CAESAEAN SECTION

SR.ELIZABETH M.A LECTURER FMCON

Nomenclature and History

Name derived from lex cesarea-a Roman law promulgated in 715 B.C. Abdominal delivery in a dying woman to get a baby. Or to perform postmortem abdominal delivery for separate burial.

 Latin Verb caedere which means to cut. French Obstetrician, Francois Mauriceau first reported caesarean section in 1668. Kronig in 1912,introduced lower segment vertical incision. Kehrer in 1881 did the transverse lower segment operation for the first time. Munro Kerr in 1926 not only reintroduced the present technique of lower segment operation but also popularized.

Definition
It is an operative procedure whereby the fetuses after the end of 28th week are delivered through an incision on the abdominal and uterine walls.

 Primary caesarean section Repeat caesarean section (subsequent pregnancies)

Incidence
Factors for increasing caesarean section Identification of at risk fetuses before term Identification of at risk mothers. Wider use of repeat C.S. in cases with previous caesarean delivery. Rising incidence of elderly pimigravidae. Decline in difficult operative or manipulative vaginal deliveries.

 Decline in vaginal breech delivery Increased diagnosis of fetal distress and fear of litigation. Adoption of small family norm

Indications
1.Absolute Indications Vaginal delivery is not possible, CS is needed even with a dead fetus. 1. Central placenta praevia 2. Contracted pelvis or CPD 3. pelvic mass causing obstruction 4. Advanced carcinoma cervix 5. Vaginal obstruction (atresia, stenosis)

2.Relative Indications
Vaginal delivery may be possible with or without aids. But risks to the mother and /or to the baby are high. 1. CPD 2. Previous caesarean delivery(CPD, previous two CS, scar dehiscence, previous classical C.S) 3. Non reassuring FHR 4. Dystocia 5. Antepartum Haemorrhage

6. Malpresentations 7. Failed surgical induction 8. Bad obstetric history 9. Hypertensive disorders 10.Medical and gynaecological disorders

3. Common Indications
Primigravidae CPD Fetal distress dystocia

Multigravidae Previous CS APH malpresentations

Maternal Indications
CPD and contracted pelvis Inadequate uterine force Previous classical cesarean section Previous LSCS Placenta praevia Eclampsia or pre-eclampsia Dystocia Carcinoma cervix

Fetal indications
Fetal distress Prolapse of umbilical cord Mal presentation Bad obstetrical history and habitual intrauterine death of fetus Abruption placenta Multiple pregnancy Maternal HIV infection

Time of operation
Elective Emergency Elective When the operation is done at a pre arranged time during pregnancy to ensure the best quality of obstetrics, anaesthesia, neonatal resuscitation and nursing services.

Time
Maturity is certain the operation is done about one week prior to the expected date of confinement. Maturity is uncertain Ultrasound assessment in first or second trimesters. Amniocentesis to ensure fetal maturity. Spontaneous onset of labour is awaited and then CS is done.

Type of operation
Lower segment Classical or Upper segment

Lower segment caesarean section

The extraction of the baby is done through an incision made in the lower segment through trans peritoneal approach.

Classical
The baby is extracted through an incision made in the upper segment of the uterus. Indications A. Lower segment approach is difficult 1. Dense adhesions due to previous abdominal operation 2. Severe contracted pelvis with pendulous abdomen

B. Lower segment approach is risky 1. Big fibroid on the lower segment 2. Carcinoma of cervix 3. Repair of difficult and high VVF 4. Severe degree of placenta praevia with engorged vessels in the lower segment

Lower segment Caesarean Section

Pre operative preparation Informed written permission for the procedure, anaesthesia and blood transfusion is obtained. Abdomen is srubbed with soap and non organic iodide lotion. Hair may be clipped. Pre medicative sedation Antacid before transferring to the theatre

Premedication Ranitidine or Metaclopramide NG tube if needed Emptying the bladder, Keep catheter in place Checking of FHS Presence of Neonatologist

Anaesthesia
Spinal Epidural General

Position
Supine 15 tilt

Incision
Vertical Infraumbilical or paramedian Transverse 3cm above the symphisis pubis

Advantages of transverse incision

More post operative comfort Fundus of the uterus can be better palpated during immediate post-operative period. Less chance of wound dehiscence Cosmetic value Less chance of incisional hernia.

Disadvantages
Takes a little longer time and as such unsuitable in acute emergency operation. Blood loss is little more Requires competency during repeat section Unsuitable for classical operation.

Packing
The Doyens retractor is introduced. The peritoneal cavity is now packed of using two taped large swabs. The tape ends are attached to artery forceps. This will minimize spilling of the uterine contents in to the general peritoneal cavity.

Uterine incision
Peritoneal incision The loose peritoneum of the utero-vesical pouch is cut transversely across the lower segment with convexity downwards at about 1.25cm below its firm attachments to the uterus. The lower flap of the peritoneum is pushed down a little.

Muscle incision The most commonly used incision is low transverse Advantages 1. Ease of operation. 2. less bladder dissection 3. less blood loss 4. easy to repair 5. complete reperitonisation 6. less adhesion formation 7. less risk of scar rupture

Other type of Incisions

Lower segment transverse Lower segment vertical J incision Classical incision Inverted T incision

Low transverse incision

A small transverse incision is made in the midline by a scalpel at a level slightly below the peritoneal incision until the membranes of the gestation sac are exposed. Two index fingers are then inserted through the small incision down to the membranes and the muscles of the lower segment are split transversely across the fibers.

 The method minimizes the blood loss but requires experience. Alternatively the incision may be extended on either sides using a pair of a curved scissors to make it a curved one of about 10cm in length, the concavity directed upwards.

Delivery of the head

The membranes are ruptured if still intact The blood mixed amniotic fluid is sucked out by continuous suction. The Doyens retractor is removed. The head is delivered by hooking the head with the fingers which are carefully inserted between the lower uterine flap and the head until the palm is placed below the head.

 As the head is drawn to the incision line the assistant is to apply pressure on the fundus. If the head is jammed, an assistant may push up the head by sterile gloved fingers introduced in to the vagina. The head can be also delivered using either wrigleys forceps

Delivery of the trunk

As soon as the head is delivered, the mucus from the mouth ,pharynx and nostrils is sucked out using rubber catheter attached to a electric sucker. After the delivery of the shoulders intravenous oxytocin 20 units or metergin0.2mg is to be administered.

 The rest of the body is delivered slowly and the baby is placed in a tray placed in between the mothers thigh and with the head tilted down for gravitational drainage. The cord is cut in between two clamps and the baby is handed over to the nurse. The Doyens retractor is reintroduced.

Delivery of the placenta

The placenta is extracted by traction on the cord with simultaneous pushing the uterus towards the umbilicus per abdomen using the left hand . the membranes are to be carefully removed preferably intact and even a small piece, if attached to the decidua should be removed using a dry gauze. dilatation of the internal os is not required. Exploration of the uterine cavity is desirable.

Suture of the uterine wound

the margins of the wound are picked up by Alis tissue forceps or Green Armytage haemostatic clamps. The uterine incision is sutured in three layers.

 First layer the first stitch is placed on the far side in the lateral angle of the uterine incision and is tied with 0 chromic catgut or vicryl. A continuous running suture taking deeper muscles excluding the decidua ensures effective apposition.

 Second layer -the superficial muscles and fascia by continuous suture. Third layer-the peritoneal flap by continuous inverting suture. Concluding part The mops placed inside are removed and the number verified. Peritoneal toileting is done and the blood clots are removed meticulously.

 The tubes and ovaries are examined. Doyen's retractor is removed. After being satisfied that the uterus is well contracted, the abdomen is closed in layers. The vagina is cleansed of blood clots and a sterile vulval pad is placed.

Post operative care

First 24 hours Meticulous observation for 6-8 hours TPR, BP, amount of bleeding, and behaviour of uterus. Fluid- 2 to 2.5 litres Blood transfusion in cases of anaemia or excessive blood loss. oxytocics

Prophylactic antibiotics Analgesics Breast feeding Ambulation and exercises- leg, ankles, deep breathing ,sitting or walking-prevent deep vein thrombosis and pulmonary embolism

Day 1 Observe for bowel sound Oral feeding-clear liquid, coffee tea. Day 2 Light solid diet Laxatives Day 5-6 Stitches are removed

 Transverse D-5 Longitudinal D-6 Discharge Patient is discharged on the day following removal of the stiches. Health education

Classical caesarean section

Abdominal incision is longitudinal about 15cm in length, 1/3rd of which extends above the umbilicus. After opening the peritoneal cavity, the uterus is centralized and packs are placed on each sides A longitudinal incision of about 12.5 cm is made on the midline of the anterior wall of the uterus starting from below the fundus.

 The incision is deepened along its entire length until the membranes are exposed which are punctured. The baby is delivered as breech extraction Methergin Placental removal Suture of the uterine incision Uterus is returned back into the abdominal cavity

 Packings are removed Peritoneal toileting is done The abdomen is closed in layers

Merits and demerits

Lower segment
techniques Slight difficult Blood loss is less The wall is thin and as such apposition is perfect Perfect peritonisation is possible Technical difficulty in placenta praevia or transverse lie

Classical
Technically easy Blood loss is more The wall is thick and apposition of the margins is not perfect Not possible Comparatively safer in such circumstances.

Post operative

Haemorrhage and shock-less Peritonitis is less Peritoneal adhesion and intestinal obstruction are less

More

More More because of imperfect peritonisation

Convalescence is better Relatively poor Morbidity and mortality are lower Morbidity and mortality are higher

Wound healing

The scar is better healed The scar is weak because because of : of:
Perfect muscle apposition due to thin margins Imperfect muscle apposition because of thick margins

Minimal wound heamatoma

The wound remains quiescent during healing process

More wound haematoma formation

The wound is in a state of tension due to contraction and relaxation of the upper segment. As a result, the knots may slip or the sutures may become loose Chance of gutter formation on the inner aspect is more

Chance of gutter formation is unlikely

During future pregnancy

Scar rupture is less 0.5-1.5%

More risk of scar rupture 4-9%

Complications
Due to operation or anaesthesia Intra operative complications Extension of uterine incision to one or both the edgesinvolve uterine vessels broad ligament haematoma Uterine lacerations-laterally or inferiorly to vagina Bladder injury two layer closure with 2-0 chromic catgut, continuous bladder drainage for 7-10 days

 Urethral injury Gastrointestinal tract injury Uterine atony and primary post partum haemorrhage Morbid adherent placenta

Post operative complications

Maternal-immediate Post partum haemorrhage Shock Anaesthetic hazards Infections Intestinal obstructions Thromboembolic disorders

Wound complications Wound sepsis, sanguineous or frank puss, haematoma, dehiscence, burst abdomen.

Post mortem cesarean birth

If a pregnant woman does not survive serious trauma, it may still be possible for her child to be born safely by postmortem CS birth. This is usually attempted if the fetus is past 24 weeks and less than 20 minutes has passed since the mother died. Infant survival is best in these circumstances if no longer than 5 minutes has passed.

 No consent Classical incision Personnel to resuscitate the baby.

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