for Students and Doctors

1. Dr. Jagat Bdr. Thapa
PAHS-SOM
10th June 2018
Cesarean Section (CS)

2.  Cesarean section has been part of human culture since
ancient times and there are tales in both Western and
non-Western cultures of this procedure resulting in live
mothers and offspring.
 According to Greek mythology, Apollo removed
Asclepius, founder of the famous cult of religious
medicine, from his mother's abdomen.
 Numerous references to cesarean section appear in
ancient Hindu, Egyptian, Grecian, Roman, and other
European folklore.
Brief History

3.  Yet, the early history of cesarean section remains
shrouded in myth and is of dubious accuracy.
 Even the origin of "cesarean" has apparently been
distorted over time. It is commonly believed to be
derived from the surgical birth of Julius Caesar, however
this seems unlikely since his mother Aurelia is reputed to
have lived to hear of her son’s invasion of Britain.
 At that time the procedure was performed only when the
mother was dead or dying, as an attempt to save the
child for a state wishing to increase its population.
 Roman law under Caesar decreed that all women who
were so fated by childbirth must be cut open; hence,
cesarean.

4.  Other possible Latin origins include the verb "caedare,"
meaning to cut, and the term "caesones" that was
applied to infants born by postmortem operations.

 Ultimately, though, we cannot be sure of where or when
the term cesarean was derived.
 Until the sixteenth and seventeenth centuries the
procedure was known as cesarean operation.
 This began to change following the publication in 1598
of Jacques Guillimeau's book on midwifery in which he
introduced the term "section.“
 Increasingly thereafter "section" replaced "operation."

5.  During its evolution cesarean section has meant
different things to different people at different times.
 The indications for it have changed dramatically from
ancient to modern times.
 Despite rare references to the operation on living
women,
 The initial purpose was essentially to retrieve the
infant from a dead or dying mother;
 This was conducted either in the rather vain hope of
saving the baby's life, or as commonly required by
religious edicts, so the infant might be buried
separately from the mother.

6.  Above all it was a measure of last resort, and the
operation was not intended to preserve the mother's
life.
 It was not until the nineteenth century that such a
possibility really came within the grasp of the medical
profession.
 Many of the earliest successful cesarean sections took
place in remote rural areas lacking in medical staff and
facilities.
 In the absence of strong medical communities,
operations could be carried out without professional
consultation.
 This meant that cesareans could be undertaken at an
earlier stage in failing labor when the mother was not
near death and the fetus was less distressed.

7.  Andreas Vesalius's monumental general anatomical text De
Corporis Humani Fabrica, published in 1543, depicts normal
female genital and abdominal structures.
 French obstetrician, Francois Mauriceau first reported
cesarean section in 1668.
 In 1876, Porro performed subtotal hysterectomy. It was Max
Sanger in 1882, who first sutured the uterine walls.
 In 1907, Frank described the extraperitoneal operation.
 Kronig in 1912, introduced lower segment vertical incision
and it was popularized by De Lee (1922).
 Although Kehrer in 1881 did the transverse lower segment
operation for the first time, Munro Kerr in 1926 not only
reintroduced the present technique of lower segment
operation but also popularized it.

8.  Since 1940, the trend toward medically managed
pregnancy and childbirth has steadily accelerated.
 Many new hospitals were built in which women gave
birth and in which obstetrical operations were
performed.
 By 1938, approximately half of U.S. births were taking
place in hospitals. By 1955, this had risen to ninety-nine
percent.

9.  Hormonal pregnancy tests that confirm fetal existence
have been available since the 1940’s.
 The fetal skeleton could be seen using X-rays, but, the
long-term hazards of radiation prompted researchers to
seek other imaging technology.
 The answer in the post-war era came from wartime
technology.
 Ultrasound, or sonar equipment that had been
developed to detect submarines, became the
springboard for soft tissue ultrasonography in the late
1940's and early 1950's.

10.  Cesarean delivery is defined as birth of a fetus via
laparotomy and then hysterotomy after a period of
viability.
 Definition does not include removal of fetus from
abdominal cavity in case of rupture uterus.
 WHO recommends an ideal caesarean rate of 15-20%.
 But in most countries it is more than 15-20%
Cesarean Section

11.  The incidence of cesarean section is steadily rising.
 responsible factors:
 Increased safety of the operation due to improved
anesthesia, availability of blood transfusion and
antibiotics,
 Rising incidence of primary cesarean delivery
 Identification of at risk fetuses before term
 Identification of high-risk pregnancy
 Wider use of repeat CS
 Rising rates of induction of labor and failure of
induction
Increasing Incidence of CS

12.  Decline in operative vaginal (mid forceps, vacuum) delivery
and manipulative vaginal delivery (rotational forceps)
 Decline in vaginal breech delivery
 Increased number of advanced maternal age and
associated medical complications. Most are nulliparous
 Adoption of small family norm- neither the obstetricians,
nor the patients are ready to accept any risk of abnormal
labor
 Wider use of electronic fetal monitoring and increased
diagnosis of fetal distress
 Cesarean delivery on maternal request
Increasing Incidence of CS

13. 1. Absolute: Vaginal Delivery is not possible like;
 Central placenta previa
 Contracted pelvis or cephalopelvic disproportion (CPD)
(absolute)
 Pelvic mass causing obstruction like broad ligament and
cervical fibroids
 Advanced cervical carcinoma
 Vaginal obstruction (Atresia, stenosis)
Indications of CS

14. 2. Relative indications: vaginal delivery is possible but
high risk to mother and foetus
 Cephalopelvic disproportion (relative)
 Previous c/s
 Non reassuring FHS
 Dystocia
 APH (placenta previa, Abruptio placenta)
 Malpresentations
 Failed IOL, NPOL
 Bad obstetrics history
 Hypertensive disorders like severe pre-eclampsia,
eclampsia
 Some Medical and gynaecological disorders
Indications of CS

15.  Previous Caesarean
 Dystocia
 Fetal distress
 Cephalopelvic disproportion
 Malpresentations ( esp. Breech)
 Failure of induction
 Antepartum haemorrhage
Common indications

16.  Valid in the absence of maternal indications of
abdominal delivery;
 Intrauterine fetal death
 Gross congenital malformations
 Extreme prematurity
 Coagulation defect
Contraindications of CS

17. A. According to timing:
1. ELECTIVE
 When the caesarean section is done as a planned
procedure to ensure optimal preoperative
preparation and surgical conditions
2. EMERGENCY
 When the caesarean section is done because of
sudden deterioration in maternal / fetal condition or
during labour due to non progress / failed induction
/ failed trial
Types of Cesarean Section

18. B. According to the site of uterine incision
1. Upper segment caesarean section (classical
C.S.):
 Incision is in the upper uterine segment and it is
always vertical.
2. Lower segment caesarean section (LSCS):
 It is the commoner type.
 The incision given in the lower uterine segment and
may be transverse (the usual) or vertical in the
following conditions:
 Presence of lateral varicosities.
 Constriction ring to cut through it.
 Deeply engaged head.
Types of Cesarean section

19. C. According to number of the operation
1. Primary caesarean section: for the first time.
2. Repeated caesarean section: with previous
caesarean section(s).
Types of Cesarean Section

20. D. According to opening the peritoneal cavity
1. Transperitoneal:
 The ordinary operation where the peritoneal cavity
is opened before incising the uterus.
2. 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 of Cesarean Section

21. 1. Preoperative actions/Patient preparation
 Check all pre-op Investigations
 Fetal presentation, position and FHS should be checked
 Keep patient NPO for at least 8 hours
 Valid informed consent
 Inj. Ranitidine 50 mg IV half to one hour before the
procedure
 Inj. Metoclopramide 10 mg IV half to one hour before
the procedure
 Check all the instruments and supplies required for CS
are available
 Foleys catheterization
Techniques of lower segment
Cesarean Section (LSCS)

22. 2. Anaesthesia
 Spinal (Most widely preferred)
 Epidural
 GA
3. Position
 Supine position, or
 15degree lateral tilt to prevent supine hypotension
/venocaval compression
4. Abdominal cleaning and draping
5. Abdominal incision
 Transverse ( Pfannensteil /Joel-Cohen)
 Post op pain is less
 Less chance of wound dehiscence / incisional hernia
 Cosmetically better

23.  Vertical infraumbilical midline
 Rapid entry into abdomen
 Capable of extention
 Blood loss minimal
6. Once abdomen opened- dextrorotation of uterus
corrected
7. Doyen retractor- visualize lower segment
8. Peritoneum over lower segment identified divided
transversely- seperated from bladder by blunt dissection

24. 9. Uterine incision
Lower segment transverse (Commonest)
 Small incision in lower segment-extended laterally (Up
to 10 cm)
 If Inadequate space- J shaped or inverted T incision
 Advantages of lower segment uterine incision:
 Apposition better
 Lesser bleeding due to less vascularity
 Less active uterine segment
 Healing better
 Stretch during subsequent pregnancy is along the
line of incision
 Chances of rupture during subsequent pregnancy/
labour are less

25. The loose vesicouterine serosa
above the bladder reflection is
grasped with forceps and incised
with Metzenbaum scissors.
The loose serosa above the upper
margin of the bladder is elevated and
incised laterally.

26. Cross section shows blunt dissection of the bladder off the
uterus to expose the lower uterine segment.

27. The myometrium is carefully
incised to avoid cutting the fetal
head.
After entering the uterine cavity, the
incision is extended laterally with fingers
or with bandage scissors

28. 10. Delivery of baby
 Cephalic presentation
 Hand slipped into uterine cavity
 Head is levered out gently, fundal pressure by
assistance
 Floating head- use forceps to deliver the baby.
 Breech presentation
 feet hooked out first
 rest delivered as vaginal breech delivery

29.  Transverse or oblique lie
 corrected to longitudinal lie before
 making uterine incision.
 Transverse lie with ruptured membranes &
undeveloped lower segment
 extension of uterine incision required in J shaped
or inverted T incision
Delivery of the fetal head.

30. The anterior and then the posterior shoulder are delivered.

31. 11. Closure of uterine incision
 OXYTOCIN infusion started as soon as baby is delivered
 Uterine fundus contracts-placenta and membranes
extrudes spontaneously removed
 Wipe with moist pad- ensure uterine cavity is empty
and cervical canal is open
 Uterine edges- held with ALLIS forceps or GREEN
ARMYTAGE forceps
Techniques of lower segment Cesarean
Section (LSCS)

32. The cut edges of the uterine incision are approximated with a running-lock
suture anchored at either angle of the incision.
 The uterine incision is closed in a single layer with
chromic catgut No: 1 or No: 2 using a interlocking
running suture to achieve haemostaisis
 Any bleeding points- controlled with figure of eight
sutures

33. 12. Closure of Abdomen
 PERITONEUM- closed or not closed
 RECTUS SHEATH - non absorbable sutures (proline) to
reduce wound dehiscence & incisional hernia
 SUBCUTANEOUS TISSUE – closed
 SKIN- mattress sutures of silk, sub-cuticular sutures or
clips are used
13. Vaginal toileting and patient transfer
Techniques of lower segment Cesarean
Section (LSCS)

34. INDICATIONS
 Access to lower uterine segment is restricted
because of adhesions
 Lower segment approach is not possible due to
 Anterior placenta previa
 Large fibroids in the lower uterine segment
 Transverse lie ( Dorso inferior positions)
 Pregnancy with Carcinoma cervix
 Post mortem caesarean section
Classical (Vertical incision) cesarean
section

35.  Nil orally for 24hrs
 Crystalloids for 24 hrs.
 Antibiotics as per hospital policy and Pain relief
 Care of the bladder (I/O charting)
 Monitor
 Vital parameters
 Vaginal bleeding
 Urine output
 Hydration
Postoperative care in CS

36.  Palpate the uterine fundus: Location and consistency
 Encourage early breast feeding
 Sips to liquid diet after 12-24 hrs., liquid to soft diet on
day 2 and normal diet on day 3 onward of operation
 Discharge from hospital after 72-96 hrs.
 Counsel on discharge:
 f/u for Stitch removal on 7th-10th post operative day
 Taking supplements and necessary medications
 Contraceptive advice
 To void exertion for 4 – 6 weeks
Postoperative care in CS

37. A. Intraoperative complications
 Primary haemorrhage (Primary PPH)
 Injury to internal organs
 Injury to the baby
 Difficulty in delivery of the head
 Anaesthetic complications
Complications of Cesarean Section

38. C. Late complications
 Secondary PPH
 Incisional hernia
 Scar endometriosis
 Vesico-vaginal fistula
 Scar rupture in the next
pregnancy
 Bladder injury
B. Postoperative
complications
 Paralytic ileus
 Respiratory
complications
 Infections, Peritonitis
 Pelvic abscess
 Pelvic
thrombophlebitis
 Deep vein thrombosis
and pulmonary
embolism
 Wound dehiscence
Complications of Cesarean Section

39.  The indications for cesarean section have varied tremendously
through our documented history.
 They have been shaped by religious, cultural, economic,
professional, and technological developments -- all of which
have impinged on medical practice.
 Finally, in the late twentieth century, in mainstream Western
medical society the fetus has become the primary patient once
labor has commenced.
 As a result, we have seen in the last decades, a marked increase
in resort to surgery on the basis of fetal health indications.
 An operation that virtually always resulted in a dead woman
and dead fetus now almost always results in a living mother
and baby-a transformation as significant to the women and
families involved as to the medical profession
Bottom line

40. Thank You!