CESAREAN SECTION

Dr shams reha

OBJECTIVES
1.
2.
3.
4.

DEFINITION
INCIDENCE
INDICATIONS
TYPES OF
CAESAREAN
SECTION
5. PROCEDURE
6. PREOPERATIVE
PREPARATION
7. PREPARATION IN
THEATRE

8.ANESTHESIA
9.VARIANTS OF CSECTION
10. COMPLICATIONS
OF C-SECTION
11.ANESTHESIA
COMPLICATION
12.PREGNANCY
AFTER ONE CSETION

THE TERM
CESAREAN SECTION
is derived from
TWO LATIN WORDS

CAEDERE means to cut

SECTIO means an act of
cutting

CESAREAN SECTION
NUMA POMPOLIS , King of Rome , in
715 BC, brought in a law which
forbade the burial of a pregnant
women unless her child has been
removed & burried separately
In 200 BC , this practice was called
Lex Caesarea, when the kings became
Caesars(Used as a title and form of
address for Roman emperors.

1- DEFINITION
Caesarean section the operation
performed to deliver the baby
after the age of viability (24
weeks) through an abdominal
incision

It is called HYSTROTOMY if
performed before the age of
viability

INDICATIONS FOR
CS
BASED ON THE TIMING OF CS AT THE TIME
OF DECISION MAKING, THE INDICATIONS
ARE GROUPED UNDER ONE OF
1. EMERGENCY C-SECTION:
FOUR CATEGORIES

2. URGENT C-SECTION:
3. SCHEDULED C-SECTION:
4. ELECTIVE C-SECTION:

EMERGENCY C-SECTION:
CATEGORY 1
There is an immediate threat to the
mother or the fetus.
ideally c-section should be done with in
next 30 mints e.g.
cord prolapse
scar rupture
abruption
scalp pH <7.20
prolonged FHR deceleration < 80 beats/
mint.

URGENT C-SECTION
CATEGORY 2
There is maternal or fetal compromise
but was not immediately life
threatening.
Here the delivery should be completed
within
6075 min and
cases with FHR abnormalities are those
of concern.

SCHEDULED CS
CATEGORY 3
The mother needed early delivery but
there was no maternal or fetal
compromise.
This group has a wide range of indications
It may be a case of failure to progress
where the CS is planned within the next
hour or two
or it may be a case of growth-restricted
fetus in the preterm period with absent
end diastolic flow but a normal CTG or

SCHEDULED CS
CATEGORY 3
a case with pre- eclampsia where the
liver or renal function tests are
gradually deteriorating where the CS
is planned for within hours to days.
The timing of the CS would vary but
some plan should be in place to
deliver before further deterioration
occurs

ELECTIVE CS
CATEGORY 4

THE DELIVERY IS TIMED TO SUIT THE MOTHER AND

STAFF.

THESE ARE CASES WHERE THERE IS AN

INDICATION FOR CS BUT THERE IS NO
URGENCY
placenta praevia with no active bleeding
malpresentations, (e.g. brow, breech)
history of previous hysterotomy or vertical
incision CS
past history of repair of vesico-vaginal or rectovaginal fistulae or stress incontinence
HIV infection.

2-INCIDENCE
The incidence is 15-20 % of
the deliveries

INDICATIONS:
ABSOLUTE INDICATIONS
RELATIVE INDICATIONS
A- FETAL INDICATIONS
B-MATERNAL INDICATIONS
C-FETOMATERNAL INDICATIONS

ABSOLUTE INDICATIONS
A- FETAL INDICATIONS:
cord prolapse before 7 cm dilatation
B-MATERNAL INDICATIONS:
MAJOR DEGREE P-PREVIA
UPPER SEGMENT C-SECTION SCAR
PREVIOUS 2 LOWER SEGMENT C-SCAR
PREVIOUS VVF REPAIR
MATERNAL MEDICAL DISORDERS:
Marfans Syndrome
CARCINOMA CERVIX

ABSOLUTE INDICATIONS
C-FETOMATERNAL INDICATIONS:
GROSSLY CONTRACTED PELVIS
PERSISTENT TRANSVERSE LIE
PERSISTENT MENTOPOSTERIOR
POSITION
PERSISTENT BROW AND
FOOTLING BREECH
PRESENTATION

RELATIVE INDICATIONS
A-FETAL INDICATIONS:
Fetal distress
IUGR
Placental abruption
Fetal thrombocytopenia
Maternal infections e.g. HIV, genital
herpes
Rh isoimmunization
Cord prolapse beyond 7 cm

RELATIVE INDICATIONS
MATERNAL INDICATIONS:
P PREVIA TYPE 1 & 2
PE & ECLAMPSIA
PREVIOUS ONE C-SECTION
MATERNAL MEDICAL DISORDERS :
DIABETES , CARDIAC DISEASE,
RESPIRATORY DISEASE
MATERNAL PREFFERENCE

RELATIVE INDICATIONS
FETOMATERNAL INDICATION:
CPD
FETAL MALPRESENTATIONS : BROW
PRESENTATION IN EARLY LABOUR,
FLEXED BREECH
FETAL MACROSOMIA
PELVIC TUMORS: LOWER SEGMENT
FIBROID, BIG OVARIAN CYST IN POD

TYPES OF CAESAREAN
SECTION
THE CS IS DESCRIBED BASED ON THE TYPE OF
INCISION ON THE UTERUS

CESAREAN SECTION.
(A), CLASSIC; (B), LOW VERTICAL; (C), TRANSVERSE INCISIONS.

4-TYPES OF C-SECTION
1- LOWER SEGMENT C-SECTION:
2- UPPER SEGMENT C-SECTION: (classical
c section)
o Postmartum c-section
o Fibroid in lower uterine segment
o Cervical carcinoma
o Placenta previa
o Poorly formed lower segment
o Extensive bladder adhesions
3- MODIFIED CLASSICAL (De-Lee incision)

COUNSELLING
SKILLFULLY, SYMPATHETICALLY AND
PROFESSIONALLY
INDICATION,PROCEDURE AND
COMPLICATION
TYPE OF ANESTHESIA
STERILIZATION DURING ANTENATAL
PERIOD
BLOOD TRANSFUSION
THE OBJECTIVE OF COUNSELLING IS TO
MAKE THE WOMEN AND HER FAMILY
AWARE NOT TO HORRIFY

PREOPERATIVE
PREPARATION

PRE-OPERTIVE EVALUATION:
ORAL INTAKE: MENDELSON SYNDROME
CATHETERIZATION
BLOOD ARRANGEMENTS:
ANTIBIOTICS:
HEPARIN THERAPY: ONLY IN HIGH RISK
GROUPS
FAMILY/PERSONAL HISTORY OF THROMBOEMBOLISM
POSITIVE ANTI-PHOSPHOLIPID ANTIBODY
ETC
GENERAL MEASURES:

PREPARATION IN
THEATRE

LEFT LATERAL POSITION

O2 INHALATION
PEDIATRICIAN
UNDER SPINAL ANESTHESIA:
ARRANGEMENTS IF MOTHER
WANT TO HOLD THE BABY

ANESTHESIA
GENERAL ANESTHESIA
REGIONAL ANESTHESIA
LOCALNINFILTERATION

GENERAL ANESTHESIA
INDICATIONS
URGENT DELIVERY e.g. cord prolapse ,
Ab placentae

SEVERE HAEMORRHAGE
CARDIAC DISEASES e.g.
pulmonary/aortic stenosis
ANATOMICAL PROBLEMS: kyphoscoliosis
, spina bifida
COAGULOPATHY e.g. congenital/acquired

INDUCTION DELIVERY
INTERVAL
A good fetus acid base status can be
maintained up to 30 MINUTES AFTER
THE INDUCTION OF ANESTHESIA ,
provided patient is nursed in left
lateral position and oxygen is
administered in 100 % concentration
The uterine incision delivery interval
when
exceeds
3
MINUTES
is
associated with low Apgar score and
fetal acidosis

REGIONAL ANESTHESIA
THE MOTHER IS AWAKE AND STILL FEELS
A PART OF PROCESS OF CHILD BIRTH
NO RISK OF ASPIRATION/FAILED
INTUBATION
LESS BLOOD LOSS
QUICK RECOVERY , EARLY MOBILIZATION
& ORAL
INTAKE
EARLY BONDING WITH NEWBORN

LOCAL INFILTREATION
IS ACHIEVED BY ADMINISTRATION OF LOCAL
ANESTHETIC AGENT INTO THE FOLLOWING
SITES
Subcutaneous injection towards the
anterior edges of ribs 8-11 bilaterally
Additional infiltration at incision area
Infilteration into retropubic space,
rectus sheath and peritonium across
lower segment
Patient must remain fully co operative
It is effective only in skin and
peritonium
but
manipulation
of
internal organs causes severe pain

TECHNIQUE OF LSCS

ABDOMINAL WALL INCISION:

vertical midline
vertical paramedian
Pfannestiel incision

VARIANT OF CSECTION

RHESUS NEGATIVE MOTHER

packing the para-colic gutters
avoid manual removal of placenta
peritoneal lavage
FETAL MALPRESENTATIONS /
MALPOSITION
Obstructed labour
Preterm delivery
Placenta previa

COMPLICATIONS
1. INTRAOPERTIVE HAEMORRHAGE
2. URINARY TRACT INJURIES
3. BOWEL INJURIES
4. POSTOPERATIVE COMPLICATIONS
5. PARALYTIC ILEUS
6. THROMBO EMBOLISM
7. INFECTIONS
8. URINARY COMPLICATIONS
9. PSYCHOLOGICAL COMPLICATIONS
10.ANESTHESIA COMPLICATION

POST OPERATIVE CARE

GENERAL CARE
I/V FLUIDS
ANALGESIA
MOBILIZATION
CARE OF CATHETER
ORAL INTAKE
BABY CARE
CARE OF WOUND
PATIENT COUNSELLING

PREGNANCY AFTER ONE C-SECTION

PREGNANCY AFTER ONE

C-SECTION

THE RISK OF SCAR RUTURE

SCAR
RUPTURE
MATERNAL
MORTALITY
FETAL
MORTALITY

LOWER
SEGMENT
C-SECT

0.5 %

0.05%
12.5%

CLASSICA
L C-SECT

2.2 %
5 %
73 %

MANAGEMENT DURING
PREGNANCY
A WOMEN SHOULD HAVE REPEAT
CSECTION IF
HAD PREVIOUS CLASSICAL
CSECTION
De-Lee OPERATION
EXTENSION OF LOWER UTERINE
SEGMENT INCISION INTO UPPER
SEGMENT

THE EVALUATION OF PATIENT

REVIEW OF PREVIOUS CSECTION
NOTES
THE INDICATION
THE TYPE AND PLACE OF C-SECTION
LEVEL OF SURGEON
ANY POST OPERATIVE COMPLICATION
PRESENCE OF ANY ADDITIONAL RISK
FACTOR IN PRESENT PREGNANCY

THE EVALUATION OF
PATIENT
IN CURRENT PREGNANCY

ANY OTHER RISK FACTOR

SIZE AND LIE OF FETUS
AMOUNT OF LIQOUR VOLUME
LEVEL OF PRESENTING PART
PELVIC DIMENSION AND BISHOP SCORE
THE CLINICAL AND RADIOLOGICAL( XRAY,CT SCAN,MRI) PELVIMETRY IN THE
EVALUATION OF PATIENTS WHERE
PREVIOUS C-SECTION WAS CARRIED
OUT FOR CPD ARE NOT GREATLY
HELPFUL

IDEAL PATIENT FOR THE

TRIAL OF LABOUR AFTER
ONE C-SECTION

The previous c-section is carried out

in a hospital by a trained person &
there
was
no
intrapartum
or
postpartum complication
The c-section was carried out for nonrecurrent indication e.g. fetal distress
No risk factor in current pregnancy
The presenting part is well applied to
the lower uterine segment & the
labour starts spontaneously

TRIAL OF LABOUR
TRIAL OF UTERINE SCAR
is defined as giving chance to
deliver vaginally by keeping a
very low thresh hold for csection.
it should be allowed in a hospital
fully equipped with facilities for
emergency c-section

SIGNS OF SCAR
RUPTURE:
1. FETAL DISTRESS
2. MATERNAL
TACHYCARDIA
3.FRESH VAGINAL
BLEEDING

TRIAL OF UTERINE SCAR

Scar tenderness alone is of less value in
determining scar dehiscence , unless
accompanied by any of the above feature
Continuous electronic FHR monitoring
should be used for early detection of fetal
distress
Epidural analgesia block can be used in
patient with c-section as it do not block
pathological pain
Syntocinon use (for labour augmentation)
should be decided by a senior person &
ideally be used in combination with
intrauterine pressure catheter

A C-SECTION
SHOULD BE
PERFORMED
IF ANY OF THE
SIGNS OF SCAR
DEHISCENCE
APPERRS
OR
CERVIX FAILS TO
DIALTE AT A RATE OF
1 CM/HR IN THE
PRESENCE
OF
OPTIMAL
UTERINE
CAVITY