Cesarean Section

Definition
CS is an attempt to deliver a fetus,
placenta and membrane after 28
weeks of gestation, through an
incision on the abdominal wall and
the intact uterus
Removal of a fetus outside the
uterus (abdominal pregnancy) or
through a ruptured uterus or before
28 weeks is then not a CS.
 Objective
1. To reduce infant and maternal
morbidity
2. To reduce infant and maternal
mortality
 Indications
A. Based on urgency
Absolute or Relative
Emergency or Elective
B. Based on prognosis
Maternal indication
Fetal indication
Combined
C. General indications, based on
certain clinical situation or diagnosis
 General indications based on
diagnosis
Fetopelvic or cephalo pelvic
disproportion
Obstruction of birth canal
Uterine disfunction
Malposition or malpresentation
Maternal diseases
Scarred uterus or anomaly of the uterus
Cancer of the cervix
 Fetal indications (I)
Fetal distress
Malpresentation or malposition
Failed vacuum or forceps
Expensive child
Cord prolapsed
Placental insufficiency (IUGR)
 Fetal indications (II)
Incompatibility of rhesus
Post term pregnancy
Genital herpes
Diabetes mellitus
Elderly primigravida (>35 th)
Poor obstetric history
Giant fetus (> 4000 grams)
 Maternal indication
(Fetus already died)

Total placenta previa

Severe PE or Eclampsia, failed
induction
Threatened Uterine Rupture,
transverse lie
 Combined indications
Placenta previa
Abruptio placenta, alive fetus
Severe Preeclampsia /Eclampsia
FPD/CPD
Threatened Uterine Rupture (Over
stimulation)
 Contraindications
Severe chorioamnionitis
Very poor fetal prognosis, exp:
extremely premature, severe
congenital anomaly.
Fetal death, except in case of
placenta previa
No adequate facilities for surgical
procedure
 Types of Cesarean Section
Based on incision
1. Classical or corporal (vertical incision)
2. Low segment (horizontal incision)
Based on time
1. Emergency CS
2. Elective CS
Other
1. Extraperitoneal CS
2. Cesarean hysterectomy
 Clasic CS, Indications (1)

1. Difficult to reach the LUS

2. Transverse lie
3. Fetal distress
4. Placenta previa, anterior
implantation
5. Followed by sterilization
 Classic CS, Advantages
1. Faster
2. Easier
 Classic CS, Disadvantages

1. Bleeding may be more profuse

2. Difficult to luxate fetal head
3. Reperitonisation is incomplete
4. Risk of rupture during future
pregnancy
Low segment CS, Indications

Longitudinal lie
No problem with the LUS
Future pregnancy is expected
Low segment CS (Advantages)
Less bleeding
Incision to placenta is avoided
Easy to luxate fetal head
Easy to close (suture)
Good reperitonization
Risk of rupture in the next pregnancy
is minimal
 Low segment CS
(Disadvantages)
Takes more time
Bleeding may be more severe, if the
incision runs too laterally
Injury to the bladder may happen, if the
incision is too low
During repeated CS, post laparotomy,
or post infection, LUS may be too
difficult to identify
Cesarean histerectomy (1)
Definition: Cesarean section followed by
hysterectomy
Indications:
Uncontrolled bleeding
Placenta acreta, increta dan percreta
Multiple mioma
Cervical or ovarial ca
Unrepairable uterine rupture
Infection
 Cesarean histerectomy(2)
Complications
Morbidity and mortality is higher:
Takesmore time
Trauma to gut and bladder is higher

More bleeding

Psychological effects
No menstruation
Becomes steril
 Complication of CS
Bleeding (Atonia, Too large incision)
Infection (Incision site, peritonitis)
Trombophlebitis
Trauma (Gut, Bladder, Baby)
Ileus
Complications due to anesthesia and
surgical action
 Delivery after CS

Once cesarean always cesarean

Trial of vaginal delivery
Labor will progress easily
No significant complication to mother
and baby
 Contraindications to vaginal
delivery:
Repeated cesarean section
Vertical incision
Absolut indication for CS
Malposition and mal presentation
Maternal diseases (DM, Toxaemia)
Fetal distress, expenssive child etc.
 Maternal Death due to CS
10-30 cases per 100.000
Causes
Bleeding
Infection
Anesthesia
Pulmonary emboli
Heart and renal failure due to prolonged
hipotension
Maternal Death due to CS
(Risk Factor)
Elderly women
Grandemulti gravida
Obesity
PROM
Maternal diseases
Complicated pregnancy
Low social economic condition
 Infant Mortality
Theoretically it is not higher
Practically it is higher, because:
Complication of pregnancy
Misdetermination of age
Fetal distress
 Preparation for CS
Hemoglobin min. 10 g/dL
Heart, lung, electrolyte, liver and kidney, are
normal
Fast 6-8 hours
Match Blood, 250-500 ml
Antacid (30 ml) 1 hour before
Ampicillin 1 gram iv, 15-30 minutes before
operation
 Monitoring post operation
Stop oral feeding until peristaltics is good
Ivfd: Dextrose 5% and Na Cl 3:1
Closed monitoring of vital sign and fluids
balance
Antibiotics: Ampicillin 3 X 1000 mg and
Gentamycin 2 X 80 mg for 3 days
Vitamin
Mobilisation on day 2
Removal of suture on day 7
Discharge on day 8.