Caesarean Section Guide by Dr. Obiokonkwo

CAESAREAN SECTION
DR. OBIOKONKWO, A.C
[MBBS, U. PHARCOURT]
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
AHMAD SANI YARIMAN BAKURA SPECIALIST HOSPITAL
GUSAU, ZAMFARA STATE

13:22 http://www.facebook.com/imezi 2
OUTLINE

Introduction

Epidemiology

Indications/Contraindications

Classifications

Pre-Op preparation

Procedure

Post-Procedure

Complications

Future and Controversies

Conclusion

Introduction

Caesarean section is the delivery of a foetus
through surgical incisions made on the abdominal
wall [laparotomy] and the uterine wall
[hysterotomy] after 28 weeks of gestation

This definition considers only the location of the
foetus, regardless of the outcome

The procedure did not emanate from Julius
Caesar's reign as the adjective 'caesarean' may
suggest

Introduction

Pompilius II in 720 BC enacted a law, the Rex
Cesare, from which the Rex Regis was derived

The law required that infants be delivered
abdominally after maternal death to facilitate
separate burial

Surviving children thus born were called caesones

Introduction

The term, 'caesarean section' is regarded by
some as tautology as the words 'caesarean' and
'section' may have been derived from the Latin
words 'caedere' and 'seco' respectively, both
meaning 'to cut'

The term 'caesarean delivery' or 'caesarean birth'
has consequently been adopted by many as
opposed to the former

Introduction

Caesarean deliveries were later then performed
to separate the mother and foetus in an attempt
to save the foetus of a moribund mother

It subsequently developed into a surgical
procedure used to resolve feto-maternal
complications not amenable to vaginal delivery
due to mechanical limitations, or to temporize
delivery for maternal or foetal benefit

Introduction

This procedure is currently being performed for a
variety of foetal and maternal indications, and
such indications have expanded to consider the
patient's wishes and preferences

The following historical points are worth noting:
 Earliest report of surviving infant, 508 BC [Gorgias of
Sicily]
 First performed on a living patient, 1610. She died 25
days later
 First report of uterine closure was in 1769
 Lower segment uterine incision was first described in

Epidemiology

The CSR varies from country to country, and in a
country like ours, varies from region to region

The ideal CSR according to WHO in 1985 is
between 10 and 15%, as rates higher than these
at the population level are not associated with
reductions in maternal and newborn mortality
rates [1]

Epidemiology

Frequency and rates:
− USA, rose from 4.5% in 1965 to 32% in 2007
− England and Wales, from 4% in 1970 to 21.3% in
2000
− Ghana, 21% [Kwawukume, 2002]
− Nigeria, rose from 9.4% in 1970s to 34.6% in 2002
[Ibekwe PC, 2004]
− ASYBSH, 14.4% [2]

The pattern has been that of a progressive
increase

Indications

Recommended to prevent maternal and/or
foetal morbidity when contraindication to labour
is present or vaginal delivery is unsafe

It may be
– Absolute or relative
– Recurrent or non recurrent
– Maternal/foetal/combined

Indications

Maternal
– Severe PE/E with unfavourable cervix
[absolute]
– Previous classical c/s [absolute]
– Previous extensive uterine surgeries
– Obstructive pelvic tumours e.g. fibroids
– Previous reconstructive vaginal surgeries
– Previous 3rd
degree perineal tear repair
– Cervical insufficiency with abdominal
cerclage
– Vulval herpes simplex virus

Indications

Foetal
– Foetal distress in first stage of labour
– Transverse lie in labour [absolute]
– Face presentation in mento-posterior
position
– Multiple gestation with malpresentation of
leading foetus
– Foetal macrosomia
– Very low birth weight
– Conjoint twins
– Cord prolapse

Indications

Foeto-maternal
– Cephalo-pelvic disproportion
– Failure to progress
– Abnormal placentation
– Abruptio placenta with a live baby
– Contracted pelvis

Caesarean delivery on maternal request

Contraindications

Severe pulmonary disease in the mother where
post op survival may be jeopardized

Known karyotypic or congenital anomaly e.g.
trisomy 13 and anencephaly respectively

Refusal by patient

Classification

Based on timing at the time of decision making
[RCOG 2001]
– Category 1: emergency – there's
immediate threat to mother and foetus.
Surgery should be within 30 minutes
– Category 2: urgent – foetal or maternal
compromise not immediately life
threatening e.g., foetal heart rate
abnormalities. Surgery should be within 1
hour

Classification

Based on timing at the time of decision making
[RCOG 2001]
– Category 3: scheduled – mother needs
early delivery but there is no compromise to
either e.g., failure to progress, pre pre-
eclampsia with gradually worsening lab
parameters. Surgery is planned for a few
hours to a few days
– Category 4: elective – delivery is timed to
suit mother and staff. There is an indication

Classification

Most caesareans occur for other reasons which
have contributed to the rising CSR in recent times

There was also a lack of consensus about the
situations in which the benefits of a caesarean for
either the mother or the foetus outweighs the risks

In 1996, Robson and co devised a system of
classification dividing all pregnant women using a
maternity service into 10 groups

Classification

This system has been adapted my several
authorities with modification, including the WHO

The system uses 5 parameters, viz:
– Obstetric history [parity, previous c/s]
– Onset of labour [spontaneous, induced]
– Lie and presentation
– Number of foetuses
– Gestational age [term, preterm]

Robson's 10-Group Classification

Pre-Op Preparation

Obtain informed consent

For elective cases, patient should fast as follows
– 2 hours from clear fluids
– 6 hours from light meal
– 8 hours from regular meal [ Crenshaw et al,
2006]

Emergency cases should have an NG tube
passed and abdominal contents emptied

Pre-Op Preparation

Other preparations include
– Securing IV access with IVF 5% D/S or ringers
lactate
– Pass a urethral catheter
– Placement of an external foetal monitor
– Pre-Op medication [antibiotics, atropine}
– Abdominal preparation

Review by surgeon, paediatrician and
anaesthetist

Pre-Op Preparation

Lab investigations
– FBC, E,U,Cr, clotting profile, urinalysis
– Screen for transmissible diseases
– Group and cross match blood

Imaging studies to confirm lie, presentation,
placentation

Pre-Op Preparation

Abdominal preparation
– Used to include shaving maternal
abdomen the night before surgery
– Current recommendation is to shave in the
theatre, just before skin prep
– Shaving the night before actually increases
the bacterial count on the maternal
abdomen [3]
– Shave only hairs that physically interfere
with the procedure itself
– There is no reason to shave most of the
patients

Pre-Op Preparation

Skin preparation: the Association of Surgical
Technologists, AST, recommendations amongst
others, [WEF 2008]
– Patient to bathe or shower the night before
surgery with an antiseptic, eg, chlorhexidine
gloconate, CHG
– Alcohol is an accepted antiseptic agent,
but should not be used as a single agent
– Contaminated areas require special
attention and should be prepped last
– The patient skin prep should be well
documented in the patient chart

Surgical Safety Check-list

Briefing – before induction of anaesthesia
– Anaesthesia equipment safety check
– Confirm patient information
– Review final test results
– Confirm essential imaging displayed
– ASA class
– Allergies
– Medication


Briefing – before induction of anaesthesia
– VTE prophylaxis
– Difficult airway/ Aspiration risk
– Monitoring devices
– Anticipated blood loss
– Reviews – surgeon(s), anaesthesiologist(s),
nurse(s)
– Patient positioning and support
– Expected procedure time / Post-Op
destination


Time out – Before skin incision
– Team members introduce selves by name
and role
– Team members verbally confirm 'brief'
– “Does anyone have any other questions or
concerns before proceeding?


Debriefing – Before patient leaves theatre
– Surgeon and team members review
• Procedure
• Important intra-op events
• Fluid balance
– Anaesthesiologist and team members
review
• Recovery plans


Debriefing – Before patient leaves theatre
– Nurse(s) and team members review
• Instruments / sponge / needle counts
• Specimen labelling and management

Procedure

Involves the following steps
– Laparotomy
– Hysterotomy
– Delivery of the foetus and placenta
– Uterine repair
– Closure

Procedure

Laparotomy
– Approximate length of 15 cm or more
– Excision of previous scar is essential for
better results and cosmetic appearance
– Includes the following
• Midline infraumbilical [longitudinal]
• Maylard [transverse]
• Joel-Cohens [transverse]
• Pfannenstiel [transverse]
• Paramedian [logitudinal]

Procedure

Midline infraumbilical
– Provides quicker access to the uterus
– Associated with less blood loss
– Gives good exposure to abdominal and
pelvic organs
– The rectus sheath is either incised along the
length with a scalpel, or a small incision is
made and extended with scissors
– Peritoneum is entered at the superior
aspect of the incision to avoid bladder
injury

Procedure

Paramedian
– Used if classical c/s is contemplated
– The upper 1/3rd is above the umbilicus
– The lower 2/3rd is below the umbilicus

Procedure

Pfannenstiel
– A transverse incision 3 cm above the
symphysis pubis, curved slightly cephalad
– Extends slightly beyond the lateral borders
of the rectus muscle bilaterally and carried
to the fascia
– The fascia is incised bilaterally along the full
length of the incision
– Underlying rectus muscle is separated from
the fascia both superiorly and inferiorly with
blunt and sharp dissection
– Rectus muscles are separated in the

Procedure

Maylard
– Made 2-3 cm above the symphysis pubis
– Involves transverse incision of the anterior
rectus sheath bilaterally
– The medial 2/3rd of the rectus muscles are
divided bilaterally
– The superficial inferior epigastric vessels are
identified and ligated bilaterally
– Transversalis facia and peritoneum are
identified and incised transversely
– Gives better access and quicker than

Procedure

Joel-Cohens
– A straight transverse incision made 3 cm
below a line joining the anterosuperior iliac
spines
– Incision is carried down to the anterior
sheath of the rectus fascia
– 3-4 cm incision is made here and bluntly
opened by stretching in a craniocaudal
fashion
– The rectus muscles are retracted laterally
and parietal peritoneum bluntly opened by
digital dissection

Procedure

Transverse [vs longitudinal]:
– Take slightly longer to enter the peritoneal
cavity
– Are less painful
– Have with less risk of developing incisional
hernia
– Preferred cosmetically
– Preferred when operating on the obese
– Limits view of the upper abdomen
– Cannot be further extended if needed
– Less risk of fever

Procedure
A. Pfannenstiel
B. Joel-Cohen
C. Midline vertical

Procedure

Access the degree of rotation by palpation. It's
commonly dextrorotated

Retract the bladder

Pack the paracoloc gutters

Create a bladder flap using Metzenbaum scissors.
Evidence shows it's not always necessary,
especially in a non-laboured patient [4]

Procedure

Hysterotomy
– Low transverse [Kerr]
– Low vertical [De Lee]
– J-shaped
– U-shaped
– Inverted T
– Classical

Procedure

Low transverse [Kerr]
– Popularized by Kerr in 1926
– Used in more than 90% of all cases
– Incision is made 1-2 cm above the original
margin of the bladder with a scalpel and
continued down till the foetal membranes
are seen
– Initial incision is 2-3 cm centrally and
extended with the fingers bilaterally
– Requires less bladder dissection
– Less space available bilaterally

Procedure

Low vertical [De Lee]
– Indicated in poorly formed LUS, eg, in
preterm deliveries
– They avoid the uterine arteries bilateraly
– A trial of labour is possible in subsequent
pregnancies
– Risk of uterine rupture in subsequent
pregnancies is less than 1.5% [5]
– Requires extensive bladder dissection to
keep the incision 10-12 cm in the LUS
– There may be an unwanted extension of

Procedure

J-Shaped
– Used in difficult situations that may require
extension of a transverse incision to the
upper segment
– The extension is made on the most
accessible part of the uterus
– There is a greater risk of uterine rupture is
subsequent pregnancies
– Increases the duration of surgery
– Example is shoulder impaction mistaken for
breech

Procedure

U-Shaped
– Indicated in the delivery of an impacted
foetal head
– Has more room bilaterally than the Kerr
incision
– Incision is made with a broad base,the
convexity towards the pelvis and the ends
cephalad
– Less risk of lateral extension and injury to
uterine vessels

Procedure

Inverted T
– Similar indication as for J-Shaped incision
– Both are associated with more blood loss

Procedure

Classical
– Incision is made 10 cm on the anterior
surface of the uterus
– Should be done quickly because of the risk
of haemorrhage is greater
– Risk of cutting the foetus is greater than in
all the afore mentioned
– Delivery should be by breech extraction

Procedure

Classical [indications]
– Transverse lie with back down, ruptured
membranes and hand prolapse
– Large fibroids in the LUS
– Preliminary to caesarean hysterectomy
– Very thin previous classical scar
– Preterm breech with ruptured membranes
– Extreme prematurity, before of the LUS
– Dense adhesions in LUS
– Cancer of the cervix

Procedure

Classical [advantages]
– Rapid entry into the uterus
– No lateral extension into the vessels of the
broad ligaments
– Easy entry into the uterus when there is
fibroids in the LUS

Procedure

Classical [disadvantages]
– Increased intra-op blood loss
– High risk of adhesion formation
– High risk of uterine rupture in sunsequent
pregnancies
– Less chance of VBAC

Procedure
A. Low transverse
B. J- extension of 'A'
C. T- extension of 'A'
D. Classical

Procedure

Delivery of the baby
[cephalic]
– Place dominant
hand into the
uterus so that
the back of
hand is against
the LUS & fingers
cup the foetal
head
– Firm, gentle
traction is used
to elevate the
foetal head

Procedure

Delivery of the baby
[impacted foetal
head]
– A third assistant
to glove and
elevate head
through the
vagina
– Then proceed as
above
– Or employ a
Wrigley's forceps

Procedure

Delivery of the baby [breech]
– Manipulate feet to uterine incision and
deliver by extraction
– Deliver arms and head, maintaining flexion
of the head

Delivery of the baby [transverse]
– Convert to cephalic and deliver

Procedure

Special situations
– Bandl's [pathological retraction] ring
• Incise through the ring
• IV nitroglycerin may be used to relax
uterus
– Anterior placenta praevia
• Insinuate the hand between the
uterine walls and placenta to reach
the membranes and quickly deliver the
baby
• Incise through the placenta and

Procedure

Delivery of the placenta
– Cord traction
– Manual delivery
– Spontaneous expulsion

Procedure

Uterine repair
– Uterus may or may not be exteriorized
– May be closed in a single or double layer
– Chromic catgut or polyglycolic may be
used
– Clean out remnant membranes with
mounted gauze
– Clamp any active bleeder with green
armitage
– Retract bladder and identify lower lip of
incision
–

Procedure

Closure
– Inspect pelvis and exclude injury to
adjacent organs
– Remove any clots seen
– Irrigation may or may not be performed
– No need to reapproximate the peritoneum
or muscle
– Close the rectus sheath with PGA or nylon 1
– Close subcutaneous tissue if >2 cm

Procedure

Closure
– Rectus sheath may be closed with PGA or
nylon
– Because of the 10 mm zone of collageolysis
surrounding the fascial incision, 'bites' should
be taken >1 cm from the fascial edge to
achieve maximal wound strength
– Skin may be closed either subcut or
interrupted
– PGA, chromic, nylon and staples are viable
options

Misgav Ladach Method

Popular in several hospitals in Israel [??Introduced
by Michael Stark – Controversial!]

A randomized trial in a hospital of same name
popularized this method

Advantages
– Reduced operating time
– Improved post op recovery
– Ideal for resource poor settings as only 2
lengths of suture material are necessary [1

Misgav Ladach Method

Essential steps include
– Joel-Cohen abdominal incision
– Single layer closure of the uterus
– Non closure of the peritoneum
– 2-3 mattress sutures to approximate the skin

Apply tissue forceps to the spaces between
sutures for 5 minutes and remove just before the
application of the wound dressing

Perimortem Caesarean Delivery
• Earliest indication for caesarean delivery
• Currently indicated in the event of sudden
maternal cardiac arrest with a live foetus in utero
• Surgery should be initiated within 4 minutes of
cardiac arrest with the aim of foetal delivery within
5 minutes of arrest
• Delivery after 5 minutes, but within 15 minutes of
arrest have been shown to beneficial to most
infants with a fairly intact neurological system

• The procedure should benefit both the mother
and foetus
• The likelihood of good maternal and foetal
outcome increases with decreased interval to
delivery time, and decreased interval to return to
spontaneous circulation, vice versa [6, 7]
• Performance of a PMCD outside of an OR under
non sterile conditions is not likely to negatively
impact on maternal survival, because only 3% of
witnessed in-hospital cardiac arrests make it to
discharge [8]

• PMCD should never be performed on a patient
who is unstable, but not in cardiac arrest because
maternal well being takes precedence over foetal
well being

Post-Procedure

Vital signs every 15 min for the first 1-2 hours

Urine output monitoring hourly

Palpate uterus to ensure it feels firm

Any active bleeding par vaginam?

Ensure adequate pain control

Fluid management – 3-4L in the first 24 hours post-
op

Remove catheter after 12-24 hours

Post-Procedure

Oral sips may be started within 12-24 hours and
advanced accordingly

Encourage early ambulation by 1st
post-op day

Encourage early initiation of breastfeeding if
patient plans to breastfeed

Post-op PCV check by 1st
post-op day

Patient may be discharged by day 3-4 if no
complication

Discuss plans for contraception

Complications

Caesarean birth is associated with a great deal of
maternal morbidity, and sometimes,mortality

Compared with vaginal deliveries, caesarean
delivery has twice the rate [5]

The overall mortality rate is 6-22 deaths per
100,000 live births in the US

In UNTH, it was 40/100,000 in 1989

Up to 1/2 of maternal deaths following a
caesarean are directly attributable to the
operative procedure itself

Complications

Risk for complications include
– Excessive speed [adage: speed kills!
literally]
– Lack of experience
– Low station of vertex
– GA less than 32 weeks
– Advanced labour
– PROM
– Faulty surgical technique, especially lack of
attention to haemostasis

Complications

Intra-op
– Unwanted extension of uterine incisions with
injury of the vessels
– Uterine atony
– Damage to internal structures [ureters,
bowel, bladder]
– Injury to foetus

Complications

Post-op
– Infections [wound sepsis, UTI,
endomyometritis]
– Wound breakdown
– Slow return of bowel function
– Thromboembolism

Reducing Caesarean Rates

I n Feb and March 2014 respectively, American
College of Obstetricians and Gynaecologists,
ACOG and Society for Maternal-Foetal Medicine,
SMFM released guidelines for the safe prevention
of primary caesarean births [9, 10] as follows:
– Prolonged latent phase should be
permitted
– Define active phase as from 6 cm cervical
dilatation
– In active phase, more time should be
permitted for labour to progress

– Multiparous women shold be allowed to
push for 2 or more hours, and primiparous
women should be allowed to push 3 or
more hours
– Techniques to aid vaginal deliveries, eg,
forceps should be employed
– Patients should be encouraged to avoid
excessive weight gain during pregnancy
– Access to non medical interventions during

– External cephalic version should be
performed for breech presentation
– Women with twin gestation, if the first is
cephalic, should be permitted trial of
labour

Psychological Aspects of Post Caesarean
Procedure

Loss of idealized delivery

Insult from peer group

Associated morbidity and mortality

Deformed body contour

Interrupted relationship with baby/husband

Anger at hospital staff

Loss of self esteem as a woman

Psychological Aspects of Post Caesarean
Procedure

Management include

Clear and realistic information

Minimise unnecessary separation

Post natal counselling

Going forward ...

Patient needs to know why they had a caesarean
delivery and the kind of uterine incision made

VBAC may be attempted for patients with non
recurrent indications with up to 70% success rate

The risk of developing placenta accreta is present
in subsequent pregnancies [4% for primary, 25%
for 1 previous & 40% for 2 previous scars]

Recent trials

CAESER

CORONIS... develop further

Controversies

Clean out uterus or
not?

Dilate cervix or not?

Exteriorize or not?

Repair in 1 or 2 layers?

Irrigate or not

Put a drain or not

Caesarean for breech
presentation

CDMR – grant or reject
• What constitutes a
'suitable indication'?
• What is 'proper
technique'?
• What is the correct
terminology to describe
the procedure?

Conclusion

Over the past several decades, caesarean births
have increased dramatically

Although the operation is now safer, maternal
morbidity and mortality are still higher than that
for vaginal birth

As obstetricians, we must continually ensure that
caesarean deliveries are not performed for
inappropriate indications

THANK YOU FOR LISTENING ...

References
1.http://www.who.int/reproductivehealth/publications/maternal_he
2.Morbidity and mortality review for the month of May, 2015
at the Obstetrics and Gynaecology department of Ahmad
Sani Yariman Bakura Speciaist Hospital, Gusau
3.Greenmall MJ, Evans M, Pollack AV: Mid-line or transverse
laparotomy? A random controlled clinical trial period Br J
Surg 67:188, 1980
4. Hohlagshwandtner M, Reucklinger E, Hussein P, Joura
EA. Is the formation of a bladder flap at caesarean
necessary? A randomised trial. Obstet Gynecol 2001 Dec
98(6): 1089-92
5. Landon MB. Vaginal birth after caesarean delivery. Clin
Perinatol 2008 Sep 35(3): 491-504, ix-x.
6.Blackhall LT, Ziogas A, Azen SP: Low survival rate after

Caesarean Section Guide by Dr. Obiokonkwo

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