of the articles that we're going to talk about here today, is standardizing cesarean section and then what to do with our cesarean section complications, how to handle them and what does the evidence show. So there we go. All right. So our objectives are going to be describing the necessity of standardizing our cesarean section procedures. Why do we want to do it? To improve our patient care and reduce complications. To analyze the impact of standardizing cesarean section protocols on maternal and neonatal outcomes. Review the data that supports these practices and discuss how to handle c-section complications and strategies to implement in your own practice evidence-based standardization of cesarean section. Okay, so first we're going to go, but why, right? No one likes protocols. And so I'm sure everyone is like, come on, we really need a protocol for our c-sections. But then I think I'll convince you, like, okay, fine. What does the evidence show? Let's hear it. But the good thing is we still need to use our brains. So we're going to talk about what to do during complicated cesarean sections and some recommendations, some thoughts on pluses and minuses of some of the recommendations. Okay. So why standardize cesarean sections? Why do we all have to kind of have a similar practice? So first of all, it's the most commonly performed major abdominal surgery. There were 1.1 million cesarean sections in the United States in 2019. So the benefits of standardizing. So first and foremost, it does give improved outcomes to have a standardization of procedures. So there's a really good study out of Canadian hospitals where one hospital did standardize their procedure for inguinal hernia repairs, and they showed a four-fold decrease in recurrence of their inguinal hernias compared to the other Canadian hospitals that did not have a standardization of their protocol. And then fewer surgical infections. So right now it looks like the standardization alone seems to suggest a lower infection rate and not necessarily even the technique you use. So we're going to go through what the evidence shows for techniques and what's recommended, but whatever you come up with, having kind of a set way that you're going to do things when things go routine decreases the rate of post-operative infections. And it's probably partly because of shorter operative times. When you have a way that you know you're going to do things, that everybody on your team knows you're going to do things, you have a shorter operative time. And also a really good, interesting read that goes along with this and having a standardized procedure, if you haven't read it, I recommend it. It's called Random Acts of Medicine. It's a really good book. And it's economists and physicians. They're I think mostly internal medicine physicians, but they look at different things that could alter someone's outcome in healthcare. And so for example, one chapter, they talk about a surgeon's morbidity and mortality rate on the day before and the day of their birthdays compared to all the other days throughout the year. And there's a slight uptick in surgeons morbidity and mortality rates on the day before and the day of their birthdays compared to the rest of the year. Just kind of showing that there might be other things going on outside of work that are distracting, changing maybe how we practice, how quick we're trying to get through a case. Whereas if you have a standardized procedure, you're less likely to have these human errors because you're always doing things kind of the same way. You're going to save time and money. So there are fewer unnecessary steps. You're only doing the things that are necessary for the procedure and are actually going to improve your outcomes. Fewer unnecessary sutures or instruments pulled during your procedure. And then especially if you're training residents, students, any sort of trainee, then you're giving the reasons for why you're altering. So then at least, because I'm going to tell you, I don't follow every single one of these recommendations exactly as it's stated. And just like I tell my residents, I'll tell you my reason for why, but I can tell them what the recommendation is and I can tell them why I'm veering from that recommendation. And it does have improved resident autonomy by their senior years. If everyone's doing a procedure in a pretty similar way and they don't have to walk into every surgery being like, wait a minute, does this surgeon like to close in one layer? Do they close in two layers? Do they close the peritoneum? Do they not? Do they make a bladder flap? What sutures do they use? If there's more of a standardized procedure, then we can have more autonomous residents by their third and fourth years. All right. So how do we know which techniques are better? Is it just that one person decided to publish an article being like, I think my way is the best way? No, we actually have 155 randomized control trials, meta-analyses, or systematic reviews between 1960 and 2012. And then an additional 216 articles were written on different aspects of the cesarean section between 2012 and 2019. And then there's two great papers that a lot of my recommendations are going to come from and kind of where I veered off from to show you the data. And one is the AJOG, Heiress Society Recommendations, written in 2018. And if you haven't read this, I recommend it. It's actually a three-part series. There is the pre-op cesarean section recommendations, the intra-op cesarean section recommendations, and then the post-operative recommendations. It's a great series. And then more recently, the Green Journal wrote the case for standardizing cesarean delivery technique, and they published that in 2020. All right. So using kind of those two major papers as a guideline for discussing what the evidence is for each different technique for cesarean section. Okay. So starting at the beginning, antibiotics and preparation. AJOG gets really specific with the recommendations for this, and they recommend IV antibiotics, about 60 minutes before the start of cesarean section with a first-generation cephalosporin. I think most of us are using ANSEF. And then if someone is in labor or rupture of membranes, they recommend adding azithromycin to your antibiotics. And then a chlorhexidine alcohol skin prep. And then they do recommend a vaginal preparation. So vaginal preparation does show a decreased risk in endometritis from about 8.3% when you don't do a vaginal prep to 4.3% when you do do a vaginal prep. The Green Journal did not address the preparations and the antibiotics for cesarean section. So most of it is coming from the data from AJOG and other articles that support what their recommendations are. And then AJOG also addresses at this point in their article that they recommend regional anesthesia, which we know, and they recommend not letting your patient get hypothermic. Okay. Thank you. We agree. Surgical incision. So the Green Journal is really broad in their recommendation for this, and they just say Joel Cohen has lower operative times and lower blood loss. So then the Green Journal gets more specific with each layer and essentially agrees that a Joel Cohen method has improved outcomes. And what they base this on is six randomized control trials and one Cochrane review that's been written since 2013. And they compared operative times, post-op analgesia requirements, febrile illnesses post-operatively, blood loss, and duration of stay in the hospital. And so based on that, they recommended a skin incision two to three centimeters above the pubic symphysis. They recommended sharp entry with blunt expansion, both for the subcutaneous tissue and for the fascia. So kind of like most of us do a crash cesarean section, you start to enter sharply, but then you're going to expand everything in a blunt fashion, including your fascia. If you can, you're going to expand that bluntly. And then they recommend blunt entry into the peritoneum. They also recommend no superior or inferior dissection of the fascia. So you're not going to grab the fascia superiorly and dissect the muscle off or go inferiorly and dissect the muscle off. When I can, this is what my residents and I try to follow with entry. Now, this is where using our clinical judgment and our operative skills come in handy, because if I have a repeat cesarean section where we can't find the midline to enter the muscle or to enter the peritoneum, then we will veer off of this. So before starting surgery, I remind them that this is our goal. But if we reach a layer where this is not working, then we will modify. If we can't see a clear midline area to enter the muscle and the peritoneum, then we will expand our fascia superiorly. If we're having a hard time finding a clear area in the peritoneum where there's clearly not bladder underneath, then we will start to sharply dissect the peritoneum to make sure that we are avoiding the bladder. So ideal situation, this is what we do. We veer from this if we have to. Bladder flap. I think this one is a little bit more controversial. The Gray Journal did not address bladder flap, and the Green Journal very specifically recommends to omit the bladder flap. So they cite, sorry, I've been coughing for about four weeks, they cite reduced short and long-term bladder symptoms with no difference in bladder injury. So I wanted to get a little bit better data on that and not just tell you what the Green Journal showed, but to kind of give more data on what supports this. So there was a 2017 double-blinded randomized control trial in the Journal of Family and Reproductive Health. It was 128 primary caesarean sections. And overall in the study, omitting the bladder flap had shorter incision to baby time, overall shorter operative time, less post-operative pain, and a shorter hospital stay. This study saw less blood loss with omitting the bladder flap, but they did acknowledge that three other studies done before this did not see a difference in blood loss, but they did see the same difference in shorter time to baby, shorter operative time, less post-operative pain, and shorter hospital stays. And there was ultimately no difference in bladder injury rates. So omitting the bladder flap. Our uterine incision, the Gray Journal says to do two centimeters above the vesicle uterine fold. They say sharp until the membranes bulge, and then you do blunt expansion in a cephalad to caudad fashion. The only difference with the Green Journal is they say to do a two to three centimeter sharp incision, and then to actually bluntly enter the uterus, and then also expand in a cephalad to caudad fashion. The only difference between them is how deep you're going to go with your scalpel before you start to bluntly expand. Placenta, membrane, cervix, Gray Journal did not address. The Green Journal does recommend that placenta be delivered spontaneously. Spontaneous placenta delivery does overall have a lower blood loss. Membranes. I find this one a little bit controversial because they say to only wipe if membranes are visualized. I find this one difficult because how are you going to see the membranes if the uterus is pooling with blood? So what we've been doing is just a gentle wipe to see if there's any retained membranes. We're not aggressive. We don't do an aggressive sweep all the way up to the fundus if our bleeding is okay and we don't see any membranes. And their recommendation is based off of only one randomized control trial of 206 women that showed no benefit of uterine wiping. So I think it does at least support not being aggressive with your uterine wiping, but again, if you need to do a wipe to see if there's any retained membranes, I think that that's reasonable. And then no cervical dilation. Okay, this is one that I feel like within our department even, that there's a lot of controversy and there's still a lot of ongoing research about the best way to repair your hysterotomy. So the Gray Journal in 2018 did say to do two layers and there was no strong evidence for what type of suture. The Green Journal, they recommend exteriorizing. So when they put together all the data, exteriorizing the uterus did show a lower blood loss, but they acknowledged that leaving the uterus in situ had improved nausea, vomiting, and resumption of bowel motility. And their point was basically, those are things we can easily fix with pretty benign medications versus more blood loss leads to more blood transfusions and possibly higher complication rates. So just based on that, they recommended exteriorizing. What I've done in my practice is just kind of meeting in the middle. If we can see our corners and our bleeding is controlled, then we leave the uterus in situ because why provoke the nausea, vomiting, if we don't have to? If there's an extension, we can't see our corners very well, we can't tell how close we are to the uterine artery, then we will exteriorize if we need to to control blood loss. And then even more controversial is that the Green Journal recommended a single layer closure. And theirs was based on several studies. I'm gonna talk to you about some of them in just a second. The other thing I wanted to address a little bit, because there's no strong evidence for suture, the only study I could find about suture material is one randomized control trial out of Turkey published in the Journal of Investigative Surgery in 2019. There were 96 patients, and overall they looked at polyfilament suture versus a monofilament suture. And the monofilament suture showed a greater residual myometrial thickness compared to the polyfilament. So I have overall switched to a monofilament suture for my uterine repair. But I mean, again, one study does not equal fact, so I think it's still reasonable if you prefer a polyfilament until more research is done on suture type. Uterine repair though. So the recommendation to do a single layer closure, and I'm gonna tell you what we basically know so far based on the studies that have been done. So there was a 2018 systematic review in the British Journal of Obstetrics and Gynecology, and it put together 20 studies of 15,053 women. And they were looking overall at the residual myometrial thickness after repair. So they were not looking at uterine rupture rates. They're just looking at an ultrasound after a woman is healed, what is their residual myometrial thickness? And they did see a greater residual thickness with a double layer closure. Dysmenorrhea was higher for a single layer closure, but they did see that residual myometrial thickness was greater with an unlocked suture. Double layer locked, or I'm sorry, double layer not locked is better than a single layer locked, was one recommendation they were able to give from this study. And they also did show that excluding the decidua as you repaired your hystereotomy does decrease the risk of a niche. If everyone remembers what a niche is, it's an outpouching, usually seen on ultrasound at the area of the healed cesarean section scar. It's also called an isthmus seal or a C-section scar dehiscence. It can be as well. And so they just saw fewer niches on ultrasound if you left out the decidua. There was also a 2011 systematic review in the International Journal of Gynecology and Obstetrics. This looked at nine studies, 5,810 women, and they actually looked at uterine rupture rates during a trial of labor after cesarean section. And a single layer versus a double layer overall showed no difference in uterine rupture rates. But then they went even further to break it down, looking at single layer locked versus single layer not locked versus double layer locked and double layer not locked. And what they did see is increased uterine rupture rates with a locked single layer versus a double layer. An unlocked single layer though, did not show a difference compared to a double layer. And again, they also show that excluding the decidua decreases your niche prevalence. So overall, what I've seen, there was another article I read that was just giving the overall recommendations of where we're at with uterine hysterotomy repair. And all we know so far is that if you're going to lock, if you're going to lock your sutures, you need to do a double layer. And if you don't lock, you technically don't need that second layer because overall the data supports that a not locked single layer is equivalent to a double layer locked. Overall, blood loss was higher with locked suture surprisingly, because I think one reason people are a little bit resistant to stopping locking is that they're concerned about the total blood loss of the procedure. But overall, the blood loss was higher with a locked suture in this 2011 systematic review, but the operative time was less. So again, I have gone to, what I'm doing in my practice is I no longer lock, but I'm not ready to give up my second layer until there's more clear evidence on whether or not a double layer is better than a single layer. So I am not locking either layer, but I am still doing two layers. All right, so for the remainder of the closure, the Gray Journal recommended no peritoneal closure, re-approximate the subcutaneous tissue if there's more than two centimeters of tissue, and then to do a subcuticular skin closure. Green Journal got a little bit more specific. They said to omit irrigation, peritoneal closure, and rectus approximation. They recommended gashel closure in a continuous fashion. They do recommend irrigating subcutaneous tissue, and then re-approximating also if greater than two centimeters and a subcuticular skin closure. Okay, so that's all great and wonderful when you have a primary cesarean section, no complications, no other issues. But obviously, like I mentioned, when I talked about what I do in my practice with my residents, we need to also think about approaches to cesarean sections when there's complications, because not every C-section is going to be routine. Okay, so there is another wonderful article, and I actually, this sparked reading this out of a personal issue, and I'll explain when I get to the section of why I started doing research on the data on this. But there's a 2020 literature review in the European Journal of Obstetrics and Gynecology and Reproductive Biology that talks about the difficult cesarean section, and they break it down by four categories, issues with the lower uterine segment and access to the lower uterine segment when you have problems with fetal extraction, damage to surrounding organs, and then abnormal placentation. Some of the recommendations I'm going over are from that article, and then some are some other studies that I looked at outside of there because this was a European journal, so some of the recommendations that they have in their article don't exactly match what the data has shown in the U.S. to be best practice. So to start with the difficult lower uterine segment, they talk about leiomyomas, and they recommend removing the lower uterine segment leiomyoma before delivery. So leaving them alone if they're not in your way, if they're at the fundus, if they're posterior, to not remove a leiomyoma at the time of cesarean section. But if it's going to prevent you from doing a low transverse incision to actually excise the fibroid before doing your hystereotomy. So it's based on a systematic review, 2,301 patients had myomectomies at the time of their cesarean section, 1,599 did not. The group that had a myomectomy did overall have a greater drop in hemoglobin, but ultimately no difference in blood transfusion. So while they did have a little bit higher of a blood loss, they did not require more blood transfusions. So giving that access to the lower uterine segment so you don't have to do a high transverse or a classical cesarean section is beneficial. In terms of obesity, when it's hard to get to that lower uterine segment because a patient is obese, with a BMI greater than 45, the recommendation is to perform a supraumbilical transverse incision. And obviously it's hard to choose between doing a supraumbilical versus suspending up the pannus and doing a low transverse incision. Now, there are some newer devices that are coming out. One in particular is gonna alter potentially the data on healing and how to do our cesarean sections. And it's one that allows the patients to go home with their pannus suspended up off of the incision. And the hope is that by keeping the pannus up off of the incision for at least a week postoperatively, that it will decrease the incision infection rates. So this obviously isn't including that data because that is very new. But so doing that supraumbilical incision overall has shown to have better exposure to lower uterine segment than trying to hold up the pannus and do a suprapubic incision and overall an easier extraction of the newborn. But there is a higher EDL and longer overall operative times by doing the supraumbilical incision. A BMI over 30 subcuticular suture had fewer complications actually compared to staples. So it's reasonable to consider subcuticular sutures for your obese patients. And a BMI over 40 overall at the six week mark, there was no difference between subcuticular suture and staples, but potentially higher rate of a little bit of a dehiscence of the wound in the initial couple of weeks postoperatively. So while you don't see a difference at six weeks, it can be really bothersome to the patients to have that wound dehiscence in their first few weeks postoperatively. So considering staples and your BMI over 40. In terms of previous abdominal surgeries, there's not a whole lot of recommendations because there's no support for routine adhesion barriers or peritoneal closure. Nothing is proven to decrease the rate of scar tissue and adhesions when you go in for a repeat surgery. So it's just being careful with your dissection, trying to avoid the bladder, what we all do anyways. Okay, fetal extraction. So this is actually the reason why I looked up this article. I had one day with one of my excellent senior residents that we'd had a patient pushing for a while and she was arrest of descent, took her for a C-section and my senior resident was trying to get the head out and she's like, Dr. Cox can't do it. She's like, it's not coming. And so of course like, oh, I'll get it. And so I reach in and I'm trying to deliver the head and I cannot get it to come out of the pelvis. We tried a hand from below. So we were going on about 10 minutes of not being able to get this baby out. And so finally I just reached up, grabbed the feet and the baby flipped right out easily. Luckily for me, baby started crying right away, which I was happy for, but in some ways it's like, you just nearly killed me baby and now you're crying like nothing happened. I was like, well, gosh, that flip to breach was extremely easy after we were struggling and struggling to try and get the head up. What is the data? What are the recommendations on fetal extraction with a deeply impacted fetal head? And overall this article, the one I read from 2020 did say that the POLE method has fewer maternal complications, less uterine extensions and less endometritis. They saw no difference in bladder or urethral injuries, injuries to uterine artery or fetal complications. They saw no difference. So I wanted to look into a little bit deeper and see if there was any other studies on the PUSH versus the POLE method. PUSH being the hand from below, POLE being flipping to breach. So there was a 2023 systematic review in the European Journal of Obstetrics, Gynecology and Reproductive Biology. So since that initial article published, they looked at 16 studies and their primary outcome was uterine extension rates. And reverse breach was better than the PUSH method for uterine extensions. There was no difference between the PUSH method and the PATWARD hands technique. And if you don't know what that is, I'm gonna show you in just a second because I've never done that before nor do I think I ever will do that. I think I'm more likely to flip to breach. Secondary outcomes they looked at were reverse breach for better blood transfusion rates, better bladder injury, overall less postpartum hemorrhage, fewer NICU admissions and better APGAR scores. So even their secondary outcomes was improved with a flip to breach versus PUSH method. Okay, so the PATWARD hands maneuver is basically where you take the baby with a deeply impacted fetal head and you're gonna deliver both arms first and then put your hands under both axilla and flip the baby to breach that way. Okay, so it's a little hard to visualize. So I just wanted to show this video. I'm gonna fast forward to the part where they're actually getting the baby out. Okay, so now you're gonna see, they're gonna reach in and they're gonna deliver one arm. First, they're trying to get the head up from being impacted. And then when they cannot, they go for the arms. There's one arm out. Okay, so now they have both arms out and now you can see he has both fingers under the axilla and is trying to bring the baby up through the incision by flipping the baby to breach. It's a little anxiety-inducing to watch. And then in a second here he'll get the baby all the way through the incision and then the head will just come up from the pelvis and out. So that's the Padware Hand Maneuver. So overall they did not see improved outcomes with the Padware Hands Maneuver. The improved outcomes were with actually reaching up grabbing the feet and then flipping the baby to reach that way. This maneuver is easiest when the baby is OP because then as you can imagine if you can picture all you have to do is reach up grab the baby's feet and it's just an easy backward roll flipping the baby out from that position. A little bit more challenging when your baby's in an OA position whether it's ROA LOA or direct OA because then you're going to have to add a rotational component. And if they're certainly ROA or LOA then usually you can just grab the feet from the side of the abdomen and start to rotate the baby as you pull the feet out and deliver from breach rotating the baby as you go so you don't hyperextend the neck. If the baby's direct OA then you're going to have to do an internal rotation and then grab the feet and deliver from breach. Okay and then transverse line. So this article did say that a low transverse incision is reasonable even with a back down baby if you are skilled at internal version. So you would make your low transverse incision and then you would reach internally to flip your baby over grab the feet and then extract. And with this method they did show a fewer than eight percent rate of requiring a T incision to get the baby out. In terms of answers on the boards or what you do in your practice a classical cesarean section is always an acceptable answer for a fetus back down because this is only recommended if you feel comfortable enough to do an internal version and then flip the baby to breach. If you do not feel comfortable with that maneuver then it is reasonable with a fetus back down to do a classical incision. Okay damage to other organs. We're just going to go into all the different things that could be injured here. So this is another great article actually done by one of my colleagues here at Loyola Dr. Laura Glasser. She did it before her time coming here though she did it when she was at Northwestern and wrote an article with Dr. Magdy Malad at Northwestern in obstetrics and gynecology in 2019 where they just go through all the recommendations of what to do in obstetrics and gynecology surgery when you have an injury. So for the bladder overall if it's a one to two centimeter injury to the bladder not at the trigone so the dome somewhere else a single layer closure with a delayed absorbable suture is reasonable. And you don't need to necessarily call urology for this. If you feel comfortable just doing your single layer closure for a small injury and then you'll just leave your foley in for seven to ten days. If it's greater than two centimeters they do recommend a double layer delayed absorbable suture. Again depends on your comfortability whether or not you feel comfortable doing this on your own or calling urology. And then frequently too we will backfill the bladder to make sure that our seal is watertight and then leave the foley in for seven to ten days. And then if it's at the trigone then you need to call urology because they need to determine whether or not the injury has extended into the ureter so that should not be for you to do for repair. In terms of ureteral injuries again this is calling urology but I also feel like this is a question that sometimes comes up on boards that we still have to know how these repairs are going to be done. So for a minor ligature or crush injury if urology can pass a stent then just leaving a stent in for four to six weeks while the inflammation goes down and the area heals is reasonable. If there is a transection of the ureter and this is the area where they get specific sometimes on the boards, if the injury is in the upper third of the ureter you're going to do a ureter ureterostomy. If it's in the middle third also a ureter ureterostomy it's hard to say it's a mouthful right but you want to make sure that it's tension free if they're going to do that. And then in the distal third that's where you can do a ureteroneocystotomy and use your psoas hitch if there's um if it's needed to make that tension free because again you want that repair to be tension free and so that's where you would use your psoas hitch in the distal third of the ureter. Okay in terms of small bowel injuries, cirrhosal injuries technically you don't even have to repair if it's just cirrhosal and does not go any deeper or you can over sew it with a 3-0 delayed absorbable suture just in a cross-sectional plane. So again just a cirrhosal injury is reasonable for you to repair on your own if you're confident that it's just a cirrhosal injury. Again you're never wrong for calling in general surgery if you're unsure want them to run the bowel or want them to do your repair. For a partial thickness you're going to do a 2-0 or 3-0 delayed absorbable suture and you're going to do this perpendicular to the longitudinal plane. So even if your injury is in the longitudinal plane you want to make sure that you do not narrow the bowel lumen. Okay because you notice if you start stitching it in the direction that the injury is there's a chance that as you close that injury you're going to narrow the lumen of the bowel and create a stricture in that area. So in this situation you actually would put a suture here on this end of the injury and a suture here on this end of the injury to pull it so that you create an apex to repair the injury in a perpendicular fashion to the bowel so you're not narrowing the lumen. Okay if it's full thickness less than a centimeter you can repair in one to two layers similar to a partial thickness but if it's a larger injury if it's a full thickness injury greater than a centimeter it may require a resection and reanastomosis at that time so that would be up to general surgery. Large bowel injuries you can follow generally the same principles as small bowel. The big thing though is afterwards you want to copiously irrigate the pelvis and then you're going to want to do a proctoscopy to make sure that your repair is airtight. All right abnormal placentation so this is another one that I feel like for low-lying placentas is a little bit debatable and not everyone's really comfortable with some of the recommendations. So for a placenta previa we all know we're going to do a cesarean section between 36 and 0 and 37 and 6. It's the low-lying placenta that becomes more debatable. So Alizee and colleagues had a study published in the Green Journal in September of 2022. It was a retrospective multi-study multi-center study in France of 171 women. 70 underwent a trial of labor and 101 underwent an elective cesarean section with a low-lying placenta. In these groups in the 0 to 10 millimeters from the cervix so their low-lying placenta was somewhere between right next to the cervix to 10 millimeters away. There were 27 women in the trial of labor group and 67 women in the elective cesarean section group. In the 11 to 20 millimeter group there were 38 women in the trial of labor, 31 women in the elective cesarean section group. Overall between these groups they saw no difference in postpartum hemorrhage rates and they saw no difference in severe maternal morbidity, blood transfusions, admissions to the ICU, need for hysterectomy, and sepsis they were looking at for severe maternal morbidities. So but the one thing to keep in mind is the vaginal delivery rate for a low-lying placenta between 0 to 10 millimeters from your cervix is only about an 18.5 percent rate. For 11 to 20 millimeters though it was a 50 percent rate of fast successful vaginal delivery. The need for an emergent cesarean section was as high as 50 percent for the 0 to 10 millimeter group and 11 to 20 millimeter group was 27 percent. So in my practice I've gone to having a risks benefits discussion with my patients discouraging a trial of labor for 0 to 10 millimeters because of that high rate of needing a cesarean section and failing a trial of vaginal delivery. But having a risk benefits conversation about having a trial of labor for the patients who have a low-lying placenta that's 11 to 20 millimeters away from the cervix it's reasonable to try that. In terms of placenta accretas and percretas, so recommendations are delivery between 34 and 0 and 35 and 6. Your incision should be far from the placenta and you should have a planned c-hyst. In terms of maintaining fertility and maintaining the uterus after an accreta, I'm not going to get into that because that's a large discussion about how to manage that. Methotrexate, doing hysterox, hysteroscopy, resection of the remainder of the placenta if need be and the rate of needing an emergent hysterectomy in patients that you're managing in that way. If you are not at an accreta center and a patient wants to maintain their fertility, I do recommend that you send those patients to an accreta center that has a lot of experience with fertility maintenance after an accreta. I want to dive a little bit deeper into the recommendations of how to manage our planned accretas with c-hysts. The data on stents, it's a little bit mixed. In June of 2023, the Journal of Maternal Fetal and Neonatal Medicine had a retrospective cohort study of 99 patients and overall this showed that stents had no protective benefit over ureteral catheters. So they still did preoperatively have something in the ureters, either a ureteral catheter or ureteral stents. And there was a higher rate of complications postoperatively with the stents, which are meant more for long-term retention and not short-term retention versus ureteral catheters, usually a little bit more flexible and they're typically more for short-term use. So great as an option for identifying your ureters when you have a planned cesarean hysterectomy. And then in November of 2022 in obstetrics and gynecology, they had a retrospective cohort study of 236 patients. And in that study, stents overall showed no lower GU injury compared to no stents. So overall that study did not recommend it. But then there's another study in 2021 in the Journal of Maternal Fetal and Neonatal Medicine, retrospective cohort 44 patients, and that also showed no rejection in GU injuries. So the data is mixed. And so I would say for now, if you're at a center that is keeping their own accretas, it's reasonable to consider stents or ureteral catheters if that's an option with your urologists. You're going to want to make sure that you're doing a cesarean hysterectomy, a planned one, in a facility that has a urologist available on call and they're aware, ideally a gynecologic oncologist who's around and aware, and that you're planning preoperatively in a multi-specialty fashion to prepare for this. If not, then you should consider sending your accretas to an accreta center. I will say at Loyola, they send all of their known accretas to an accreta center. We do not keep our own, even if they're having a planned C-hyst. In terms of uterine artery embolization at the time of C-hyst or uterine artery balloons, UAE has shown a clear benefit in decreased blood loss, either in conservative management, where you're trying to maintain the uterus, or in a planned cesarean hysterectomy. So basically you have interventional radiology involved in your preoperative planning. They are available in the operative room. You deliver the baby and then they do their uterine artery embolization before you start your cesarean hysterectomy, if you're doing a planned cesarean hysterectomy. Otherwise, they do use this as well for patients that are planning to try and keep their uterus postoperatively. So far, there's mixed results on intraoperative blood loss and overall no difference in the need for emergent hysterectomy with uterine artery balloons. So it's basically just the main thing is that there's not enough data yet to say that uterine artery balloons have a benefit. And there's just more data for long-term use of uterine artery embolization with accretas and cesarean hysterectomies. All right, so that is my long list of references on these two pages. So we'll take any questions you guys have. There's some in the chat here. Let me start pulling them up. I heard about the device that will allow the panus to remain elevated at conference in 2019. Is it being used anywhere? I have not seen it used anywhere. We have not taken it at Loyola yet. We did have someone come and demonstrate the device for use postoperatively. But anywhere I've been, and to clarify, I also have done locum tenens for a year before coming to Loyola. And I did not see it being used at any hospital that I've gone to. A question, drains in obese patients subcutaneously? There is no proven benefit to using drains. The recommendations are to omit drains. What about fetal pillow for impacted head at C-section? Excellent question. So there is not enough data yet on the fetal pillow. It's again relatively new in terms of all this data we have for a cesarean section and how to best extract a baby. So there's a lot more data on the push and the pull method than there is on the fetal pillow. So I did look into the fetal pillow and there's just no data to compare that head-to-head to the push and the pull method. Anyone using VLOC for hystereotomy closure? No, I have not seen VLOC used for hystereotomy closure. And again there's not a lot of studies on suture type. There's some with chromic and there's some rumors going around that they're actually going to discontinue chromic which I don't think is actually true. I think they're going to limit its use. So there's some older studies that did show more niche formation with chromic compared to a polyfilament suture, but other than that there's not a ton of research on the different types of suture and what to use. Mainly just that one study I told you between a polyfilament versus a monofilament, but nothing comparing a VLOC. Next question, why do you suppose blunt dissection causes less infection, decreased infection? Yeah, so the decreased infection rate is probably directly related to the overall operative time because there is a significantly lower operative time when you can bluntly dissect versus when you have to sharply dissect. But also you have to think about your patients that are eligible for blunt dissection. Usually these are your patients without a lot of adhesions and so your overall operative time is going to be lower. The more significant thing is the blood loss and the theory on why our blood loss is lower is because sometimes the vasculature will move out of the way with blunt dissection versus when you're doing a sharp dissection you're going to cut right through the vasculature. So you have less blood loss because sometimes those vessels won't tear and you won't get as much bleeding. Okay, Dr. Lim has some great questions here. The next one, in an earlier slide you were talking about bladder flap minimizing post-op issues such as pain. Why do you suppose that is such if it takes less than five seconds to develop a bladder flap? This is true. It's a very simple layer and there's actually a few other studies that I was looking at. I included the most significant one and a lot of the symptoms that they find post-operatively with the bladder flap is a lot of bladder irritation both short-term and long-term. The pain is a little bit hard to explain. It seems like all the other layers would be a lot more painful that a patient wouldn't notice the difference between a bladder flap done and a bladder flap not done. So it might be related to that sensation of bladder irritation and they're feeling the irritation of that exacerbating the pain. Otherwise I don't know and it is an easy layer to do. I will say probably about 90% of the time my residents and I are omitting the bladder flap. If it's tacked up, if it's in our way, if I don't think we're going to be able to do a good double layer closure, we will take the bladder flap down. Another one from Dr. Lim. Have you ever heard of an OBGYN keeping fluid in the abdomen after a cesarean to decrease adhesion formation? I have never heard of that. I did not come across any studies of that. The only thing was the commentary about omitting irrigation but I've never heard of it being left in the abdomen. No. He's one of our GYN oncologists so always nice to hear from him. Next question. Why don't you close anterior peritoneum and bladder flap to reduce the risk of uterus scarring to the abdominal fascia? So I think it sounds like the layer is like closing the peritoneum over the hysterotomy like where the bladder flap would be done. Right. Yeah. There's no evidence of any benefit to that or decrease. So similar to closing the peritoneum, there's no evidence that that's going to decrease adhesion rate. I can get why you would think that because I overall have a couple of reasons of why I'm still doing a double layer closure. And one is because there's not enough data, like I said, to support completely eliminating the second layer yet. And it's also that theoretical potential decrease risk in adhesions to me when you embrocate your hysterotomy versus leaving those raw edges exposed. But in terms of peritoneal closure, whether it's the peritoneal closure over your hysterotomy or your abdominal peritoneum, there's no proven benefit to lower adhesion rates. And it's going to add more operative time. So then the longer your operative time, the higher risk you are for post-operative infections. Okay. Dr. Lim says you are correct about ureteral stent catheter, no decrease rate of injury, but it does make it a lot easier to repair. Yes, that's true too. And identify. And then he, Mary Donna Rapacio asked, do you use intercede over hysterotomy? I do not. No. Overall, again, the data doesn't support any difference in adhesion rates, but studies on that are hard to do because it's a lot of subjective data on adhesion rates when you're looking at a repeat surgery after using those adhesion barriers, but I don't. Dr. Barquette, how well do you approximate myometrium to myometrium? Is it all bunched up or is it edge to edge? So edge to edge and we eliminate the decidua and we bring our myometrium edge to edge, but then we do still embrocate over that. Okay. So I will wait for a couple more questions if there are any, I was going to ask. So like just from a strategic planning, you know, obviously these are, some of these can be really difficult cases. Like what do you, which cases do you suggest, like, you know, having help going in or, you know, you've got groups with kind of less experienced, more experienced people, like what are the situations where you want to be prepared going in with like the best hands on deck? Yeah. So definitely once you're getting into your fourth and fifth cesarean section, I'm trying to remember the numbers exactly in the, I forget if it's in the postpartum hemorrhage practice bulletin, but the rate of postpartum hemorrhage and the need for a C-hyst at the time of repeat cesarean section for a fifth C-section. I want to say the rate of postpartum hemorrhage, oh gosh, approaches like 40% on their fifth cesarean section. And the chance of needing a C-hyst goes up to about 8% by their fifth cesarean section. So if you're not in a facility where they are readily available, backup, either a backup physician who has more experience, urologists around, or gyne-oncologists around to help with your C-hyst if necessary, then doing some preoperative planning to make sure those people are available. I was saying if you can read the operative report and previous operative reports comment on a lot of adhesions, you can assume that they're probably going to have even worse adhesions with a repeat C-section. So also being prepared for those when you go ahead. And at my hospital, we've seen some cases recently of like BMIs like over 60, any specific tips you would have on like cases like that? Yeah. And again, I feel like it's so hard. I know those recommendations say to go super umbilical, but that is such a hard decision because then you're going to be going through all those, all that layer, that large layer. And you also have to watch not to go from skin to skin. You want to make sure that's why they say super umbilical so that you can try to avoid just getting to the other end of your pannus. And you think about as the pannus descends, as your BMI goes up, the umbilicus is probably actually at the level of your suprapubic area if you were to lift the pannus up. So it is a hard decision trying to choose between going through all those layers versus lifting the pannus up and going underneath and accepting your infection risk postoperatively. And I will say frequently, we will still elevate the pannus and try to go suprapubic if we can. And then we do, if the pannus is too large, we will go super umbilical and just have a lot of hands around for retraction. Yeah. We had a case a few weeks ago and my partner did that, which, you know, I just feel like that's not, you know, not like I've done as many C-sections as others, but I was just like, that's, you know, can be difficult. But the patient's pannus was kind of hanging town, you know, when she walked around. So it was just the most direct access. Yeah. Yeah. And it's hard because their infection rates are really high for their incision afterwards. The other interesting thing, and it's not as useful for the morbidly obese patients because the Alexis retractors aren't big enough, is that Loyola has recently started a little bit of a modified protocol to decrease postoperative infection rates with cesarean sections. And they've gone to recommending routine use of Alexis retractors, which is great because I do anyways. I just like them. I tried to look up the data, which is why I did not include anything about Alexis retractors. So I tried to look up the data they're using to support that change in protocol of using Alexis retractors to decrease postoperative infection, and I couldn't find anything for it. I'll have to follow up with them and ask what they're using to base those recommendations on, but we have gone to a protocol with routine Alexis retractor use and then antimicrobial sutures. Okay. We have a few more questions coming in. Dr. Tucker, I think I've missed, I may have missed the commentary regarding benefits of re-approximation of rectus muscles. There's no proven benefit to re-approximating the rectus muscles. Yeah. I'm sure there are some plastic surgeons who would disagree with us, but there is no proven benefit. And even in plastic surgery, when they do re-approximate the rectus muscles, they typically use a permanent suture and our patients, unless we can be sure that they are done with childbearing, we're not going to put in a permanent suture in the rectus muscles. So no proven benefit to it. If I cut the muscle, if I'm dealing with a lot of adhesions and I have to cut the muscle to get into the peritoneum in a safe space, I will re-approximate with a mattress suture the area that I've cut, but where I separate in the midline, there's no benefit to repair. Okay. Another question from Dr. Lim. Are there any type of dressings that you use over the incision that you found working best? Example, silver, provino, pico dressing, et cetera. I've seen those used at some of the hospitals I cover in locums, but I still occasionally cover outside shifts. But again, there's no data to support them. I think part of the problem is the number of years that some of these things have been out to decrease infection risk. I know the data is pretty good on that superficial wound vac, that there is ultimately no difference in outcomes, infection rates with the wound vac, but the other dressings, I have not seen any clear evidence of benefit or it not being beneficial. I think we just don't know yet. We do not use them routinely here at Loyola. Okay. Dr. Otuya and then Dr. Riggs, questions, one about any data about the Traxie retractor, and then is there any one PANUS retractors such as the Traxie that you prefer? We use the Traxie and actually everywhere I've been has used the Traxie. I think they just, unless I'm wrong, I think they were the first ones to actually come to market with a PANUS retractor. When I was in residency, we used surgical tape taped to the bed as a PANUS retractor. And then when the Traxie came out, we switched to the Traxie. I did not find, as I was doing my research, any evidence on Traxie and especially looking at obese patients, it just wasn't mentioned. So I just don't know that there's any studies, at least that I came across directly comparing Traxie and like what they would compare it to. Because I don't know that anybody is leaving the PANUS, unless they're going supraumbilical, anyone who's going suprapubic, no one is leaving the PANUS down. You have to get the PANUS up. And so whether you do that with a Traxie or the tape or any other PANUS retractors, so then I guess you would compare each PANUS retractor to each other versus the way we did it back when I was in training of taping the PANUS to the bed, but I did not see anything comparing those. Okay. Another question from Dr. McMahon, if less pain with blunt dissection is due to decreased operative time and I can do a C-section in 20 to 30 minutes with sharp dissection, what's the rationale for me to change to blunt? And I don't, because when they, let me go back to the slide, they looked at a few different outcomes and it was not just pain. It was operative time, postoperative analgesia requirements, febrile illness, blood loss, and duration of stay. So they looked at all of those factors in these six randomized control trials when they combined them in the systematic review and the one Cochran review, and they looked at all of those factors to come up with these recommendations of Joel Cohen. So I did not see anywhere in that study because I reviewed a few of these randomized control trials that benefited, that lean towards Joel Cohen and your blunt dissection. And I didn't see anything directly saying that the blunt dissection decreased the pain, but overall, all of these outcomes were improved with blunt dissection compared to sharp. So post-op analgesia requirements, if you just looked at that alone for Joel Cohen versus sharp dissection, maybe you wouldn't see any difference in postoperative pain. But it's not necessarily the operative time that's decreasing the postoperative pain. It's probably partly how the cesarean section is done. And it can even be because part of Joel Cohen is eliminating the superior and inferior dissection of the fascia. So it can even be related to eliminating that superior and inferior dissection of the fascia off of the muscle.

Deepa Ilangovan

Dr. Cox-Padota

OBGYN

cesarean section

maternal outcomes

neonatal outcomes

COVID-19 vaccination

IVF success rates

surgical techniques