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Caesarean Section: An interactive session

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Caesarean Section: An interactive session

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Caesarean Section: An interactive session

  1. 1. ABOUBAKR ELNASHAR Caesarean Section An interactive session
  2. 2. 1. WHAT IS DEFINITION OF EMERGENCY CS? 1. Within 30 minutes 2. Within 75 minutes 3. Needing early delivery but no maternal or fetal compromise 4. At a time to suit the patient and the maternity team ABOUBAKR ELNASHAR
  3. 3. Immediate threat to life of woman or fetus: Within 30 minutes 1-Emergency Maternal or fetal compromise which is not immediately life threatening Within 75 minutes 2-Urgent Needing early delivery but no maternal or fetal compromise Proper decisions about rapid delivery. Rrapid delivery may be harmful in certain circumstances 3-Scheduled At a time to suit the patient and the maternity team 4-Elective NICE Guideline November 2011 Decision-to-delivery interval for CS ABOUBAKR ELNASHAR
  4. 4. 2. WHAT IS TIMING OF PLANNED CS? 1. 37 w 2. 38 w 3. 39 w 4. 40 w ABOUBAKR ELNASHAR
  5. 5.  The risk of respiratory morbidity is increased in babies born by CS before labour, but this risk decreases significantly after 39 w: planned CS should not routinely be carried out before 39 Ws. • Medically/obstetrically indicated CS are performed when clinically indicated, without assessment of fetal lung maturity. (NICE , 2004 & 2011 [Grade B ]) ABOUBAKR ELNASHAR
  6. 6. 3. HOW TO PREVENT RDS? 1. Repeated Corticosteroids courses 2. Single corticosteroid course 3. Dexamethasone 6 mg/12 hs for 4 doses 4. Corticosteroid only before 35 w ABOUBAKR ELNASHAR
  7. 7. Prophylactic Corticosteroids:  Dexamethasone  6mg/12 h for 4 doses  significantly decrease admission to the neonatal ICU for respiratory morbidity  {It Improves alveolar fluid drainage}  It is for CS Category 4 (Elective) (Sotiriadis et al Cochrane SR, 2009).ABOUBAKR ELNASHAR
  8. 8. 4. HEMATOLOGICAL INVESTIGATION BEFORE CS: What is correct? 1. Pregnant women should be offered haemoglobin 2. CS for APH should be carried out at a maternity unit with on-site blood transfusion services. 3. Eclampsia is not risk factor for blood transfusion 4. Clotting screen is indicated before CS in uncomplicated pregnancies ABOUBAKR ELNASHAR
  9. 9.  Pregnant women should be offered haemoglobin assessment before CS to identify those who have anaemia.  Although blood loss of >1000 ml is infrequent after CS (4-8% of CS) it is a potentially serious complication  Pregnant women having CS for APH (abruption, P. praevia) are at increased risk of blood loss of >1000 ml: CS carried out at a maternity unit with on-site blood transfusion services. (NICE Guideline 2004 & 2011) ABOUBAKR ELNASHAR
  10. 10. Risk factors for requiring Blood transfusion include :  Placental abnormalities: previa, accreta, or abruption  Eclampsia or HELLP syndrome  Preoperative hematocrit <25 %(HB 8.5g/d)  Use of general anesthesia  History of ≥5 CS (Berghella , UpTpoDate,2016) ABOUBAKR ELNASHAR
  11. 11. Pregnant women who are healthy with uncomplicated pregnancies should not routinely be offered the following tests before CS:  Cross-matching of blood  Clotting screen (NICE , 2004, 2011) ABOUBAKR ELNASHAR
  12. 12. 5. WHAT ARE INDICATIONS A FOLEY S CATHETER? 1. Regional anaesthesia 2. General anaethesia 3. Repeat CS ABOUBAKR ELNASHAR
  13. 13. Indwelling Urinary Catheter  Women having CS with regional anaesthesia require an indwelling urinary catheter to prevent over-distension of the bladder {anaesthetic block interferes with normal bladder function}. (NICE , 2004 & 2011)  There is no convincing evidence that routine placement of an indwelling catheter is advantageous (Berghella , UpTpoDate,2016) ABOUBAKR ELNASHAR
  14. 14. 6. ANTIBIOTIC PROPHYLAXIS FOR CS: ALL ARE TRUE EXCEPT? 1. Antibiotics are given 0 to 60 minutes before making the incision. 2. They reduce the risk of postoperative infections. 3. Single IV dose of a narrow-spectrum antibiotic, such as cefazolin 4. Co-amoxiclav is recommended in pretem ABOUBAKR ELNASHAR
  15. 15.  Antibiotic Prophylaxis for CS  Preoperative antibiotic prophylaxis rather than after cord (Grade A )  Antibiotics are given 0 to 60 minutes before making the incision.  They reduce the risk of postoperative infections. (NICE , 2011; Berghella , UpTpoDate,2016) ABOUBAKR ELNASHAR
  16. 16.  Choose antibiotics  Effective against endometritis, UT and wound infections, which occur in 8%  Single IV dose of a narrow-spectrum antibiotic, such as cefazolin  2 gm for patients <120 kg  3 gm for patients ≥120 kg  Multiple doses are more costly, without clearly improving outcome.  Do not use co-amoxiclav in preterm when giving antibiotics before skin incision.  Clindamycin and Gentamicin for women with serious penicillin allergy (NICE , 2011; Berghella , UpTpoDate,2016) ABOUBAKR ELNASHAR
  17. 17. 7. FOR THROMBOPROPHYLAXIS ALL ARE CORRECT EXCEPT 1. For all women undergoing CS, mechanical thromboprophylaxis is advisable. 2. For women undergoing CS at high risk of DVT, mechanical thromboprophylaxis plus pharmacological thromboprophylaxis are recommended. 3. Pharmacologic prophylaxis is begun 24 h postoperatively 4. Mechanical and pharmacological prophylaxis are continued until the woman is fully ambulating 5. Prophylactic dose of Enoxaparin (Clexane) is 80 mg/d for wt 50-90 kgABOUBAKR ELNASHAR
  18. 18. Thromboprophylaxis  For all women undergoing CS, mechanical thromboprophylaxis is advisable (Grade 2C).  For women undergoing CS at high risk of DVT, mechanical thromboprophylaxis plus pharmacological thromboprophylaxis are recommended (Grade 2C).  Pharmacologic prophylaxis is begun 6 to 12 h postoperatively, after concerns for hemorrhage have decreased.  Mechanical and pharmacological prophylaxis are continued until the woman is fully ambulating (NICE , 2004 & 2011Berghella , UpTpoDate, 2016) ABOUBAKR ELNASHAR
  19. 19.  Thromboprophylaxis should be offered because the increased risk of venous thromboembolism at CS  Graduated stockings  Hydration  Early mobilization  Unfractionated or LMW heparin (NICE; 2011) ABOUBAKR ELNASHAR
  20. 20. 8. INDICATIONS OF ANTEPARTUM CONSULTATION WITH AN ANESTHESIOLOGIST: 1. Women with coagulopathy 2. Severe obesity 3. Restriction or abnormality of the spine 4. Cardiovascular or respiratory disease. 5. All of the above Grant ,UpToDate, 2016ABOUBAKR ELNASHAR
  21. 21. 9. WHICH OF THE FOLLOWING IS WRONG? 1. General anaesthesia is safer and results in less maternal and neonatal morbidity than regional anaesthesia. 2. For General anaesthesia reduction of gastric acidity is recommended 3. Preoxygenation is recommended 4. The operating table for CS should have a lateral tilt of 15 degrees ABOUBAKR ELNASHAR
  22. 22.  Regional anaesthesia is safer: less maternal and neonatal morbidity than general anaesthesia.  This includes women who have a diagnosis of placenta praevia.  For General Anaesthesia for CS  Reduction of gastric acidity: to prevent Mendelson Syndrome  Nonparticulate antacid (eg, sodium citrate, ranitidine or metoclopramide)  Preoxygenation women because of their reduced functional residual capacity (Grant ,UpToDate, 2016NICE Guideline 2004&2011) ABOUBAKR ELNASHAR
  23. 23. 10. FOR PREVENTION OF REGIONAL ANESTHESIA-INDUCED HYPOTENSION: 1. Volume expansion using (500 IV Saline or Ringer lactate) 2. Vasopressors: ephedrine or phenylephrine 3. Uterine displacement 15 degree (left). 4. All of the above ABOUBAKR ELNASHAR
  24. 24. Choice of Anaesthesia for CS It is influenced by : 1. Urgency of the procedure 2. Maternal status 3. Specific contraindications 4. Physician and patient preference. (Grant ,UpToDate, 2016)ABOUBAKR ELNASHAR
  25. 25. 11. CS TECHNIQUE: WHICH IS CORRECT? 1. The transverse incision of choice should be Pfannenstiel Incision 2. When there is a well formed lower uterine segment, sharp rather than blunt extension of the uterine incision 3. Placenta should be removed using controlled cord traction and not manual removal ABOUBAKR ELNASHAR
  26. 26. Joel Cohen Vs Pfannenstiel The transverse incision of choice should be Joel Cohen incision because it is associated with:  Less  Fever  Pain  analgesic requirements  blood loss  Shorter  duration of surgery  hospital stay. (Hofmeyr , Cochrane Database Syst Rev. 2007; NICE 2004 & 2011) ABOUBAKR ELNASHAR
  27. 27. Joel Cohen Incision  Skin incision:  Straight  3 cm below the line that joins anterior superior iliac spines slightly higher than Pfannenstiel  Subseqent layers opened bluntly if necessary extended with scissors and not a knife. ABOUBAKR ELNASHAR
  28. 28. Pfannenstiel Incision  Skin:  Curved incision  two fingers breadths above the symphysis pubis  midportion of the incision within the shaved area of the pubic hair  Sheath: Transverse incision .  Rectus M Separated bluntly  Parietal peritoneum incised at the midline ABOUBAKR ELNASHAR
  29. 29. When there is a well formed lower uterine segment, blunt rather than sharp extension of the uterine incision should be used because it reduces;  Blood loss  Incidence of postpartum hemorrhage  The need for transfusion at CS Placenta should be removed using controlled cord traction and not manual removal as this reduces the risk of  endometritis  blood loss without increasing operating time. (NICE Guideline 2004 &2011) ABOUBAKR ELNASHAR
  30. 30. 12. THE FOLLOWING MANOEUVRES MAY BE USED FOR FLOATING HEAD 1. Rotation of chin or occiput to the front and application of forceps 2. Kielland forceps application (Warenski method) with traction on the foetal head as occipito transverse, then rotation to the occipito-anterior position and delivery by extension 3. Vacuum extraction. 4. All of the above ABOUBAKR ELNASHAR
  31. 31. Floating head: A high floating head: extension of the uterine wound delay in delivering the infant. ABOUBAKR ELNASHAR
  32. 32. 13. WHICH IS NOT RECOMMENDED IN MANAGEMENT OF DEEPLY IMPACTED HEAD? 1. Deepen the plane of anaesthesia, achieve uterine relaxation if the presenting part has been gripped tightly. 2. Head high position of the patient 3. Place a hand in the lower uterine segment in the standard fashion to cup and then disengage the foetal head. 4. An assistant can place a sterile, gloved hand into the vagina from the introitus and disengage the foetal head from below 5. Lower vertical incision if a constriction ring is suspected. ABOUBAKR ELNASHAR
  33. 33. Head low position to disimpact the foetal head, along with upward pressure on the foetal shoulder by the operator. ABOUBAKR ELNASHAR
  34. 34. 14. WHICH OF THE FOLLOWING IS WRONG 1. Extraperitoneal repair of the uterus is recommended 2. Two-layer uterine closure rather than a one-layer 3. Neither the visceral nor the parietal peritoneum should be sutured 4. Routine closure of the subcutaneous tissue space 5. Mass closure with slowly absorbable continuous sutures for midlune abdominal incision ABOUBAKR ELNASHAR
  35. 35.  Extraperitoneal repair of the uterus is not recommended because  more pain  It does not improve operative outcomes such as haemorrhage and infection (Int J Gynaecol Obstet. 2011. NICE Guideline 2004 & 2011)  7 additional RCTs 3183 women, febrile complications and surgical time were similar between uterine exteriorization and intraabdominal repair decision to exteriorize the uterus should be guided by surgen preference (ASRM, 2014) ABOUBAKR ELNASHAR
  36. 36. 2 layer not one layer: The effectiveness and safety of single layer closure of the uterine incision is uncertain. Single-layer closures were associated with a higher uterine rupture risk than double-layer closure in women attempting VBAC (Berghella UpToDate, 2016; Int J Gynaecol Obstet. 2011) ABOUBAKR ELNASHAR
  37. 37. Neither the visceral nor the parietal peritoneum should be sutured  Reduces:  operating time  postoperative analgesia  improves maternal satisfaction (Wilkinson& Enkin (Cochrane Review) 1997. 2004.NICE Guideline 2004 & 2011 Layell et al, 2006) ABOUBAKR ELNASHAR
  38. 38. Routine closure of the subcutaneous tissue space should not be used, unless the woman has more than 2 cm SC fat {does not reduce the incidence of wound infection} (NICE Guideline 2004 & 2011)ABOUBAKR ELNASHAR
  39. 39. In the rare circumstances that a midline abdominal incision is used at CS:  mass closure with slowly absorbable continuous sutures should be used { fewer incisional hernias and less dehiscence than layered closure} (NICE Guideline 2004 & 2011)ABOUBAKR ELNASHAR
  40. 40. 15. WHAT ARE INDICATIONS FOR VERTICAL UTERINE INCISION? 1. Poorly developed Lower uterine segment in extreme preterm 2. Fetal abnormality as conjoined twins. 3. Cancer Cervix 4. Postmortem delivery 5. All the above ABOUBAKR ELNASHAR
  41. 41. INDICATIONS FOR VERTICAL UTERINE INCISION? 1. Poorly developed L US + Extr. preterm 2. Fetal abnormality as conjoined twins. 3. Cancer Cervix 4. Postmortem delivery 5. Back down transverse lie 6. Lower U segment leiomyoma 7. Densely adherent bladder 8. Anterior placenta previa or accreta ABOUBAKR ELNASHAR
  42. 42. 16. OPERATIONS NOT RECOMMENDED AT THE TIME OF CS 1. Abdominoplasty 2. Minilap- cholecystectomy or laparoscopic cholecystectomy 3. Appendectomy 4. Hernia repair 5. Myomectomy ABOUBAKR ELNASHAR
  43. 43. Abdominoplasty at the time of CS not recommended to perform It is recommended to wait for several months or a year Minilap cholecystectomy or laparoscopic cholecystectomy in selected patients is safe Appendectomy or hernia repair can be combined with CS when indicated ABOUBAKR ELNASHAR
  44. 44. Myomectomy during CS with does not appear as hazardous as was thought before. 1. Careful patient selection 2. Adequate experience 3. Efficient haemostatic measures 4. Bilateral uterine a ligation may be used to minimize blood loss ABOUBAKR ELNASHAR
  45. 45. Myomectomy may be considered for: 1. Accessible subserous accessible myoma less than 6 cm 2. Myoma in lower segment to avoid upper segment incision 3. Pedunculated myoma 4. Intrmaural myoma may be removed with caution Myomectomy should be avoided: 1. Inaccessible myoma 2. Large fundal, intramural fibroids 3. Fibroid greater than 6 cm in diameter ABOUBAKR ELNASHAR
  46. 46. 17. CS IN MORBIDLY OBESE PREGNANT WOMEN. ALL IS CORRECT EXCEPT 1. Preanesthetic evaluation 2. Low transverse skin incisions are feasible and preferred to vertical skin incisions in these women. 3. Closure of the subcutaneous layer is generally recommended. 4. Vertical uterine incision is superior ABOUBAKR ELNASHAR
  47. 47. CS in Morbidly obese pregnant women (BMI>40 kg/ m2) Increased risk of pregnancy complications increased rate of CS Preanesthetic evaluation Scheduled cesarean.  Low transverse skin incisions are feasible and preferred to vertical skin incisions in these women.  Closure of the subcutaneous layer is generally recommended.  Transverse uterine incisions are definitely superior, impact future pregnancy outcomes, and must be the first choice.  The role of subcutaneous drains still remains controversial ABOUBAKR ELNASHAR
  48. 48. 18. CS IN MORBIDLY OBESE PREGNANT WOMEN. ALL IS CORRECT EXCEPT 1. The dose of thromboprophylaxis needs to be higher 2. Prophylactic antibiotics reduce postoperative infections 3. Weight reduction postpartum 4. Breast feeding is not recommended ABOUBAKR ELNASHAR
  49. 49.  The dose of thromboprophylaxis needs to be higher and adjusted according to body weight.  Prophylactic antibiotics reduce postoperative infections in obese women and are highly recommended  Weight reduction postpartum, with a permanent change in diet and lifestyle.  Breast feeding, which may promote further weight reduction, must be encouraged. ABOUBAKR ELNASHAR
  50. 50. 19. TO PREVENT SURGICAL SITE INFECTION AFTER CS. All is correct except 1. Maintain strict glycemic control in DM 2. Higher dose of preoperative antibiotics in obese 3. IV antibiotic prophylaxis 4. Shaving for preoperative hair removal. If hair removal is necessary to perform the skin incision ABOUBAKR ELNASHAR
  51. 51.  TO PREVENT SURGICAL SITE INFECTION AFTER CS 1. Maintain strict glycemic control in DM 2. Higher dose of preoperative antibiotics in obese 3. IV antibiotic prophylaxis 4. Clippers for preoperative hair removal. If hair removal is necessary to perform the skin incision ABOUBAKR ELNASHAR
  52. 52. 20. TO PREVENT SURGICAL SITE INFECTION AFTER CS. All is correct except 1. Chlorhexidine-alcohol for skin prep immediately before surgery 2. Alcohol based hand rub for preoperative antisepsis 3. Close the skin with staples 4. Closure of the subcutaneous fat for women with a tissue thickness of more than 2 cm ABOUBAKR ELNASHAR
  53. 53.  TO PREVENT SURGICAL SITE INFECTION AFTER CS 1. Chlorhexidine-alcohol for skin prep immediately before surgery 2. Alcohol based hand rub for preoperative antisepsis. {more effective than conventional surgical scrub} 3. Close the skin with subcuticular sutures {lower risk of wound complications compared with staples} 4. Closure of the subcutaneous fat is associated with a decreased risk of wound disruption for women with a tissue thickness of more than 2 cm ABOUBAKR ELNASHAR
  54. 54. RECOMMENDED  Use (Joel Cohen incision)  Use blunt extension of the uterine incision: cephalad- caudad direction  Use controlled cord traction for removal of the placenta  Close the uterine incision with two suture layers  Prophylactic antibiotics: Single dose, ampicillin or first-generation cephalosporin 15-60 min prior to incision  Prevention of PPH  Oxytocin 5 IU by slow IV injection at CS  Oxytocin infusion10-40IU in 1 L crystalloid over 4-8 h ABOUBAKR ELNASHAR
  55. 55. NOT RECOMMENDED  Close subcutaneous space (unless > 2 cm fat).  Use superficial wound drains.  Suture either the visceral or the parietal peritoneum  Manually remove the placenta.  Supplemental oxygen Does not reduce morbidity from infection  Cervical dilation Does not reduce morbidity from infection  Subcutaneous drain Does not reduce wound morbidity ABOUBAKR ELNASHAR

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