Caesarean section

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Caesarean section

  1. 1. CAESAREAN SECTION DR. NAHEED BANO Assistant Professor Gynae/Obs. Unit 1 Holy Family Hospital, Rawalpindi
  2. 2. CAESAREAN SECTION • Name given to the operation performed to deliver the baby after the age of viability through an abdominal incision and is used as an alternative route to the natural vaginal birth. • Delivery of one or more babies by surgical incision through abdominal wall and uterine wall.
  3. 3. HISTORY • Goes back to 715 B.C when Numa Pompillus the king of Rome brought in a law which forbade the burial of pregnant women unless her child had been removed from abdomen and buried separately. • First recorded successful caesarean section done by Jacob Nufer on his wife for pronged obstructed labour in 1588.
  4. 4. HISTORY
  5. 5. One of the earliest printed illustrations of Cesarean section. Purportedly the birth of Julius Caesar. A live infant being surgically removed from a dead woman. From Suetonius' Lives of the Twelve Caesars, 1506 woodcut.
  6. 6. INCIDENCE 21% of all deliveries. Reasons for increase in incidence:  Prior caesarean delivery.  Multifetal gestation.  Use of intra-partum electronic fetal monitoring.  Changes in obstetric training.  Medico legal concerns.  Expectations of pregnancy outcome.
  7. 7. INDICATIONS FOR CAESAREAN SECTION Four Principal Indications:  Dystocia ( inadequate progress of labor ).  Suspected fetal compromise.  Malpresentations.  Prior caesarean birth.
  8. 8. INDICATIONS FOR CAESAREAN SECTION Previous caesarean section: Dystocia: 26.1% 23.0% Malpresentations: Suspected fetal compromise: 11.7% 10.7% OTHERS: Placental disorders Multifetal gestation Fetal disease Maternal medical conditions Cephalopelvic disproportion
  9. 9. TYPES OF CAESAREAN SECTION • Lower segment CS. • Upper segment (classical) CS. • Modified classical (de-lee) CS.
  10. 10. PATIENT PREPARATION • Counseling. • Written informed consent. • Pre-operative evaluation. • Preparation of incision area. • Bladder catheterization. • Blood arrangements. • Antibiotics. • Heparin therapy.
  11. 11. PATIENT PREPARATION IN OPERATION THEATRE  Left lateral tilt at least 15 degree.  Oxygen inhalation.  Pediatrician should be available.  Auscultation of fetal hearts before starting.
  12. 12. ANESTHESIA • General anesthesia. • Spinal anesthesia. • Epidural anesthesia. • Local infiltration.
  13. 13. SKIN INCISIONS • Pfannenstiel incision. • Joel-Cohen incision. • Midline incision. • Para-median incision.
  14. 14. Pfannenstiel incision
  15. 15. Joel-Cohen incision
  16. 16. COMPARISON OF PFANNENSTIEL & MIDLINE INCISION • • • • • • PFANNENSTIEL INCISION Slow to perform (53 mins ). Difficult to extend. Limited exposure. Wound breakage is rare. Cosmetically much better. Incisional hernia formation is rare. MIDLINE INCISION • Fast, operation time <45 mins. • Easy to extend. • Superior exposure. • More common. • Poor cosmetically. • More common.
  17. 17. OPENING THE ABDOMEN • The skin incision should extend well down into the fatty layers. • Small incision is given in the rectus sheath and is then extended the full length of the skin incision using either the scalpel or the dissecting scissors. • Midline is identified and the recti separated. • The incision is then extended the entire length of the wound by inserting the index finger of each hand and drawing the hands apart.
  18. 18. SKIN INCISION
  19. 19. SEPARATION OF RECTI
  20. 20. OPENING THE PARIETAL PERITONEUM
  21. 21.   OPENING THE VISCERAL PERITONEUM
  22. 22. SEPARATION OF BLADDER
  23. 23. UTERINE INCISIONS • Lower transverse incision (98.5%). • Classical (1.1%). • Inverted T (0.4%). • Low vertical.
  24. 24. LOW TRANSVERSE INCISION • Transverse incision at 1-2 cm below the junction of upper and lower segment. • Smiley shaped. • Gentle strokes with scalpel. • Extend laterally with curved scissors with curve upward or with index fingers. • Once membrane ruptured, deliver baby within 3 minutes.
  25. 25. TYPES OF INCISIONS
  26. 26. LOWER SEGMENT CESAREAN SECTION
  27. 27. LOWER SEGMENT CESAREAN SECTION Standard method ADVANTAGES:  Lower segment is less vascular  Less risk of rupture of uterine scar  Decreased risk of illeus and peritonitis  Decreased risk of adhesions and post op obstruction  Easy and rapid healing
  28. 28. CLASSICAL INCISION Midline longitudinal incision in uterine wall. INDICATIONS: • Transverse lie with the fetal back inferior. • As a preliminary to caesarean hysterectomy, treating carcinoma of cervix • Previous classical caesarean section • Large cervical fibroid • Placenta Praevia with large vessels in lower segment.
  29. 29. CLASSICAL INCISION • Preterm delivery with poorly formed lower segment. • Severe adhesions in lower segment reducing accessibility. • Postmortem caesarean section.
  30. 30. CLASSICAL CESAREAN SECTION
  31. 31. LOW VERTICAL INCISION INDICATIONS: • Lower uterine segment is not formed. • To cut Contraction ring to deliver baby.
  32. 32. COMPARISON OF LOWER SEGMENT & CLASSICAL CAESAREN. LOWER SEGMENT CS. Incision: Transverse incision in lower segment. Muscle Damage: Less Haemorrhage: Less haemorrhage Suturing: More fibrous tissue make suturing easy. UPPER SEGMENT CS. Vertical incision in upper segment. More More haemorrhage Less fibrous tissue makes upper segment rigid so suturing difficult.
  33. 33. COMPARISON OF LOWER SEGMENT & CLASSICAL CAESAREN Technical Difficulty: Size of incision may not be adequate and may extend in broad ligament and open major vessels. Bladder Injury: More common Post-OP Recovery: Quick Long Term Consequences: Less adhesion formation Size of incision is mostly adequate with adequate exposure. Less common May be delayed More adhesion formation
  34. 34. COMPARISON OF LOWER SEGMENT AND CLASSICAL CAESAREN Subsequent Pregnancy: Lower segment scar is not under pressure during next pregnancy and stretch only in labor. Risk of scar rupture is 0.5%. Scar is under tension during pregnancy and can rupture during antenatal period as well as in labor ( 2.2% ).
  35. 35. DELIVERY OF THE BABY • Head lifted with hand to apply to uterine incision. • Fundal pressure by assistant. • Outlet forceps. • Upward pressure through vagina.
  36. 36. DELIVERY OF BABY
  37. 37. DELIVERY AS BREECH
  38. 38. DELIVERY OF PLACENTA • Active management of third stage. • Hold uterine angles by green-armitages. • Remove placenta by cord traction. • Avoid manual removal as it increase risk of hemorrhage and infection.
  39. 39. RCOG RECOMMENDATION •At CS, the placenta should be removed using controlled cord traction and not manual removal as endometritis. this reduces the risk of
  40. 40. EXTERIORIZATION OF UTERUS FOR REPAIR  Better visualization.  Facilitates repair.  Decrease blood loss.  No increase in febrile morbidity. DISADVANTAGES:  Pain.  Vagal induced vomiting due to stretch.
  41. 41. RCOG RECOMMENDATIONS • Intraperitoneal repair of the uterus at CS should be undertaken. Exteriorization of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes hemorrhage and infection. such as
  42. 42. CLOSURE OF UTERUS • Two layers with continuous sutures. • Absorbable suture material. • Second layers buries the first one and makes wound strong and water tight. • Ensure that the first lateral suture is well beyond the lateral margin of angle. • Start suturing at the side away from surgeon. • Sutures generally placed 1cm apart.
  43. 43. SECURING UTERINE ANGLES
  44. 44. DOUBLE LAYER UTERINE CLOSURE
  45. 45. RCOG RECOMMENDATION • 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.
  46. 46. CLOSURE OF VISCERAL PERITONEUM ADVANTAGES:  Restore anatomy.  Reduction in infection.  Reduction in adhesion formation.  Reduction in wound dehiscence.
  47. 47. CLOSURE OF THE VISCERAL AND PARIETAL PERITONEUM
  48. 48. CLOSURE OF PARIETAL PERTONEUM
  49. 49. RCOG RECOMMENDATION • Neither the visceral nor the parietal peritoneum should be sutured at CS because this reduces operating time, the need for postoperative analgesia improves maternal satisfaction. and
  50. 50. CLOSURE OF FAT  Routine closure of the subcutaneous 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.  Superficial wound drains should not be used at CS because they do not decrease the incidence of wound infection or wound hematoma.
  51. 51. SKIN CLOSURE  Interrupted suture.  Staples (Rapid but increase pain).  Subcuticular suture. .
  52. 52. DO,S OF CAESARIAN ACCORDING TO RCOG  Wear double gloves for CS for women who are HIV-positive  Use a transverse lower abdominal incision (Joel Cohen incision)  Use blunt extension of the uterine incision  Give oxytocin (5iu) by slow intravenous injection  Use controlled cord traction for removal of the placenta
  53. 53. DO,S OF CAESARIAN ACCORDING TO RCOG  Close the uterine incision with two suture layers  Check umbilical artery pH if CS performed for fetal compromise  Consider women’s preferences for birth  Facilitate early skin-to-skin contact for mother and baby
  54. 54. DON’TS OF CAESAREAN SECTION Don’t:  Close subcutaneous space (unless > 2 cm fat)  Use superficial wound drains  Use separate surgical knives for skin and deeper tissues  Routine use of forceps to deliver babie’s head  Suture either the visceral or the parietal peritoneum  Exteriorize the uterus  Manually remove the placenta
  55. 55. POST-OPERATIVE MONITORING • Recovery Area – one-to-one observations until the woman has airway control, cardio respiratory stability and can communicate. • In The Ward – half hourly observations (respiratory rate, heart rate, blood pressure, pain and sedation) for 2 hours, then hourly if stable. • For Epidural Opioids And Patient-controlled Analgesia With Opioids – hourly monitoring during the CS, plus 2 hours after discontinuation.
  56. 56. CARE OF WOMAN AND BABY  Provide additional support to help women to start breastfeeding as soon as possible.  Offer diamorphine (0.3–0.4 mg intrathecally) or epidural diamorphine (2.5–5 mg) to reduce the need for supplemental analgesia.  Offer non-steroidal anti-inflammatory analgesics to reduce the need for opioid analgesics.  Women who are feeling well and have no complications can eat or drink when they feel hungry or thirsty.
  57. 57.  After regional anesthesia remove catheter when woman is mobile (> 12 hours after top-up).  Remove wound dressing after 24 hours, keep wound clean and dry.  Discuss the reasons for the CS and implications before discharge from hospital.  Offer earlier discharge (after 24 hours) to women who are recovering, with no pyrexia and have no complications.
  58. 58. RECOVERY FOLLOWING CS • Offer postnatal care, plus specific post-CS care, and management of pregnancy complications. • Prescribe regular analgesia. • Monitor wound healing. • Inform women they can resume activities (such as driving, exercise) when pain is not distracting or restricting.
  59. 59. CONSIDER CS COMPLICATIONS • Endometritis if excessive vaginal bleeding. • Thromboembolism if cough or swollen calf. • Urinary tract infection if urinary symptoms. • Urinary tract trauma (fistula) if leaking urine.
  60. 60. COMPLICATIONS OF CAESAREAN SECTION • ANESTHESIA RELATED: Aspiration syndrome Hypotension Spinal Headache
  61. 61. HEMORRHAGE • Uterine vessels damage • Uterine atony • Placenta previa/accreta • Lacerations Uterine lacerations Vertical lacerations into vagina Broad Ligament
  62. 62. URINARY TRACT • After prolong obstructed labour • Injury to vesico uterine space (Previous cesarean section) • Low vertical uterine incision
  63. 63. GASTROINTESTINAL TRACT • Ileus • Early oral intake Decrease time of return of bowel sounds Decrease post op stay Decrease abdominal distension
  64. 64. RESPIRATORY TRACT • Atelectasis/Pneumonia • Treatment Deep breathing exercise Postural drainage
  65. 65. THROMBOEMBOLSIM • Major cause of maternal morbidity/mortality • Increased chances in * Emergency LSCS * Advanced Maternal age * Obesity * Inherited thrombophilia disorders
  66. 66. PROPHYLAXIS • Use of mechanical calf compression intra op • Use of calf compression stocking • Subcut heparin (Low molecular wt heparin)

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