Caesarean Section

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Presented by

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Dr. Shikha Sharma

Definition

Removal of a fetus from the uterus by abdominal incision, after 28 weeks of pregnancy.

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It is called hysterotomy, if removal is done before 28 weeks of pregnancy.

Caesarean section

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It is one of the

oldest

obstetric operation

Caesarian section

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Historical aspect:--

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In times of Julius Caesar, the law was called Lax Caesesara.

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The term Caesarian section was first used by James Gullimeau, in his book of midwifery published in 1598.

Caesarian section

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Historical aspect:--

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• 1882 -- Sanger introduced technique of

suturing of uterus.

• 1912 ---Lower segment caesarian segment

section was first performed by Kronig

and latter by Monro kerr.

• 1940 --- In Ahmedabad (India) first L.S.C.S.

was performed by late Dr.(miss)

S.C.Pandya .

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Caesarian section

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Once a caesarian section always a caesarian section.

Dr.E.B.carngin 1916

Modified to:-

Once a caesarian not always a caesarian.

Now modified to:-

Once a caesarian, always a hospital delivery

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Caesarian section

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Incidence of C.S. is rising:--

Formally it was 10 to 15 % but now it 25 to even as high as 50%

Rising incidence is more because of fetal indications. There is a trend to do repeat C.S. without giving trial in Pt. with previous C.S. Doctor do not want to take any risk with the child, & doctor has fear of medico legal problems.

C.S. has also become more safe due to :-

Better anesthesia, more availability of blood transfusion, better antibiotics, better suture material etc. Hence C.S. is more frequently done, even at a trivial indication.

Caesarian section

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Maternal mortality after C.S. is bet.5 to 30 per 1000

Perinatal mortality is 5 to 10% -due to:--

• Emergency operation.
• Fotal asphyxia-(RDS)
• Prematurely-
• Infection.
• Intracranial hemorrhage.
• Fracture dislocation of big bones.

Caesarian section

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Indications of C.S.:-

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Non recurrent indications:-

1. Fetal distress
2. Breech presentation
3. Placenta previa.
4. Occipito posterior presentation.

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Recurrent Indication:-

Contracted pelvis

Caesarian section

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Most commen indications of C.S.:-

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1. Severe degree contracted pelvis.
2. Central placenta pravia
3. Breech with extended limbs in elderly primi.
4. Transverse presentation, or hand prolapse and cervix not fully dilated.
5. Fetal distress and cervix not fully dilated.
6. Brow presentation.
7. Previous 2 L.S.C.S.

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Caesarian section

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• Elective C.S.

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• Emergency C.S.

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Caesarian section

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keep in mind……

• An atraumatic abdominal delivery is

always preferred to a traumatic

difficult vaginal delivery.

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Elective caesarian section (Planned operation)

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Advantages are:-

1. Patient with empty stomach and surgeon usually with full breakfast
2. Best anesthetist available at that time
3. Best assistant and nursing staff.

Disadvantages are :-

4. If wrong judgment, premature child may be born.
5. Cervix may not be dilated and hence poor drainage of lochia
6. Lower segment is not formed and hence uterine incision in lower part of upper segment.

Emergency caesarian section (Unplanned)

Working under adverse circumstances:-

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1. Patient may be with full stomach and surgeon may be with empty belly
2. Odd working hours either of day or night
3. Anesthetist, assistant and nursing staff may not be of our choice.

Advantage is :-

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4. Mature child as patient is in labor
5. Cervix is open, better drainage of lochia.
6. Lower segment is well formed.

Caesarian section

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• Mortality and morbidity are

significantly higher in,following

emergency C.S. than a

planned C.S.

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Consent for CS

Consent for CS should be requested after providing pregnant women with evidence based information and in a manner that respects the woman’s dignity, privacy, views and culture whilst taking into consideration the clinical situation.

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Preoperative testing and preparation for CS

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Pregnant women should be offered a haemoglobin assessment before CS to identify those who have anaemia. Although blood loss of more than 1000ml is infrequent after CS (it occurs in 4 to 8% of CS) it is a potentially serious complication.

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Pregnant women having CS for ante partum haemorrhage, abruption, uterine rupture and placenta praevia are at increased risk of blood loss greater than 1000 ml and should have the CS carried out at a maternity unit with on-site blood transfusion services.

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Cont…….

• Prescribe antibiotics (one dose of first-generation cephalosporin or ampicillin)

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• To reduce the risk of aspiration pneumonitis: Empty stomach, Pre-medication with Give an antacid (sodium citrate 0.3% 30 mL or magnesium trisilicate 300 mg) + Cimetidine IV 1 hr before CS

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• Women having CS with regional anesthesia require an indwelling urinary catheter to prevent over-distension of the bladder, because the anaesthetic block interferes with normal bladder function

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Caesarian section

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Types of anesthesia

• Spinal.

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• General.

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• Epidural.

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• Local.

Caesarian section

Spinal anesthesia

• It is best and cheapest
• More popular now in European countries.
• Patient remain conscious.
• Less incidence of cardiac arrest.
• Drug used is 5% lignocain- hyperbaric 1.5 to 2 cc
• Some times difficult for anesthetist to find space due to lumber lordosis of pregnancy.
• Some times there is fall of blood pressure.
• Post operative spinal headache.
• Rarely meningitis, or total spinal may occur.
• Spinal anesthesia should not be given if Pt. has already low B.P. or baby has transverse presentation or deeply engaged head or failed forceps or failed vacuum delivery.

Caesarian section

Local anesthesia

• This is rarely requires except in conditions, like vary low patient as in central placenta preavia or in deeply sedated Pt. of eclampsia.
• If doctor is working in a place where anesthetist is not available and surgeon has to manage all alone, local anesthesia is used.
• Drug used is 0.5% Lignocain. Total quantity to be used is not more than 100 c.c.
• In this anesthesia, the surgeon may not be as comfortable as spinal or general anesthesia.

Caesarian section

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Epidral anesthesia

These days patients are asking for painless delivery and for that, many times continuous epidural anesthesia is given. If the trial of labor fails, patient may be taken for caesarian section or forceps delivery. In that case caesarian may be performed in the same epidural anesthesia.

It is a good anesthesia with less risk of fall of blood pressure.Due to lumber lordosis of pregnancy, some times epidural becomes technically difficult.

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Caesarian section

General anesthesia

• Many times Pt. demand G.A.
• Drug used is I.V. Pentothal sodium with oxygen and Nitrous oxide and muscle relaxant.
• Intubations some times difficult, if anesthetist is not well experienced.
• Incidence of cardiac arrest is more than spinal.
• Post operative vomiting is common.
• If Pt. has taken food, regurgitation complication like aspiration pneumonia may occur.
• Deep anesthesia, only to be given after baby has been delivered.
• Pt. at sleep but anesthetist has to be alert in G.A.

Caesarian section

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Ecbolics

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• Inj. Ergometrin 0.5 mg I.M. or I.V.
• Inj Oxytocin 10 to 20 units in 500

ml. glocose saline or ringer Lactate

• Inj. Prostagandin i.m.

Maternal Position During CS

• All obstetric patients undergoing CS should be positioned with left lateral tilt to avoid aorto-caval compression
• By tilting the operating table to the left

or place a pillow or folded linen under her right lower back

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Prepare The skin

• Wash the area around the proposed incision site with soap and water,

• Do not shave the woman’s pubic hair as this increases the risk of wound infection. The hair may be trimmed, if necessary

Sterlize The Skin

• Patients skin at the operation site is routinely of poscleaned with antiseptic solutions before surgery. Antiseptic skin cleansing before surgery is thought to reduce the risk toperative wound infections
• Apply antiseptic solution three times to the incision site using a high-level disinfected ring forceps and cotton or gauze swab. If the swab is held with a gloved hand, do not contaminate the glove by touching unprepared skin;
• Begin at the proposed incision site and work outward in a circular motion away from the incision site;
• At the edge of the sterile field discard the swab.
• Never go back to the middle of the prepared area with the same swab. Keep your arms and elbows high and surgical dress away from the surgical field.

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Drape The Skin

• Drape the woman immediately after the area is prepared to avoid contamination:
• If the drape has a window, place the window directly over the incision site first.
• Unfold the drape away from the incision site to avoid contamination

Caesarian section

Incision on abdominal wall

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• Verticl midline- it is easy, more working place but incidence of incisional hernia is high.
• Paramedian:-- Less chances of incisional hernia than midline incision.

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• Pfennensteil transverse:- it is made 3 cm above the symphysis pubis, is most popular, less pain full, early mobility of patient, & less chances for dehiscence. It has also a cosmetic value.

Its disadvantages is, it takes more time to open abdomen, less exposure than vertical scar, and at repeat caesarian is more difficult.

Pfennesteil skin Incision

• More time to open and close abdomen.
• Less exposure than vertical incision.
• Repeat C.S. is more difficult, with previous

phenestial incision.

• Not advisable in obstructed labor

and with transverse presentation.

• Less pain and early ambulation to patient .
• Early discharge from hospital.
• Less chances for incisional hernia.
• It is a cosmetic scar- called Bikini incision.

Excision of previous scar

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• Always at the beginning of operation by

an elliptical incision. Excising previous

scar at the end of operation is difficult.

• Multiple scars –multiple surgeon’s name,

multiple signatures on skin.

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Name of the surgeon is always

written on the scar

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Parietal Peritoneal Incision

• Use fingers to make an opening in the peritoneum near the umbilicus then lengthen the incision up and down in order to see the entire uterus.
• Or Use scissors to lengthen the incision up and down in order to see the entire uterus.

Carefully, to prevent bladder injury, use scissors to separate layers and open the lower part of the peritoneum

Packs

• The uterus is centralised, the bowel and omentum are packed off with moist laparotomy pads,

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Visceral Peritoneal Incision

• Place a bladder retractor over the pubic bone.
• Use forceps to pick up the loose peritoneum covering the anterior surface of the lower uterine segment and incise with scissors.
• Extend the incision by placing the scissors between the uterus and the loose serosa and cutting about 3 cm on each side in a transverse fashion.
• Use two fingers to push the bladder downwards off of the lower uterine segment. Replace the bladder retractor over the pubic bone and bladder.

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Caesarian section

Uterine Incision

• Transverse lower segment
• Curves incision – Concavity towards fundus of uterus
• Inverted T incision.
• Classical
• J shaped.
• Lower segment verticle

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Caesarian section

Lower segment C.S Classical C.S.

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• Lower segment edges are
• thin, hence suturing is

better.

• Lower segment is a passive

segment so does not

contract, so healing is better.

• Lower segment is covered

with peritoneum, It remains

in pelvis so less chances

for adhesions formation.

• Chances for ruptures Ut. in

next pregnancy much less.

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• Upper segment edges are
• thick and hence difficult to

approximate.

• Upper segment is active

segment so contraction makes

stitches loose.

• Upper segment is not covered

with peritoneum, and remains

in abdomen so more chances

for adhesions formation.

• Chances for ruptures Ut. in next

pregnancy 8 times more.

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• Severe Kypho- scoliosis & lower segment

not approachable.

• Big varicose veins in lower segment.
• Cervical fibroid with pregnancy.
• Transverse presentation with big child.
• Constriction ring in uterus.
• Central placenta pravia. (some times)
• Previous difficult V.V.F. repair.
• Pregnancy with cancer cervix.
• Post mortem C.S.

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Indications of Classical Cesarean section

Caesarian section

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Initial Uterine incision should be small

by knife and then

• Enlarging it by scissors
• Enlarging it by knife
• Enlarging it by tearing it with fingers.

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Try to avoid rupturing of membranes at incision.

Catch uterine edges with Ellisis forceps,

Swab holder or Green Aarmitage forceps.

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Caesarian section

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How to deliver of head?

• By putting hand to disengaged head and than bringing out of incision
• Application of short forceps.
• Pushing head from below by a strong persons wearing gloves, especially in case of failed forceps, deeply jammed head or occipito post. presentation or deep transverse arrest.

Safe delivery of the fetal head during cesarean section

• With the goals of minimizing delay, head compression, and strain on the uterine incision, a sequence of maneuvers the elevate, rotate, and reduce (ERR) technique for expeditious delivery of the head from a deep pelvic station To prevent extension of the uterine incision and risk injury to the uterine vessels and bladder
• Position yourself so your upper trunk, arm, and hand move as a unit to elevate the head.
• Elevate. Lock the fingers into a quarter-circle around the vertex. Apply traction out of the pelvis with the hand and the entire extended arm
• Rotate. Grasp the fetal head between the thumb and fingers and rotate it so the occiput faces the incision.
• Reduce. Push the lower edge of the uterine incision down until it is posterior to the fetal head..

Caesarian section

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Problem of floating head

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• In elective cesarean section, floating head

is more difficult to deliver than an

engaged head.

• Use short forceps in floating head.
• In twins- for delivery of second child, if it is

breech, it is easy. If it is cephalic, do internal

podalic version, or try apply vacuum forceps.

Caesarian section

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Problem of deeply jammed head

• Always give general anesthesia with Halothain

to relax uterus.

• Never- never attempt in spinal anesthesia.
• Ask a strong person to push head from below

with gloved hand, to disengage head.

Clearing air passages of child after birth

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• Surgeon himself managing.

Hanging the child- holding it by feet.

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• Suction with rubber catheter.

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• Using mucous catheter.

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• Hand over to a pediatrician.

Caesarian section

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Delivery of trunk

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• At the time of delivery of trunk

bi-aromial diameter should always be in line of uterine incision and not perpendicular to it.

Delivery of placenta

• 3^rd stage of labor- duration is 5 to7 minutes

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• Let placenta separate by itself.

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• Never pull out placenta before it separates.

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• I.V.Methegine &10 to 20 units Syntocinon in drip.

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• Practice spontaneous delivery of placenta.

Problem of central placenta pravia

• Anterior placenta-
• Try to find out membrane up or down, rt. Or left.

If you fail, cut placenta quickly and first remove child.

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• Posterior placenta–

(Dangerous placenta of Stall-Worthy.)

To stop bleeding or oozing from lower post segment,

pack it systematically with multiple roller packs. Push first

end in cervical canal. Remove pack after 24 hours.

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Some time as a desperate measure you may need

Internal iliac ligation, or subtotal hysterectomy, to save Pt.

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Cesarean section

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Bringing uterus out at pelvis

(uterine exteriorization)

At suturing :--

Rarely required unless uncontrolled bleeding.

It can can cause febrile morbidity and

venous air remobilization

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After suturing :--

To detect posterior wall rupture and any

congenital uterine anomaly.

Uterine incision suturing

Suturing material--- Mostly Vicryl 1

Single layer

Now a days many prefer single layer continuous suture. In elective C.S. where low. segment not formed and is thick, single layer suturing may not be possible.

Double layer

1st layer ---continuous 40 mm heavy needle No-1 suture

2^nd layer -- continuous 40mm needle 1/0 suture

Peritoneum --continuous 40 mm needle 1/0 suture

Some prefer suturing first both uterine angles, to stop bleeding. Some prefer interrupted stitches for the first layer.

Peritoneal Closure

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peritoneal closure vs non-closure (Pelvic, parietal, both )

• Non-closure associated with less post-op fever

but no significant effect on wound infection or endometritis.

• New trial fewer adhesions in closure

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• Neither the visceral nor parietal peritoneum should be sutured at CS as this reduces operating time, the need for postoperative analgesia and improves maternal satisfaction.

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Cont….

Materials for closure of the peritoneum

plain catgut vs vicryl vs chromic catgut

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Cesarean section

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The mobs put in abdominal

& Uterine cavity are all

removed & counted doubly

by surgeon himself.

Sheath

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Chromic catgut vs plain catgut vs vicryl for sheath repair

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Locked continuous vs non-locked continuous closure

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The subcutaneous tissue

The subcutaneous tissue (fat and/or camper fascia) closure vs no closure.

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• No effect on wound infection alone (but closure associated with less “wound complication” and no effect on endometritis).
• Routine closure of the subcutanoues tissue space should not be used, unless the woman has more than 2 cm subcutaneous fat, because it does not reduce the incidence of wound infection.

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Subcutaneous stitches

• Subcutaneous continous absorbable suture vs interrupted absorbable suture
• No effect on infection

Skin closure�

• Compared staples vs absorbable sub-

cuticular suture.

• No effect on infection.
• Obstetricians should be aware that the effects of different suture materials or methods of skin closure at CS are not certain.
• More RCTs are needed to determine the effect of staples compared to subcuticular sutures for skin closure at CS on postoperative pain,cosmetic appearance and removal of sutures and staples.

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Immediate post-operative care

• After surgery is completed, the woman will be monitored in a recovery area
• to ensure that the uterus remains contracted, that there is no excessive vaginal bleeding or bleeding at the incision site, that there is adequate urine output, and to monitor routine vital signs (blood pressure, temperature, breathing). Pain medication is also given, initially through the IV line, and later with oral medications.
• When the effects of anesthesia have worn off, about four to eight hours after surgery, the woman is transferred to a postpartum room

Caesarian section

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Maternal complcations:-

Immediate:-

Haemorrage,

Shock, sepsis,

Anesthetic hazards,

Thrombosis and wound complication.

Paralitic ilius.

Late:-

Incisional hernia.

Ruptured uterus in next pregnancy

Do

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• 􀀹 Wear double gloves for CS for women who are HIV-positive
• 􀀹 Use a transverse lower abdominal incision (Joel Cohen incision)
• 􀀹 Use blunt extension of the uterine incision
• 􀀹 Give oxytocin (5iu) by slow intravenous injection
• 􀀹 Use controlled cord traction for removal of the placenta
• 􀀹 Close the uterine incision with two suture layers
• 􀀹 Check umbilical artery pH if CS performed for fetal compromise
• 􀀹 Consider women’s preferences for birth (such as music playing in theatre)
• 􀀹 Facilitate early skin-to-skin contact for mother and baby

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Don’t

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• 􀂃 Don’t Close subcutaneous space (unless > 2 cm fat)
• Don’t Use superficial wound drains
• 􀂃 Don’t Use separate surgical knives for skin and deeper tissues
• 􀂃Don’t Use routinely use forceps to deliver babies head
• Don’t Suture either the visceral or the parietal peritoneum
• 􀂃Don’t Exteriorise the uterus
• 􀂃Don’t Manually remove the placenta

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Cesarean section

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Misgav Ladch Hospital method of C.S.

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• Skin incision – phenestial.
• Peritonium opened transversely.
• Single layer non locking suturing of uterine incision.
• Pelvic and parital peritoneum not sutured.
• Reported as safe, simple ,fast and cost effective.
• Least post operative pain and early ambulation.

Cesarean section

Caesarian hysterectomy

(Porro’s section)

• It refers to an operation

when C.S. is followed

by removal of uterus.

Cesarean section

Indications of Porro’s section

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Ato

• Atonic uterus and uncontrolled P.P.H.
• Morbid adherent placenta
• Extensive laceration of uterus in case of

ruptured Ut. & extensive tear in broad

ligament.

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• Couvalair uterus.
• Grossly infected uterus

Caesarian section

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Prophylaxis against scar rupture

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• Ask patient to preserve operation card and all relevant case papers and reports.
• Put emphasis on follow up in next pregnancy, from vary beginning to end.
• Insist on hospital delivery with previous C.S.
• Now a days obstetricians are either to busy or are too much afraid to give trial of labor in case with previous C.S. and hence repeat elective C.S. is for them a safe short cut.

Caesarian section

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Pregnancy and labor following C.S.

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Trial of labour is attempted when:-

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• Non recurrent indication of previous C.S.
• Well engaged head.
• Previous L.S.C.S. with uneventful recovery.
• Anterior cephaalic position of child.
• Average size child.
• Good trained staff to monitor the patient.
• Efficient emergency operative facility available at vary short notice.

Thank you