CS

Caesarean delivery: Definition:

• Caesarean delivery: Definition Caesarean delivery is defined as the

birth of a foetus through incisions in the abdominal wall (laparotomy)
and the uterine wall (hysterotomy) after 28 weeks of pregnancy.
•
Caesarean delivery: Definition:
• Caesarean delivery: Definition It is an operative procedure whereby
the fetuses after the end of 28 th week, are delivered through an
incision on the abdominal and uterine walls.
History of Caesarean
• History of Caesarean delivery The origin of the Caesarean section is somewhat uncertain. The hypothesis that Julius Casear was
the product of a Caesarean delivery is unlikely to be true in view of the probability of fatality associated with the procedure in the
ancient times and the observation that his mother, Aurelia, corresponded with him during his campaigns in Europe many years
later.
• History –The term may have as its origin the Latin verb ‘cadere’, to cut; the children of such birth were referred to as caesones. It is
also possible that the term stems from the Roman law known as Lex Regis, which mandated postmortem operative delivery so that
the mother and child could be buried separately; the specific law is referred to historically as Lex Cesare.
•
Historical Advances By the mid seventeenth century, French obstetrician F. Mauriceau reported sections on living woman.
Although surgeons possessed the anatomic knowledge necessary to perform a Caesarean delivery
• Cont’d In 1800s, they were limited by their inability to provide anesthesia and control infection. The introduction of diethyl ether
and later chloroform as anesthetic agents increased the feasibility of major abdominal surgery.
•
Historical Advances – Cont’d Surgical techniques were also a limiting factor. Surgeons were hesitant to reapproximate the uterine
incision for fear that permanent sutures would increase the likelihood of infection and cause uterine rupture in subsequent
pregnancies. Not surprisingly, women continued to die from blood loss and infection.
• – Cont’d The Porro procedure (1876) combined subtotal Caesarean hysterectomy with marsupilization of the cervical stump. In
1882, Max Sanger in Germany first sutured uterine wall in Caesarean section using silver wire and silk with careful attention to
haemostasis. Frank (1907) described extraperitoneal lower segment operation to avoid peritonitis. Beck (1919) and De Lee (1922)
introduced lower segment operation by vertical incision. Munro Kerr (1926) gave the transverse lower segment incision for
Caesarean delivery the world today.
Incidence:

• Incidence Reduced parity: almost half of the pregnant women are nulliparous,
thus an increased number of caesarean births might be expected for conditions
which are more common in primigravida. Older women are having children and
frequency of caesarean deliveries increases with advancing age.
• Incidence – Cont’d Extensive use of electronic foetal monitoring and increased
caesarean deliveries for non-reassuring foetal heart rate picked up by this
technique is compared with intermittent foetal heart rate auscultation. By 1990,
83% of all breech presentations were delivered abdominally. The incidence of mid
pelvic vaginal deliveries (high presentation) has decreased.
•
Incidence – Cont’d Concern for malpractice litigation has contributed significantly
to the present caesarean delivery rate Socioeconomic and demographic factors
may play a role in caesarean birth rate.
INDICATIONS:

• INDICATIONS The indications are broadly divided into two categories: Absolute Relative
• ABSOLUTE INDICATIONS Central placenta praevia Contracted pelvis or cephalopelvic
disproportion Pelvic mass causing obstruction (cervical or broad ligament fibroid)
Advanced carcinoma cervix Vaginal obstruction (atresia, stenosis)

RELATIVE INDICATIONS:
• Cephalo-pelvic disproportion (relative) Previous caesarean delivery Non reassuring FHR
(fetal distress) Dystocia may be due to (three Ps) relatively large fetus (passenger), small
pelvis (passage) / or inefficient uterine contractions (power). Antepartum haemorrhage
(a) placenta praevia and (b) abruption placenta.
• RELATIVE INDICATIONS –Malpresentations Failed surgical induction of labour, Failure to
progress in labour. Bad obstetric history Hypertensive disorders Medical-Gynaecological
disorders
Common Indications :

• Common Indications Primigravidae: Cephalopelvic disproportion

(CPD) Fetal distress (non-reassuring fetal FHR) Dystocia (three Ps)
Multigravidae: Previous caesarean delivery (28%) Antepartum
hemorrhage (Placenta Previa, placental abruption) Malpresentation
(Breech)
Contraindications :

• Contraindications Very low birth weight baby Maternal coagulation

defects
Time of Operation in Caesarean Delivery :

• Time of Operation in Caesarean Delivery Elective CS Emergency CS

Criteria for timing of elective repeat caesarean delivery An ultrasound
obtained at 12 to 20 weeks confirms the gestational age of at least 39
weeks determined by clinical history and physical examination.
Types of caesarean section :

• Types of caesarean section Lower segment caesarean section (99.8%)

Classical or Upper segment 0.02%. Caesarean hysterectomy 0.18%.
Extra peritoneal lower segment operation.
Types of caesarean section :

• Types of caesarean section Lower segment caesarean section (99.8%)

Classical or Upper segment 0.02%. Caesarean hysterectomy 0.18%.
Extra peritoneal lower segment operation.
Preparation of the mother :

• Preparation of the mother Psychological Preparation Physical

Preparation Anesthesia Position
Incision on the Abdomen:

• Incision on the Abdomen A low transverse incision is made about two

fingers breadth above the symphysis pubis (modified pfannenstiel) or
above the symphysis pubis (pfannenstiel or bikini line incision). Some
obstetricians make a vertical infraumbilical or paramedian incision,
which extends from about 2.5 cm below the umbilicus to the upper
border of the symphysis pubis.
• Incision on the Abdomen The anatomic layers incised are: Fat Rectal
sheath Muscle (rectus abdominis ) Abdominal peritoneum Uterine
muscle.
Advantages and Disadvantages of Transverse
Incision:
• Advantages and Disadvantages of Transverse Incision Advantages
Disadvantages Postoperative comfort is more Takes a little time and
as such unsuitable in acute emergency operation Fundus of the
uterus can be better palpated during immediate post-operative
period Blood loss is little more Less chance of wound dehiscence
Cosmetic value Requires competency during repeat section Less
chance of incisional hernia Unsuitable for classical operation
Delivery of the Head :

• Delivery of the Head The uterine cavity is then opened, the

membranes are ruptured and the amniotic fluid is aspirated. 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.
Obstetric forceps (Wrigley’s forceps) are often used to extract the
head from the pelvis.
Delivery of the Trunk :

• Delivery of the Trunk As soon as the head is delivery, the mucus from
the mouth, pharynx and nostrils is to be sucked out using rubber
catheter attached to an electric sucker. When the baby is born, an
oxytocic drug (methergine 0.2 mg) is administered before the
placenta and membranes are delivered. The cord is cut between two
clamps and the baby is given to the nurse.
Removal of the Placenta and Membranes :
• Removal of the Placenta and Membranes The placenta is extracted by
traction on the cord with simultaneous pushing on the fundus
towards the umbilicus (controlled cord traction). The placenta and
membranes are removed intact.
Suturing of the Uterine Wound :
• Suturing of the Uterine Wound The margins of the wound are picked
up by Allis tissue forceps or Green Armytage hemostatic clamps. The
uterine muscle is sutured in two layers using continuous running
sutures, the second of which tends to align the cut edges of the pelvic
peritoneum. Repair of the rectus sheath brings the rectus abdominis
into alignment. The subcutaneous fat is sometimes sutured and
finally the skin is closed with sutures or clips.
Postoperative Care :
• Postoperative Care Immediate Care (4-6 hours): In the immediate
recovery period, the blood pressure is recorded every 15 minutes.
Temperature is recorded every two hours. The wound must be
inspected every half hour to detect any blood loss.
Postoperative care:
• Immediate Care (4-6 hours) : Immediate Care (4-6 hours) The lochia
are also inspected and drainage should be small initially. Following
general anesthesia, the woman is nursed in the left lateral or
‘recovery’ position until she is fully conscious, since the risks of airway
obstruction or regurgitation and silent aspiration of stomach contents
are still present. Analgesia is given as prescribed.
Postoperative care:
• First 24 hours :
• First 24 hours IV fluids (5% dextrose or Ringer’s lactate) are continued.
Blood transfusion is helpful in anemic mothers for speedy postoperative
recovery. Injection methergine 0.2 mg may be repeated intramuscularly.
Parenteral antibiotic is usually given for the first 48 hours.
• Analgesics in the form of pethidine 75-100 mg are administered as
required. Ambulation is encouraged on the day following surgery and baby
is brought to her.
• The blood pressure, pulse and temperature are usually checked every four
hours. Oral feeding is started with clear liquids and then advanced to light
and regular diet. IV fluids are continued for about 48 hours. Urinary
catheter may be for about 48 hours.
•
Urinary catheter may be removed on the following day when the
woman is able to get up to the toilet the woman is helped to get out
of bed as soon as possible and encouraged to become fully mobile.
The mother must be encouraged to rest as much as possible and
needed help is to be given with care for the baby. This should
preferably take place at the mother’s bedside and should include
support with breastfeeding. The mother is usually discharged with the
baby after the abdominal skin stitches are removed by the 4 th or 5 th
day.
Merits and Demerits of Lower Segment
Operation over classical :
• Merits and Demerits of Lower Segment Operation over classical Lower
Segment Classical Techniques
• Technically slight difficult
• Blood loss is less
• The wall is thin and as such apposition is perfect
• Perfect peritonisation is possible
• Technical difficulty in placenta previa or transverse lie.
• 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
• : Lower Segment Classical Postoperative Hemorrhage and shock – less
Peritonitis is less even in infected uterus because of perfect
peritonisation and if occurs, localized to pelvis. Peritoneal adhesions
and intestinal obstruction are less Convalescence is better Morbidity
and mortality are much lower. More Chance of peritonitis is more in
presence of uterine sepsis More because of imperfect peritonisation
Relatively poor Morbidity and mortality are high