CESAREAN SECTION & VBAC

Introduction
DEFINITION:
Cesarean delivery is defined as the birth of a
fetus , placenta & membranes through
incisions in the abdominal wall (laparotomy)
and the uterine wall (hysterotomy) after 28
weeks of pregnancy.
pregnancy
Note:
Surgical delivery of fetus prior to age of
viability (28wks) is called Hysterotomy
Surgical removal of the fetus from the
abdominal cavity in the case of rupture of
the uterus or in the case of an abdominal
pregnancy is called laparotomy.
Prevalence and trend
The cesarean section rate worldwide is
15 % of births.
The mean cesarean delivery rate in
developed countries is 21.1 %
Mexico, Brazil, and Italy have the highest
rate (over 35 %)
Africa has the lowest (< 5 %)
Ethiopia 0.7% (2000), 1% (2005)
Rural 0.3%
Urban 9%
WHO recommendations
C/S 10% in a low risk population
C/S 15% in a high risk population
There is no justification to have a
caesarean section rate of higher
than 10 - 15 %. WHO
 Prevalence and trend
The cesarean delivery rate rise progressively WHY? not
completely understood, but
Obstetric Factors
ed primary cesarean
delivery
Failed/ ed labor induction
operative vaginal delivery
ed macrosomia/ elective
cesarean for macrosomia
in vaginal breech delivery
ed repeat cesarean rate
Decreased utilization of
VBAC
The widespread use of
electronic fetal monitoring .
Maternal Factors
Increased proportion of
women > age 35
ed nulliparous women
Increased elective primary
cesarean deliveries
Concern over pelvic floor
injury associated with
vaginal birth.
Physician Factors
Malpractice litigation
concerns
Indications For C/S
Indications can be:-
Absolute Or Relative;
Relative Or
Maternal Or Fetal; Or
Common
The commonest indications are:-
Fetal distress
CPD
Repeat cesarean
Four most common indications (80%)
Failure to progress during labor (30 %)
Previous hysterotomy (related to myomectomy or other
uterine surgery)
surgery (30 %)
%
Fetal malpresentation (11 %)
%
Nonreassuring fetal status (10 %)
%
Maternal
Repaired fistula
Specific cardiac disease (Marfan's syndrome,
unstable coronary artery disease)
disease
Specific respiratory disease (Guillian-Barr
syndrome)
syndrome
Conditions associated with increased
intracranial pressure
Mechanical obstruction of the lower uterine
segment (tumors, fibroids)
Mechanical vulvar obstruction (condylomata)

Cx Ca
Fetal
Non-reassuring fetal status
Breech
EFW >3500gm
Extended neck
Footling

PMTCT
Maternal genital herpes

Twin-
Twin 1st non cephalic
High order multiple pregnancy

Congenital anomalies

Cord prolapse,

Severe IUGR
Maternal-fetal
Previous Cesarean [30 % of all C S ].
Cephalopelvic disproportion

Placental abruption

Placenta previa

Macrosomia (Excessive Fetal Wgt

>4.5kg)
>4.5kg
Obstructed labor

Transverse lie

Failed induction and augmentation

Cx Dystocia,
Dystocia
 Contraindications
No absolute contraindications.
When no indications.
Benefits must outweigh risks.

Cesarean deliveries are categorized as either:-

Primary = first cesarean delivery
Repeat = after a previous cesarean birth
The total cesarean delivery rate is the sum of
these two components.
Benefits of C/S
Reduction in perinatal morbidity and
mortality
Elimination of intrapartum events
associated with perinatal asphyxia (if
elective)
Reduction in traumatic birth injuries
Reduction in stillbirth beyond 30
weeks' gestation
Possible protective effect against pelvic
floor dysfunction
PMTCT
Risks of C/S
Increased short-term morbidity
Increased endometritis, transfusion,
venous thrombosis rates
Increased length of hospital stay and
longer recovery time
Increased long term morbidity
Increased risk for placenta accreta &
hysterectomy with subsequent
cesarean deliveries
Pre - Op Considerations.
Decision Making & Recording.
Clinical hx including anesthetic risk assessment,
drug history
Informed Consent.
Blood Hct, Hb, ABO & Rh, U/A if not done.
done
U/S to rule out Congenital anomaly, Prematurity,
EFW and Fetal Wellbeing.
Specific Ix if indicated like RFT, LFT
Avoid Sedatives once decided C/S .
Give clear antacids PO or Inj Ranitidine 150 mg
IM stat.
Folleys Catheter,
Catheter
Prophylactic antibiotics
Check FHB on table.
table
Timing Of C/S
CD may be performed because of maternal or fetal
problems that arise during labor,
labor or they may be
planned before the mother goes into labor
Elective cesarean delivery
Decisions must take into account the risk to the
infant associated with delivery before 39
weeks' gestation
Respiratory distress syndrome is indeed
seen in "term" infants
Emergency cesarean section
In cases of suspected or confirmed acute fetal
compromise,
compromise delivery should be accomplished as
soon as possible.
The accepted standard (DDI) is within 30
minutes.
Abdominal entry (incisions)
Usually either:
Subumbilical midline vertical or
Suprapubic transverse incision is used.
Joel cohen
pfannensteil
Incise the skin and subcutaneous tissue
Make a small incision over the fascia
Dissect the rectus and pyramidalis muscles
Elevate the peritoneum at the upper edge of
the incision by holding it with two artery
forceps about 2 cm apart.
apart Incise between
the two artery forceps with scalpel to
open the peritoneal cavity.
Correct the uterus if dextro-rotated
Insert moistened packs on each side of
the uterus
Insert a bladder retractor
Factors that influence the type of
incision
The urgency of the delivery,

Prior incision type , and

The potential need to explore the

upper abdomen for nonobstetric

pathology
Surgeons experience
Supra pubic transverse Vertical incision
Pfannensteil, Joel Cohen It is quickest to
is most commonly used
make,
make
since it is associated with
Less postoperative Cause less
pain,
pain bleeding and
Greater wound nerve injury,
injury and
strength,
strength and Can be easily
Better cosmetic
extended (imp in
results than the
vertical midline incision obese)
Uterine Incision
Extraperitoneal cesarean section;
section
Latzko operation (Obsolete)
Intraperitoneal cesarean section
1- Lower segment
A-- A transverse or curved (horizontal), Kerr
operation (99%)
B--Vertical incision in the lower uterus,
Selheim operation
2 - Classical-
Classical a vertical incision in the
main body of the uterus. Sanger
operation (<1%)
3 - Inverted T-shaped incision,
incision Delee
operation
4 -J shaped
The type of incision depends up
on several factors;
Position & size of fetus,
Location of placenta,

Development of lower Ux segment,

+/- of leiomyoma
Close the uterine incision with two layers
of continuous inverting stitches starting
from the edge the 1st bite just behind the edge
with Chromic 1- or 0-catgut or polyglycolic
(Vicryl).
Close the Fascia with continuous Vicryl no 2
Approximate the subcutaneous layer with
chromic 2-0 catgut
Close the skin with continuous subcuticular
stitch or interrupted silk as needed.
Check uterine contraction and clean any
clot in the vagina.
Transverse incision -Known as Monroe Kerr or Kerr
incision
Advantages
Less blood loss,
loss
Less need of bladder dissection
Easy to reapproximate
Low risk of rupture in subsequent Pregnancy
Does not promote adherence of bowel or omentum to
the incisional line.
line
Disadvantages
Lateral extension is associated with risk of laceration
of major blood vessels
J or inverted T incision is required if larger incision is
Low vertical
It is performed in the lower Uterine segment
It is as strong as low transverse incision
Disadvantage of low vertical incision
Extension cephald to the fundus & caudally to the
bladder, Cervix or Vagina.
The low vertical incision may not be truly low as
the separation b/n upper & lower segment is not
easy clinically
Classical vertical incision-
A vertical incision that extends into the upper uterine
segment/fundus
Rarely performed because in subsequent pregnancies it is
associated with a higher frequency of uterine rupture &
a higher rate of maternal morbidity
Anaesthesia
1. General anaesthetic.
2. Regional anaesthesia (Epidural / Spinal block ).
Considerably safer than general anaesthesia with respect to
maternal mortality
It allows the mother to remain awake, experience
the birth,
birth and have immediate contact with her
infant.
3. Infiltration of local anaesthetic agents.
Rarely required except in conditions, e.g. deeply sedated
Pt.
Where anesthetist is not available and surgeon has to
manage all alone, local anesthesia is used.
Drug used is 0.5% Lignocain.
Lignocain Total quantity to be
used is not more than 100 c.c.
The surgeon may not be as comfortable
Complications of Cesarean Delivery
Intraoperative Complications
Uterine Lacerations

Bladder $ Ureteral Injury

GIT Injury

Uterine Atony

Placenta Accreta

Maternal morbidity and mortality are increased in cesarean

delivery compared with vaginal birth,

birth
Maternal Postoperative Morbidity
Endomyometritis

Wound Infection

Thromboembolic Disease

Septic Pelvic Thrombophlebitis

Anesthetic Complications .
Iatrogenic cut on fetus common.
Prematuarity, Increased RDS .
Future pregnancies
Placenta previa, Adherent placenta, Repeat cesarean
Immediate complications
Intraoperative damage to organs such as the bladder
or ureters
Anesthetic complications including aspiration
pneumonia
Haemorrhage, Infection
Thromboembolism
Maternal mortality is greater after caesarean than
vaginal delivery
Transient tachypnoea of the newborn is more
common after caesarean section.
Long-term risks include an increased risk of
Uterine rupture in subsequent pregnancies
Limitation of number of children
Placenta previa, Placental abruption,
Placenta accrete
Post Op Care Of C/S
Close watch 6 8 hrs.:
hrs monitor pulse,
BP and amount of bleeding & Hgt of
uterus.
uterus
IV Fluids for 24hrs or till bowel sounds
are heared.
Oxytocins may be repeated.
Anti pain,
Remove urinary catheter when fully
awake
Early ambulation.
Proper wound care
Postoperative follow-up
Immediate:
Immediate
Check and record vital signs on arrival to the ward and every 30 min once

she is fully awake and stabilized

Check urine output

Check for vaginal bleeding and uterine consistency

Late:
Check and record vital signs and urine output every 4-6 hours .

Start sips of fluid after ascertaining that she conscious and bowel

sounds are active..

Discontinue IV fluids once started fluid diet unless there is other IV

medication
Provide analgesics as required

Ambulate early, Deep breathing and coughing are encouraged.

Look for evidences of PPH, pulmonary infection, UTI, and wound

infection
Initiate breast-feeding and skin-to skin contact with the baby as soon

as the mother is awake

Open the wound site and remove stitches on the 6 th day

Discharge when vital signs are with in normal range, mother has started

regular feeding, breast-feeding is initiated and there is no evidence of

wound infection
Elective Repeat Cesarean Delivery
If elective repeat cesarean delivery is planned,
it is essential that the fetus be mature.
mature
Delivery is best planned at 39 weeks of
gestation
See table for ACOGs criteria

Compared with vaginal delivery, c/s birth is associated with

increased risks, including
Anesthesia,
Hemorrhage,
Damage to the bladder and other organs,
Pelvic infection,
Scarring,
Scarring
Despite this, an elective repeat cesarean is considered by many women to
be preferable to attempting a trial of labor
Assure fetal maturity!!!
Table . Establishment of Fetal Maturity Prior to Elective Repeat
Delivery ACOG
Fetal maturity may be assumed if one of the following criteria is met:
1. Fetal heart sounds have been documented for 20 weeks by
nonelectronic fetoscope or for 30 weeks by Doppler ultrasound
2. It has been 36 weeks since a positive serum or urine HCG
pregnancy test was performed by a reliable laboratory

3. An ultrasound measurement of crown-rump length, obtained at

611 weeks, supports current gestational age of 39 weeks or
more

4. Clinical history and physical and ultrasound examination

performed at 1220 weeks support current gestational age of
39 weeks or more

In all other instances, fetal pulmonary maturity must be documented by :-

Amniocentesis for Fetal Lung Maturity
The onset of spontaneous labor is awaited.
Additional surgical procedures
during cesarean
Cesarean Hysterectomy
INDICATION:-
Uncontrolled PPH,
Severe infection with or without rupture
of uterus.
TYPE Total and Subtotal
Tubal ligation
Modified Pomeroy
The Irving Procedure
The Uchida Procedure
PREOPERATIVE ISSUES
Laboratory testing
Hemoglobin & blood type and antibody screen
Antibiotic prophylaxis
A single IV & narrow spectrum antibiotic; 30min
(eg, ampicillin 2 g or cefazolin 1 to 2 g)
Significantly reduced the incidence of
Postoperative fever,
Endometritis,
Wound infection,
Urinary tract infection , and
Serious infection
Thromboembolism prophylaxis
Intermittent intra- and post-operative pneumatic leg compression and
Early ambulation,
ambulation
Prophylactic anticoagulation in high-risk women
Bladder catheterization
Convenience Vs UTI
Hair removal
Clipped rather than shaved 31
POSTOPERATIVE CARE
Monitor for evidence of :-
Uterine atony
Excessive vaginal or incisional bleeding
Oliguria
Blood pressure for hypo or hypertension,
hypertension
Patient controlled opioid analgesia followed by oral
NSAID = adequate analgesia
Early ambulation (when the effects of anesthesia
have abated)
Oral intake (4-8 hrs of surgery) are encouraged.
Stimulating the gastrocolic reflex.
reflex

32
COMPLICATIONS
Endometritis
35 to 40 % without prophylaxis
4 to 5 % after scheduled c/s with intact membranes,
85 % after an extended labor with ROM
Wound infection
2.5 to 16 percent; four to seven days c/s
Septic pelvic thrombophlebitis
Hemorrhage
Mean blood loss =1000 mL
2 to 3 % require blood transfusion
Uterine atony
Placenta accreta
Extensive uterine injury
Extension 33
Urinary and gastrointestinal injuries
Bladder injury = 0.28%
Ureteral injury= 0.10%
Ileus
Maternal mortality
Related to the underlying medical and
obstetrical factors
Vaginal birth = 0.04 per 1000
Cesarean birth = 0.53 per 1000

Iatrogenic prematurity and birth trauma

34
LONG-TERM RISKS
Abnormal placentation
Placenta previa, Accreta,
Subfertility
Scar complications
Ectopic pregnancy in the scar = 1/1000
Numbness or pain (Ilioinguinal and
Iliohypogastric)
Incisional endometriosis
Uterine rupture
35
 VBAC
VAGINAL BIRTH AFTER

CESAREAN DELIVERY
Introduction
VBAC a trial of labor and vaginal birth
in a woman with a previous caesarean
section
VBAC plays a key role in reducing the
incidence of caesarean sections
Three possible outcomes for the woman who
has had a prior cesarean delivery:
A successful VBAC
An unsuccessful Trial Of Labor After Cesarean

(TOLAC) resulting in a repeat cesarean

delivery, or
An ERCD.
Neither ERCD (elective repeat cesarean
delivery) nor VBAC is without risk.
Successful VBAC is associated with the
lowest morbidity.
The highest risks for maternal and
neonatal morbidity are associated with
unsuccessful TOLAC that culminates in a
repeat cesarean delivery
 Pregnancy with Hx of previous caeserean section
has increased risk of:
Uterine rupture,

Placenta accreta,

PPH,

Peripartal hysterectomy

Planning the route of delivery should be

addressed early in prenatal care.
The decision for TOLAC or ERCD should be made by
the woman in consultation with her provider.
The success rate for women who attempt TOLAC
is approximately 75 %.
Prerequisites vary in different
protocols
In Ethiopia
Only one previous transverse lower
segment caesarean
Singleton, vertex, < 4 kg estimated weight
Adequate pelvic capacity;
capacity no pelvic
contraction
Spontaneous labor onset; no oxytocin use
No other significant obstetric
complications e.g. post term, APH, IUGR,
preeclampsia etc
No documented fetal distress
Conducted in a facility equipped and
staffed for conducting a caesarean
Factors associated with trial of labor after
cesarean delivery
Factors resulting in an increased likelihood of successful
TOLAC
Prior vaginal birth
Spontaneous labor
Advanced cervical dilation on admission
Factors resulting in a decreased likelihood of successful TOLAC
African American or Hispanic ethnicity
Increased maternal age
Single marital status
Less than 12 years education
Delivery at rural or private hospital
Recurrent indication for initial cesarean delivery
FACTORS AFFECTING SUCCESS RATE OF TOLAC
Indication for prior cesarean delivery
The rate of successful TOLAC by indication for prior cesarean

delivery is
75 % for fetal malpresentation,
malpresentation
60 % for nonreassuring fetal heart rate pattern,
pattern and
54 % for failure to progress or cephalopelvic
disproportion
History of prior vaginal delivery
For successful TOLAC with prior vaginal delivery 3.90;

with prior VBAC 4.76

Admission labor status:
When admitted to the labor unit, women in spontaneous

labor or with a high bishop score are more likely to have

successful TOLAC
Benefit of VBAC Risk
Less postpartum Uterine
febrile morbidity rupture
Less transfusion Failed VBAC
Reduced Increased
anesthesia risk
Shorter hospital
fetal and
stay maternal
Less cost postpartum
morbidity

43
 Factors influencing the risk of
rupture

Type and location of the

previous incision.
Unknown uterine scar type?
type
Two case series reported rates
of VBAC success and uterine
rupture similar to those
women with documented
previous low-transverse
uterine incisions.
incisions
45
Lower segment scar Classical scar
Thin cut margins Difficult to appose thick
facilitate perfect muscle layer. Pockets
apposition with out formed with blood in-
leaving any pocket. between.
Remains inert while Contract and retract
healing while healing loosening
the suture
Scar stretch during px
along the line of the Stretch at right angle to
scar. the scar.
Trophoblastic
Low chance of scar
penetration weakens the
weakening by placental
scar.
attachment.
Rupture may occur
Rupture may occur only during pregnancy and
during labor labor. 46
 Obstetric history
a previous vaginal birth significantly
reduces the risk of uterine rupture.
The length of time between deliveries.
The longer the interval between deliveries,
the lower the risk of rupture.
23 fold increased risk of uterine rupture in
those who having interdelivery intervals of
< 24 months
Closure of prior incision?
A single layer closure of incision in the
primary cesarean delivery may increase the
risk of uterine rupture 4-fold during a
subsequent trial of labor.
Lower Bishop Score on admission
 Labor induction with either
oxytocin or a prostaglandin.
Birth weight exceeding 4000
gms.
Number of Prior Cesarean
Incisions
1.8 % for women with two prior
cesarean deliveries.
Antenatal care
Review of the medical record
Indication of C/S
Type of surgery

Clinical pelvimetry

Fetal weight estimation

Counseling
Informed consent
Labor and Delivery
Considerations
Prompt evaluation
An IV line
Continuous electronic monitoring of
fetal heart rate or every 15 minutes
Uterine contractions every 30 min.
Epidural Analgesia
Not a contraindication
Vaginal delivery rates are similar among
women who receive an epidural for labor
compared with those who do not.
Progress of labor with a partograph.
Watch for evidence of scar
dehiscence
Abdominal or uterine

tenderness
Vaginal bleeding

FHR abnormality

V/S
Uterine Scar
Exploration
Routine post delivery uterine
exploration?
Excessive vaginal bleeding or signs of
hypovolemia at delivery require prompt
and complete assessment of the previous
scar and the entire genital tract.
Asymptomatic scar dehiscences heal
well and there are no data to suggest that
future pregnancy outcome is better if the
dehiscence is surgically repaired.
Diagnosis of uterine
rupture
Scar rupture has insidious onset compared
with rupture following obstructed labor.
Silent rupture
Vaginal bleeding and abdominal pain
less than 10 percent
Irritation of the diaphragm.
Uterine contraction abnormalities.
FHR abnormalities
The common sign
33 to 100 % of cases
Sudden, severe late decelerations
Bradycardia
Undetectable fetal heart action
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