CAESAREAN SECTIONCAESAREAN SECTION

DR. NAHEED BANODR. NAHEED BANOAssistant ProfessorAssistant Professor

Gynae/Obs. Unit 1Gynae/Obs. Unit 1

Holy Family Hospital, Rawalpindi Holy Family Hospital, Rawalpindi

CAESAREAN SECTIONCAESAREAN SECTION

• Name given to the operation performed to deliver Name given to the operation performed to deliver the baby after the age of viability through an the baby after the age of viability through an abdominal incision and is used as an alternative abdominal incision and is used as an alternative route to the natural vaginal birth.route to the natural vaginal birth.

• Delivery of one or more babies by surgical Delivery of one or more babies by surgical incision through abdominal wall and uterine wall.incision through abdominal wall and uterine wall.

HISTORYHISTORY

• Goes back to 715 B.C when Numa Pompillus the Goes back to 715 B.C when Numa Pompillus the king of Rome brought in a law which forbade the king of Rome brought in a law which forbade the burial of pregnant women unless her child had burial of pregnant women unless her child had been removed from abdomen and buried been removed from abdomen and buried separately.separately.

• First recorded successful caesarean section done First recorded successful caesarean section done by Jacob Nufer on his wife for pronged obstructed by Jacob Nufer on his wife for pronged obstructed labour in 1588. labour in 1588.

HISTORYHISTORY

One of the earliest printed illustrations of Cesarean section. One of the earliest printed illustrations of Cesarean section.

Purportedly the birth of Julius Caesar. A live infant Purportedly the birth of Julius Caesar. A live infant

being surgically removed from a dead woman. being surgically removed from a dead woman.

From Suetonius' Lives of the Twelve Caesars, 1506 woodcut.From Suetonius' Lives of the Twelve Caesars, 1506 woodcut.

INCIDENCEINCIDENCE

21% of all deliveries.21% of all deliveries.

Reasons for increase in incidence:Reasons for increase in incidence:

Prior caesarean delivery.Prior caesarean delivery.

Multifetal gestation.Multifetal gestation.

Use of intra-partum electronic fetal monitoring.Use of intra-partum electronic fetal monitoring.

Changes in obstetric training.Changes in obstetric training.

Medico legal concerns.Medico legal concerns.

Expectations of pregnancy outcome. Expectations of pregnancy outcome.

INDICATIONS FOR CAESAREAN INDICATIONS FOR CAESAREAN SECTIONSECTION

Four Principal Indications:Four Principal Indications:

Dystocia ( inadequate progress of labor ).Dystocia ( inadequate progress of labor ).

Suspected fetal compromise.Suspected fetal compromise.

Malpresentations.Malpresentations.

Prior caesarean birth.Prior caesarean birth.

INDICATIONS FOR CAESAREAN INDICATIONS FOR CAESAREAN SECTIONSECTION

Previous caesarean section:Previous caesarean section: 26.1%26.1%

Dystocia:Dystocia: 23.0%23.0%

Malpresentations:Malpresentations: 11.7%11.7%

Suspected fetal compromise:Suspected fetal compromise: 10.7%10.7%

OTHERS:OTHERS:

Placental disordersPlacental disorders

Multifetal gestationMultifetal gestation

Fetal diseaseFetal disease

Maternal medical conditionsMaternal medical conditions

Cephalopelvic disproportionCephalopelvic disproportion

TYPES OF CAESAREAN SECTIONTYPES OF CAESAREAN SECTION

• Lower segment CS.Lower segment CS.

• Upper segment (classical) CS.Upper segment (classical) CS.

• Modified classical (de-lee) CS. Modified classical (de-lee) CS.

PATIENT PREPARATION PATIENT PREPARATION

• Counseling.Counseling.

• Written informed consent.Written informed consent.

• Pre-operative evaluation.Pre-operative evaluation.

• Preparation of incision area.Preparation of incision area.

• Bladder catheterization.Bladder catheterization.

• Blood arrangements.Blood arrangements.

• Antibiotics.Antibiotics.

• Heparin therapy.Heparin therapy.

PATIENT PREPARATION IN PATIENT PREPARATION IN OPERATION THEATREOPERATION THEATRE

Left lateral tilt at least 15 degree.Left lateral tilt at least 15 degree.

Oxygen inhalation.Oxygen inhalation.

Pediatrician should be available.Pediatrician should be available.

Auscultation of fetal hearts before starting.Auscultation of fetal hearts before starting.

ANESTHESIAANESTHESIA

• General anesthesia.General anesthesia.

• Spinal anesthesia.Spinal anesthesia.

• Epidural anesthesia.Epidural anesthesia.

• Local infiltration.Local infiltration.

SKIN INCISIONSSKIN INCISIONS

• Pfannenstiel incision.Pfannenstiel incision.

• Joel-Cohen incision. Joel-Cohen incision.

• Midline incision.Midline incision.

• Para-median incision.Para-median incision.

Pfannenstiel incisionPfannenstiel incision

Joel-Cohen incisionJoel-Cohen incision

COMPARISON OF PFANNENSTIEL & COMPARISON OF PFANNENSTIEL & MIDLINE INCISIONMIDLINE INCISION

PFANNENSTIEL PFANNENSTIEL INCISIONINCISION

• Slow to perform (53 Slow to perform (53 mins ).mins ).

• Difficult to extend.Difficult to extend.

• Limited exposure.Limited exposure.

• Wound breakage is Wound breakage is rare.rare.

• Cosmetically much Cosmetically much better.better.

• Incisional hernia Incisional hernia formation is rare.formation is rare.

MIDLINE INCISIONMIDLINE INCISION

• Fast, operation time Fast, operation time <45 mins.<45 mins.

• Easy to extend.Easy to extend.

• Superior exposure.Superior exposure.

• More common.More common.

• Poor cosmetically.Poor cosmetically.

• More common.More common.

OPENING THE ABDOMENOPENING THE ABDOMEN

• The skin incision should extend well down into the The skin incision should extend well down into the fatty layers.fatty layers.

• Small incision is given in the rectus sheath and is Small incision is given in the rectus sheath and is then extended the full length of the skin incision then extended the full length of the skin incision using either the scalpel or the dissecting scissors.using either the scalpel or the dissecting scissors.

• Midline is identified and the recti separated.Midline is identified and the recti separated.

• The incision is then extended the entire length of The incision is then extended the entire length of the wound by inserting the index finger of each the wound by inserting the index finger of each hand and drawing the hands apart.hand and drawing the hands apart.

SKIN INCISIONSKIN INCISION

SEPARATION OF RECTISEPARATION OF RECTI

OPENING THE PARIETAL OPENING THE PARIETAL PERITONEUMPERITONEUM

OPENING THE VISCERAL OPENING THE VISCERAL PERITONEUMPERITONEUM

  

SEPARATION SEPARATION OF BLADDEROF BLADDER

UTERINE INCISIONSUTERINE INCISIONS

• Lower transverse incision (98.5%).Lower transverse incision (98.5%).

• Classical (1.1%).Classical (1.1%).

• Inverted T (0.4%).Inverted T (0.4%).

• Low vertical.Low vertical.

LOW TRANSVERSE INCISIONLOW TRANSVERSE INCISION

• Transverse incision at 1-2 cm below the junction Transverse incision at 1-2 cm below the junction of upper and lower segment.of upper and lower segment.

• Smiley shaped.Smiley shaped.

• Gentle strokes with scalpel.Gentle strokes with scalpel.

• Extend laterally with curved scissors with curve Extend laterally with curved scissors with curve upward or with index fingers.upward or with index fingers.

• Once membrane ruptured, deliver baby within 3 Once membrane ruptured, deliver baby within 3 minutes. minutes.

TYPES OF TYPES OF INCISIONS INCISIONS

LOWER SEGMENT CESAREAN LOWER SEGMENT CESAREAN SECTIONSECTION

LOWER SEGMENT CESAREAN LOWER SEGMENT CESAREAN SECTIONSECTION

Standard methodStandard method

ADVANTAGES:ADVANTAGES:

Lower segment is less vascularLower segment is less vascular

Less risk of rupture of uterine scarLess risk of rupture of uterine scar

Decreased risk of illeus and peritonitisDecreased risk of illeus and peritonitis

Decreased risk of adhesions and post op Decreased risk of adhesions and post op obstructionobstruction

Easy and rapid healingEasy and rapid healing

CLASSICAL INCISIONCLASSICAL INCISION

Midline longitudinal incision in uterine wall.Midline longitudinal incision in uterine wall.

INDICATIONS:INDICATIONS:

• Transverse lie with the fetal back inferior.Transverse lie with the fetal back inferior.

• As a preliminary to caesarean hysterectomy, treating As a preliminary to caesarean hysterectomy, treating carcinoma of cervixcarcinoma of cervix

• Previous classical caesarean section Previous classical caesarean section

• Large cervical fibroidLarge cervical fibroid

• Placenta Praevia with large vessels in lower segment.Placenta Praevia with large vessels in lower segment.

CLASSICAL INCISIONCLASSICAL INCISION

• Preterm delivery with poorly formed lower Preterm delivery with poorly formed lower segment.segment.

• Severe adhesions in lower segment reducing Severe adhesions in lower segment reducing accessibility.accessibility.

• Postmortem caesarean section.Postmortem caesarean section.

CLASSICAL CESAREAN SECTIONCLASSICAL CESAREAN SECTION

LOW VERTICAL INCISIONLOW VERTICAL INCISION

INDICATIONS:INDICATIONS:

• Lower uterine segment is not formed.Lower uterine segment is not formed.

• To cut Contraction ring to deliver baby.To cut Contraction ring to deliver baby.

COMPARISON OF LOWER SEGMENT COMPARISON OF LOWER SEGMENT & CLASSICAL CAESAREN. & CLASSICAL CAESAREN.

LOWER SEGMENT CS.LOWER SEGMENT CS. UPPER SEGMENT CS.UPPER SEGMENT CS.

Vertical incision in upper Vertical incision in upper segment.segment.

MoreMore

More haemorrhageMore haemorrhage

Less fibrous tissue makes Less fibrous tissue makes upper segment rigid so upper segment rigid so suturing difficult. suturing difficult.

Incision:Incision:

Transverse incision in lower Transverse incision in lower segment.segment.

Muscle Damage:Muscle Damage:

Less Less

Haemorrhage:Haemorrhage:

Less haemorrhageLess haemorrhage

Suturing:Suturing:

More fibrous tissue make More fibrous tissue make suturing easy.suturing easy.

COMPARISON OF LOWER SEGMENT COMPARISON OF LOWER SEGMENT & CLASSICAL CAESAREN& CLASSICAL CAESAREN

Technical Difficulty:Technical Difficulty:Size of incision may not be Size of incision may not be

adequate and may adequate and may extend in broad extend in broad ligament and open ligament and open major vessels.major vessels.

Bladder Injury:Bladder Injury:More common More common Post-OP Recovery:Post-OP Recovery:Quick Quick Long Term Consequences:Long Term Consequences: Less adhesion formationLess adhesion formation

Size of incision is mostly Size of incision is mostly adequate with adequate adequate with adequate exposure.exposure.

Less common Less common

May be delayedMay be delayed

More adhesion formationMore adhesion formation

COMPARISON OF LOWER SEGMENT COMPARISON OF LOWER SEGMENT AND CLASSICAL CAESARENAND CLASSICAL CAESAREN

Subsequent Pregnancy:Subsequent Pregnancy:

Lower segment scar is Lower segment scar is not under pressure not under pressure during next pregnancy during next pregnancy and stretch only in labor. and stretch only in labor. Risk of scar rupture is Risk of scar rupture is 0.5%.0.5%.

Scar is under tension Scar is under tension during pregnancy and during pregnancy and can rupture during can rupture during antenatal period as well antenatal period as well as in labor ( 2.2% ).as in labor ( 2.2% ).

DELIVERY OF THE BABYDELIVERY OF THE BABY

• Head lifted with hand to apply to uterine incision.Head lifted with hand to apply to uterine incision.

• Fundal pressure by assistant.Fundal pressure by assistant.

• Outlet forceps.Outlet forceps.

• Upward pressure through vagina.Upward pressure through vagina.

DELIVERY DELIVERY OF BABYOF BABY

DELIVERY AS BREECHDELIVERY AS BREECH

DELIVERY OF PLACENTADELIVERY OF PLACENTA

• Active management of third stage.Active management of third stage.

• Hold uterine angles by green-armitages.Hold uterine angles by green-armitages.

• Remove placenta by cord traction.Remove placenta by cord traction.

• Avoid manual removal as it increase risk of Avoid manual removal as it increase risk of hemorrhage and infection.hemorrhage and infection.

RCOG RECOMMENDATIONRCOG RECOMMENDATION

•At CS, the placenta should be removed using At CS, the placenta should be removed using

controlled cord traction and not manualcontrolled cord traction and not manual

removal as this reduces the risk of removal as this reduces the risk of

endometritis.endometritis.

EXTERIORIZATION OF UTERUS EXTERIORIZATION OF UTERUS FOR REPAIRFOR REPAIR

Better visualization.Better visualization.

Facilitates repair.Facilitates repair.

Decrease blood loss.Decrease blood loss.

No increase in febrile morbidity.No increase in febrile morbidity.

DISADVANTAGES:DISADVANTAGES:

Pain.Pain.

Vagal induced vomiting due to stretch.Vagal induced vomiting due to stretch.

RCOG RECOMMENDATIONSRCOG RECOMMENDATIONS

• Intraperitoneal repair of the uterus at CS Intraperitoneal repair of the uterus at CS

should be undertaken. Exteriorization of should be undertaken. Exteriorization of

the uterus is not recommended because it is the uterus is not recommended because it is

associated with more pain and does not associated with more pain and does not

improve operative outcomes such as improve operative outcomes such as

hemorrhage and infection.hemorrhage and infection.

CLOSURE OF UTERUSCLOSURE OF UTERUS

• Two layers with continuous sutures.Two layers with continuous sutures.

• Absorbable suture material.Absorbable suture material.

• Second layers buries the first one and Second layers buries the first one and makes wound strong and water tight.makes wound strong and water tight.

• Ensure that the first lateral suture is well Ensure that the first lateral suture is well beyond the lateral margin of angle.beyond the lateral margin of angle.

• Start suturing at the side away from Start suturing at the side away from surgeon.surgeon.

• Sutures generally placed 1cm apart.Sutures generally placed 1cm apart.

SECURING UTERINE ANGLESSECURING UTERINE ANGLES

DOUBLE LAYER UTERINE CLOSUREDOUBLE LAYER UTERINE CLOSURE

RCOG RECOMMENDATIONRCOG RECOMMENDATION

• The effectiveness and safety of single layer The effectiveness and safety of single layer

closure of the uterine incision is uncertain.closure of the uterine incision is uncertain.

Except within a research context, the Except within a research context, the

uterine incision should be sutured with two uterine incision should be sutured with two

layers.layers.

CLOSURE OF VISCERAL PERITONEUMCLOSURE OF VISCERAL PERITONEUM

ADVANTAGES:ADVANTAGES:

Restore anatomy.Restore anatomy.

Reduction in infection.Reduction in infection.

Reduction in adhesion formation.Reduction in adhesion formation.

Reduction in wound dehiscence.Reduction in wound dehiscence.

CLOSURE OF THE VISCERAL AND PARIETAL PERITONEUM

CLOSURE OF PARIETAL PERTONEUMCLOSURE OF PARIETAL PERTONEUM

RCOG RECOMMENDATIONRCOG RECOMMENDATION

• Neither the visceral nor the parietal Neither the visceral nor the parietal

peritoneum should be sutured at CS peritoneum should be sutured at CS

because this reduces operating time, the because this reduces operating time, the

need for postoperative analgesia and need for postoperative analgesia and

improves maternal satisfaction.improves maternal satisfaction.

CLOSURE OF FATCLOSURE OF FAT

Routine closure of the subcutaneous tissue Routine closure of the subcutaneous tissue space should not be used, unless the woman space should not be used, unless the woman has more than 2 cm subcutaneous fat, has more than 2 cm subcutaneous fat, because it does not reduce the incidence of because it does not reduce the incidence of wound infection.wound infection.

Superficial wound drains should not be Superficial wound drains should not be used at CS because they do not decrease the used at CS because they do not decrease the incidence of wound infection or wound incidence of wound infection or wound hematoma.hematoma.

..SKIN CLOSURESKIN CLOSURE

Interrupted Interrupted

suture.suture.

Staples (Rapid Staples (Rapid

but increase but increase

pain).pain).

Subcuticular Subcuticular

suture.suture.

DO,S OF CAESARIAN ACCORDING TO DO,S OF CAESARIAN ACCORDING TO RCOGRCOG

Wear double gloves for CS for women who Wear double gloves for CS for women who are HIV-positiveare HIV-positive

Use a transverse lower abdominal incision Use a transverse lower abdominal incision (Joel Cohen incision)(Joel Cohen incision)

Use blunt extension of the uterine incisionUse blunt extension of the uterine incision

Give oxytocin (5iu) by slow intravenous Give oxytocin (5iu) by slow intravenous injectioninjection

Use controlled cord traction for removal of Use controlled cord traction for removal of the placentathe placenta

DO,S OF CAESARIAN ACCORDING TO DO,S OF CAESARIAN ACCORDING TO RCOGRCOG

Close the uterine incision with two suture Close the uterine incision with two suture layerslayers

Check umbilical artery pH if CS Check umbilical artery pH if CS performed for fetal compromiseperformed for fetal compromise

Consider women’s preferences for birth Consider women’s preferences for birth

Facilitate early skin-to-skin contact for Facilitate early skin-to-skin contact for mother and babymother and baby

DON’TS OF CAESAREAN SECTIONDON’TS OF CAESAREAN SECTION

Don’t:Don’t: Close subcutaneous space (unless > 2 cm fat)Close subcutaneous space (unless > 2 cm fat) Use superficial wound drainsUse superficial wound drains Use separate surgical knives for skin and Use separate surgical knives for skin and

deeper tissuesdeeper tissues Routine use of forceps to deliver babie’s headRoutine use of forceps to deliver babie’s head Suture either the visceral or the parietal Suture either the visceral or the parietal

peritoneumperitoneum Exteriorize the uterusExteriorize the uterus Manually remove the placentaManually remove the placenta

POST-OPERATIVE MONITORINGPOST-OPERATIVE MONITORING

• Recovery Area –Recovery Area – one-to-one observations until the one-to-one observations until the woman has airway control, cardio respiratory woman has airway control, cardio respiratory stability and can communicate.stability and can communicate.

• In The Ward –In The Ward – half hourly observations half hourly observations (respiratory rate, heart rate, blood pressure, pain (respiratory rate, heart rate, blood pressure, pain and sedation) for 2 hours, then hourly if stable.and sedation) for 2 hours, then hourly if stable.

• For Epidural Opioids And Patient-controlled For Epidural Opioids And Patient-controlled Analgesia With Opioids –Analgesia With Opioids – hourly monitoring hourly monitoring during the CS, plus 2 hours after discontinuation.during the CS, plus 2 hours after discontinuation.

CARE OF WOMAN AND BABYCARE OF WOMAN AND BABY

Provide additional support to help women to start Provide additional support to help women to start breastfeeding as soon as possible.breastfeeding as soon as possible.

Offer diamorphine (0.3–0.4 mg intrathecally) or Offer diamorphine (0.3–0.4 mg intrathecally) or epidural diamorphine (2.5–5 mg) to reduce the epidural diamorphine (2.5–5 mg) to reduce the need for supplemental analgesia.need for supplemental analgesia.

Offer non-steroidal anti-inflammatory analgesics Offer non-steroidal anti-inflammatory analgesics to reduce the need for opioid analgesics.to reduce the need for opioid analgesics.

Women who are feeling well and have no Women who are feeling well and have no complications can eat or drink when they feel complications can eat or drink when they feel hungry or thirsty.hungry or thirsty.

After regional anesthesia remove catheter when After regional anesthesia remove catheter when woman is mobile (> 12 hours after top-up).woman is mobile (> 12 hours after top-up).

Remove wound dressing after 24 hours, keep Remove wound dressing after 24 hours, keep wound clean and dry.wound clean and dry.

Discuss the reasons for the CS and implications Discuss the reasons for the CS and implications before discharge from hospital.before discharge from hospital.

Offer earlier discharge (after 24 hours) to women Offer earlier discharge (after 24 hours) to women who are recovering, with no pyrexia and have no who are recovering, with no pyrexia and have no complications.complications.

RECOVERY FOLLOWING CSRECOVERY FOLLOWING CS

• Offer postnatal care, plus specific post-CS care, Offer postnatal care, plus specific post-CS care, and management of pregnancy complications.and management of pregnancy complications.

• Prescribe regular analgesia.Prescribe regular analgesia.

• Monitor wound healing.Monitor wound healing.

• Inform women they can resume activities (such as Inform women they can resume activities (such as driving, exercise) when pain is not distracting or driving, exercise) when pain is not distracting or restricting.restricting.

CONSIDER CS COMPLICATIONSCONSIDER CS COMPLICATIONS

• Endometritis if excessive vaginal bleeding.Endometritis if excessive vaginal bleeding.

• Thromboembolism if cough or swollen calf.Thromboembolism if cough or swollen calf.

• Urinary tract infection if urinary symptoms.Urinary tract infection if urinary symptoms.

• Urinary tract trauma (fistula) if leaking urine.Urinary tract trauma (fistula) if leaking urine.

COMPLICATIONS OF CAESAREAN COMPLICATIONS OF CAESAREAN SECTIONSECTION

• ANESTHESIA RELATED:ANESTHESIA RELATED:

Aspiration syndromeAspiration syndrome

HypotensionHypotension

Spinal HeadacheSpinal Headache

HEMORRHAGEHEMORRHAGE

• Uterine vessels damageUterine vessels damage

• Uterine atonyUterine atony

• Placenta previa/accretaPlacenta previa/accreta

• Lacerations Lacerations

Uterine lacerationsUterine lacerations

Vertical lacerations into vaginaVertical lacerations into vagina

Broad LigamentBroad Ligament

URINARY TRACT URINARY TRACT

• After prolong obstructed labourAfter prolong obstructed labour

• Injury to vesico uterine space (Previous cesarean Injury to vesico uterine space (Previous cesarean

section)section)

• Low vertical uterine incisionLow vertical uterine incision

GASTROINTESTINAL TRACTGASTROINTESTINAL TRACT

• Ileus Ileus

• Early oral intakeEarly oral intake

Decrease time of return of bowel soundsDecrease time of return of bowel sounds

Decrease post op stayDecrease post op stay

Decrease abdominal distensionDecrease abdominal distension

RESPIRATORY TRACT RESPIRATORY TRACT

• Atelectasis/PneumoniaAtelectasis/Pneumonia

• TreatmentTreatment

Deep breathing exercise Deep breathing exercise

Postural drainagePostural drainage

THROMBOEMBOLSIM THROMBOEMBOLSIM

• Major cause of maternal morbidity/mortalityMajor cause of maternal morbidity/mortality

• Increased chances in Increased chances in

* Emergency LSCS* Emergency LSCS

* Advanced Maternal age * Advanced Maternal age

* Obesity* Obesity

* Inherited thrombophilia disorders* Inherited thrombophilia disorders

PROPHYLAXISPROPHYLAXIS

• Use of mechanical calf compression intra opUse of mechanical calf compression intra op

• Use of calf compression stockingUse of calf compression stocking

• Subcut heparin (Low molecular wt heparin) Subcut heparin (Low molecular wt heparin)