Extraperitoneal cesarean section: what is it?

The extra-peritoneal cesarean section is a gentler method of childbirth than the classic cesarean section. What is that ? How's it going ? Explanations with Dr Olivier Ami, gynecologist-obstetrician.

  Extraperitoneal cesarean section: qu'est-ce que c'est ?

Extraperitoneal caesarean section is little practiced and little known in France. However, this way of giving birth by caesarean section has existed since the 1990s, when it was developed by Dr Denis Fauck and Pr Jacques Henri Ravina. Sometimes criticized by some health professionals because it is not well known, it nevertheless has many advantages for patients. We take stock with the gynecologist-obstetrician Olivier Ami, who practices it.

What is an extra-peritoneal caesarean section?

In homage to Dr. Fauck, the extra-peritoneal caesarean section is also called FAUCS (French AmbUlatory Cesarean Section), or ambulatory caesarean section. When performed, ' Unlike in some techniques, on does not try to take off the bladder where it is adherent to the peritoneum [the membrane which covers the abdominal cavity and the viscera which are there, editor's note], but we push simply the bladder on the side to reach the uterus' , explains Dr. Ami, which allows for less pain at the end of the procedure. Like the classic caesarean section, it is performed with spinal anesthesia. However, the dose of anesthetics used is less important: ' In intraperitoneal techniques , we have an anesthesia that goes up very high and with a large dose, what prevents movement of the legs and lasts longer several hours . With extraperitoneal caesarean section, there is no need to anesthetize a they use because there is less pain, so we use half the dose of that used for a classic cesarean' . The fact that the anesthesia is less dosed allows the patient to move on the table, but also to push the baby out, as for a vaginal delivery. Right after the procedure, she can stand up and carry her baby . “It changes the birth experience a lot. and ' , underlines the gynecologist-obstetrician.

Classic cesarean and extra-peritoneal cesarean: what are the differences?

Precisely, the FAUCS has many differences with the classical caesarean section. The first is therefore the fact that the anesthesia is less important, but also that there is no no need to use morphine because it is much less painful. And who says absence of morphine, says lack of urinary catheter , because there is no medicine that will 'block the sphincter of the bladder and ' . Extraperitoneal caesarean section is also less painful after childbirth: 'Women are on paracetamol and anti-inflammatories for the first twenty-four hours and, often, two or three days later, they take nothing more.' The absence of a urinary catheter and the fact that the pain is less important favor the mobility of the patients: 'They can walk right away, better and more easily. They can really carry their baby. We are in a protocol of early autonomy and not early rehabilitation, that is to say a protocol of autonomy which concerns the main functions: eating a real meal afterwards, peeing on my own, not needing help, support or medication to walk smoothly' , says Dr. Ami. Regarding the birth itself, women can push, see their baby come out, cut the cord and do skin-to-skin in the operating room right away . 'For us, it's an organized birth in the operating room: it's not centered on the cesarean section, it's focused on the birth, the attachment between the parents and the child. And that's very important' , underlines our expert.

In what cases can an outpatient caesarean section be used?

There are no contraindications to extraperitoneal caesarean section . “We can do it in an emergency as well as on a programmed basis, we can do it on any type of patient, on any type of fetal presentation” , explains Dr. Olivier Ami. However, he indicates that there are small differences when it comes to performing it depending on the term of the pregnancy: 'We can do it first at any term, but there are small particularities, especially if it is done at a premature term. The peritoneal cul-de-sac changes a lot depending on the progress of the pregnancy. For instance, the is not at all in the same place at 36 weeks of amenorrhea as at 40 weeks. So there are things to know but we can do it at any term '.

Where can you give birth by extra-peritoneal caesarean section in France?

FAUCS is much less widespread in France than in other countries . How to explain it? 'It's because there aren't many doctors who know how to do it. It's not more complicated but, as with any surgery, it can be learned. You have to train with those who know' , answers the obstetrician-gynecologist. As of this writing, August 2022, there are only four maternities that offer extraperitoneal caesarean section in our country : the Clinique de La Muette in Paris, the Clinique des Franciscaines in Versailles, the Polyclinique Santa Maria in Nice and the Lisieux Hospital, which is the only public establishment where a gynecologist-obstetrician is trained in this method and where anesthetists practice an early autonomy method called 'Patient Standing'.

Extra-peritoneal caesarean section, how much does it cost?

In theory, nothing . ' Since the year 2000, Doctor Fauck has obtained from social security that caesareans are at the same price as normal deliveries in France and the he Social Security code only codifies the mode of delivery, not the technique used. So there is no difference in reimbursement between a classic caesarean section and a FAUCS. The technique itself does not generate any particular additional cost' , explains Dr. Ami. However, as we explained above, it is mainly practiced in private establishments. There may therefore be excess fees which will not be covered by health insurance, but which may be covered by the mother's mutual insurance company, according to her contract. Additionally, our expert would like to point out: 'As with any medical act, we ask for consent for the excess of fees and we apply tact and moderation. It is therefore not a medicine reserved for the rich, and there are patients who have the Complementary health solidarity (ex-CMU-C) who give birth at the Clinique de La Muette at the Social Security rate without any problem' . As for the additional cost generated by the fact of giving birth in a private clinic, he considers that 'these are sums compatible with the means that people have' , when it is not supported by their mutual.

How is the scar after an extra-peritoneal caesarean section?

The scar after an extra-peritoneal caesarean section is like that created by a classic caesarean section . However, it can be a little smaller, explains Dr. Ami based on the comments of his patients who have had a classic cesarean section before. He justifies it thus: ' The incision should be at least the size of the baby's head , taking into account the 30% elasticity of the skin. House introduced the hand, with the head it is a little bigger. We have therefore modified this by using spoons , which are thinner than a hand, and which allow you not to open too wide. It's not like a spoon or forceps extraction in a vaginal birth: there's nothing blocking, so there's no risk of getting your head stuck. We just direct your head to guide her through the incision, so it's absolutely not dangerous and it's not and can't be traumatic for the baby, unlike an instrumental extraction by vaginal route where the goal is to pass a bony obstacle by compressing the head and rotating it. In caesarean section, the soft tissues can be opened wider at any time, but on a took the gamble to do incision at the minimum size, and on n'a couldn't find any downside to doing it that way. It is considered that the less we open, the better it is for moms , and besides, when they have already had a classic caesarean section, they notice that the incision is smaller. Denis Fauck has always believed that it should be the surgeon who complicates the task rather than complicating the task for the patient. That should be everyone's reasoning.'

Source journaldesfemmes.fr