Cesarean Delivery
Dawit Desalegn
November, 2010
Cesarean Section
• The birth of a fetus through incisions in the
abdominal wall (Laparatomy) and the uterine
wall (Hystere...
HISTORY OF CESAREAN DELIVERY
• there is evidence from both early Western and
non-Western societies
• the term “cesarean” h...
History cont…
• Roman law under Caesar specified surgical removal of
the fetus before burial of deceased pregnant women.
•...
Cont…
• New methods for anesthesia = C/S for obstructed labor
gained popularity over destructive procedures
• But mortalit...
Cont…
• 1880 - 1925 = transverse incisions of the uterus
– reduced the rate of infection and rupture
• Extraperitoneal c/s...
• Cesarean deliveries are categorized as
either:-
• primary = first cesarean delivery
• repeat = after a previous cesarean...
PREVALENCE
• C/S rate worldwide = 15 % of births
• Mexico, Brazil, and Italy = over 35 %
• Africa has the lowest = < 5%
• ...
• Reasons why the cesarean rate quadrupled
between 1965 and 1988
1. Women are having fewer children, thus, a
greater perce...
6. Rates of labor induction continue to rise
7. Obesity
8. Concern for malpractice litigation
9. Concern over pelvic floor...
INDICATIONS
• performed when the clinician and patient feel that
abdominal delivery is likely to provide a better
maternal...
• not possible to catalog comprehensively
all appropriate indications for cesarean
delivery,
• over 80 percent are perform...
Additional, less common indications include:-
• Abnormal placentation
– placenta previa, vasa previa, placenta accreta
• M...
Prior Cesarean Delivery
• For many decades, a scarred uterus was believed to
contraindicate labor out of fear of uterine r...
• ACOG (1988) recommended that, in the
absence of a contraindication, a woman with one
previous low-transverse cesarean de...
Trial of Labor versus Repeat Cesarean
• Studies after 1989 = VBAC might be riskier than
anticipated
• uterine rupture and ...
Elective Repeat Cesarean Delivery
• compared with vaginal delivery, cesarean birth is
associated with increased risks, inc...
Assure fetal maturity!!!
• Establishment of Fetal Maturity Prior to Elective Repeat
C/S (ACOG Guidline)
1. Fetal heart sounds have been documented ...
• In all other instances, fetal pulmonary
maturity must be documented by :-
Amniocentesis for Fetal Lung Maturity
The on...
• The most recent recommendations of the ACOG
(2004) for selecting appropriate candidates:-
1. No more than 1 prior low-tr...
Type of Prior Uterine Incision
• LUST C/S = lowest risk of symptomatic rupture
• Classical incision = highest rates of rup...
Estimated Risks for Uterine Rupture in Women
with a Prior Cesarean Delivery
Prior Uterine Incision Estimated Rupture (%)
C...
Risk Factors for Rupture
• women with uterine malformations who have
undergone cesarean delivery = 8%
• women with a prior...
• Closure of Prior Incision
– Single Vs Double layer
• Healing of the Cesarean Incision
– regeneration of the muscular fib...
• Number of Prior Cesarean Incisions
– 0.8% Vs 1.8% - 3.7% = prior one Vs two
• Indication for Prior Cesarean Delivery
• s...
• Labor Induction or augmentation
– 2.3% Vs 0.4%
• Epidural analgesia
– Masks the pain of rupture
PREOPERATIVE ISSUES
Laboratory testing
– hemoglobin & blood type and antibody screen
Aspiration Prevention
Antibiotic prop...
Cont…
Thromboembolism prophylaxis
• Intermittent intra- and post-operative pneumatic
leg compression and
• Early ambulatio...
POSTOPERATIVE CARE
Monitor for evidence of :-
– uterine atony
– excessive vaginal or incisional bleeding
– oliguria
– Bloo...
COMPLICATIONS
• Endometritis
– 35 to 40 percent without prophylaxis
– 4 to 5 % after scheduled c/s with intact membranes,
...
• Urinary and gastrointestinal injuries
– Bladder injury = 0.28%
– Ureteral injury= 0.10%
– Ileus
• Maternal mortality
– r...
LONG-TERM RISKS
• Abnormal placentation
– Placenta previa, Accreta,
• Subfertility
• Scar complications
– Ectopic pregnanc...
- IS THERE AN UNSAFE NUMBER OF REPEAT C/S?
• insufficient data on which to base recommendations
for the "safe" number of r...
Stay Natural
Thank You
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Cesarean delivery

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Cesarean delivery

  1. 1. Cesarean Delivery Dawit Desalegn November, 2010
  2. 2. Cesarean Section • The birth of a fetus through incisions in the abdominal wall (Laparatomy) and the uterine wall (Hysteretomy). • This definition does not include removal of the fetus from the abdominal cavity – in the case of rupture of the uterus – in the case of an abdominal pregnancy
  3. 3. HISTORY OF CESAREAN DELIVERY • there is evidence from both early Western and non-Western societies • the term “cesarean” has been debated over time. • originally believed to have been derived from the birth of Julius Caesar, • it is unlikely that his mother, Aurelia, would have survived the operation. • Her knowledge of her son's invasion of Europe many years later indicates that she survived childbirth
  4. 4. History cont… • Roman law under Caesar specified surgical removal of the fetus before burial of deceased pregnant women. • Religious edicts required separate burial for the infant and mother. • Thus, the term cesarean more likely refers to – being cut open as the Latin verb “caedare” means to cut. • Cesarean operation was the preferred term before the 1598 publication of Guillimeau, – introduced the term “section.
  5. 5. Cont… • New methods for anesthesia = C/S for obstructed labor gained popularity over destructive procedures • But mortality rates remained very high, – sepsis and peritonitis • Surgeons complete the operation without closing the uterus – hemorrhage, sepsis • 1876, Eduardo Porro advocated routine hysterectomy with cesarean delivery • Silver wire stitches were developed by the gynecologist J. Marion Sims
  6. 6. Cont… • 1880 - 1925 = transverse incisions of the uterus – reduced the rate of infection and rupture • Extraperitoneal c/s • introduction of penicillin in 1940 • low cervical incision = Munro Kerr, 1926 • became technique of choice • Rate increasing since then ; – 1970 = 5% ; – 2004 = 29%
  7. 7. • Cesarean deliveries are categorized as either:- • primary = first cesarean delivery • repeat = after a previous cesarean birth • The total cesarean delivery rate is the sum of these two components.
  8. 8. PREVALENCE • C/S rate worldwide = 15 % of births • Mexico, Brazil, and Italy = over 35 % • Africa has the lowest = < 5% • China = 20 to 60 %, ( rural/urban) • Teaching hospitals in India = 25% • Here = 20 – 25%
  9. 9. • Reasons why the cesarean rate quadrupled between 1965 and 1988 1. Women are having fewer children, thus, a greater percentage of births are among nulliparas, 2. Average maternal age is rising, old-nullipara 3. The use of electronic fetal monitoring 4. Breech presentation 5. Incidence of midpelvic forceps and vacuum deliveries has decreased
  10. 10. 6. Rates of labor induction continue to rise 7. Obesity 8. Concern for malpractice litigation 9. Concern over pelvic floor injury associated with vaginal birth 10. Socioeconomic and Demographic factors
  11. 11. INDICATIONS • performed when the clinician and patient feel that abdominal delivery is likely to provide a better maternal and/or fetal outcome than vaginal delivery. • “Unscheduled " or "unplanned “ or “Emergency” – as a result of concerns identified after labor has begun • “Scheduled " or "planned” “Elective” – are used when the decision to perform is planned antepartum
  12. 12. • not possible to catalog comprehensively all appropriate indications for cesarean delivery, • over 80 percent are performed because of :- 1. Prior cesarean delivery = 30% 2. Dystocia = 30% 3. Fetal distress = 10% 4. Breech presentation = 11%
  13. 13. Additional, less common indications include:- • Abnormal placentation – placenta previa, vasa previa, placenta accreta • Maternal infection – HSV, HIV • Multiple gestation • Fetal bleeding diathesis • Mechanical obstruction to vaginal birth – tumor previa • Women at increased risk of complications from tissue trauma – invasive cervical ca., – active perianal IBD, – repair of a VVF/RVF – Repair of pelvic organ prolapse
  14. 14. Prior Cesarean Delivery • For many decades, a scarred uterus was believed to contraindicate labor out of fear of uterine rupture. • In 1916, Cragin = – "Once a cesarean, always a cesarean." • Whitridge Williams (1917) termed the statement "an exaggeration." • 1978 was another milestone in the history of prior cesarean delivery = 83% VBAC vs 2% • Evidence had accrued that uterine rupture was infrequent and rarely catastrophic
  15. 15. • ACOG (1988) recommended that, in the absence of a contraindication, a woman with one previous low-transverse cesarean delivery be counseled to attempt labor in a subsequent pregnancy • By 1996 = 30 percent of women with a prior cesarean were being delivered vaginally • The most remarkable change in obstetric practice over the last two decades
  16. 16. Trial of Labor versus Repeat Cesarean • Studies after 1989 = VBAC might be riskier than anticipated • uterine rupture and its associated complications clearly are increased with a trial of labor • But absolute risk of rupture = 7 per 1000 • Maternal mortality does not appear to differ significantly • A trial of labor resulting in death or injury to the fetus is about 1 per 1000  Is a 1 per 1000 risk of having an otherwise healthy fetus die or be damaged as a result of a trial of labor acceptable?
  17. 17. Elective Repeat Cesarean Delivery • compared with vaginal delivery, cesarean birth is associated with increased risks, including – anesthesia, – hemorrhage, – damage to the bladder and other organs, – pelvic infection, – scarring, • Despite this, an elective repeat cesarean is considered by many women to be preferable to attempting a trial of labor
  18. 18. Assure fetal maturity!!!
  19. 19. • Establishment of Fetal Maturity Prior to Elective Repeat C/S (ACOG Guidline) 1. Fetal heart sounds have been documented for 20 weeks by nonelectronic fetoscope or for 30 weeks by Doppler ultrasound 2. It has been 36 weeks since a positive serum or urine chorionic gonadotropin pregnancy test 3. An ultrasound measurement of crown-rump length, obtained at 6–11 weeks, supports current gestational age of 39 weeks or more 4. Clinical history and physical and ultrasound examination performed at 12–20 weeks support current gestational age of 39 weeks or more
  20. 20. • In all other instances, fetal pulmonary maturity must be documented by :- Amniocentesis for Fetal Lung Maturity The onset of spontaneous labor is awaited.
  21. 21. • The most recent recommendations of the ACOG (2004) for selecting appropriate candidates:- 1. No more than 1 prior low-transverse cesarean delivery 2. Clinically adequate pelvis 3. No other uterine scars or previous rupture 4. Physician immediately available throughout active labor who is capable of monitoring labor and performing emergency cesarean delivery 5. Availability of anesthesia and personnel for emergency cesarean delivery
  22. 22. Type of Prior Uterine Incision • LUST C/S = lowest risk of symptomatic rupture • Classical incision = highest rates of rupture • Importantly, in about one third of classical scar:-  rupture before the onset of labor.  several weeks before term
  23. 23. Estimated Risks for Uterine Rupture in Women with a Prior Cesarean Delivery Prior Uterine Incision Estimated Rupture (%) Classical 4 – 9 T-Shaped 4 – 9 Low Vertical 1 – 7 Low Transverse 0.2 – 1.5
  24. 24. Risk Factors for Rupture • women with uterine malformations who have undergone cesarean delivery = 8% • women with a prior vertical incision in the lower uterine segment without fundal extension may be candidates for VBAC • Women who have previously sustained a uterine rupture:- – LUS-rupture = 6% – Fundal- rupture = 32%
  25. 25. • Closure of Prior Incision – Single Vs Double layer • Healing of the Cesarean Incision – regeneration of the muscular fibers? – fibroblast proliferation? • If the cut surfaces is closely apposed, – minimal proliferation of connective tissue • Inter delivery Interval – MRI = complete uterine involution and restoration of anatomy may require at least 6 months – <18 Vs >18 months
  26. 26. • Number of Prior Cesarean Incisions – 0.8% Vs 1.8% - 3.7% = prior one Vs two • Indication for Prior Cesarean Delivery • success rate = 60 – 80% – Breech = 91% – Distress = 84% – Dystocia = 67 – 77% – Stage of labor at decision 73% Vs 13% • Prior Successful Vaginal birth (before or after a C/S)!!!
  27. 27. • Labor Induction or augmentation – 2.3% Vs 0.4% • Epidural analgesia – Masks the pain of rupture
  28. 28. PREOPERATIVE ISSUES Laboratory testing – hemoglobin & blood type and antibody screen Aspiration Prevention Antibiotic prophylaxis • a single IV & narrow spectrum antibiotic; 30min – (eg, ampicillin 2 g or cefazolin 1 to 2 g) • significantly reduced the incidence of – postoperative fever, – endometritis, – wound infection, – urinary tract infection, and – serious infection
  29. 29. Cont… Thromboembolism prophylaxis • Intermittent intra- and post-operative pneumatic leg compression and • Early ambulation, • Prophylactic anticoagulation in high-risk women Bladder catheterization • Convenience Vs UTI Hair removal • clipped rather than shaved
  30. 30. POSTOPERATIVE CARE Monitor for evidence of :- – uterine atony – excessive vaginal or incisional bleeding – oliguria – Blood pressure for hypo or hypertension, • Patient controlled opioid analgesia followed by oral NSAID = adequate analgesia • Early ambulation (when the effects of anesthesia have abated) • Oral intake (4-8 hrs of surgery) are encouraged. – stimulating the gastrocolic reflex.
  31. 31. COMPLICATIONS • Endometritis – 35 to 40 percent without prophylaxis – 4 to 5 % after scheduled c/s with intact membranes, – 85 % after an extended labor with ROM • Wound infection – 2.5 to 16 percent; four to seven days c/s • septic pelvic thrombophlebitis • Hemorrhage – mean blood loss =1000 mL – 2 to 3 % require blood transfusion – uterine atony - placenta accreta – extensive uterine injury - extension
  32. 32. • Urinary and gastrointestinal injuries – Bladder injury = 0.28% – Ureteral injury= 0.10% – Ileus • Maternal mortality – related to the underlying medical and obstetrical factors – Vaginal birth = 0.04 per 1000 – Cesarean birth = 0.53 per 1000 • Iatrogenic prematurity and birth trauma
  33. 33. LONG-TERM RISKS • Abnormal placentation – Placenta previa, Accreta, • Subfertility • Scar complications – Ectopic pregnancy in the scar = 1/1000 – Numbness or pain (Ilioinguinal and Iliohypogastric) – Incisional endometriosis • Uterine rupture
  34. 34. - IS THERE AN UNSAFE NUMBER OF REPEAT C/S? • insufficient data on which to base recommendations for the "safe" number of repeat cesarean deliveries • Several issues should be considered and discussed with the patient preoperatively: 1. Complications relating to abnormal placentation 2. Complications relating to adhesion formation 3. Complications relating to trial of labor 4. Other long-term complications
  35. 35. Stay Natural
  36. 36. Thank You

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