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CC BY-NC-ND 4.0 · Surg J (N Y) 2020; 06(S 02): S104-S109
DOI: 10.1055/s-0040-1712927
Precision Surgery in Obstetrics and Gynecology
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

“En Caul” Cesarean Delivery for Extremely Premature Fetuses: Surgical Technique and Anesthetic Options

Takeshi Murakoshi
1   Department of Obstetrics and Gynecology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu City, Shizuoka, Japan
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Publication History

Publication Date:
16 June 2020 (online)

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Abstract

The risks and technical difficulties at the cesarean delivery for extremely premature infant under 1,000g are as follows: (1) a premature infant is very weak for pressure of uterine wall or human hands, (2) skin of infant is really premature and weak, (3) uterine wall is thick and difficult to incise at lower segment of uterus, (4) classical vertical incision or reverse T-shape incision are at risk for future uterine rupture, and (5) at the timing of rupture of membrane, uterine wall may contract drastically and the infant is trapped the uterine wall, so called “hug-me-tight-uterus”.

To resolve the problems, we use the technique of “En Caul” cesarean delivery with nitroglycerin. Intravenous injection of nitroglycerin just before uterine incision made the rapid and sufficient relaxation of uterine muscle. After getting adequate uterine relaxation, U- or J-shaped incision is made to lower segment of the uterus; however, we never incise the membrane before the infant was delivered. The baby is delivered with wrapped amniotic fluid and the membrane, which protect the infant against the pressure of uterine wall or surgeon’s hands. The infant is gently handled to neonatologist by “En Caul” with the placenta. Neonatologist can make the membrane ruptured and resuscitation. Own blood transfusion can be made through the umbilical cord and placenta, if the infant was anemic or hypovolemic.

Keywords

extremely premature infant - cesarean delivery - en caul - unruptured amniotic membrane
 

  • References

  • 1 Pearson JF. En caul cesarean section for delivery of the low birth weight baby. In: Farook AA. , ed. A Colour Atlas of Childbirth and Obstetric Techniques. London, United Kingdom: Wolfe Publishing Ltd.; 1990: 137-141
    Google Scholar
  • 2 Lin CH, Lin SY, Yang YH. , et al. Extremely preterm cesarean delivery “en caul”. Taiwan J Obstet Gynecol 2010; 49 (03) 254-259
    CrossrefPubMedGoogle Scholar
  • 3 Jin Z, Wang X, Xu Q, Wang P, Ai W. Cesarean section en caul and asphyxia in preterm infants. Acta Obstet Gynecol Scand 2013; 92 (03) 338-341
    CrossrefPubMedGoogle Scholar
  • 4 Abouzeid H, Thornton JG. Pre-term delivery by Caesarean section ‘en caul’: a case series. Eur J Obstet Gynecol Reprod Biol 1999; 84 (01) 51-53
    CrossrefPubMedGoogle Scholar
  • 5 Murakoshi T, Naruse H, Omori G. , et al. Technical tips of cesarean delivery for extremely premature fetuses; anesthesia options, J-shape uterine incision, and “En Caul” cesarean delivery. Gynecol Obstet Surg 1999; 10: 55-63
    PubMedGoogle Scholar
  • 6 O'Grady JP, Parker RK, Patel SS. Nitroglycerin for rapid tocolysis: development of a protocol and a literature review. J Perinatol 2000; 20 (01) 27-33
    CrossrefPubMedGoogle Scholar
  • 7 Murakoshi T. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS NOW, No. 3. Cesarean section. (Japanese). Tokyo: Medical View 2010:64–71