Cesarean section

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Cesarean section

  1. 1. By Ahmed Mowafy IbrahimResident of obstetrics and gynecology Qena University Hospital South Valley University
  2. 2. List of Content Definition Historical Aspects Incidence Indications and contraindications Classifications Operative techniques Complications C.S versus V.D VBAC RCOG Guidlines
  3. 3. Definition It is the delivery of the fetus through an incision in the abdominal wall (laparotomy) and uterine wall (hysterotomy) after the age of viability. It is the third common surgical operation in the world. (WHO 2006)  1st is appendicectomy  2nd is cataract surgery  3rd is cesarean section
  4. 4. Historical Aspects Cesarean section has been part of human culture since ancient times and there are tales in both Western and non-Western cultures Numerous references to cesarean section appear in ancient Hindu, Egyptian, Grecian, Roman, and other European folklore depict the procedure on apparently dead women.
  5. 5. Historical Aspects In the ancient roman age. The king numa pomphilus (2nd king of Rome 762 – 715 B.C) issued a group of laws called “Lex Regia” which prevent to bury a dead pregnant women before the child had been extracted from her abdomen. In the age of Julius Cesar this law became known as “Lex Césara” and hence the name cesarean … The legend that the Cesar himself was born by this way is not sure. Others say that the word cesarean is derived from the latin word “caedere” whisch means “to cut”.
  6. 6. Historical Aspects Year 1500 : Jacob Neufer, a Carpenter asked permission of local mayer to cut open abdomen of his wife who was in prolonged labor with his saw. First request was not granted. He went second time and his request was granted. He opened his wife abdomen. The term “Caesarian section” was first used by “James Gullimeau”, in his midwifery book published in 1598.
  7. 7. Historical Aspects Lots of attempts were carried out in the 19th century but the majority failed Year 1876: Eduardo Porro an Italian obstetrician introduced a technique of amputation of body of uterus after C.S. at this time this technique achieved a major imrovement of abdominal delivery. Even to day Caesarian hysterectomy is called Porro’s section.
  8. 8. Historical Aspects In the second half of the 19th century cesarean section became a possible method in treatment of major obstetric problems due to:1. Introduction of ether anesthesia2. Carbolic acid antisepsis3. Technique of suturing the uterus introduced by Sanger in 1882
  9. 9. Historical Aspects 1912: Lower segment caesarian segment section was first performed by Kronig and latter by Monro kerr. and popularized in the USA by DeLee in 1922. 1926: The transverse uterine incision was described by Munro Kerr
  10. 10. Historical Aspects With further improvement in antibiotic therapy , blood transfusion and attention to fine operative details the cesarean section is rising since the nineteen sixties to present time .
  11. 11. Incidence It is the third common surgical operation in the world (WHO 2006) .  1st is appendicectomy  2nd is cataract surgery  3rd is cesarean section 20% - 25% of deliveries anually by C.S. In USA the incidence increased from 4.5% in 1965 to 25% in 1988 then declines to 20.7% in 1996 due to increased VBAC.
  12. 12. Incidence Causes of increased incidence :1. Attempt to  perinatal mortality2. Medical malpractice3.  use of midpelvic ventose and forceps4.  use of electronic fetal monitorng5. Delivering most of breech presentation by C.S6. Repeat CS7. Non-medical consideration of obstetrician8. Women selection (C.S on demand)
  13. 13. Incidence Causes of increased incidence :9. In western societies , women marry late and end in becoming elderly primigravida this  the need for C.S
  14. 14. Incidence Situation in Egypt :1. National income can not afford having one-third of annual birth by C.S2. Difficulties in availability of blood banks, anesthesiology and incubators3. The increased need for repeat C.S4. Maternal mortality and morbidity is higher in C.S than vaginal delivery especially with repeat C.S when not all facilities are available
  15. 15. Incidence How to  the increased C.S rate ?1. Training and education of obstetricians.2. Encouraging VBAC3. Obstetrician should be encouraged to give the patient a full operative report about C.S including the indication and complications occurred during the operation
  16. 16. IndicationsI. Maternal indicationsII. Fetal indicationsIII.Feto-maternal indications
  17. 17. IndicationsI. Maternal indications :  Birth canal obstruction: 1. Contracted pelvis 2. Soft tissue obstruction. 3. Abdominal cerclage operation  herpes simplex virus : to decrease the risk of intrapartum transmission  Gynecologic operations : o Rpair of vesico-vaginal fistula o Fothergill’s operation o Repair of stress incontinence
  18. 18. IndicationsI. Maternal indications :  Third trimester bleeding 1. Placenta previa 2. Placental abruption  Maternal disease: Indicated but difficult delivery: o hypertensive disorders o D.M o IUGR
  19. 19. IndicationsI. Maternal indications :  Uterine scar with weak myometrium: 1. Myomectomy with opening of the cavity. 2. Hysterotomy 3. Cesarean section scar in the following conditions  Decision During labour: a. Signs and symptoms of uterine scar dehiscence. b. Arrest of satisfactory progress during labor. c. Development of fetal distress during labour
  20. 20. IndicationsI. Maternal indications :  Uterine scar with weak myometrium: 3. Cesarean section scar in the following conditions  Decision before labour: a. previous classic C.S. b. Previous uterine rupture c. previous vertical LSCS that extended into the upper uterine segment. d. previous LSCS that extended laterally or downwards. e. recurrent indication for C.S f. multiple pregnancy.
  21. 21. IndicationsII. Fetal indications :  Fetal Asphyxia: fetal scalp pH <7.2.  Malpresentation: examples 1. Occipto-posterior position (DTA , POP) 2. Face presentation: all cases of M.P. and impacted cases of M.A. position. 3. Breech presentation 4. Brow presentation 5. Cord presentation and prolapse if fetus is living
  22. 22. IndicationsII. Fetal indications :  Fetal anomalies: 1. Hydrocephalus: 2. Abdominal wall defects e.g. omphalocele to avoid its rupture during vaginal delivery.  Abnormal fetal weight: 1. Fetal macrosomia >4500gm. 2. Low-birth weight infant: < 1500 gm.  A precious baby: 1. Elderly primigravida. 2. Bad obstetric history. 3. Long period of infertility
  23. 23. IndicationsIII. FETOMATERNAL INDICATIONS: 1. Arrest of labour " dystocia“. 2. Failed induction of labour. 3. Inadequate uterine contractility despite oxytocin administration. 4. Arrest of cervical dilatation or fetal descent. 5. Impending rupture uterus.
  24. 24. Indications Most common indications for C.S.:-1. Repeat C.S2. Severe degree contracted pelvis.3. Malpresentations4. Fetal distress5. Woman demand (elective C.S)
  25. 25. Indications Absolute indications of C.S :1. Previous classic C.S. or CS extending to upper segment2. Previous ≥2 LSCS3. Previous LSCS with malpresentation4. Previous repair of vesicovaginal fistula5. Extreme degree of contracted pelvis6. Placenta previa centralis
  26. 26. Contraindications “ THERE IS NO CONTRAINDICATIONS TO C.S. IF THE FETUS IS LIVING “ C.S should be performed on dead fetus in the following conditions ( SAME ABSOLUTE INDICATIONS ) 1. Severe degree of contracted pelvis 2. Placenta previa centralis 3. Presence of abdominal cerclage 4. Soft tissue obstruction 5. Previous 2 or more C.S 6. Prvious repair of vesicovaginal fistula
  27. 27. Classifications and Types of CSAccording to Urgency :RCOG classification of CS according to urgency Proposed by “Lucas et al “ April 2010
  28. 28. Classifications and Types of CSAccording to Urgency : Category I → Emergency CS :Immediate threat to life of woman or fetus Category II → Urgent CS :Maternal or fetal compromise which is not immediately life-threatening Category III → Scheduled CS :Needing early delivery but no maternal or fetal compromise Category IV → Elective CS :At optimal time for woman and maternity team
  29. 29. Classifications and Types of CSAccording to gestational age:Before the age of viability → hysterotomyAfter the age of viability → cesarean sectionAccording to uterine incision: Transverse LSCS (Kerr incision) Vertical LSCS (De-Lee incision) Upper segment C.S. Others : Inverted –T , Hockey- stick incision
  30. 30. By Ahmed Mowafy IbrahimResident of obstetrics and gynecology Qena University Hospital South Valley University
  31. 31. List of Content Definition  Historical Aspects  Incidence  Indications and contraindications  Classifications  Operative techniques Complications C.S versus V.D VBAC RCOG Guidlines
  32. 32. Operative TechniquesBefore CS you should : Take a patient consent Be sure that FHS are still audible Be sure that the indication is still valid Do routine U/S → (site of placenta - presenting part) Do preoperative testing (HB , Co-agulation profile ) Ensure availability of blood Be sure that neonatal resuscitation team is available Give IV fluids (preload) Give a prophylactic antibiotics Fix a Foley’s catheter in the bladder
  33. 33. Operative TechniquesSteps :I. PositionII. AnesthesiaIII. Surgical drapingIV. Abdominal wall incisionV. Uterine wall incisionVI. Extraction of the fetus and afterbirthVII.Repair of uterine wallVIII.Repair of abdominal wall incision
  34. 34. Operative TechniquesI. Position a. Supine b. 15 left lateral tilt of theatre table
  35. 35. Operative TechniquesII. Anesthesia II. general III. spinal IV. Epidural V. Combined spinal and epidural VI. local
  36. 36. Operative TechniquesII. AnesthesiaSpinal anesthesia :Advantages:1. Simple and rapid onset2. Minimal fetal exposure to drug . Allow time for careful abdominal wall incision and good haemostasis3. Does not cause uterine atony4. Patient is awake and take part in birth occasion5. Small doses of intrathecal morphia could be given to ensure post-operative analgesia6. Avoidance of complication of general anesthesia uterine atony and pulmonary aspiration
  37. 37. Operative TechniquesII. AnesthesiaSpinal anesthesia :Disadvantages :1. Hypotension2. intrapartum nausea and vomitting3. spinal headache4. Post-operative shivering
  38. 38. Operative TechniquesII. AnesthesiaEpidural anesthesia :Advantages1. Less incidence of hypotension because of slow onset of sympathetic block2. Less incidence of spinal headache3. Allow repeated administration through epidural catheter if the surgery is prolonged4. Epidural catheter allow administration of post-operative analgesia
  39. 39. Operative TechniquesII. Anesthesiacontra indication to regional anesthesia (spinal – epidural) :1. Severe maternal hypertension2. Severe hypovolemia3. Hypotension due to any cause4. Morbid obesity5. Tocolysis with terbutaline6. Congenital maternal heart disease where hypotension increase rt. to lt. shunt7. Coagulation disorders8. Emergency CS9. Patient refusal
  40. 40. Operative TechniquesII. AnesthesiaGeneral anesthesia :advantages1. Can be given quikly (suitable for emergency CS)2. Blood pressure and breathing are easily controlled3. Better with bleeding and clotting abnormalities4. Better in patient with psychological problems5. Can be used in presence of infection that can spread to spinal area
  41. 41. Operative TechniquesII. AnesthesiaGeneral anesthesia :disadvantages1. Extraction of the fetus should be within 15 min. Nitous oxide can cross placental blood barrier cardiodepressant effect on the fetus2. Acid aspiration syndrome3. High incidence of uterine atony (Effect of halothan)4. The patient doses not take apart in birth occasion
  42. 42. Operative TechniquesII. AnesthesiaLocal anesthesia (extremely rare):IndicationsPatient with bad general condition that not suitable neither togeneral nor to regional anesthesia ; severe coagulopathy , difficultairway with the following precautions1. Midline incision2. No exteriorisation of the uterusDrawbacks1. Need long time2. Patient discomfort3. Does not provide satisfactory operating conditions
  43. 43. Operative TechniquesIII.Surgical draping and towelingApply antiseptic solution three times to the incision site using ahigh-level disinfected ring forceps and cotton or gauze swab thentoweling that allows good exposure
  44. 44. Operative TechniquesIV.Abdominal wall incisiona. Longtudinal abdominal incisionsSub-umblical vertical midline incisionb. Transverse abdominal Incisionc 1. Pfannenstiel incision 2. Joel Cohen incision 3. Maylard incision 4. Cherny incision
  45. 45. Operative TechniquesIV.Abdominal wall incision
  46. 46. Operative TechniquesIV.Abdominal wall incisionPfannenstiel incision:Low transverse incision that curves gently upward, placed in anatural skin fold, this incision is located two finger breadths abovethe pubic symphysisAdvantages:1. Early movement of the patient2. Excellent cosmetic results3. Less incidence of incisional herniaDisadvantages:1. More bleeding2. Limited exposure of adnexae
  47. 47. Operative TechniquesIV.Abdominal wall incisionSub-umblical vertical midline incisionThe incision is made in the midline extending tow fingers belowthe umblicus to the symphysis pubisAdvantages:1. Takes less time2. Less bleeding3. Good exposure of pelvic viscera and adnexaeDisadvantages:1. Higher incidence of wound infection2. Poor cosmetic result3. Higher incidence of Hernia
  48. 48. Operative TechniquesV. Uterine wall incision 1. Low transverse incision 2. Classical incision 3. Low vertical incision 4. J-shaped incision 5. T-shaped incision
  49. 49. Operative TechniquesV. Uterine wall incision
  50. 50. Operative TechniquesV. Uterine wall incision Differences between upper & Lower uterine segment Upper segment Lower segmentPerit. covering Firmly attached Loosely attachedMuscle layer Thick ; arranged in 3 layers Thin ; arranged in 2 layers outer longtudinal , inner outer longtudinal and inner circular and middle circular interlacing fibers forming figure of 8 around blood vesselsdecidua Well developed Poorly developedFet. membranes Firmly attached Loosely attachedRole in labour Active ; contraction + Passive ; stretched retraction
  51. 51. Operative TechniquesV. Uterine wall incision 1. Low transverse lower segment incision (standard) ( kerr incision )Advantages:1. Easy to perform.2. Less bleeding.3. Easier to repair.4. If infection occurs, it is limited to extraperitoneal space.5. Lower incidence of ileus, intestinal obstruction6. Lower incidence of adhesions to intestine and omentum
  52. 52. Operative TechniquesV. Uterine wall incision 1. Low transverse lower segment incision (standard)Advantages:7. Better healing =lower risk of rupture as: a. Proper coaptation of the edges during suturing as they are thin. b. LUS contains more fibrous tissue - easy placement of sutures without cutting. c. Not subjected to stresses during healing d. Lower possibility of placental implantation on LUS. e. Less tension on it in future pregnancies.
  53. 53. Operative TechniquesV. Uterine wall incision 2. Upper segment (classical type) → rarely usedIndications :1. Difficult access to lower segment due to presence of ( fibroids , varicose veins and extensive adhesions )2. Repaired vesicovaginal fistula3. Impacted shoulder presentation4. Postmortem C.S5. Cancer cervix
  54. 54. Operative TechniquesV. Uterine wall incision 3. Low vertical incision (De-Lee incision)Indications :1.Underdeveloped lower uterine segment (Preterm fetus)2.Transverse lie with back down.3.Hydrocephalus.4.Varicosities on LUS5.Contraction ring
  55. 55. Operative TechniquesVI.Extraction of the fetus and afterbirth
  56. 56. Operative TechniquesVII.Aspirate nose and mouth of newbornVIII.Cord Clamping Delayed cord clamping benefits include: 1. decreased neonatal anaemia 2. Better systemic and pulmonary perfusion 3. better breastfeeding outcomes 4. Decrease incidence of neonatal jundiceIX.Give Newborn To PediatricianX. Repair of uterine wall incisionXI.Repair of abdominal incision
  57. 57. ComplicationsI. Intra opertaive complicationsII. Early postoperative complicationsIII.Delayed " long-term“ complications
  58. 58. ComplicationsI. Intra opertaive complications A. Anesthetic 1. usually with general anesthesia 2. failure of endotracheal intubation 3. inhalation of gastric contents "Mendelson syndrome “ 4. amniotic fluid embolism 5. cardiac arrest 6. severe convulsions. B. Bleeding: more than the average (1000 ml) Failure of blood coagulation mechanisms: DIC, HELLP syndrome
  59. 59. ComplicationsI. Intra opertaive complications C. Uterine abnormalities: 1. Atony. 2. Uterine incision:  Lateral extension to uteine vessels.  Downward extension to cervix, vagina, or bladder. 3. Presence of uterine myomata. D. Placental abnormalities:  Placenta previa.  Abruptio placentae  Incomplete removal of the placenta: accreta, anomalies.
  60. 60. ComplicationsI. Intra opertaive complications E. Trauma:  Urinary tract injury:  Bladder injury: due to o Difficult dissection off the lower uterine segment o Bladder trauma during uterine incision o Extension of uterine incision to the bladder  Ureteric injury: due to o Extension of the uterine incision. o Secondary to hemostatic sutures in the base of the broad ligament.
  61. 61. ComplicationsI. Intra opertaive complications E. Trauma:  Bowel injury: Due to  Blunt dissection of thick adhesions due to previous surgery, PID.  Putting a clamp on the bowel.  Needle or suture passing through it.  Sharp dissection by a scalpel or scissors.
  62. 62. ComplicationsII. Early postoperative complications 1. Post anesthetic complications:  Respiration difficulties.  Paralytic ileus and intestinal obstruction.  Deep venous thrombosis and pulmonary embolism 2. Uterine bleeding: reactionary or secondary. 3. Trauma: fistula. 4. Infection: endometritis, peritonitis, cystitis, chest infection, wound infection. 5. Psychological complications.
  63. 63. ComplicationsIII.Delayed " long-term“ complications 1. Adhesions: • Tubo-peritonal leading to infertility. • Bladder adhesions making subsequent surgeries difficult. • Intrauterine adhesions if the anterior and posterior walls of the uterus were sutured together Asherman syndrome. • Intestinal adhesions leading to intestinal obstruction • Chronic pelvic pain 2. Weak uterus: • Perforation if D&C is done in the presence of a weak scar. • Rupture of the uterus at the site of the scar in future pregnancies. 3. Risk of incisional hernia. 4. Higher risk of placenta accreta.
  64. 64. Vaginal Birth After CS “VBAC” Definition :It is the trial of vaginal birth after C.S. inprevious pregnancy.• In the past → once cesarean, always cesarean• Now → Once CS always hospital delivery• Risk of uterine dehiscence of LSCS is 0.2%
  65. 65. Vaginal Birth After CS “VBAC” Conditions that should be fulfilled before trial of VBAC A. Non-recurrent indication. B. Previous C.S.: o Known type; single transverse LSCS type. o Proper surgical technique: use of delayed absorbable sutures is preferred. o Smooth postoperative course. No infection. o A long interval between C.S. and current pregnancy. C. Current pregnancy: o Single fetus. o Vertex presentation. o Average fetal weight. o No medical risks. o No other indication for C.S
  66. 66. Vaginal Birth After CS “VBAC” Conditions that should be fulfilled before trial of VBAC D. Competent obstetrician to follow the patient in a well- equipped hospital capable of performing urgent C.S. once uterine dehiscence is detected. 1. Available anesthesia 2. Good nursing 3. Available operation room 4. Available blood 5. Available neonatal resuscitation team
  67. 67. Vaginal Delivery vs CS Fetal outcome
  68. 68. Vaginal Delivery vs CS Maternal outcome1. Physical problems in mothers: due possible complications2. Hospitalization of mothers: If a woman has a cesarean there is a more hospital stay3. Breastfeeding: Recovery from surgery poses challenges for getting breastfeeding under way, and a baby who was born by cesarean is less likely to be breastfed and get the benefits of breastfeeding.4. Health of babies: Babies born by cesarean are more likely to: a. be cut during the surgery (usually minor) b. have breathing difficulties around the time of birth c. experience asthma in childhood and in adulthood.
  69. 69. Vaginal Delivery vs CS Maternal outcome5. Future reproductive problems for mothers: a. ectopic pregnancy: pregnancies that develop outside her uterus or within the scar b. reduced fertility, due to either less ability to become pregnant again or less desire to do so c. placenta previa: the placenta attaches near or over the opening to her cervix d. placenta accreta: the placenta grows through the lining of the uterus and into or through the muscle of the uterus e. placental abruption: the placenta detaches from the uterus before the baby is born f. rupture of the uterus: the uterine scar gives way during pregnancy or labor.
  70. 70. RCOG Guidelines Timing of planned CSThe risk of respiratory morbidity is increased in babies born by CSbefore labour, but this risk decreases significantly after 39 weeks.Therefore planned CS should not routinely be carried out before 39weeks. Delivery time for emergency CSDelivery at emergency CS for maternal or fetal compromise shouldbe accomplished as quickly as possible, taking into account thatrapid delivery has the potential to do harm. A decision-to-deliveryinterval of less than 30 minutes is not in itself critical in influencingbaby outcome, but remains an audit standard for response toemergencies within maternity services.
  71. 71. RCOG Guidelines Preoperative testing and preparation for CS grouping and saving of serum cross-matching of blood a clotting screen preoperative ultrasound for localisation of placenta Anesthesia for CS Pregnant women having a CS should be given information on different types of post- Women who are having a CS should be offered regional anaesthesia because it is safer and results in less maternal and neonatal morbidity than general anaesthesia. This includes women who have a diagnosis of placenta praevia.
  72. 72. RCOG Guidelines Maternal request for CS ( C.S on demand ) When a woman requests a CS in the absence of an identifiable reason, the overall benefits and risks of CS compared with vaginal birth should be discussed and recorded. When a woman requests a CS because she has a fear of childbirth, she should be offered counseling (such as cognitive behavioural therapy) to help her to address her fears in a supportive manner, because this results in reduced fear of pain in labour and shorter labour. An obstetrician has the right to decline a request for CS in the absence of an identifiable reason. However the woman’s decision should be respected and she should be referred for a second opinion.
  73. 73. RCOG Guidelines Abdominal-wall incision CS should be performed using a transverse abdominal incision because this is associated with less postoperative pain and an improved cosmetic effect compared to a midline Use of separate surgical knives The use of separate surgical knives to incise the skin and the deeper tissues at CS is not recommended because it does not decrease wound infection.
  74. 74. RCOG Guidelines Uterine dissection When there is a well formed lower uterine segment, blunt rather than sharp extension of the uterine incision should be used as it reduces blood loss, incidence of postpartum hemorrhage and the need for transfusion at CS. Cord clamping Suggested benefits of delayed cord clamping include decreased neonatal anaemia; better systemic and pulmonary perfusion; and better breastfeeding outcomes. Possible harms are polycythaemia, hyperviscosity, hyperbilirubinaemia, transient tachypnoea of the newborn and risk of maternal fetal transfusion in rhesus negative women
  75. 75. RCOG Guidelines Use of uterotonics Oxytocin 5 IU by slow intravenous injection should be used at CS to encourage contraction of the uterus and to decrease blood loss Method of placental removal At CS, the placenta should be removed using controlled cord traction and not manual removal as this reduces the risk of endometritis.
  76. 76. RCOG Guidelines Exteriorisation of the uterus Intraperitoneal repair of the uterus at CS should be undertaken. Exteriorisation of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes such as haemorrhage and infection. One- vs. two-layer closure of uterus 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
  77. 77. RCOG Guidelines Closure of the peritoneum Neither the visceral nor parietal peritoneum should be sutured at CS as this reduces operating time, the need for postoperative analgesia and improves maternal satisfaction. Closure of subcutaneous tissue Routine closure of the subcutanoues 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.
  78. 78. RCOG Guidelines Hospital stay after C.S Length of hospital stay is likely to be longer after a CS (an average of 3–4 days) than after a vaginal birth (average 1–2 days). However, women who are recovering well, are apyrexial and do not have complications following CS should be offered early discharge (after 24 hours) from hospital and follow up at home, because this is not associated with more infant or maternal readmissions.

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