CAESAREAN SECTION
Part 1
Definitions
Cesarean delivery
the birth of a fetus through incisions in the abdominal
wall (laparotomy) and the uterine wall (hysterotomy).
Cesarean hysterectomy
When an abdominal hysterectomy is performed at the
time of cesarean delivery, most often because of
emergent complications such as intractable
hemorrhage.
Postpartum hysterectomy:
If hysterectomy is done within a short time after vaginal
delivery.
Definitions
Dystocia:
failure to progress in labor
the cervix will not dilate (expand) further or
(after full dilation) the head (presenting part) does
not descend through the mothers pelvis
Cause:
an obstruction or constriction of the birth passage or
abnormal size, shape, position, or condition of the
fetus.
Frequency
The cesarean delivery rate has increased
United States:
Rose from 4.5% to 31.8% of all deliveries
between 1970 to 2007
(Hamilton and colleagues, 2009; MacDorman and associates,
2008).
Explanations
1. Nulliparas
1. Women having fewer children
2. Rising average maternal age
2. Use of electronic fetal monitoring
3. Better outcome for breech presentation babies
4. Decreased incidence of forceps and vacuum
deliveries
5. Rising rates of labor induction (nulliparas)
6. Obesity
7. Preeclampsia
Explanations
8. VBAC has decreased
9. Elective cesarean deliveries
10.Malpractice litigation
11.Epidural anaesthesia
Indications
FETAL:
Non-reassuring fetal heart pattern (10%)
To avoid fetal hypoxia of labour:
Pre-eclampsia;
Very low birth weight (< 2500 g) /Intrauterine growth
restriction.
Malposition and Malpresentations (11%):
Transverse lie/arrest
Breech (if vaginal criteria not met)
Brow
Face mentum posterior
Indications
FETAL:
Prolapsed cord
keep hand in vagina and push baby up and off cord
until c-section done
Congenital anomalies
Multiple pregnancy
Indications
MATERNAL-FETAL:
Failure to progress in labor (30%) despite
adequate stimulation; at least 2 or more hours of
adequate labor
Arrest of descent
Arrest of dilation
Failed forceps
APH
Placenta abruption
Placenta previa
Indications
MATERNAL-FETAL:
Conjoined twins
Peri mortem: Upon death of mother in late
pregnancy, a live fetus can be removed peri
mortem.
HIV positive mother
Indications
MATERNAL:
Repeat cesarean delivery (30%)
Disorderly uterine action
Epidural analgesia
Chorioamnionitis
Maternal position during labour
Birthing position in second stage labor
Poor past obstetric history
HIV (viral load dependent)
Active herpes virus
Indications
MATERNAL:
Immune Thrombocytopenic Purpura (ITP)
Contracted pelvis,
e.g., congenital, fracture
Obstructive tumors
Abdominal cerclage
Reconstructive vaginal surgery, e.g., fistula repair
Medical conditions,
e.g., cardiac, pulmonary, thrombocytopenia, HELLP
Indications
NOTE:
Only few are absolute
The only absolute indications are:
gross disproportion and
the higher grades of placenta praevia.
Technique
Pre-op:
Counseling:
Communicate clearly and in the patients
language
the indication for surgery,
the other alternatives available
the reason(s) for preferring caesarean section over
them,
the preferred approach, and
the risks, benefits and the adverse effects.
Technique
Pre-op:
Clarify doubts:
the type of anaesthesia preferred,
tentative duration of surgery,
the recuperative time, and
any impact on subsequent pregnancies/ deliveries.
Emotional stress after C/S
Usually self-limiting but may require counsellor or
pharmacotherapy
Partner / supportive family members
opinions / concerns regarding the procedure.
Technique
Preparation:
Complete hx and P/E
Haematological tests:
Hb, BCT, serum urea, RBS
Gp and X-match required blood products.
Pre-op ECG & CXR
women with comorbidities such as cardiorespiratory
disorders or malignancy.
USS
Abc cover (within 30min)
Technique
Shaving
(controversial)
Anaesthesia
General anaesthetic.
Epidural block.
Spinal block.
Infiltration of local anaesthetic agents.
Technique
Position:
Supine inclined to the left
Abdominal incision
suprapubic transverse
midline vertical
paramedian or mid-transverse; special circumstances
NOTE:
sufficient length (estimated fetal size)
Blood vessels
previous intra-abdominal surgery
the bladder may be pushed cephalad in obstructed
labor
Modified Pfannenstiel
Lower, transverse, slightly curvilinear incision, 2 to
3 cm above the symphysis pubis, with the
midportion of the incision within the shaved area of
the pubic hair/ at the pubic hairline,
extends slightly beyond the lateral borders of the
rectus muscles.
Adv:
Follows Langers lines
Decreased post op pain, wound dehisence and
incisional hernia
Modified Pfannenstiel
D/Adv:
Repeat C/S is time consuming and difficult because of
scarring
C/i:
When a large operating space is essential
where access to the upper abdomen is required
Others:
MayLard incision
rectus muscles are divided sharply or with
electrocautery
Joel-Cohen and Misgav-Ladach methods
Uterine incision
Kerr technique (1921)
Low-segment transverse incision
Adv:
Wound is extraperitoneal; less risk of intraperitoneal
infection.
Fewer post-operative complications.
It is easier to repair
Healing of scar is better for lower segment
site least likely to rupture during subsequent
pregnancy
no adherence of bowel or omentum to the incisional
line.
Uterine incision
Other:
Low-segment vertical incision as described by
Krnig in 1912
Uterine incision
Classical incision
vertical incision into the body/upper segment
and reaches the uterine fundus.
Fetal Indications:
Transverse lie
Large fetus
Back-down
Very small fetus (2428 weeks), esp. if breech
Multiple fetuses
Uterine incision
Classical incision
Maternal Indications:
Difficulty exposing or safely entering the LUS
densely adhered bladder (previous surgery)
A leiomyoma occupies the LUS
If the cervix has been invaded by cancer;
Massive maternal obesity which precludes safe
access to the LUS; and
Some cases of placenta previa with anterior
implantation or thru a prior uterine incision
Procedure
Uterus is commonly found to be dextrorotated
Put a moistened laparotomy pack in each lateral
peritoneal gutter
the bladder flap is grasped in the midline with
forceps and incised transversely with scissors.
separate a 2-cmwide strip of serosa, then incise
Gently separate bladder from the underlying
myometrium (<5cm) by blunt or sharp
dissection.
Caution: Dilated cervix and upper vagina
Procedure
The loose vesicounterine serosa is grasped with the forceps.
The hemostat tip points to the upper margin of the bladder.
The retractor is firmly positioned against the symphysis
Procedure
The loose serosa above the upper margin of the
bladder is elevated and incised laterally.
Procedure
The bladder is dissected off the uterus to expose the
lower uterine segment.
Procedure
Transverse LUS incision approx. below the upper
margin of the peritoneal reflection
Initiate with scalpel in midline then widen with
fingers
Caution: Injury to fetus
Procedure
The myometrium is incised carefully to avoid cutting the fetal head.
After entering the uterine cavity, the incision is extended laterally
with bandage scissors (A) or with the fingers (B)
Delivery of the fetus
In a cephalic presentation, a hand is slipped into
the uterine cavity between the symphysis and
fetal head.
Elevate and gently guide head with the fingers
and palm through the incision, aided by modest
transabdominal fundal pressure.
Upward pressure exerted by a hand in the vagina .
Deliver shoulders (oxy 10iu) and rest of body
Exposed nares and mouth are mopped or
aspirated with a bulb syringe
Clamp, cut cord and give baby to a team member
Fingers are insinuated between the symphysis pubis and the fetal head
until the posterior surface is reached. The head is lifted carefully
anteriorly and, as necessary, superiorly to bring it from beneath the
symphysis forward through the uterine and abdominal incisions as
modest transabdominal fundal pressure pressure is applied .
Delivery of the placenta
Fundal massage
begun as soon as the fetus is delivered,
reduces bleeding and hastens placental delivery.
Spontaneously along with CCT
this reduces the risk of operative blood loss and
infection,
Removed manually.
Immediately, it is examined for completion.
Uterine repair
Uterus may be exteriorized
Adv:
The relaxed, atonic uterus can be recognized quickly
and massage applied.
The incision and bleeding points are more easily
visualized, clamped and repaired.
Adnexal exposure is superior, and thus, tubal
sterilization is easier.
D/adv:
Discomfort and vomiting caused by traction if
S(R)/A is used
Uterine repair
Uterine cavity is inspected and either suctioned or
wiped out with a gauze pack
Edges and each lateral angle of the uterine incision
are examined carefully for bleeding.
Individually clamped large vessels are (best) ligated
with a suture
Incision is closed with one (continuous locking) or
two layers of continuous 0- or #1 absorbable
suture
The initial and final sutures are placed just beyond
the angles of the uterine incision
Uterine repair
Carefully select the site of each stitch
Avoid withdrawal of the needle once it penetrates
the myometrium
Inspect the repaired uterine incision
individual bleeding sites can be secured with figure-
of-8 or mattress sutures.
Serosal edges may be approximated with a
continuous 2-0 chromic catgut suture (optional)
If tubal sterilization is to be performed, it can be
done at this stage.
Reposition/ replace the uterus
Abdominal closure
All packs are removed
the paracolic gutters and cul-de-sac are emptied
of blood and amniotic fluid using gentle suction.
may be irrigated with warm saline and suctioned.
Sponge and instrument counts
If correct, the abdominal incision is closed in
layers.
bleeding sites are located, clamped, and ligated or
coagulated with an electrosurgical blade.
Parietal peritonem: continuous 2-0 absorbable suture
Rectus muscles: allowed to fall into place
Abdominal closure
Rectus fascia:
delayed-absorbable sutures 0-gauge
Interrupted or continuous, non-locking technique and
no more than 1 cm apart
Subcutaneous tissue:
if 2cm or more, use 2-0 or 3-0 absorbable stitch.
Skin
vertical mattress sutures of 3-0 or 4-0 silk or
equivalent suture; or
running 4-0 subcuticular stitch using delayed-
absorbable suture; or
with skin clips
Abdominal closure
Clean with antiseptic and dress with sterile gauze
Massage uterus
Also helps to expel clots pV
Post operative care
Fluids / feeding
I.V fluids for 24 hours,
A light diet is started within 12-24hrs
Normal solid/ semisolid diet after another 24 hours.
Self retaining urinary catheter is usually left in situ
for 24-48 hours after the surgery
Early ambulation is encouraged.
Change of antiseptic abdominal dressing may be
done after 5 to 6 days.
Antibiotics;
If the wound gets infected, antibiotics are given
depending on the culture report.
Post operative care
If unabsorbable sutures have been placed in the
skin, they are removed after a week of surgery.
Full physical activity is resumed by the end of 10-
14 days post operatively.
Encourage hygiene
Coital abstinence is advised for atleast 2 weeks.
Complications
Immediate
Haemorrhage
transverse extension of uterine incision extend into
uterine vessels and posterior wall
Always have 2 units of cross-matched blood available.
Injury to pelvic organs and/or fetus
Bladder, ureters and bowel
surgery complicated by adhesions or
emergency surgery being done quickly
Pain
Analgesia
Complications
Immediate
Anaesthesia
Hypersensitivity to the drugs
Aspiration pneumonia
Complications
Early
Abdominal distension
Common for a day or so.
Await events.
Ileus
Mild regional ileus may last 24 hours.
Await events and avoid overloading the gut (keep on
i.v. fluid for 24 hours).
If longer (a lot of handling and packing of the gut)
treat with stomach aspiration and I.V. fluids.
Complications
Early
Thromboembolism
Much higher risk after CS than after vaginal delivery.
Avoid thrombosis by:
TED stockings intraoperatively until woman fully
mobilized.
Intraoperative compression stockings.
Intraoperative subcutaneous heparin continued daily
until woman fully mobilized.
Early mobilization and leg exercises.
Keep woman well hydrated post-operatively.
Avoid embolism by taking leg and pelvic signs seriously
and anticoagulating early.
Complications
Early
Thromboembolism
Prevent thrombosis with prophylactic anticoagulation
(subcutaneous heparin) in all women and particularly
those women at higher risk:
Aged over 35.
Obese.
Past history of thrombosis, particularly if
oestrogen associated (e.g. oral contraception).
Anaemia.
Complications
Early
Infection
Wound sepsis and dehiscence
Endometritis
Necrotic uterus
Watch asepsis and antisepsis.
Give prophylactic antibiotics to all women.
May proceed to postpartum hysterectomy
Complications
Long term:
Abnormal placental implantation in subsequent
pregnancies
Increased risk of uterine rupture if mother
delivers vaginally next time.
Adhesions
Rare
Endometriosis
