3. CAESAREAN SECTION
• Name given to the operation performed to deliver
the baby after the age of viability through an
abdominal incision and is used as an alternative
route to the natural vaginal birth.
• Delivery of one or more babies by surgical
incision through abdominal wall and uterine wall.
4. HISTORY
• Goes back to 715 B.C when Numa Pompillus the
king of Rome brought in a law which forbade the
burial of pregnant women unless her child had
been removed from abdomen and buried
separately.
• First recorded successful caesarean section done
by Jacob Nufer on his wife for pronged obstructed
labour in 1588.
6. One of the earliest printed illustrations of Cesarean section.
Purportedly the birth of Julius Caesar. A live infant
being surgically removed from a dead woman.
From Suetonius' Lives of the Twelve Caesars, 1506 woodcut.
7. INCIDENCE
21% of all deliveries.
Reasons for increase in incidence:
Prior caesarean delivery.
Multifetal gestation.
Use of intra-partum electronic fetal monitoring.
Changes in obstetric training.
Medico legal concerns.
Expectations of pregnancy outcome.
8. INDICATIONS FOR CAESAREAN
SECTION
Four Principal Indications:
Dystocia ( inadequate progress of labor ).
Suspected fetal compromise.
Malpresentations.
Prior caesarean birth.
12. PATIENT PREPARATION IN
OPERATION THEATRE
Left lateral tilt at least 15 degree.
Oxygen inhalation.
Pediatrician should be available.
Auscultation of fetal hearts before starting.
18. COMPARISON OF PFANNENSTIEL &
MIDLINE INCISION
•
•
•
•
•
•
PFANNENSTIEL
INCISION
Slow to perform (53
mins ).
Difficult to extend.
Limited exposure.
Wound breakage is
rare.
Cosmetically much
better.
Incisional hernia
formation is rare.
MIDLINE INCISION
• Fast, operation time
<45 mins.
• Easy to extend.
• Superior exposure.
• More common.
• Poor cosmetically.
• More common.
19. OPENING THE ABDOMEN
• The skin incision should extend well down into the
fatty layers.
• Small incision is given in the rectus sheath and is
then extended the full length of the skin incision
using either the scalpel or the dissecting scissors.
• Midline is identified and the recti separated.
• The incision is then extended the entire length of
the wound by inserting the index finger of each
hand and drawing the hands apart.
26. LOW TRANSVERSE INCISION
• Transverse incision at 1-2 cm below the junction
of upper and lower segment.
• Smiley shaped.
• Gentle strokes with scalpel.
• Extend laterally with curved scissors with curve
upward or with index fingers.
• Once membrane ruptured, deliver baby within 3
minutes.
31. LOWER SEGMENT CESAREAN
SECTION
Standard method
ADVANTAGES:
Lower segment is less vascular
Less risk of rupture of uterine scar
Decreased risk of illeus and peritonitis
Decreased risk of adhesions and post op
obstruction
Easy and rapid healing
32. CLASSICAL INCISION
Midline longitudinal incision in uterine wall.
INDICATIONS:
• Transverse lie with the fetal back inferior.
• As a preliminary to caesarean hysterectomy, treating
carcinoma of cervix
• Previous classical caesarean section
• Large cervical fibroid
• Placenta Praevia with large vessels in lower segment.
33. CLASSICAL INCISION
• Preterm delivery with poorly formed lower
segment.
• Severe adhesions in lower segment reducing
accessibility.
• Postmortem caesarean section.
37. COMPARISON OF LOWER SEGMENT
& CLASSICAL CAESAREN.
LOWER SEGMENT CS.
Incision:
Transverse incision in lower
segment.
Muscle Damage:
Less
Haemorrhage:
Less haemorrhage
Suturing:
More fibrous tissue make
suturing easy.
UPPER SEGMENT CS.
Vertical incision in upper
segment.
More
More haemorrhage
Less fibrous tissue makes
upper segment rigid so
suturing difficult.
38. COMPARISON OF LOWER SEGMENT
& CLASSICAL CAESAREN
Technical Difficulty:
Size of incision may not be
adequate
and
may
extend
in
broad
ligament
and
open
major vessels.
Bladder Injury:
More common
Post-OP Recovery:
Quick
Long Term Consequences:
Less adhesion formation
Size of incision is mostly
adequate with adequate
exposure.
Less common
May be delayed
More adhesion formation
39. COMPARISON OF LOWER SEGMENT
AND CLASSICAL CAESAREN
Subsequent Pregnancy:
Lower segment scar is
not
under
pressure
during next pregnancy
and stretch only in labor.
Risk of scar rupture is
0.5%.
Scar is under tension
during pregnancy and
can
rupture
during
antenatal period as well
as in labor ( 2.2% ).
40. DELIVERY OF THE BABY
• Head lifted with hand to apply to uterine incision.
• Fundal pressure by assistant.
• Outlet forceps.
• Upward pressure through vagina.
45. DELIVERY OF PLACENTA
• Active management of third stage.
• Hold uterine angles by green-armitages.
• Remove placenta by cord traction.
• Avoid manual removal as it increase risk of
hemorrhage and infection.
46. RCOG RECOMMENDATION
•At CS, the placenta should be removed using
controlled cord traction and not manual
removal
as
endometritis.
this
reduces
the
risk
of
47. EXTERIORIZATION OF UTERUS
FOR REPAIR
Better visualization.
Facilitates repair.
Decrease blood loss.
No increase in febrile morbidity.
DISADVANTAGES:
Pain.
Vagal induced vomiting due to stretch.
48.
49. RCOG RECOMMENDATIONS
• Intraperitoneal repair of the uterus at CS
should be undertaken. Exteriorization of
the uterus is not recommended because it is
associated with more pain and does not
improve
operative
outcomes
hemorrhage and infection.
such
as
50. CLOSURE OF UTERUS
• Two layers with continuous sutures.
• Absorbable suture material.
• Second layers buries the first one and
makes wound strong and water tight.
• Ensure that the first lateral suture is well
beyond the lateral margin of angle.
• Start suturing at the side away from
surgeon.
• Sutures generally placed 1cm apart.
54. RCOG RECOMMENDATION
• The effectiveness and safety of single layer
closure of the uterine incision is uncertain.
Except within a research context, the
uterine incision should be sutured with two
layers.
55. CLOSURE OF VISCERAL PERITONEUM
ADVANTAGES:
Restore anatomy.
Reduction in infection.
Reduction in adhesion formation.
Reduction in wound dehiscence.
59. RCOG RECOMMENDATION
• Neither the visceral nor the parietal
peritoneum should be sutured at CS
because this reduces operating time, the
need
for
postoperative
analgesia
improves maternal satisfaction.
and
60. CLOSURE OF FAT
Routine closure of the subcutaneous 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.
Superficial wound drains should not be
used at CS because they do not decrease the
incidence of wound infection or wound
hematoma.
62. DO,S OF CAESARIAN ACCORDING TO
RCOG
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
63. DO,S OF CAESARIAN ACCORDING TO
RCOG
Close the uterine incision with two suture
layers
Check umbilical artery pH if CS
performed for fetal compromise
Consider women’s preferences for birth
Facilitate early skin-to-skin contact for
mother and baby
64. DON’TS OF CAESAREAN SECTION
Don’t:
Close subcutaneous space (unless > 2 cm fat)
Use superficial wound drains
Use separate surgical knives for skin and
deeper tissues
Routine use of forceps to deliver babie’s head
Suture either the visceral or the parietal
peritoneum
Exteriorize the uterus
Manually remove the placenta
65. POST-OPERATIVE MONITORING
• Recovery Area – one-to-one observations until the
woman has airway control, cardio respiratory
stability and can communicate.
• In The Ward – half
hourly
observations
(respiratory rate, heart rate, blood pressure, pain
and sedation) for 2 hours, then hourly if stable.
• For Epidural Opioids And Patient-controlled
Analgesia With Opioids – hourly monitoring
during the CS, plus 2 hours after discontinuation.
66. CARE OF WOMAN AND BABY
Provide additional support to help women to start
breastfeeding as soon as possible.
Offer diamorphine (0.3–0.4 mg intrathecally) or
epidural diamorphine (2.5–5 mg) to reduce the
need for supplemental analgesia.
Offer non-steroidal anti-inflammatory analgesics
to reduce the need for opioid analgesics.
Women who are feeling well and have no
complications can eat or drink when they feel
hungry or thirsty.
67. After regional anesthesia remove catheter when
woman is mobile (> 12 hours after top-up).
Remove wound dressing after 24 hours, keep
wound clean and dry.
Discuss the reasons for the CS and implications
before discharge from hospital.
Offer earlier discharge (after 24 hours) to women
who are recovering, with no pyrexia and have no
complications.
68. RECOVERY FOLLOWING CS
• Offer postnatal care, plus specific post-CS care,
and management of pregnancy complications.
• Prescribe regular analgesia.
• Monitor wound healing.
• Inform women they can resume activities (such as
driving, exercise) when pain is not distracting or
restricting.
69. CONSIDER CS COMPLICATIONS
• Endometritis if excessive vaginal bleeding.
• Thromboembolism if cough or swollen calf.
• Urinary tract infection if urinary symptoms.
• Urinary tract trauma (fistula) if leaking urine.
75. THROMBOEMBOLSIM
• Major cause of maternal morbidity/mortality
• Increased chances in
* Emergency LSCS
* Advanced Maternal age
* Obesity
* Inherited thrombophilia disorders
76. PROPHYLAXIS
• Use of mechanical calf compression intra op
• Use of calf compression stocking
• Subcut heparin (Low molecular wt heparin)
