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CESARIAN SECTION
Definition:
Cs is removal of a fetus from the uterus by abdominal (laparotomy) &
uterine incisions (hysterotomy), after 28 weeks of pregnancy.
Hysterotomy, if removal is done before 28 weeks of pregnancy.
Indications:
1. Previous hysterotomy (30%)
2. Failure to progress during labor (30%)
3. Fetal malpresentation (11%)
4. Non reassuring fetal status (10%)
Less common indications
5. Multiple gestations
6. Abnormal placentation (placenta previa, vasa previa, placenta accreta)
7. Mechanical obstruction (macrosomia, fetal anomalies as severe hydroceph,
large leiomyoma, condyloma acuminata, severely displaced pelvic fracture)
8. Maternal infections (herpes simplex , HIV)
9. Fetal bleeding diathesis
10. Women who are at increased risk of complications from tissue trauma
related to cervical dilation, decent & expulsion of the fetus, episiotomy
(invasive cervical cancer, active perianal IBD, rectovaginal fistula repair or
pelvic organ prolapse)
Contraindication:
No absolute C/I
Absence of an appropriate indication
Pyogenic infection of the abdominal wall
Timing:
Cesarean deliveries may be performed because of maternal or fetal problems or
planned before the mother goes into labor.
1. Elective cesarean delivery before labor has begun (Planned operation),
but decisions must take into account fetal risk with delivery before 39w.
2. Emergency cesarean section after labor has begun, accomplished as soon
as possible in cases of suspected or confirmed acute fetal compromise.

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Elective Cs (Planned operation)
Advantages are:-
1. Patient with empty stomach (NPO).
2. Best anesthetist available at that time
3. Best assistant and nursing staff.
Emergency Cs (Unplanned)
Disadvantages are :-
1. Patient may be with full stomach
2. Odd working hours (day or night)
3. Anesthetist, assistant and nursing
staff may not be of your choice
Disadvantages are :-
1. Premature child if wrong judgment.
2. Uterine incision in lower part of
upper segment if the lower segment
is not formed.
3. Poor drainage of lochia (undilated
cervix).
Advantage are :-
1. Mature child as patient is in labor
2. Lower segment is well formed
3. Better drainage of lochia (open
cervix).

PREOPERATIVE ISSUES
1. Assesment of fetal pulmonary maturity
2. Anesthesiology consultation

PREOPERATIVE TESTING AND PREPARATION FOR CS
1. Hb assessment
2. On-site blood transfusion services
3. To reduce the risk of aspiration pneumonitis (Empty stomach & antacid)
4. Urinary catheter
5. Skin cleansing
6. Antibiotic prophylaxis
7. Thromboembolism prophylaxis (risk factors are pregnancy & Cs)
a. 1 additional risk factor thromboprophylaxis & compression stocking.
b. Multiple risk factors thromboprophylaxis, compression stockings
and/or pneumatic compression device.
8. Fetal heart rate monitoring
9. Fetal presentation & placental location.




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IMMEDIATE POST-OPERATIVE CARE
Monitoring of the woman in the recovery area.
Ensure that the uterus remains contracted, no excessive vaginal bleeding or
bleeding at the incision site, adequate urine output & monitor routine VS.
Analgesia
Antibiotics if there were signs of infection as fever, so continue antibiotics until
the woman is fever-free for 48 hours.
Drinking : oral intake is initiated 8-12 hours post-op
Catheter removal: once a woman is mobile after a regional anaesthetic and not
sooner than 12 hours after the last epidural top up dose.
Ambulation started 6-12 hours post-op (enhances circulation, encourages deep
breathing, stimulates return of normal gastrointestinal function, encourage foot
and leg exercises and mobilize as soon as possible, usually within 24 hours).




COMPLICATIONS
INTRAOPERATIVE POSTOPERATIVE LATE
Bleeding & the need
for blood transfusion
Hysterectomy
Complications of
anesthesia
Damage to the bladder,
ureter, colon
Fetal injury
Retained placental
tissue
Bleeding
Gaseous distension
Paralytic illeus
Wound dehiscence &
infection
UTI, pulmonary infx
DVT, PE & death

Uterine rupture in
subsequent
pregnancies
Abnormal placentation
Tubal and pelvic
adhesion
Scar complications
Incisional hernia







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Major Cesarean Complications
Serious bleeding during or after surgery
Infection
Organ damage (uterus, fallopian tubes, ovaries, bladder, and/or ureters)
Damage to the intestines (perforation or a hole in its lining or a burn injury)
Blood vessel injury, blood clots
Nerve damage
Uterine rupture at the scar from a previous cesarean section or surgery
Wound breakdown
Complications from high BP
Risk Factors for Major Cesarean Complications
Diabetes, heart, lung, or kidney disease
Overweight, alcohol taking
Seizure disorders
STDs, Hepatitis
Minor Cesarean Complications
Infections in the mother or baby, UTI
Minor bleeding
Separation of a scar on the uterus from a previous cesarean delivery
Hemorrhoids
Constipation, Ileus (temporary stoppage of bowel activity)
Abnormal or painful scar
Allergic skin reaction












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CESARIAN SECTION TECHNIQUE
1. Laparatomy
Vertical (midline infraumbilical) Incision
Horizontal/Transverse Incision: (common)
Pfannenstiel (more common)
Maylard
Joel Cohen
2. Hysterotomy (incision in the uterus)
Classic Incision (Sanger)
Low Transverse (Monroe-Kerr) 90%
Low Vertical (Sellheim or Kronig or DeLee)
3. Delivery of Fetus
4. Repair of Uterus
5. Abdominal Closure

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VERTICAL (MIDLINE INFRAUMBILICAL) INCISION (the quickest to make)
It should be of sufficient length to allow delivery of the infant without
difficulty. Therefore, its length should correspond with the estimated fetal size.
Sharp dissection is performed to the level of the anterior rectus sheath, which is
free of SC fat to expose a strip of fascia in the midline about 2 cm wide.
The rectus & pyramidalis muscles are separated in the midline
The transversalis fascia and preperitoneal fat are dissected carefully to reach the
underlying peritoneum.
The peritoneum is opened carefully with 2 hemostats placed about 2 cm apart.
The tented fold of peritoneum between the clamps is then examined and
palpated to be sure that omentum, bowel, or bladder is not adjacent.
The peritoneum is incised superiorly to the upper pole of the incision and
downward to just above the peritoneal reflection over the bladder.
The loose reflection of peritoneum above the upper margin of the bladder and
overlying the anterior lower uterine segment (the bladder flap) is grasped in the
midline and incised transversely.
The lower flap of peritoneum is elevated, and the bladder is gently separated by
blunt or sharp dissection from the underlying myometrium.
Advantages
o Quicker access to the uterus & less blood loss
o Commonly enhanced by diastasis of the rectus muscles
o Easier examination of the upper abdomen
o Easier access and better visualization of significant intra-abdominal
adhesions from previous operations.










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TRANSVERSE INCISION
Take slightly longer to enter the peritoneal cavity
Less painful
Smaller risk of developing an incisional hernia
Preferred cosmetically
Excellent visualization of the pelvis

PFANNENSTIEL INCISION
Curved slightly cephalad at the level of the pubic hairline
Extends slightly beyond the lateral borders of the rectus muscle bilaterally and
is carried to the fascia that is incised bilaterally for the full length of the incision
Underlying rectus muscle is separated from the fascia both superiorly and
inferiorly with blunt and sharp dissection
Clamp and ligate any blood vessels encountered
Rectus muscles are separated in the midline, and the peritoneum is entered
MAYLARD INCISION
2-3 cm above the symphysis and is quicker than a Pfannenstiel incision
Transverse incision of the anterior rectus sheath and rectus muscle bilaterally
Identify and possibly ligate the superficial inferior epigastric vessels.
If more than two thirds of the rectus muscle is divided, identify and ligate the
deep inferior epigastric vessels
Transversalis fascia and peritoneum are identified and incised transversely
JOE COHEN INCISION
Its performed by a superficial transverse cut in the abdomen, about 3 cm below
an imaginary line connecting the anterosuperior iliac spines, cutting only
through the cutis.
In the midline (free from large blood vessels), the cut is deepened to the fascia.
A small transverse opening is made in the fascia, and then the fascia is opened
transversely underneath the fat tissue and blood vessels by pushing the slightly
open tip of a pair of straight scissors, first in one direction, and then in the other.
The fascia is stretched caudally and cranially using the index fingers to make
room for the next step.
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The surgeon and his assistant each insert their index and third fingers under the
muscles, and stretch the muscles, blood vessels, and the fat tissue by manual
bilateral traction.
Advantages
o Shorter operating time & less blood loss
o Shorter time from skin incision to birth of the baby
o Less risk of fever
o Shorter duration of postoperative pain
o Reduced time to oral intake
o Lower analgesic requirements
o However, Maylard incision with transection of the rectus muscles is
associated with increased blood loss.
CLASSIC INCISION (SANGER)
It is the simplest and quickest incision to perform.
Its a longitudinal incision in the anterior fundus.
Its used infrequently because of the significant risk of uterine rupture in
subsequent pregnancies, which can occur before labor begins.
Indications:
o Transverse lie with the back down (most cases).
o Invasive carcinoma of the cervix
o Lower segment lesions (myomas) that prohibit adequate uterine closure
Uterine closure is more difficult because of the thick muscular upper segment,
and the potential for blood loss is greater.
LOW TRANSVERSE (MONROE-KERR)
Its the preferred incision and the one most frequently used today.
Its made in the noncontractile portion of the uterus, minimizing chances of
rupture or separation in subsequent pregnancies.
The incision requires creation of a bladder flap and lies behind the peritoneal
bladder reflection, allowing reperitonealization.
Uterine closure is accomplished more easily because of the thin muscle wall of
the lower segment, and the potential for blood loss is lowest.
This incision may involve potential extension into the uterine vessels laterally
and into the cervix and vagina inferiorly.
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LOW VERTICAL (SELLHEIM OR KRONIG)
The vertical incision begins in the noncontractile lower segment but usually
extends into the contractile upper segment.
This incision is used when a transverse incision is not feasible.
Indications:
o The lower uterine segment may not be developed & the transverse
incision may not provide enough room for delivery of the infant.
o Malpresentations of the term or premature infant may necessitate a
vertical incision to allow more room for delivery of the infant.
o This incision is sometimes used when an anterior placenta previa is noted
to facilitate delivery without cutting through the body of the placenta.
UTERINE INCISION PROCEDURE
The uterus is entered through the lower uterine segment about 1 cm below the
upper margin of the peritoneal reflection.
It is important to place the uterine incision relatively higher in women with
advanced or complete cervical dilatation to minimize both lateral extension of
the incision into the uterine arteries and unintended entry into the vagina.
This is done by using the vesicouterine serosal reflection as a guide.
Then after that we should incise the exposed lower uterine segment for 1 to 2
cm in the midline transversely (carefully to avoid injury to the fetus).
Once the uterus is opened, the incision can be extended by cutting laterally and
then slightly upward.
It is very important to make the uterine incision large enough to allow delivery
of the head and trunk of the fetus without either tearing into or having to cut
into the uterine arteries and veins through the lateral margins of the uterus.
Once the uterus is opened, the amniotic sac is ruptured by toothed or Kochers
forceps and the baby delivered.






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DELIVERY OF FETUS
Place one hand inside the uterine cavity between the uterus and the babys head.
With the fingers, grasp and flex the head.
Gently lift the babys head through the incision taking care not to
extend the incision down towards the cervix.
With the other hand, gently press on the abdomen over the top of
the uterus to help deliver 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.
To minimize fetal aspiration of amniotic fluid, exposed nares and
mouth are aspirated with a bulb syringe before the thorax is
delivered.
The shoulders then are delivered using gentle traction plus fundal pressure.
After the shoulders are delivered, an intravenous infusion containing about two
ampules or 20 units of oxytocin per liter of crystalloid is infused at 10 mL/min
until the uterus contracts satisfactorily.
The rest of the body readily follows.
The uterine incision is observed for any vigorously bleeding sites.
REPAIRING THE UTERUS
After placenta delivery, the uterus may be lifted through the incision & the
fundus covered with a moistened laparotomy pack.
Although some clinicians prefer to avoid it, uterine exteriorization often has
advantages that outweigh any disadvantages.
The relaxed, atonic uterus can be recognized quickly and massage applied).
The incision and bleeding points are visualized more easily and repaired;
especially if there have been extensions laterally.
Adnexal exposure is superior, and thus tubal sterilization is easier.
The principal disadvantage is from discomfort and vomiting caused by traction
in cesarean deliveries performed under regional analgesia.
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Immediately after delivery and inspection of the placenta, the uterine cavity is
inspected and either suctioned or wiped out with a gauze pack to remove
avulsed membranes, vernix, clots, and other debris.
The upper and lower cut edges and each lateral angle of the uterine incision are
examined carefully for bleeding.
Individually clamped large vessels are best ligated with a suture ligature
The uterine incision is then closed with one or two layers of continuous
absorbable sutures.
The initial suture is placed just beyond one angle of the uterine incision with
each suture penetrating the full thickness of the myometrium.
If approximation is not satisfactory after a single-layer continuous closure, or if
bleeding sites persist, then more sutures are required.
Either another layer of sutures may be placed so as to achieve approximation
and homeostasis, or individual bleeding sites can be secured with figure-of-
eight sutures.

ABDOMINAL CLOSURE
All packs are removed, and the paracolic gutters and cul-de-sac are emptied of
blood and amniotic fluid using gentle suction.
After the sponge and instrument counts are found to be correct, the abdominal
incision is closed in layers.
Neither the visceral nor parietal peritoneum should be sutured at CS reduces
operating time, need for postoperative analgesia & improves maternal
satisfaction, decrease risk for adhesions.
The rectus muscles are allowed to fall into place, and the subfascial space is
checked for homeostasis.
With significant diastases, the rectus muscles may be approximated with one or
two figure-of-eight sutures.
The overlying rectus fascia is then closed.
SC TISSUE CLOSURE
Routine closure of the SC tissue space should not be used, unless the woman
has more than 2cm SC fat, because it doesnt reduce the incidence of wound
infection.
May be closed with an absorbable suture or simply reapproximated by closure
of the skin.
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