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  • 1. Presentation on Caesarean delivery By Daniel Angamo, IEOS year – I Instructor: Dr. Yisihak Tesemma, Obstetrician & Gynecologist Venue: Mizan Aman General Hospital
  • 2. Caesarean section Definition: The delivery of a viable fetus through an incision in the abdominal wall and uterus, usually carried out after viability has been reached i.e. 28 – 38 weeks of gestation onwards. Definition does not include removal of fetus from abdominal cavity in case of rupture uterus. WHO recommends an ideal caesarean rate of 15-20%.
  • 3. Why called so?? The technique was not widely used until the 1920s. According to legend, Julius caesar was born by this operation There is disagreement concerning the adjective ‘cesarean’ describing this procedure did not emanate from Julius Caesar's reign but rather from Numa Pompilius II, who in 730 BC decreed the procedure be performed upon women dying in the last few weeks of pregnancy in the hope of saving the child. The term may arise from a combination of the latin verbs (caedere) and (Seco) both meaning to cut. It was a fatal operation until beginning of 20th century. Now the most common operation performed worldwide
  • 4. INCIDENCE:  The incidence of caesarean section is steadly raising.  During the last decade there has been 2 – 3 folds rise in the inciddence from the initial rate of about 5% – 10%.  The incidence of the procedure was stable(3-5%) for many years, yet since 1960s, the rate of CS was rising steadily reaching (20-25%) in late 1980s.
  • 5. Why rates increasing? An increase in the rate is due to: • Increased awareness of fetal well being and idenification of risk factors have caused reduction of difficult operation or manipulative vaginal deliveries – high forceps and difficult mid forceps are abandoned in favour of Caesarean Section. • Increased safety of operation due to improved anesthesia, availability of blood transfusion and antibiotics. • Increase in repeat caesareans(>50% increase).
  • 6. • Increased diagnosis of intrapartum fetal distress(10-15% increase). • Increase in pregnancies by invitro fertilization • Increased repeated C.S due to increased primary C.S. • Destructive operations are abandoned in favour of C.S. • Demand of client and malpractice suites. • Decreased morbidity and mortality with C.S encourages its use. • Dystocia (30% increase). Why rates increasing?
  • 7. Types of C/S based on time of operation A. Elective caesarean section: The operation is done at a pre- selected time before onset of labour, usually at completed 39 weeks. It means pre-planning for doing caesarean section. Indication: CPD Placenta previa at ANC Bad obstetric history
  • 8. Advantages of elective caesarean section; * Pre-operative good preparation as regard sterilisation and antiseptic measures, fasting and bowel preparation. * The risk of puerperal sepsis is minimised. * The operation is scheduled and working is in ease. Types of C/S based on time of operation …
  • 9. Disadvantage of Elective caesarean section; * The risk of immaturity of the foetus or its lung is present. * Higher incidence of respiratory distress syndrome. * The lower segment may be not well formed. * Postpartum haemorrhage is more liable to occur. * Imperfect drainage of lochia as the cervix is closed so it should be dilated by the index finger introduced abdominally through the uterine incision. Types of C/S based on time of operation …
  • 10. B. Emergency caesarean delivery: When the operation is performed due to unforseen complication arising either during pregnancy or labour without wasting time following the decision. Indication: Cord prolapse, fetal distress Uterine rupture Eclampsia Prolonged first stage of labour Abnormal uterine contraction Types of C/S based on time of operation …
  • 11. a. Lower segment caesarean section (LSCS): ‒ It is the commonest type. ‒ The incision is done in the lower uterine segment and may be transverse (the usual) or vertical(rarely). b. Upper segment caesarean section (classical C/S): ‒ The incision is done in the upper uterine segment and it is always vertical. Types … based on site of uterine incision …
  • 12. a. Primary caesarean section: ‒ Done for the first time. b. Repeated caesarean section: ‒ There is previous caesarean section(s). Types … based on number of operation …
  • 13. a. Transperitoneal: The ordinary operation where the peritoneal cavity is opened before incising the uterus. b. Extraperitoneal: The peritoneal cavity is not opened and the lower uterine segment is reached either laterally or inferiorly by reflecting the peritoneum of the vesico-uterine pouch . It is indicated in case of infected uterine contents as chorioamnionitis. Types … relation to peritoneal cavity …
  • 14. Indication for Caesarean section 1. Absolute: • Vaginal atresia, previous successful repair of vesico-vaginal fistula. • Advanced carcinoma of cervix • Severe degree of contracted pelvis. 2. Relative: • Cephalopelvic disproporton, • Previous uterine scar and other uterine scar threatening uterine rupture. • Multiple fetal pregnancy and/or fetal distress. • Malpresentations and/or cord prolapse • Antepartum hemorrhage • Elderly primigravidae • Chronic hypertension, Diabetes • Pelvis atresia • Dystocia or dysfunctional labour • Placental insufficiency • Caesarian section on demand – Gossman and associates (2005) estimated that 2.5 percent of all births in the United States in 2003 were defined as cesarean delivery on maternal request (CDMR).
  • 15. Bad obstetric history as recurrent intrauterine foetal death in last weeks of pregnancy or repeated intranatal foetal death. Failed induction Failed instrument Post-mortem C.S. done within 10 minutes of maternal death to save a living baby. Other indications for C/S …
  • 16. The previous C/S be an indication if, a. The cause of the previous section is permanent e.g. contracted pelvis. b. Previous section was upper segment. c. Suspected weak scar as evidenced by: ‒ History of puerperal infection after the previous section. ‒ Hysterosalpingography or hysteroscopy done after the previous section reveals a defect in the scar. ‒ Vaginal bleeding during current labour. ‒ Marked tenderness over the scar during current labour. ‒ Associated conditions as antepartumhaemorrhage or malpresentations. Previous C/S as indication
  • 17. 1. Dead foetus: except in; a. Extreme degree of pelvic contraction. b. Neglected shoulder. c. Severe accidental haemorrhage. 2. Disseminated intravascular coagulation – to minimise blood loss. 3. Extensive scar or pyogenic infection in the abdominal wall e.g. in burns. 4. Baby is too much premature 5. Presence of blood coagulation disorder Contraindications for C/s
  • 18. Preoperative preparation • Prepare mother psychologically by providing assurance and explaining the indication, procedure and need of caesarean section. • Blood grouped and cross matched for emergency requirement. • Antibiotic prophylaxis • Heparin as thromboprophylaxis • Patients scheduled for elective procedure should be kept fasting for at least 8 hours and ranitidine 150mg should be given orally in the night before and repeated one hour before surgery to prevent gastric PH • Plans to decrease potential morbidity associated with aspiration of gastric contents should be carried out in non-elective procedure including administration of oral antacid (Magnesium Citrate within 1h of start of anesthesia).
  • 19. • Patient should be cleaned and be in clean gown, valuable ornament should be taken off and all make up should be removed. • Bladder should be empty by inserting foleys catheter – this may be done before and after induction of anaesthesia. • Administration of IV infusion to avoid hypotension following spinal anaesthesia, the infusion line is maintained patent by an intra venous cannula. • Parts cleansed with antiseptic solution • Left lateral position – reduce aortocaval compression, reduce risk of supine hypotension Preoperative preparation
  • 20. Regardless of the type of abdominal wound 1. The incision should be covered with a compression dressing and should be checked through the bandage for bleeding & the vital signs are measured for signs of hemorrhage. ‒ In general, the morning of the first postoperative day, bandages are removed whether skin clips, subcuticular closure, or mattress silk sutures have been used. 2. Care is taken to assess for the development of hematomas, seromas, or wound infections. Areas of redness and palpable masses or extraordinary tenderness or induration are carefully assessed twice daily. ‒ Signs of cellulitis require cultures and antibiotic therapy. 3. The notation of a watery discharge from the wound may herald impending wound dehiscence and should be treated as an emergency. Post OP care
  • 21. 3. With primary transverse CS, the skin clips and mattress sutures are removed on the fourth or fifth postoperative day or according to wound condition. 4. As after any major surgical procedure, the potential for severe maternal postoperative complications is present. Because of the hypercoagulable state of pregnancy, the hazard of postoperative embolization is increased: * Patients are encouraged to ambulate on the first postoperative day and are made to turn, cough, and deep-breathe immediately after surgery. *The diet is progressed from clear liquids on the evening of the operative day if surgery was in the morning, usually beginning about 8 to 12 hours after surgery. *Adequate pain medication is an essential component of postoperative management. Post OP care …
  • 22. Supplies/ Equipment for C/S1. Extra drape sheet 2. Towels 3. Receiving pack for baby 4. C-section tray 5. Delivery forceps 6. Cord clamp 7. Basin set 8. Blades 9. Neonatal receiving unit 10. Self-contained oxygen 11. I.D bands 12. Suction 13. Bulb syringe 14. Solutions 15. Suture
  • 23. Anaesthesia • Anaesthesia: General inhalation anaesthesia with nitrous oxide + oxygen (the most commonly used), regional (epidural, spinal), or rarely local infiltration anaesthesia. * Position: Tilting the patient 15⁰ to the left in the dorsal position minimise the aorto-caval compression. • Mendelson’s syndrome – GA given as emergency- risk of aspiration – chemical pneumonitis. • To counteract the effect, antacids given during labour, oral fluids withheld, 30 ml 0.3 molar sodium citrate given orally – 1/2 hr before surgery. • Sellick’s manoeuvre- endotracheal intubation accompained by pressure on cricoid cartilage
  • 24. Operation procedure – general The non gravid uterus is a pelvic organ closely covered by a layer of pelvic peritoneum. As pregnancy advances, the uterus grows up into the abdomen and this peritoneum rises up with the uterus and comes into contact with the abdominal peritoneum. Each of these layers must be incision and repaired. The abdominal peritoneum is situated
  • 25. Operation procedure - general… The anatominal layers are: a) Skin b) Fat c) Rectus sheath d) Rectus abdominis e) Abdominal peritoneum f) pelvic peritoneum g) Uterine muscles
  • 26. • Once abdomen opened – dextrorotation of uterus is corrected • Doyen’s retractor- visualize lower segment • Peritoneum over lower segment identified-divided transversely- seperated from bladder by blunt dissection • Small incision in lower segment- extended laterally • Do not injure uterine vessels lying laterally Operation procedure - general…
  • 27. The operation most commonly carried out is the lower segment caesarean section. The lower segment incision is in the less muscular and active part of the uterus and heals better. The main reason for preferring the lower uterine segment technique is the reduced incidence of dehiscent pregnancy. The abdomen is opened and the loose folds of the peritoneum over the anterior aspect of the lower uterine segment and above the bladder is incised. The operator continues to incise this further to visualize the fundus of bladder which is then Operation procedure - general…
  • 28. The surgeon direct the fetal head out while the assistant applies fundal pressure to hip the delivery of the baby. Oxytocins may be given by the anesthetist after delivery of the baby and clamping the cord. When the baby and placental have been delivered the uterus is sutured. Uterine fundus contracts – placenta and membranes extrudes spontaneously removed Operation procedure - general…
  • 29. Uterine edges – held with ALLIS forceps or GREEN ARMYTAGE forceps – incision closed in 2 layers continuous sutures The peritoneum then be closed over uterine wound to exclude it from the peritoneal cavity. The rectus sheath is closed then the layers of fat and finally the skin is sutured with the surgeons choice of materials; commonly vicryl a braided polyglactin preparation is used for this. Operation procedure - general…
  • 30. a. Anterior placenta praevia – try to pass beside the placenta to reach the foetus if this is impossible cut through it but severe bleeding will result which may affect the foetus. Problems encountered during the procedure and special techniques to manage
  • 31. b. Narrow uterine incision Extension of the lower uterine segment incision may be done by: * "J" shaped or hockey-stick incision: i.e. extension of one end of the transverse semilunar incision upwards. * "U"- shaped or trap-door incision: i.e. extension of both ends upwards. * An inverted T incision: i.e. cutting upwards from the middle of the transverse incision. This is the worst choice because of its difficult repair and poor healing. Problems encountered during the procedure and special techniques to manage
  • 32. 1. Lower segment caesarean section: • It is the commonest type • After Pfannenstiel(transverse suprapubic) or bikini line skin incision, the lower uterine segment is incised transversely as described by Kerr in 1921 – occasionally, a low-segment vertical incision as described by Krӧnig in 1912 may be used. • vertical in the following conditions; ‒ Presence of lateral varicosities. ‒ Constriction ring hindering to cut through it. ‒ Deeply engaged head. Lower Segment Caesarean Section
  • 33.  Advantage of lower segment uterine incision: • Transverse incision is made in the lower segment heals faster and sucessfully than an incision in the upper segment of the uterus. • Less bleeding unless extended (as the lower segment is less vascular and away from implantation), • There is less muscle and more fibrous tissue in lower segment which reduces the risk of rupture in a subsequent pregnancy (0.2 – 0.4%). • Less ileus, stomach dilatation,  Disadvantage – the LST uterine incision has a greater tendency to extend laterally into the uterine vessels at the time of operation. Lower Segment Caesarean Section …
  • 34.  Pfannenstiel or transverse suprapubic skin incision: The incision is made at the level of the pubic hairline and is extended somewhat beyond the lateral borders of the rectus muscles. Sharp dissection is continued through the subcutaneous layer to the level of the fascia. The superficial epigastric vessels can usually be identified halfway between the skin and fascia, several centimeters from the midline. If lacerated, these may be suture ligated or coagulated with an electrosurgical blade. Lower Segment Caesarean Section …
  • 35. After the subcutaneous tissue has been separated from the underlying fascia for 1 cm or so on each side, the fascia is incised. At this level, the anterior abdominal fascia is typically composed of two visible layers, the aponeuroses from the external oblique muscle and a fused layer containing aponeuroses of the internal oblique and transverse abdominis muscles. Ideally, the two layers are individually incised during lateral extension of the fascial incision. The inferior epigastric vessels typically lie outside the lateral border of the rectus abdominis muscle and beneath the fused aponeuroses of the internal oblique and transverse abdominis muscles. Thus, extension of the fascial incision further laterally may cut these vessels. Therefore, if lateral extension is required, these vessels should be identified and cauterizedor ligated to prevent bleeding and vessel retraction if lacerated. Lower Segment Caesarean Section …
  • 36. Advantage of Pfannenstiel or transverse suprapubic skin incision: • Follows Langer lines of skin tension and has a better cosmetic appearance, better healing and less incidence of incisional hernia but it is more time consuming when there is more blood loss and gives less exposure. Lower Segment Caesarean Section …
  • 37. What if inadequate space in transverse skin incision with LSCS? *When a transverse incision is desired and more room is needed, the Maylard incision provides a safe option (Ayers and Morley, 1987; Giacalone and colleagues, 2002). *In this incision, the rectus muscles are divided sharply or with electrocautery. * The incision also may be especially useful in women with significant scarring from previous transverse incisions.
  • 38. *The subcutaneous fat is incised. *The anterior rectus sheath is incised transversely in case of Pfannenstiel incision and longitudinally in case of vertical incisions * The rectus muscles: are separated in the midline in Pfannenstiel incision or retracted laterally in case of vertical incisions * The parietal peritoneum: is opened vertically. Lower Segment Caesarean Section …
  • 39. *The uterus is centralised, the bowel and omentum are packed off with moist laparotomy pads, however this is usually unnecessary. *The loose peritoneum over the lower uterine segment is held and incised transversely, for about 10 cm in a semilunar fashion with its edges directed upwards. * The bladder is dissected downward and is retained behind a Doyne retractor placed over the symphysis. Lower Segment Caesarean Section …
  • 40. * Transverse or oblique lie be corrected to longitudinal lie before making uterine incision. * Transverse lie with ruptured membranes & undeveloped lower segment require extension of uterine incision * A stay suture may be taken superficially in the lower segment below the assumed site of uterine incision to help in its identification after evacuation of the uterus. Lower Segment Caesarean Section …
  • 41. The uterus is incised: in the same semilunar fashion by one of the following methods: • A semilunar mark is made by the scalpel cutting partially through the myometrium for 10 cm. • A short (3cm) cut is made in the middle of this incision mark reaching up to but not through the membranes. • The incision (the short 3cm cut) is completed by the 2 index fingers along the incision mark or may be enlarged by a bandage scissors over 2 fingers introduced into the uterus to protect the foetus. • If the lower uterine segment is very thin, injury of the foetus can be avoided by using the handle of the scalpel or a haemostat (an artery forceps) to open the uterus. Lower Segment Caesarean Section …
  • 42. * Membranes are ruptured by toothed or Kocher’s forceps. * Suction for the foetus is carried out before delivery of the head. * In breech or transverse lie the foetus is extracted as breech. Lower Segment Caesarean Section …
  • 43.  Delivery of the baby • In cephalic presentation the head is delivered by; a. Introducing the right hand gently below the head and lifting it up helped by fundal pressure done by the assistant, b. using one blade of the forceps or, c. using Wrigley’s forceps. • If the head is deep in the pelvis it can be pushed up vaginally by an assistant. • The Doyen’s retractor is removed after the hand or forceps blade is applied and before head extraction. • Breech presentation • Feet hooked out first • The rest delivered as vaginal breech delivery  The placenta is removed. Lower Segment Caesarean Section …
  • 44. * Closure of the uterine incision is done in 3 layers. • Chromic catgut or polyglactin used • Any bleeding points – controlled with figure-of-eight sutures • The first is a continuous locking suture taking most of the myometrium but not passing through the decidua to guard against endometriosis and weakness of the scar. • The second is a continuous or interrupted one inverting the first layer. • The third is a continuous or interrupted layer to close the visceral peritoneum of the uterus – cSlosure of visceral and/or parietal peritoneum is omitted by some surgeons. * The abdomen is then closed in layers . • Parietal peritoneum – closed or not closed • RECTUS SHEATH – non absorbable sutures-proline- to reduce wound dehiscence & incisional hernia Lower Segment Caesarean Section …
  • 45. * Less blood loss: due to less vascularity and the placental bed is away from the incision. * Easier to repair. *The resultant uterine scar is stronger *Less subsequent adhesions to the bowel and omentum. *Less liability to acute gastric dilatation and paralytic ileus. * Less liability to peritonitis due to better peritonization and healing. Advantages of the lower segment over the upper segment operation
  • 46. 2. Upper segment caesarean section: ◦ Also called classical caesarean section – is a vertical incision into the body of the uterus above the lower uterine segment and reaches the uterine fundus – it is always vertical(midline or paramedian). ◦ Is rarely performed.  Indications: * Dense adhesions due to previous abdominal operation, extensive varicosity or myoma in the lower uterine segment making its exposure or incising through it difficult or when the lower segment is not developed. * Impacted shoulder presentation. * Anterior placenta praevia. Upper Segment Caesarean Section
  • 47. Indications … * Cancer of cervix. * Constriction ring * Rapid delivery is indicated – fetal distress. * Post-mortem hysterectomy or if a concomitant tubal sterilisation will be done. * Previous successful repair of high vesico- vaginal or cervico-vaginal fistula. • It may be also performed for transverse lie, fetal major malformation (sacrococcygeal tumor, severe hydrocephalus, etc). Upper Segment Caesarean Section
  • 48. Procedure: * Abdominal incision: is vertical. * Uterine incision: 10 cm vertical incision is made in the midline of upper uterine segment without incising the peritoneal coat separately as it is adherent in the upper segment. * Extraction of the foetus: as a breech in cephalic presentation. * The last layer of the uterine incision closure includes the superficial part of the myometrium with the peritoneal covering. * The remainder of the procedure is as lower segment C.S. Upper Segment Caesarean Section
  • 49. Parameters Transverse incision Vertical incision Cosmetic appeal More Less Postoperative pain Less More Wound dehiscence Less More Incisional hernia Less More Technical skill More Less Time taken More Less Access to upper abdomen Less Good, can be extended Transverse Vs vertical skin incision
  • 50. 3. Others types of C/S & associated procedures: The lower segment vertical incision Extra peritoneal CS Caesarean hysterectomy Caesarean sterilization
  • 51. 3.1 Lower segment vertical incision Indications:Constriction ring, lower segment not formed Disadv: • Possible downward extension with injury to cervix, vagina,bladder • Extends into the upper uterine segment and has been thought to have a greater incidence of rupture during subsequent pregnancies when compared with the LST incision, although this has not been substantiated.
  • 52. 3.2 Extraperitonial caesarean The peritoneal cavity is not opened and the lower uterine segment is reached either laterally or inferiorly by reflecting the peritoneum of the vesico-uterine pouch . It is indicated in case of infected uterine contents as chorioamnionitis. (Space of Retzius)
  • 53. 3.3 Caesarean hysterectomy  Indications • Hysterectomy is carried out after caesarean section for one of the following reasons: * Uncontrollable postpartum haemorrhage – Severe atonic PPH * Unrepairable rupture uterus. * Sepsis * Multiple large myomas * Operable cancer of cervix. * Placenta accreta,increta,percreta * Couvelaire uterus. * Severe uterine infection particularly that caused by Cl. welchii. *Multiple uterine myomas in a woman not desiring future pregnancy although it is preferred to do it 3 months later.  Can be total or subtotal/supracervical
  • 54. Tubal sterilisation is usually advised during the fourth caesarean section. 3.4 Caesarean Sterilisation
  • 55. The rule that "caesarean always caesarean" had been replaced since a long time by "caesarean always hospital delivery". If the cause of the previous section is not permanent as contracted pelvis, vaginal delivery can be tried. Mode of Delivery in Subsequent Pregnancies
  • 56.  Vaginal birth after Cesarean Section(VBAC): • Because more than 25% of cesarean sections are repeat procedures, vaginal births after cesarean section (VBAC) have become increasingly supported by the medical community. • The success rate for VBAC has been reported to be from about 60% for patients who were previously delivered for pelvic dystocia to more than 70% for patients who were delivered by cesarean birth for nonrecurring conditions; such as breech presentation or fetal distress. Mode of Delivery in Subsequent Pregnancies
  • 57. The advantages of vaginal birth include decreased maternal and neonatal morbidity as well as decreased hospital time for both mother and baby. The use of oxytocin or epidural anesthesia is not contraindicated in VBAC. A trial of labor should be offered for all with a nonclassical uterine incision. Mode of Delivery in Subsequent Pregnancies
  • 58. 1. Immediate care (4-6 hours): • In the immediate recovery period,the blood pressure is recorded in every 2 hourly. • The wound must be inspected half hourly to detect any blood loss. • The lochia are inspected and drainage should be small initially, • Following general anaesthesia, the women is nursed in left lateral or recovery position until she is fully conscious. • Analgesic is given as prescribed. Post OP care …
  • 59. 2. First 24 hours: IV fluids are continued, blood transfusion is helpful in case of anemia. Parental antibiotic is usually given for 1st 48 hours,analgesics is the form of pethidine 75-100mg are given as needed. Ambulation is encouraged following day of surgery and baby is given to mother. Post OP care …
  • 60. 3. After 24 hours: TPR are usually checked every 4 hourly Orally feeding is started with clear liquid and then advanced to normal diet (usually beginning about 8 to 12 hours after surgery) and IV fluid are continued for about 48 hours. Catheter may be removed on following day when the women is able to get up to the toilet. She should be helped to get out of bed. The mother must be encouraged to provide care to the baby and should breast feed the baby. The notation of a watery discharge from the wound may herald impending wound dehiscence and should be treated as an emergency. Post OP care …
  • 61. Obstetrics and Medico-Legal aspects Legally, obstetricians and hospitals are at risk if the outcome of any birth is less than perfect, particularly if a cesarean birth was not performed.
  • 62. Maternal Morbidity: • Although maternal morbidity has decreased significantly with cesarean section, it is still between 8 and 12 times higher than for a vaginal birth. • It may result from anesthetic complications, or those that arise in the intraopertative period as injury (bladder, ureter, bowel), bleeding with consequent anemia, infectious or thromboembolic complications. Complications of caesarean section
  • 63.  Maternal Mortality: • Improved surgical and anesthesia skills, antibiotics, aseptic techniques, and blood product availability have decreased the risks of this procedure. • However, caesarean birth still holds a much greater risk for the mother, with a maternal mortality rate of 20 per 100,000 births in the United States compared with a maternal mortality rate from vaginal delivery of 2.5 per 100,000 births. • Anaesthetic accidents, including aspiration pneumonia, severe sepsis and thromboembolic and hemorrhagic complication are the main cause of maternal death. Complications of caesarean section …
  • 64.  Fetal/Neonatal Mortality and Morbidity: • The safety of cesarean birth for the neonate has increased dramatically over the past 2 decades. • Elective cesarean sections are the major cause of iatrogenic preterm delivery (1% to 20% of hyaline membrane disease (HMD) cases are products of elective cesarean delivery). • When abdominal delivery must be performed prior to fetal maturity, it is imperative to document, confirm or be assured of pulmonary maturity. • Elective cesarean delivery no earlier than 39 weeks is advised by the American College of Obstetricians and Gynecologists. • If the patient has insulin-requiring diabetes mellitus during pregnancy, or dating cannot be firmly established, an amniocentesis is recommended to confirm lung maturity via a series of lung phospholipid studies if delivery is to be undertaken prior to 39 weeks' gestation. Complications of caesarean section …
  • 65. Complications of caesarean section … Intraoperative complications: • Primary haemorrhage • Injury to internal organs • Difficulty in delivery of the head • Anaesthetic complications to the mother • Shocks related to blood loss. • Iatrogenic prematurity. • Respiratory distress syndrome to the baby. • Injury to the baby due to surgical knife. • Birth asphyxia of the baby due to anaesthesia.
  • 66. Management of intra op complications: • Atonic uterus; ‒ give oxytocin 20units in 500ml ergometrine 0.25mg im or iv ‒ prostaglandin F2 alpha 250micgram im and intramurally ‒ PGE1 200micgram rectally • Traumatic – ligation of concerned vessels • Placenta accreta Complications of caesarean section …
  • 67. Postoperative complications: • Paralytic ileus • Respiratory complications • Infections/sepsis – postoperative febrile morbidity (10%-50%), depending on whether the cesarean birth is performed electively or during labor with ruptured membranes – markedly decreased with vaginal delivery (1%-3%). ‒ Endometritis, urinary tract infection, and wound infections are the major causes of postoperative morbidity following cesarean births. • Peritonitis • Pelvic abscess • Pelvic thrombophlebitis • Deep vein thrombosis and pulmonary embolism • Wound dehiscence Complications of caesarean section …
  • 68. Late sequelae: • Secondary PPH • Incisional hernia • Scar endometriosis • Vesico-vaginal fistula • Scar rupture in the next pregnancy • Menstrual irregularity • Chronic pelvic pain • Backache • Adhesive intestinal obstruction, ruptured uterine scar in next pregnancy, placenta praevia & placenta accerta to previous scar and incisionnal hernia more common with midline subumbilical vertical incision. Complications of caesarean section …
  • 69. References 1. Gabbe__Obstetrics: Normal and Problem Pregnancies__5th Edition 2. Williams__Obstetrics__23rd Edition 3.