my ostetrics and gynecology presentation in final year.. 2012...

1. Caesarean Section
Indications and types
VISHNU AMBAREESH M S
2007 BATCH

2. • According to legend, Julius Caesar was born by
this operation and hence the origin of the term
caesarean. ????
• Used to be
invariably fatal
• Most important modification was the lower
segment transverse incision. First done by kehrer
and popularized by Munro Kerr

3. DEFINITION
• CAESAREAN SECTION is the removal of a child
through an incision in the abdominal wall of an
intact uterus.
• Term not applied to removal of a child from the
abdomen after rupture of the uterus with or
without protrusion of the whole or part of the child
into the peritoneal cavity, nor to an operation for
abdominal pregnancy.

4. INCIDENCE
• It is the most commonest operation performed
worldwide.
• Ideal CS rate is 10 to 15 % (WHO)
• Increased incidence worldwide during last 25
years.

5. Why has the incidence increased?
• Mainly due to 3 factors
1. Repeat caesarean
2. Dystocia
3. Fetal distress
• Increased safety of the surgery
• Increased demand

6. INDICATIONS
• Divided into
1. Maternal indicators
2. Fetal indicators
3. Fetomaternal indicators- coexist

7. MATERNAL INDICATORS
PREVIOUS CS
DYSTOCIA due to
1. -CPD
2. -tumours complicating pregnancy
3. -non progressive labour
4. -threatened rupture and obstructed labour
5. -failed forceps or vacuum
6. -deep transverse arrest

8. Antepartum hemorrhage
1. -placenta praevia
2. -abruptio placenta
3. -vasa praevia
4. -carcinoma cervix
Medical disorders
1. -pre-eclampsia and eclampsia
2. -coarctation of aorta

9. Maternal obstetric problem
1. -elderly nullipara
2. -prolonged period of infertility or
pregnancy following IVF
3. -bad obstetric history
4. -previous repair of nulliparous prolapse
5. -stress incontinence or fistula
6. -failed induction

10. FETAL INDICATION
• Fetal distress and cord prolapse
• Breech presentation –[footling, knee presentation,
complicated breech]
• Malpresentation [ brow, transverse lie persistent
mentoposterior ]
• Sever IUGR
• Macrosomia
• Multiple pregnancy[first twin non -vertex and
monoamniotic twin]
• HIV complicating

11. CAESARIAN SECTION - TYPES

12. CAESARAEAN SECTION -TYPES
• Lower Segment Caeserean Section(LSCS)
• Lower segment vertical incision
• Classical CS
• Extraperitoneal caeserean
• Caeserean hysterectomy

13. LSCS
• Most commonly employed type
• Involves lower segment transverse incision

14. LOWER SEGMENT VERTICAL INCISION
Indications:
• Constriction ring
• Lower segment not formed as in transverse lie
Disadvantages:
• Extension downwards may involve the
cervix,vagina and even the bladder
• Extension into the upper segment increases the
chance of rupture in next pregnancy

15. Classical Caesarean section
• Lower segment is not approachable
• Uterine incision –on the anterior uterine wall in the
upper segment above the reflection of the UV fold
of peritoneum
• Fetal foot grasped and baby delivered as breech

16. Classical CS - Indications
• Lower segment is unapproachable due to severe
adhesions or myomas
• Ca cervix
• Some cases of anterior placenta praevia with a
previous caeserean
• Some cases of transverse lie with ruptured
membranes
• Conjoined twins

17. Classical CS - Disadvantages
• Chance of scar rupture more
• General peritonitis ,if infection occurs

18. LSCS SCAR CLASSICAL SCAR
Apposition Better Difficult
Healing in
puerperium
Better as the Lower
segment is quiscent
Imperfect due to
contraction and
retraction of upper
segment
Placental
implantation
May be over the scar much more likely
Rupture .5-2% 4-8%
Timing of rupture In labour In pregnancy and
labour
Infection Less chance More chance

19. Extraperitoneal Caesarean section
• In severe infection
• Uterus opened through an extraperitoneal
approach
• Through the space of Retzius beneath the
bladder

20. Caesarean Hysterectomy
• Life saving measure for severe atonic PPH
Indications
• Severe atonic PPH
• Placenta accreta , increta, percreta
• Severe sepsis
• Multiple large myomas
• Carcinoma in situ of the cervix

21. Cesarean section is safe, but it’s not as
safe as a planned vaginal delivery
• Many pregnant women believe that undergoing a
cesarean section is a no risk surgery
• They suffer more than three times the number of
cardiac arrests, blood clots and major infections
than those who deliver vaginally