2. By
Ahmed Mowafy Ibrahim
Resident of obstetrics and gynecology
Qena University Hospital
South Valley University

3. List of Content
 Definition
 Historical Aspects
 Incidence
 Indications and contraindications
 Classifications
 Operative techniques
 Complications
 C.S versus V.D
 VBAC
 RCOG Guidlines

4. Definition
 It is the delivery of the fetus through an incision in
the abdominal wall (laparotomy) and uterine wall
(hysterotomy) after the age of viability.
 It is the third common surgical operation in the
world. (WHO 2006)
 1st is appendicectomy
 2nd is cataract surgery
 3rd is cesarean section

6. Historical Aspects
 Cesarean section has been part of human culture
since ancient times and there are tales in both
Western and non-Western cultures
 Numerous references to cesarean section appear in
ancient Hindu, Egyptian, Grecian, Roman, and other
European folklore depict the procedure on apparently
dead women.

7. Historical Aspects
 In the ancient roman age. The king numa pomphilus
(2nd king of Rome 762 – 715 B.C) issued a group of
laws called “Lex Regia” which prevent to bury a dead
pregnant women before the child had been extracted
from her abdomen.
 In the age of Julius Cesar this law became known as
“Lex Césara” and hence the name cesarean … The
legend that the Cesar himself was born by this way is
not sure.
 Others say that the word cesarean is derived from the
latin word “caedere” whisch means “to cut”.

8. Historical Aspects
 Year 1500 : Jacob Neufer, a Carpenter asked
permission of local mayer to cut open abdomen of his
wife who was in prolonged labor with his saw. First
request was not granted. He went second time and his
request was granted. He opened his wife abdomen.
 The term “Caesarian section” was first used by “James
Gullimeau”, in his midwifery book published in 1598.

9. Historical Aspects
 Lots of attempts were carried out in the 19th century
but the majority failed
 Year 1876: Eduardo Porro an Italian obstetrician
introduced a technique of amputation of body of
uterus after C.S. at this time this technique achieved a
major imrovement of abdominal delivery. Even to day
Caesarian hysterectomy is called Porro’s section.

10. Historical Aspects
 In the second half of the 19th century cesarean
section became a possible method in treatment of
major obstetric problems due to:
1. Introduction of ether anesthesia
2. Carbolic acid antisepsis
3. Technique of suturing the uterus introduced by
Sanger in 1882

11. Historical Aspects
 1912: Lower segment caesarian segment section was
first performed by Kronig and latter by Monro kerr.
and popularized in the USA by DeLee in 1922.
 1926: The transverse uterine incision was described
by Munro Kerr

12. Historical Aspects
 With further improvement in antibiotic therapy ,
blood transfusion and attention to fine operative
details the cesarean section is rising since the
nineteen sixties to present time .

14. Incidence
 It is the third common surgical operation in the world
(WHO 2006) .
 1st is appendicectomy
 2nd is cataract surgery
 3rd is cesarean section
 20% - 25% of deliveries anually by C.S.
 In USA the incidence increased from 4.5% in 1965 to
25% in 1988 then declines to 20.7% in 1996 due to
increased VBAC.

15. Incidence
 Causes of increased incidence :
1. Attempt to  perinatal mortality
2. Medical malpractice
3.  use of midpelvic ventose and forceps
4.  use of electronic fetal monitorng
5. Delivering most of breech presentation by C.S
6. Repeat CS
7. Non-medical consideration of obstetrician
8. Women selection (C.S on demand)

16. Incidence
 Causes of increased incidence :
9. In western societies , women marry late and end in
becoming elderly primigravida this  the need for
C.S

17. Incidence
 Situation in Egypt :
1. National income can not afford having one-third of
annual birth by C.S
2. Difficulties in availability of blood banks,
anesthesiology and incubators
3. The increased need for repeat C.S
4. Maternal mortality and morbidity is higher in C.S
than vaginal delivery especially with repeat C.S
when not all facilities are available

18. Incidence
 How to  the increased C.S rate ?
1. Training and education of obstetricians.
2. Encouraging VBAC
3. Obstetrician should be encouraged to give the
patient a full operative report about C.S including
the indication and complications occurred during the
operation

21. Indications
I. Maternal indications
II. Fetal indications
III.Feto-maternal indications

22. Indications
I. Maternal indications :
 Birth canal obstruction:
1. Contracted pelvis
2. Soft tissue obstruction.
3. Abdominal cerclage operation
 herpes simplex virus :
to decrease the risk of intrapartum transmission
 Gynecologic operations :
o Rpair of vesico-vaginal fistula
o Fothergill’s operation
o Repair of stress incontinence

23. Indications
I. Maternal indications :
 Third trimester bleeding
1. Placenta previa
2. Placental abruption
 Maternal disease:
Indicated but difficult delivery:
o hypertensive disorders
o D.M
o IUGR

24. Indications
I. Maternal indications :
 Uterine scar with weak myometrium:
1. Myomectomy with opening of the cavity.
2. Hysterotomy
3. Cesarean section scar in the following conditions
 Decision During labour:
a. Signs and symptoms of uterine scar dehiscence.
b. Arrest of satisfactory progress during labor.
c. Development of fetal distress during labour

25. Indications
I. Maternal indications :
 Uterine scar with weak myometrium:
3. Cesarean section scar in the following conditions
 Decision before labour:
a. previous classic C.S.
b. Previous uterine rupture
c. previous vertical LSCS that extended into the
upper uterine segment.
d. previous LSCS that extended laterally or
downwards.
e. recurrent indication for C.S
f. multiple pregnancy.

26. Indications
II. Fetal indications :
 Fetal Asphyxia: fetal scalp pH <7.2.
 Malpresentation: examples
1. Occipto-posterior position (DTA , POP)
2. Face presentation: all cases of M.P. and impacted
cases of M.A. position.
3. Breech presentation
4. Brow presentation
5. Cord presentation and prolapse if fetus is living

27. Indications
II. Fetal indications :
 Fetal anomalies:
1. Hydrocephalus:
2. Abdominal wall defects e.g. omphalocele to avoid its
rupture during vaginal delivery.
 Abnormal fetal weight:
1. Fetal macrosomia >4500gm.
2. Low-birth weight infant: < 1500 gm.
 A precious baby:
1. Elderly primigravida.
2. Bad obstetric history.
3. Long period of infertility

28. Indications
III. FETOMATERNAL INDICATIONS:
1. Arrest of labour " dystocia“.
2. Failed induction of labour.
3. Inadequate uterine contractility despite oxytocin
administration.
4. Arrest of cervical dilatation or fetal descent.
5. Impending rupture uterus.

29. Indications
 Most common indications for C.S.:-
1. Repeat C.S
2. Severe degree contracted pelvis.
3. Malpresentations
4. Fetal distress
5. Woman demand (elective C.S)

30. Indications
 Absolute indications of C.S :
1. Previous classic C.S. or CS extending to upper
segment
2. Previous ≥2 LSCS
3. Previous LSCS with malpresentation
4. Previous repair of vesicovaginal fistula
5. Extreme degree of contracted pelvis
6. Placenta previa centralis

31. Contraindications
“ THERE IS NO CONTRAINDICATIONS TO
C.S. IF THE FETUS IS LIVING “
 C.S should be performed on dead fetus in the
following conditions ( SAME ABSOLUTE INDICATIONS )
1. Severe degree of contracted pelvis
2. Placenta previa centralis
3. Presence of abdominal cerclage
4. Soft tissue obstruction
5. Previous 2 or more C.S
6. Prvious repair of vesicovaginal fistula

33. Classifications and Types of CS
According to Urgency :
RCOG classification of CS according to urgency
Proposed by “Lucas et al “ April 2010

34. Classifications and Types of CS
According to Urgency :
 Category I → Emergency CS :
Immediate threat to life of woman or fetus
 Category II → Urgent CS :
Maternal or fetal compromise which is not immediately life-
threatening
 Category III → Scheduled CS :
Needing early delivery but no maternal or fetal compromise
 Category IV → Elective CS :
At optimal time for woman and maternity team

35. Classifications and Types of CS
According to gestational age:
Before the age of viability → hysterotomy
After the age of viability → cesarean section
According to uterine incision:
 Transverse LSCS (Kerr incision)
 Vertical LSCS (De-Lee incision)
 Upper segment C.S.
 Others : Inverted –T , Hockey- stick incision

37. By
Ahmed Mowafy Ibrahim
Resident of obstetrics and gynecology
Qena University Hospital
South Valley University

38. List of Content
 Definition 
 Historical Aspects 
 Incidence 
 Indications and contraindications 
 Classifications 
 Operative techniques
 Complications
 C.S versus V.D
 VBAC
 RCOG Guidlines

40. Operative Techniques
Before CS you should :
 Take a patient consent
 Be sure that FHS are still audible
 Be sure that the indication is still valid
 Do routine U/S → (site of placenta - presenting part)
 Do preoperative testing (HB , Co-agulation profile )
 Ensure availability of blood
 Be sure that neonatal resuscitation team is available
 Give IV fluids (preload)
 Give a prophylactic antibiotics
 Fix a Foley’s catheter in the bladder

41. Operative Techniques
Steps :
I. Position
II. Anesthesia
III. Surgical draping
IV. Abdominal wall incision
V. Uterine wall incision
VI. Extraction of the fetus and afterbirth
VII.Repair of uterine wall
VIII.Repair of abdominal wall incision

42. Operative Techniques
I. Position
a. Supine
b. 15 left lateral tilt of theatre table

44. Operative Techniques
II. Anesthesia
II. general
III. spinal
IV. Epidural
V. Combined spinal and epidural
VI. local

45. Operative Techniques
II. Anesthesia
Spinal anesthesia :
Advantages:
1. Simple and rapid onset
2. Minimal fetal exposure to drug . Allow time for careful
abdominal wall incision and good haemostasis
3. Does not cause uterine atony
4. Patient is awake and take part in birth occasion
5. Small doses of intrathecal morphia could be given to ensure
post-operative analgesia
6. Avoidance of complication of
general anesthesia uterine atony and
pulmonary aspiration

46. Operative Techniques
II. Anesthesia
Spinal anesthesia :
Disadvantages :
1. Hypotension
2. intrapartum nausea and vomitting
3. spinal headache
4. Post-operative shivering

47. Operative Techniques
II. Anesthesia
Epidural anesthesia :
Advantages
1. Less incidence of hypotension because of slow onset of
sympathetic block
2. Less incidence of spinal headache
3. Allow repeated administration through epidural catheter if the
surgery is prolonged
4. Epidural catheter allow administration of post-operative
analgesia

48. Operative Techniques
II. Anesthesia
contra indication to regional anesthesia (spinal – epidural) :
1. Severe maternal hypertension
2. Severe hypovolemia
3. Hypotension due to any cause
4. Morbid obesity
5. Tocolysis with terbutaline
6. Congenital maternal heart disease where hypotension increase
rt. to lt. shunt
7. Coagulation disorders
8. Emergency CS
9. Patient refusal

49. Operative Techniques
II. Anesthesia
General anesthesia :
advantages
1. Can be given quikly (suitable for emergency CS)
2. Blood pressure and breathing are easily controlled
3. Better with bleeding and clotting abnormalities
4. Better in patient with psychological problems
5. Can be used in presence of infection that can spread to spinal
area

50. Operative Techniques
II. Anesthesia
General anesthesia :
disadvantages
1. Extraction of the fetus should be within 15 min. Nitous oxide
can cross placental blood barrier cardiodepressant effect on the
fetus
2. Acid aspiration syndrome
3. High incidence of uterine atony (Effect of halothan)
4. The patient doses not take apart in birth occasion

51. Operative Techniques
II. Anesthesia
Local anesthesia (extremely rare):
Indications
Patient with bad general condition that not suitable neither to
general nor to regional anesthesia ; severe coagulopathy , difficult
airway with the following precautions
1. Midline incision
2. No exteriorisation of the uterus
Drawbacks
1. Need long time
2. Patient discomfort
3. Does not provide satisfactory operating conditions

52. Operative Techniques
III.Surgical draping and toweling
Apply antiseptic solution three times to the incision site using a
high-level disinfected ring forceps and cotton or gauze swab then
toweling that allows good exposure

54. Operative Techniques
IV.Abdominal wall incision
a. Longtudinal abdominal incisions
Sub-umblical vertical midline incision
b. Transverse abdominal Incisionc
1. Pfannenstiel incision
2. Joel Cohen incision
3. Maylard incision
4. Cherny incision

55. Operative Techniques
IV.Abdominal wall incision

56. Operative Techniques
IV.Abdominal wall incision
Pfannenstiel incision:
Low transverse incision that curves gently upward, placed in a
natural skin fold, this incision is located two finger breadths above
the pubic symphysis
Advantages:
1. Early movement of the patient
2. Excellent cosmetic results
3. Less incidence of incisional hernia
Disadvantages:
1. More bleeding
2. Limited exposure of adnexae

57. Operative Techniques
IV.Abdominal wall incision
Sub-umblical vertical midline incision
The incision is made in the midline extending tow fingers below
the umblicus to the symphysis pubis
Advantages:
1. Takes less time
2. Less bleeding
3. Good exposure of pelvic viscera and adnexae
Disadvantages:
1. Higher incidence of wound infection
2. Poor cosmetic result
3. Higher incidence of Hernia

58. Operative Techniques
V. Uterine wall incision
1. Low transverse incision
2. Classical incision
3. Low vertical incision
4. J-shaped incision
5. T-shaped incision

59. Operative Techniques
V. Uterine wall incision

60. Operative Techniques
V. Uterine wall incision
Differences between upper & Lower uterine segment
Upper segment Lower segment
Perit. covering Firmly attached Loosely attached
Muscle layer Thick ; arranged in 3 layers Thin ; arranged in 2 layers
outer longtudinal , inner outer longtudinal and inner
circular and middle circular
interlacing fibers forming
figure of 8 around blood
vessels
decidua Well developed Poorly developed
Fet. membranes Firmly attached Loosely attached
Role in labour Active ; contraction + Passive ; stretched
retraction

61. Operative Techniques
V. Uterine wall incision
1. Low transverse lower segment incision (standard)
( kerr incision )
Advantages:
1. Easy to perform.
2. Less bleeding.
3. Easier to repair.
4. If infection occurs, it is limited to
extraperitoneal space.
5. Lower incidence of ileus, intestinal obstruction
6. Lower incidence of adhesions to intestine and omentum

62. Operative Techniques
V. Uterine wall incision
1. Low transverse lower segment incision (standard)
Advantages:
7. Better healing =lower risk of rupture as:
a. Proper coaptation of the edges during suturing as they are
thin.
b. LUS contains more fibrous tissue - easy placement of sutures
without cutting.
c. Not subjected to stresses during healing
d. Lower possibility of placental implantation on LUS.
e. Less tension on it in future pregnancies.

63. Operative Techniques
V. Uterine wall incision
2. Upper segment (classical type) → rarely used
Indications :
1. Difficult access to lower segment due to presence of ( fibroids ,
varicose veins and extensive adhesions )
2. Repaired vesicovaginal fistula
3. Impacted shoulder presentation
4. Postmortem C.S
5. Cancer cervix

64. Operative Techniques
V. Uterine wall incision
3. Low vertical incision (De-Lee incision)
Indications :
1.Underdeveloped lower uterine segment (Preterm fetus)
2.Transverse lie with back down.
3.Hydrocephalus.
4.Varicosities on LUS
5.Contraction ring

65. Operative Techniques
VI.Extraction of the fetus and afterbirth

66. Operative Techniques
VII.Aspirate nose and mouth of newborn
VIII.Cord Clamping
Delayed cord clamping benefits include:
1. decreased neonatal anaemia
2. Better systemic and pulmonary perfusion
3. better breastfeeding outcomes
4. Decrease incidence of neonatal jundice
IX.Give Newborn To Pediatrician
X. Repair of uterine wall incision
XI.Repair of abdominal incision

69. Complications
I. Intra opertaive complications
II. Early postoperative complications
III.Delayed " long-term“ complications

70. Complications
I. Intra opertaive complications
A. Anesthetic
1. usually with general anesthesia
2. failure of endotracheal intubation
3. inhalation of gastric contents "Mendelson syndrome “
4. amniotic fluid embolism
5. cardiac arrest
6. severe convulsions.
B. Bleeding:
more than the average (1000 ml)
Failure of blood coagulation mechanisms: DIC, HELLP syndrome

71. Complications
I. Intra opertaive complications
C. Uterine abnormalities:
1. Atony.
2. Uterine incision:
 Lateral extension to uteine vessels.
 Downward extension to cervix, vagina, or bladder.
3. Presence of uterine myomata.
D. Placental abnormalities:
 Placenta previa.
 Abruptio placentae
 Incomplete removal of the placenta: accreta, anomalies.

72. Complications
I. Intra opertaive complications
E. Trauma:
 Urinary tract injury:
 Bladder injury: due to
o Difficult dissection off the lower uterine segment
o Bladder trauma during uterine incision
o Extension of uterine incision to the bladder
 Ureteric injury: due to
o Extension of the uterine incision.
o Secondary to hemostatic sutures in the base of the broad
ligament.

73. Complications
I. Intra opertaive complications
E. Trauma:
 Bowel injury: Due to
 Blunt dissection of thick adhesions due to previous
surgery, PID.
 Putting a clamp on the bowel.
 Needle or suture passing through it.
 Sharp dissection by a scalpel or scissors.

74. Complications
II. Early postoperative complications
1. Post anesthetic complications:
 Respiration difficulties.
 Paralytic ileus and intestinal obstruction.
 Deep venous thrombosis and pulmonary embolism
2. Uterine bleeding: reactionary or secondary.
3. Trauma: fistula.
4. Infection: endometritis, peritonitis, cystitis, chest infection,
wound infection.
5. Psychological complications.

75. Complications
III.Delayed " long-term“ complications
1. Adhesions:
• Tubo-peritonal leading to infertility.
• Bladder adhesions making subsequent surgeries difficult.
• Intrauterine adhesions if the anterior and posterior walls
of the uterus were sutured together Asherman syndrome.
• Intestinal adhesions leading to intestinal obstruction
• Chronic pelvic pain
2. Weak uterus:
• Perforation if D&C is done in the presence of a weak scar.
• Rupture of the uterus at the site of the scar in future
pregnancies.
3. Risk of incisional hernia.
4. Higher risk of placenta accreta.

77. Vaginal Birth After CS “VBAC”
 Definition :
It is the trial of vaginal birth after C.S. in
previous pregnancy.
• In the past → once cesarean, always cesarean
• Now → Once CS always hospital delivery
• Risk of uterine dehiscence of LSCS is 0.2%

78. Vaginal Birth After CS “VBAC”
 Conditions that should be fulfilled before trial of VBAC
A. Non-recurrent indication.
B. Previous C.S.:
o Known type; single transverse LSCS type.
o Proper surgical technique: use of delayed absorbable
sutures is preferred.
o Smooth postoperative course. No infection.
o A long interval between C.S. and current pregnancy.
C. Current pregnancy:
o Single fetus.
o Vertex presentation.
o Average fetal weight.
o No medical risks.
o No other indication for C.S

79. Vaginal Birth After CS “VBAC”
 Conditions that should be fulfilled before trial of VBAC
D. Competent obstetrician to follow the patient in a well-
equipped hospital capable of performing urgent C.S. once
uterine dehiscence is detected.
1. Available anesthesia
2. Good nursing
3. Available operation room
4. Available blood
5. Available neonatal resuscitation team

81. Vaginal Delivery vs CS
 Fetal outcome

82. Vaginal Delivery vs CS
 Maternal outcome
1. Physical problems in mothers: due possible complications
2. Hospitalization of mothers: If a woman has a cesarean there is
a more hospital stay
3. Breastfeeding: Recovery from surgery poses challenges for
getting breastfeeding under way, and a baby who was born by
cesarean is less likely to be breastfed and get the benefits of
breastfeeding.
4. Health of babies: Babies born by cesarean are more likely to:
a. be cut during the surgery (usually minor)
b. have breathing difficulties around the time of birth
c. experience asthma in childhood and in adulthood.

83. Vaginal Delivery vs CS
 Maternal outcome
5. Future reproductive problems for mothers:
a. ectopic pregnancy: pregnancies that develop outside her
uterus or within the scar
b. reduced fertility, due to either less ability to become
pregnant again or less desire to do so
c. placenta previa: the placenta attaches near or over the
opening to her cervix
d. placenta accreta: the placenta grows through the lining of
the uterus and into or through the muscle of the uterus
e. placental abruption: the placenta detaches from the uterus
before the baby is born
f. rupture of the uterus: the uterine scar gives way during
pregnancy or labor.

86. RCOG Guidelines
 Timing of planned CS
The risk of respiratory morbidity is increased in babies born by CS
before labour, but this risk decreases significantly after 39 weeks.
Therefore planned CS should not routinely be carried out before 39
weeks.
 Delivery time for emergency CS
Delivery at emergency CS for maternal or fetal compromise should
be accomplished as quickly as possible, taking into account that
rapid delivery has the potential to do harm. A decision-to-delivery
interval of less than 30 minutes is not in itself critical in influencing
baby outcome, but remains an audit standard for response to
emergencies within maternity services.

87. RCOG Guidelines
 Preoperative testing and preparation for CS
 grouping and saving of serum
 cross-matching of blood
 a clotting screen
 preoperative ultrasound for localisation of placenta
 Anesthesia for CS
 Pregnant women having a CS should be given information on
different types of post-
 Women who are having a CS should be offered regional
anaesthesia because it is safer and results in less maternal and
neonatal morbidity than general anaesthesia. This includes
women who have a diagnosis of placenta praevia.

88. RCOG Guidelines
 Maternal request for CS ( C.S on demand )
 When a woman requests a CS in the absence of an identifiable
reason, the overall benefits and risks of CS compared with
vaginal birth should be discussed and recorded.
 When a woman requests a CS because she has a fear of
childbirth, she should be offered counseling (such as cognitive
behavioural therapy) to help her to address her fears in a
supportive manner, because this results in reduced fear of pain in
labour and shorter labour.
 An obstetrician has the right to decline a request for CS in the
absence of an identifiable reason. However the woman’s
decision should be respected and she should be referred for a
second opinion.

89. RCOG Guidelines
 Abdominal-wall incision
CS should be performed using a transverse abdominal incision
because this is associated with less postoperative pain and an
improved cosmetic effect compared to a midline
 Use of separate surgical knives
The use of separate surgical knives to incise the skin and the
deeper tissues at CS is not recommended because it does not
decrease wound infection.

90. RCOG Guidelines
 Uterine dissection
When there is a well formed lower uterine segment, blunt
rather than sharp extension of the uterine incision should be
used as it reduces blood loss, incidence of postpartum
hemorrhage and the need for transfusion at CS.
 Cord clamping
Suggested benefits of delayed cord clamping include decreased
neonatal anaemia; better systemic and pulmonary perfusion;
and better breastfeeding outcomes. Possible harms are
polycythaemia, hyperviscosity, hyperbilirubinaemia, transient
tachypnoea of the newborn and risk of maternal fetal
transfusion in rhesus negative women

91. RCOG Guidelines
 Use of uterotonics
Oxytocin 5 IU by slow intravenous injection should be used at CS
to encourage contraction of the uterus and to decrease blood
loss
 Method of placental removal
At CS, the placenta should be removed using controlled cord
traction and not manual removal as this reduces the risk of
endometritis.

92. RCOG Guidelines
 Exteriorisation of the uterus
Intraperitoneal repair of the uterus at CS should be undertaken.
Exteriorisation of the uterus is not recommended because it is
associated with more pain and does not improve operative
outcomes such as haemorrhage and infection.
 One- vs. two-layer closure of uterus
The effectiveness and safety of single layer closure of the
uterine incision is uncertain.
Except within a research context the uterine incision should be
sutured with two layers

93. RCOG Guidelines
 Closure of the peritoneum
Neither the visceral nor parietal peritoneum should be sutured
at CS as this reduces operating time, the need for postoperative
analgesia and improves maternal satisfaction.
 Closure of subcutaneous tissue
Routine closure of the subcutanoues tissue space should not be
used, unless the woman has more than 2 cm subcutaneous fat,
because it does not reduce the incidence of wound infection.

94. RCOG Guidelines
 Hospital stay after C.S
Length of hospital stay is likely to be longer after a CS (an
average of 3–4 days) than after a vaginal birth (average 1–2
days). However, women who are recovering well, are apyrexial
and do not have complications following CS should be offered
early discharge (after 24 hours) from hospital and follow up at
home, because this is not associated with more infant or
maternal readmissions.