Cesarean Section

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:

  1. Peritoneal incision: Transverse cut  across lower segment with convexity downwards
  2. 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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