Cesarean Section
DEFINITION:
- It is an operative procedure whereby the fetuses after the end of 28th weeks are delivered through an incision on the abdominal and uterine walls.
FACTORS FOR RISING CESARIAN SECTION RATE:
- Rising incidence of primary cesarean delivery
- Identfication of at risk fetuses before term (FGR)
- Identfication of high-risk pregnancy
- Wider use of repeat CS
- Rising rates of induction of labor and failure of induction
- Decline in operative vaginal delivery & vaginal breech delivery
- Increased number of women with age >30 years
- Wider use of electronic fetal monitoring and increased diagnosis of fetal distress
- Fear of litigation
INDICATIONS:
Absolute Indications:
- Vaginal delivery is not possible
- Central placenta previa
- Contracted pelvis or cephalopelvic disproportion
- Pelvic mass
- Advanced carcinoma cervix
- Vaginal obstruction
Relative Indications:
- Previous cesarean delivery
- Fetal distress
- Dystocia
- Antepartum hemorrhage
- Placenta previa
- Abruptio placenta
- Malpresentation
- Failed surgical induction
- Recurrent fetal loss
- Hypertensive disorders
- Medical-gynecological disorders
- Diabetes
- Coarctation of aorta
- MS, AR, AS
- Marfan’s syndrome
- Mechanical obstruction
TYPES OF OPERATIONS:
- Lower segment CS.
- Upper segment (classical) CS.
- Modified classical (de-lee) CS.
Lower segment cesarean section (LSCS):
PATIENT PREPARATION
- Counseling.
- Written informed consent.
- Pre-operative evaluation.
- Preparation of incision area
- Bladder catheterization
- Blood arrangements
- Antibiotics
- Heparin therapy.
PATIENT PREPARATION IN OPERATION THEATRE
- Left lateral tilt at least 15 degree
- Oxygen inhalation
- Pediatrician should be available
- Auscultation of fetal hearts before starting.
ANESTHESIA
- General anesthesia
- Spinal anesthesia
- Epidural anesthesia
- Local infiltration.
SKIN INCISIONS :
- Pfannenstiel incision
- Joel-Cohen incision.
- Midline incision
- Para-median incision
Uterine incision:
- Peritoneal incision: Transverse cut across lower segment with convexity downwards
- Muscle incision: Low transverse(90%):Slightly below peritoneal incision
- Ease of operation
- Less bladder dissection
- Less blood loss
- Easy to repair
- Complete reperitonization
- Less adhesion
- Less risk of scar rupture
Other:
- Lower vertical
- Classical incision (upper segment).
- “J” incision
- Inverted “T” incision
PROCEDURE:
- Two index fingers are then inserted through the incision down to the membranes and the muscles of the lower segment are split transversely.
Delivery of the head:
- Membranes are ruptured
- Suction of blood mixed amniotic fluid
- Hooking the head with fingers by elevation and flexion using the palm
- If the head is jammed push up the head by fingers introduced into the vagina
- Wrigley’s or Barton’s forceps also be used
- Mucus from the mouth, pharynx and nostrils is sucked
Delivery of the trunk
- After delivery of shoulders IV oxytocin 20 units or methergine 0.2 mg is to be administered
- Head tilted down for gravitational drainage
- Cord is cut between two clamps
- The Doyen’s retractor is reintroduced.
- The optimum interval between uterine incision and delivery should be less than 90 seconds.
Removal of the placenta and membranes:
- Traction on the cord with simultaneous pushing of the uterus towards the umbilicus per abdomen using left hand
Suture of the uterine wound:
- Allis tissue forceps or Green Armytage hemostatic clamps are used to pick margins of the wound
The uterine incision is sutured in three layers:
First layer:
- Suture material is No “0” chromic catgut or vicryl
- Continuous running suture taking deeper muscles excluding or including the decidua
Second layer:
- Continuous suture placed taking superficial muscles and adjacent fascia overlapping first layer of suture.
- Uterine muscles may be closed taking full thickness muscle and decidua
- The peritoneal flaps may be apposed by continuous inverting suture
- Concluding part: The mops placed inside are removed and the number verified.
- Peritoneal toileting is done and the blood clots are removed meticulously
- After being satisfied that the uterus is well contracted, the abdomen is closed in layers.
CLASSICAL CESAREAN SECTION:
- Abdominal incision is always longitudinal (paramedian)12.5 cm (5″) starting from below the fundus
- Delivery commonly as breech extraction.
- The uterus is eventrated.
- The placenta is extracted by traction on the cord or removed manually
| Lower Segment | Classical | |
| Techniques | Difficult | Easy |
| Blood loss is less | More | |
| Wall is thin and as such apposition is perfect | Wall is thick and apposition of the margins is imperfect | |
| Perfect peritonization possible | Not possible | |
| Technical Difficulty in placenta previa or transverse | Comparatively safer | |
| Post-operative | Less Hemorrhage and shock | More |
| Peritonitis is less | More | |
| Convalescence is better | Relatively delayed | |
| Morbidity and mortality are much lower | Morbidity and mortality are high | |
| Less Peritoneal adhesions and intestinal obstructions | More | |
| Wound healing | Perfect muscle apposition | Imperfect |
| Minimal wound hematoma | More | |
| Wound Quiescent during healing process | Wound in state of tension | |
| Chance of gutter formation is unlikely | More | |
| During future pregnancy |
Scar rupture(0.5–1.5%) | More risk of scar rupture(4–9%) |
COMPLICATIONS:
Maternal:
INTRAOPERATIVE::
- Extension of uterine incision
- Uterine lacerations
- Bladder injury
- Ureteral injury
- Gastrointestinal tract injury
- Hemorrhage
- Morbid adherent placenta (placenta accreta)
POSTOPERATIVE COMPLICATIONS:
IMMEDIATE:
- Postpartum hemorrhage
- Shock
- Anesthetic hazards:Mendelson’s syndrome
- Infections
- Intestinal obstruction
- Deep vein thrombosis and thromboembolic disorders
Wound complications:
- Sanguineous or frank pus
- Hematoma
- Dehiscence
- Burst abdomen
- Necrotizing fasciitis
- Secondary postpartum hemorrhage
REMOTE:
- Gynecological: Menstrual excess or irregularities, chronic pelvic pain or backache.
- General surgical: Incisional hernia, intestinal obstruction due to adhesions and bands.
- Future pregnancy: There is risk of scar rupture
FETAL:
- Iatrogenic prematurity
- RDS
- MATERNAL AND PERINATAL MORTALITY
Exam Important
- Indications for caesarean section in pregnancy are Aortic stenosis, M.R. & Aortic regurgitaion
- Lower Segment Caesarean section (LSCS) can be carried out under
- General anaesthesia
- Spinal anaesthesia
- Combined Spinal Epidural anaesthesia
- Absolute indication for caesarean section in pregnancy are
- Advanced Carcinoma Cervix
- Central Placenta Praevia
- Contracted Pelvis
- History of previous classical CS is the contraindication for trial of normal labour after caesarean section
- Cephalopelvic disproportion is an absolute indication for Caesarean section.
- In classical caesarean section more chances of rupture of uterus is in Upper uterine segment
- Best management in Mento-posterior presentation Caesarean section
- Absolute indication for caesarean section is Type IV placenta previa
- Ideal management of a 37 weeks pregnant elderly primigravida with placenta praevia and active bleeding is Caesarean section
- Placenat accrete complicates third stage of labour and is associated with a past history of caesarean section
- Incidence of scar rupture in previous lower segment caesarean section 1%
- Risk of rupture of uterus with previous classical caesarean section is 4-8%
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