CEASAREAN

SECTION
History
Most important modification was the
lower segment transverse incision.
First done by kehrer and
• According to legend, Julius Co
popularized by Munro Kerr legend, Julius Caesar was born
by this operation and hence the
origin of the term caesarean.
• Most important modification was
the lower segment transverse
incision. First done by kehrer and
popularized by Munro Kerr
 Incidence
• It is the most commonest operation
performed worldwide.

• Ideal CS rate is 10 to 15 % (WHO)

• Increased incidence worldwide during last

25 years.
 Cesarean section (CS)

• Caesarean section or c-section, is a delivery of

the fetus through incisions in anterior
abdominal (laprotomy) and uterine wall
(hysterotomy)
• Divided into:

1. Maternal indicators.

2. Fetal indicators.

3. Fetomaternal indicators- coexist.

 Maternal indicators

• DYSTOCIA due to:

-CPD
-tumours complicating pregnancy
-non progressive labour
-threatened rupture and obstructed
labour
-failed forceps or vacuum
-deep transverse arrest.
• Previous C.S.
 Cont.,.,
Antepartum hemorrhage
-placenta praevia
-abruptio placenta
-vasa praevia
-carcinoma cervix

Medical disorders
-pre-eclampsia and eclampsia
-coarctation of aorta
 Cont.,.,
Maternal obstetric problem:
-elderly nullipara
-prolonged period of infertility or
pregnancy following IVF
-bad obstetric history
-previous repair of nulliparous prolapse
-stress incontinence or fistula
-failed induction
 FETAL INDICATION

Fetal distress and cord prolapse •

Breech presentation –[footling, knee •
presentation, complicated breech]
Malpresentation [ brow, transverse lie •
persistent mentoposterior ]
Sever IUGR •
Macrosomia •
Multiple pregnancy[first twin non -vertex and •
monoamniotic twin]
HIV complicating •
 Fetal Indicators
• Situations in which neonatal morbidity and mortality
could be decreased by the prevention of trauma
• Malpresentations (eg, preterm breech presentations,
non-frank breech term fetuses)
• Certain congenital malformations or skeletal
disorders.
• Infection.
 “ THERE IS NO
CONTRAINDICATIONS TO C.S. IF
THE FETUS IS LIVING”
 Cont.,.,
• C.S should be performed on dead fetus in the
following conditions ( SAME ABSOLUTE
INDICATIONS):
• 1. Severe degree of contracted pelvis.
• 2. Placenta previa.
• 3. Presence of abdominal circlage.
• 4. Soft tissue obstruction.
• 5. Previous 2 or more C.S.
• 6. Previous repair of vesicovaginal fistula.
 Timing of Operation
• Elective:
When the operation is performed due to
unforeseen or acute obstetric emergencies.
• Time:
Time limit of 30 mins is thought to be
reasonable from the time of decision to the
start of the procedure.
 TYPES
• Lower Segment Caesarean
Section(LSCS).
• Lower segment vertical incision.
• Classical CS.
• Extra peritoneal caesarean.
• Caesarean hysterectomy.
 • The extraction of the baby
LSCS: is done through an incision
made in the lower segment
through a transperitoneal
approach.
• It is the only method
practiced in present day
obstetrics.
 Cont.,.,
LSCS approach is difficult in:
 Dense adhesions due to previous abdominal
operation.
 Severe CPD with pendulous abdomen.
LSCS approach is risky in:
 Big fibroid on the lower segment.
 Carcinoma cervix.
 Repair of high vulvovaginal fistula.
 Cont.,.,
 Complete anterior placenta previa with
engorged vessels in the lower segment (Risk of
hemorrhage).
 • The baby is extracted
CLASSICAL C.S: through an incision made
in the upper segment of
the uterus.
• In present day obstetrics it
is very much limited & the
operation is done only
under forced circumstances
which we have seen above
(LSCS approach difficult
and risky).
PERIMORTEM • It is done to have a live
C.S: baby (Rare).
• It is an extreme emergency
procedure.
• Classical section is done in
a women who suffered a
cardiac arrest.
• The infant may survive if
delivery is done within 10
minutes of maternal death.
 LSCS
PREOPERATIVE PREPARATION
 Informed consent for the procedure, anesthesia, &
blood transfusion is obtained.
 Abdomen: Scrubbed with soap & nonorganic iodide
lotion. Hair may be clipped.
 Premedicative sedative must not given.
 Non- particulate antacid (0.3 molar sodium citrate,
30ml) is given orally before transferring the patient
to theater.
 Cont.,.,
 Ranitidine (H2 blocker) 150mg is given orally night
before (elective procedure) and it is repeated (50mg
IM or IV) 1hr before the surgery to raise the gastric
pH.
 Metoclopramide (1omg/IV) is given to increase the
tone of lower esophageal sphincter as well as to
reduce the stomach contents. It is administered after
about 3mins of pre-oxygenation in the theater.
 The stomach should be emptied, if necessary by a
stomach tube ( Emergency procedure).
 Cont.,.,
 Ranitidine (H2 blocker) 150mg is given orally night
before (elective procedure) and it is repeated (50mg
IM or IV) 1hr before the surgery to raise the gastric
pH.
 Metoclopramide (10mg/IV) is given to increase the
tone of lower esophageal sphincter as well as to
reduce the stomach contents. It is administered after
about 3mins of pre-oxygenation in the theater.
 The stomach should be emptied, if necessary by a
stomach tube ( Emergency procedure).
 Cont.,.,
 Bladder should be emptied by a Foley's catheter
which is kept in place in the perioperative period.
 FHS should be checked once more at this stage.
 Neonatologist should be made available.
 Cross matching of blood when above average blood
loss.
 Cont.,.,
• Anesthesia: May be spinal, epidural or general
anesthesia.
• Position: Dorsal position.
• Antiseptic painting: Abdomen is painted with 7.5%
povidone iodine solution or savlon lotion to be
properly draped with sterile towels.
• Incision on abdomen: The surgeon may choose
either a vertical or a transverse skin incision.
 Cont.,.,
• Lower segment transverse incision( 3cm above
symphysis pubis).
• Lower segment vertical incision.
 Cont.,.,
• J Incision.
• Inverted T Incision.
 Cont.,.,
• Classical incision (Upper segment).
 Cont.,.,
• Doyen’s retractor is introduced.
STEPS OF LSCS
 The loose peritoneum o the lower segment is
cut transversely.
 A short incision is made in the midline down
to the membranes.
 The incision of the lower segment is being
enlarged using index finger of both hands.
 Cont.,.,
Delivery of the head:
 The membranes are ruptured if still
intact.
 The blood mixed with amniotic fluid is
sucked out by continuous suction.
 The DOYEN’S retractor is removed.
 The head is delivered by hooking the
head with fingers which are carefully
indirectly between the lower uterine
flap and the head until the palm is
placed below the head.
 Cont.,,
As the head is drawn to the incision line, the
assistant is to apply pressure o the fundus.
The head can also be delivered using either
Wrigley's forceps or Barton's forceps.
 Cont.,.,
Delivery of 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 delivery of shoulders
IV oxytocin 20 units or
methergin 0.2mg is to be
administered.
 Cont.,.,
Removal of placenta &
membranes:
 By controlled cord traction the
placenta is expelled when
unless if the placenta is not
separated spontaneously.
 Routine manual removal
should not be done.
 All membranes must be
carefully removed.
 Cont.,.,
Suturing of uterine wound:
 The margins of the wound
are picked up by Allis tissue
forceps and green armytage
forceps.
 The uterine incision is
sutured in 3 layers:
 Cont.,.,
1st LAYER:

Inserting the continuous catgut (No,“0”)

suture taking deeper muscles excluding the
decidua.
 Cont.,.,
2nd LAYER:
 A similar continuous suture is placed for taking the
superficial muscles and adjacent fascia overlapping
the first layer of suture.
 Uterine muscles may be closed using a continuous
single layer stitch.
 The peritoneum flaps may be apposed by continuous
inverting suture.
 Cont.,.,
3rd LAYER:
 The mops placed inside are removed & the no is
verified.
 Peritoneal toileting is done & the blood clots are
removed.
 The tubes & ovaries are examined.
 Doyen’s retractor is removed.
 Abdomen is closed in layers.
 Vagina is cleansed of blood clots & a sterile vulval
pad is placed.
 Cont.,.,
POSTOPERATIVE CARE:
 Cont.,.,
First 24 hrs
 Observation for the 1st 6 -8 hours.
 Periodic check up of pulse, BP, amount of vaginal
bleeding & behaviour of uterus is done.
 Fluid: Nacl (0.9%) or RL drip is continued until atleast
2-2.5L of the solution.
 Blood transfusion is helpful in anemic mothers for a
speedy post- operative recovery.
 Cont.,.,
 Oxytocics: Inj. Oxytocin 5 units IM (Slow)
OR
Methergin 0.2mg IM is given.
 Prophylactic antibiotics (Cephalosporin's, Metronidazole)
for all cesarean delivery for 2-3 days.
 Analgesics: Pethidine Hcl: 75-100mg.
 Ambulation: The patient can sit on the bed or even get
out of bed to evacuate the bladder.
 She is encouraged to move her legs & ankles to breathe
deeply to minimize leg vein thrombosis & pulmonary
embolism.
 Breast feeding initiation occurs.
 Cont.,.,
DAY 1
Oral feeding:
Plain or electrolyte water or raw tea may be given.
Active bowel sounds are observed by the end of the
day.
DAY 2-4
Light solid diet:
According to pt’s choice.
Bowel care: 3-4 teaspoons of lactulose is given at bed
time; if bowels do not move spontaneously.
 Cont.,.,
DAY 5 or 6
The abdominal skin stitches are to be
removed on the D-5 (In transverse) or D-6 (In
longitudinal).
 The patient is discharged
DISCHARGE on the day following
removal of stitches, if
otherwise fit.
Advices: Those following
normal vaginal delivery are
given.
CLASSICAL CESAREAN SECTION
 Cont.,.,
Abdominal incision is always longitudinal &
about 15cm in length,1/3rd of which extends
above the umbilicus.
The baby is delivered commonly as breech
extraction.
IV oxytocin slow (5 IU) or Methergin 0.2mg is
administered following delivery of the baby.
 Indications of classical
caesarean section

1. when the lower segment is abnormally vascular.

2. when the lower segment can not identified due to adhesion.
3. when caesarean section is done after mother‫י‬s death.
4. Cases needs rapid delivery.
5. When the foetus lie is transverse and can not be corrected.
6. When hysterectomy will follow caesarean section
Merits & Demerits of LSCS &
Classical C.S
Merits & Demerits for type of
incision
 Cont.,.,
Suture of uterine incision
• The uterus is sutured in 3 layers:
1st layer : A continuous suture is placed with
chromic catgut no. 0 or vicryl taking deep
muscles excluding the decidua.
2nd layer: A interrupted suture (1 cm apart)
using a chromic catgut no. 1 or vicryl taking
the entire depth of superficial muscles down
to the 1st layer of suture.
 Cont.,.,
3rd LAYER: Taking the peritoneum with the
adjacent muscles using chromic catgut no. “0”
& round bodied needle.
The uterus is returned back into
the abdominal cavity.
Packings are removed.
Peritoneal toileting is done.
The abdomen is closed in layers.
 Cesarean Hysterectomy
• It refers to an operation where C.S is followed
by removal of the uterus.
Indications:
Morbid adherent placenta.
Atonic uterus & uncontrolled PPH.
Big fibroid ( In parous women).
Grossly infected uterus.
Rupture uterus.
 Postpartum Hysterectomy
Surgical removal of the uterus either at the
time of cesarean delivery or in the immediate
postpartum period.
 Extra peritoneal C.S
RETZIUS
It is rare.
It was practiced in the past
in cases with severe
infection.
Lower segment is
approached
extraperitoneally by
dissecting through the
space of “RETZIUS”.
 It is an excision of a portion of both fallopian
tube.
It is done after 3rd or 4th cesarean section.
Post-operative goals:
1. Improve pulmonary function and prevent post operative
pulmonary complications( pneumonia….)
2. Improve circulation and prevent post operative circulatory
complications (DVD, edema ….)
3. Decrease incisional pain associated with coughing, movement or
breast feeding.
4. Improve healing of incision and prevent adhesion formation.
5. Prevent pelvic floor dysfunction.
6. Improve lactation and prevent sagging of the breast.
7. Correct posture.
Methods:
 Deep breathing exercises.
 Circulatory exercise.
 Early ambulation.
 Arm exercises.
 Postural correction.
 Pelvic floor exercises.
 Abdominal strengthening exercises.
 Electrotherapy to decrease incisional pain and to promote
wound healing.
 Positioning instruction.
 Physical therapy for
early post-operative days
 1st day:
 Breathing ex‫י‬s.
 Circulatory ex‫י‬s.
 Leg ex‫י‬s.
 Static abdominal contraction.
 2nd day:
 Repeat previous ex‫י‬s, add the following:
 Early ambulation to:
 Prevent muscle wasting.
 Prevent constipation.
 Prevent retension of urine
 Prevent respiratory and vascular complication.
 Arm ex‫י‬s. Half lying position.
 3rd day:
 Repeat previous ex‫י‬s, add the following:
 Pelvic floor ex‫י‬s
 4th day:
 Repeat previous ex‫י‬s, add the following:
 Pelvic rocking ex‫י‬s
 Scapular retraction.
 5th day:
 Repeat previous ex‫י‬s, add the following:
 Hip shrugging.
 Postural correction ex‫י‬s.
 6th day:
 Repeat previous ex‫י‬s, add the following:
 Pelvic rotation ex‫י‬s.
 7th day:
 Repeat previous ex‫י‬s, add the following:
 Lateral flexion (1st step)
 Trunk rotation (1st step)
 Trunk flexion (1st step).
THANK YOU