2. Primary Cesarean
Section.
Repeat Cesarean Section
First operation
performed on a patient
Performed in
subsequent
pregnancies
INTRODUCTION
Operative procedure : fetuses after the end of 28th
weeks are delivered through an incision on the
abdominal and uterine walls.
Incidence: steadily rising. - Initially 10%. 2-3 fold rise
1. Increased safety of the operation
2. Availability of blood transfusion
3. Avaibility of antibiotics,
7. a. Elective
Benefits
No hazard from labor and
• delivery process.
No pelvic floor dysfunction.
Risks
Placenta previa and
Hysterectomy
Longer recovery time
/hospital stay.
TIMING OF ELECTIVE SECTION
Maturity is certain Maturity is uncertain
Done about 1 week prior to the
expected date of confinement
(EDD)
1. Ultrasound assessment in first
or second trimesters
1.Amniocentesis for L:S ratio
used to ensure fetal maturity.
2.Otherwise spontaneous onset of
labor is awaited and then CS is
done.
8. b. Emergency - categories
1, 2 & 3
Category 1 -When there is immediate threat to the
life of the woman or the fetus.
-Decision delivery interval should be
17 minutes
Category 2 -When there is maternal or fetal
compromise which is not immediately
life threatening.
-CS should be done within 30
minutes of making decision
Category 3 There is no maternal or fetal
compromise 75 mins
Category 4 Elective section
9. SECTION(type)
LOWER SEGMENT
CESAREAN SECTION
• Extraction through
• an incision made in the
• lower segment
• Through a
• transperitoneal approach.
• Only method practiced in
present day obstetrics
• Cesarean section means
lower segment operation.
CLASSICAL
• Extracted through an
incision made in the upper
segment of the uterus.
• Its indications very much
limited (done under forced
circumstances)
10. Forced Circumstances For
Classical Section
Lower Segment
Approach Is
Difficult:
Dense
adhesions
Severe
contracted
pelvis
Lower Segment
Approach Is Risky
Big fibroid on
the lower
Carcinoma
Repair of high
VVF
Complete anterior placenta
previa with engorged vessels
11. LSCS SURGERY STEPS
a. Perioperative preparation
b. Incision
c. Delivery of
a. Head
b. Trunk
c. Placenta and membrane
d. Suturing
e. Concluding part
12.
13. a. Perioperative
Premedicative sedative must not be given.
Hair may be clipped.
Informed written permission for the procedure, anesthesia
and blood transfusion is obtained.
Abdomen is scrubbed with soap and nonorganic iodide
lotion.
14. Metoclopramide (10 mg IV) to
increase the tone of the lower esophageal
sphincter as well as to reduce the stomach contents..
Ranitidine (H2 blocker) 150 mg is given orally night before
(elective procedure) and it is repeated (50 mg IM or IV) 1
hour before the surgery
The stomach should be emptied, - stomach tube (emergency
procedure).
Nonparticulate antacid (0.3 molar sodium citrate, 30 ml) is
given orally.
15. IV cannula: sited to administer fluids (ringer’s solution, 5%
dextrose).
FHS should be checked once more at this stage.
Neonatologist should be made available.
Cross match blood
Prophylactic antibiotics should be given (IV) before making
the skin incision.
Bladder should be emptied by a foley catheter which is kept
in place in the perioperative period.
16. ANESTHESIA -Spinal, epidural or general
ANTISEPTIC PAINTING
POSITION OF THE PATIENT
INCISION
PACKING
-Painted with 7.5% povidone-iodine
solution/ savlon lotion and properly draped
with sterile towels
-Dorsal position. In susceptible cases,
-A 15° tilt to her left using a wedge till
delivery of the baby should be done.
-Vertical or a transverse skin incision.
-Modified pfannenstiel is made 3 cm above
the symphysis pubis.
-The doyen’s retractor is introduced.
-The peritoneal cavity is now packed off
using two taped large swabs.
-The tape ends are attached to artery
forceps. -This will minimize spilling of the
uterine contents into the general peritoneal
cavity
20. b. incision UTERINE
INCISION
Peritoneal
Incision
The loose
peritoneum of the
uterovesical pouch is
cut transversely
across the lower
segment
The lower flap of
the peritoneum is
pushed down a
little.
Muscle
Incision
The most
commonly used
incision (90%) is
low transverse.
21. Other types of uterine incisions
Lower vertical—may be extended upwards when
needed. - Kronig's incision
Classical incision (upper segment).
“J” incision—upward vertical extension of the initial
transverse incision.
Inverted “T” incision—upward extension from the
mid-transverse incision.
Vertical uterine incision - made when the lower
segment is poorly developed or there is complete
anterior placenta previa or any myoma occupying
the lower segment.
22.
23.
24. LOW TRANSVERSE INCISION
Made at a level slightly below the peritoneal incision
until the membranes of the gestation sac are
exposed.
Two index fingers are then inserted and the muscles
of the lower segment are split transversely across
the fibers.
This method minimizes the blood loss but requires
experience.
This is called Munro-Kerr incision
25.
26. c. Delivery Of The Head
The membranes are ruptured
The blood mixed amniotic fluid is sucked
The doyen’s retractor is removed.
The head is delivered by hooking the head with the
fingers
The head is delivered by elevation and flexion using
the palm to act as a fulcrum.
As the head is drawn to the incision line, the
assistant is to apply pressure on the fundus.
Push up the head by sterile gloved fingers
introduced into the vagina.
Delivered using wrigley’s/Baton's forceps.
27. d. Delivery Of The Trunk
Mucus from the mouth, pharynx and nostrils is sucked
out
After the delivery of the shoulders, intravenous Oxytocin
10 units is to be administered.(AMSTL- after delicery of
body)
The rest of the body is delivered slowly
Baby is placed in a tray placed in between the mother’s
thighs with the head tilted down for gravitational
drainage.
The cord is cut in between two clamps and the baby is
handed over to the pediatrician.
The doyen’s retractor is reintroduced.
The optimum interval between uterine incision and
delivery should be less than 90 seconds.
Interval > 90 seconds are associated with poor apgar
28. e. Removal Of The Placenta
And Membranes
placenta is separated spontaneously.
The placenta is extracted by traction on the cord
(controlled cord traction).
The membranes are carefully removed preferably
intact and even a small piece, if attached to the
decidua should be removed using a dry gauze.
Exploration of the uterine cavity is desirable
29. f. Suture Of The Uterine Wound
The suture of the uterine wound is done with the
uterus keeping in the abdomen.
Some, however, prefer to eventrate the uterus prior
to suture.
The margins of the wound are picked up by Allis
tissue forceps or Green Armytage hemostatic clamps
(four are required, one each for angle and one for
each margin).
The uterine incision is sutured in 2 layers.(Three -
controversial)
30. FIRST LAYER:
The first stitch is placed on the far side in the lateral angle of the
uterine incision and is tied.
The suture material is no “1” chromic catgut or vicryl and the
needle is round bodied.
A continuous running suture taking deeper muscles excludingor
including the decidua (very difficult to exclude) ensures effective
apposition of the tissues; the stitch is ultimately tied after the
suture includes the near end of the angle.
SECOND LAYER:
A similar continuous suture is placed taking thesuperficial
muscles and Adjacent fascia overlapping the first layer of suture.
Uterine muscles may be closed using a continuous single layer
stitch taking full thickness muscle and decidua.
There is controversy as regard the place of single layer or double
layer closure in relation to
The risk of subsequent scar rupture. The peritoneal flaps may be
apposed by continuous inverting suture (to prevent any raw
surface).
Nonclosure of visceral and parietal peritoneum is preferred.
31.
32. g. Concluding Part
The mops placed inside are removed and the
number verified.
Peritoneal toileting is done and the blood clots are
removed meticulously.
The tubes and ovaries are examined.
Doyen’s retractor is removed.
After being satisfied that the uterus is well
contracted, the abdomen is closed in layers.
The vagina is cleansed of blood clots and a sterile
vulval pad is placed
34. a. First 24 hours
Day 0
Observation for the first 6–8 hours is important.(Vitals,
hemorrhage)
Fluid:
Sodium chloride (0.9%) or Ringer’s lactate drip is continued until
at least 2.0–2.5 L of the solutions are infused.
Blood transfusion is helpful in anemic mothers and if the blood
loss is more than average during the operation
Oxytocics:
Injection oxytocin 5 units IM - only in case of hemorrhage.
35. Cont.
Prophylactic antibiotics
(cephalosporins, metronidazole) for all cesarean delivery is
given for 2–4 doses.(Cefotaxime)
Analgesics
in the form of Tramadol is administered and may
have to be repeated.
Ambulation:
She is encouraged to move her legs and ankles and to breathe
deeply to minimize leg vein thrombosis and pulmonary
embolism.
The patient can sit on the bed or even get out of bed to
evacuate the bladder.
Baby is
Put to the breast for feeding after 3–4 hours when mother is
stable and relieved of pain.
36. b. Day 1
Oral feeding
Clear fluids may be given.(after 6 to 8 hrs)
Active bowel sounds are observed by the end of the day.
37. c. Day 2
Light solid diet of the patient’s choice is given.
Bowel care:
3–4 teaspoons of lactulose is given at bed time.
38. c. Day 5 or day 6
The abdominal skin stitches are to be removed on the D-7
(in transverse) or D-10 (in longitudinal)
39. d. Discharge
The patient is discharged on the day following
removal of the stitches, if otherwise fit.
Patient may be discharged as early as third to as
late as seventh postoperative days
40. DIFFICULTIES IN CS
1.Floating head:
Gentle fundal pressure helps to bring the fetal head at the site of
incision which is then levered out
2. Deeply engaged head:
Trendelenburg position helps
Patwardhan's technique
Anterior shoulder
Posterior shoulder
Body ( by hooking both axillae assissted by fundal
pressure)
Head
3. Impacted shoulders - Inverted T incision
41. CLASSIC CESAREAN SECTION
Easy to perform
Abdominal incision is always longitudinal (paramedian) and about 15
cm (6") in length, 1/3rd of which extends above the umbilicus.
A longitudinal incision of about 12.5 cm (5") is made on the midlineof
the anterior wall of the uterus starting from below the fundus.
The incision is deepened along its entire length until the membranes
are exposed which are punctured.
In about 40% cases, the placenta is encountered.
In such cases, fingers are slipped between the placenta and the
uterine wall until the membranes are reached.
The baby is delivered commonly as breech extraction.
Intravenous oxytocin 10units im is administered following
delivery of the baby.
The uterus is eventrated.
The placenta is extracted by traction on the cord or removed
manually.
42. Forced Circumstances For
Classical Section
Lower Segment
Approach Is
Difficult:
Dense
adhesions
Severe
contracted
pelvis
Lower Segment
Approach Is
Risky
Big fibroid on
the lower
Carcinoma
Repair of high
VVF
Complete anterior placenta
previa with engorged vessels
43.
44.
45. SUTURE OF THE UTERINE INCISION
The uterus is sutured in three layers.
The uterus is returned back into the abdominal cavity.
The abdomen is closed in layers.
A CONTINUOUS SUTURE Chromic catgut no “0” or vicryl taking
deep muscles excluding the decidua
A SECOND LAYER OF
CONTINUOUS SUTURES
(1 cm apart) using chromic catgut no.
“1” or vicryl taking the entire depth of
superficial muscles down to the first
layer of suture.
THE THIRD LAYER OF
CONTINUOUS SUTURE
Taking the peritoneum with the
adjacent muscles using chromic catgut
no “0” and round-bodied needle
48. a. Intraoperative Complications
Extension of uterine incision to one or both the sides.
Uterine lacerations at the lower uterine incision
Bladder injury— may occur in a repeat procedure.
Ureteral injury
Gastrointestinal tract injury
Haemorrhage
Morbid adherent placenta
51. MATERNAL (remote)
REMOTE
Gynecological
Menstrual excess or
irregularities,
chronic pelvic pain
or backache
General surgical
Incisional hernia,
intestinal
obstruction due to
adhesions and
bands.
Future pregnancy
There is risk of scar
rupture
52. MATERNAL AND PERINATAL
MORTALITY:
Maternal
(1) hemorrhage and shock
(2) anesthetic hazards
(3) infection and
(4) thromboembolic disorders.
Fetal
(1) Asphyxia
(2) RDS
(3) prematurity
(4) infection and
(5)intracranial hemorrhage— attempting breech delivery
through a small incision.
