2. OUTLINE
INTRODUCTION
INDICATIONS
TYPES AND CATEGORIES
PRE-OPERATIVE CARE
PROCEDURE
POST-OPERATIVE CARE
COMPLICATIONS
PREVENTION
CONCLUSION
REFERENCES
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3. INTRODUCTION
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Caesarean delivery [ CD ] is one of the oldest and
commonly performed procedure in Obstetrics.
HISTORY- It has been hypothesized that the great
Julius Caesar was born [ 100BC ] in this manner and
the mother lived many years after his birth.
CD goes back to 715BC when Numa Pompilius the
king of Rome brought in a law which forbade the
burial of pregnant woman unless her child had been
removed from abdomen and buried separately; Lex
caeseare
4. INTRODUCTION.
First recorded successful Caesarean delivery done by
Jakob Nufer on his wife for prolonged obstructed
labour in 1588 AD.
The term caesarean was derived from the Latin verb
caedere which means to CUT; Partus ceasarcus
The term section is derived from the verb seco which
also means to CUT, hence Caesarean section seems
tautological thus, Caesarean delivery is used.
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5. INTRODUCTION..
Caesarean delivery is defined as delivery of a
fetus through a surgical incision in the abdominal
wall and the uterine wall after 28weeks of
gestation.
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6. EPIDEMIOLOGY
WHO recommends an ideal caesarean rate of 5-
15%
In united state of America it was 32.2% in 2014
15-21% in most African countries
In Korle bu TH,Accra,Ghana was 21.1% (1988-
99)
15.8% in AKTH between December and January
2010 Ahmed ZD
Some centers <5% while others >15%
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7. EPIDEMIOLOGY..
Repeat CD due to two or more previous CDs were the
commonest indications for elective CD accounting for
51.3% of cases in a study done in AKTH Yakasai A.I
and Abubakar M.Y [2010 ]
Cephalopelvic disproportion accounted for 22.9% in
cases of Emergency CD in a study done by Ahmed Z.D
in AKTH in [2010]
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8. RISING INCIDENCE ??
Increase in repeat caesareans.
Difficult instrumental delivery and vaginal breech
deliveries
Increased diagnosis of Intrapartum fetal distress
Caesarean on demand
Identification of risk of mothers and fetuses
Assisted reproductive technology
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9. TYPES
There are different ways of classifying CD
ELECTIVE CD(planned)
It is not urgent and may be scheduled well in
advance. The decision is taken before or during
pregnancy and planned for at term or as close to term
as possible .
EMERGENCY CD
Decision is taken during labour or delivery when
there is imminent danger to the mother, fetus or both.
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10. TYPES..
Primary or Repeat
Classical or lower segment
Midline sub-umbilical or Pfannestiel
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13. CATEGORIES…
CAT 1 or EMCS when there is immediate threat to the
mother or the fetus, ideally CD should be done within
the next 30min
Fetal distress
Cord prolapse
Severe abruptio with live baby
Uterine rupture
Failed instrumental delivery
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14. CATEGORIES…
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CAT 2 or Urgent CS when there is maternal or
fetal compromise but was not immediately life
threatening, delivery should be completed within
60-75min
Mal presentation in labour
APH with hypovolemia
Failed IOL
15. CATEGORIES….
CAT3 or Scheduled CS is when there is no
maternal or fetal compromise but early delivery is
needed due to concerns that continuation of the
pregnancy is likely to affect the fetus in hours or
days to come
Early labor in px booked for ELSC
Macrosomic baby in early labor
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16. CATEGORIES….
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CAT4 or Elective CS where there is an indication
for the CS but there is no urgency as such the
delivery is timed to suit mother and staff
Refused VBAC/TROLAC
2PCS
18. INDICATION..
MATERNAL INDICATIONS
Maternal disease condition
Previous caesarean delivery
Previous extensive uterine surgery
Obstructive pelvic tumors
Previous third degree perineal tear and repair
HIV-AIDS for PMTCT
Elderly Primigravida
Long history of primary or secondary infertility
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19. INDICATION ….
MATERNO-FOETAL INDICATIONS
Cephalopelvic dispropotion
Failure to progress in labour
Placenta praevia
Abruptio placenta with a live fetus
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20. CAESAREAN DELIVERY VS
MATERNAL REQUEST
Maternal request; Gossman and associates 2005
estimated that 2.5% of all births in the US in 2003
were defined as caesarean delivery on maternal
request (CDMR)
It should not be performed prior to 39week gestation
unless there is evidence of fetal lung maturity
It should be avoided in women desiring several
children because of the risk of placenta accreta
It should not be motivated by the unavailability of
effective pain management
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21. PATIENT PREPARATION
History
Past medical and Surgical
Obstetric and Gynecology
Length of labor and rupture of membrane
Examination
Abdominal/obstetric
Vaginal examination
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22. PRE-OPERATIVE CARE
Patient preparation
Urgent packed cell volume estimation
Blood grouping and cross-matching
Shaving and catheterization
Informing Theatre , Anesthetist and Pediatrician
Counseling patient and obtaining informed consent
Pre-op Antibiotics
Fluid and electrolytes
Blood???
Nil per Oral
Choice of anesthesia
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23. CHOICE OF ANESTHESIA
It is determined by multiple factors
Indication for CD and its urgency
Patient and obstetrician preferences
Skills of the Anesthetist
In most developed countries, regional anesthesia
has become the most preferred technique
because general anesthesia [GA] has been
associated with a greater risk of maternal
morbidity and mortality
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24. CHOICE OF ANAESTHESIA
In the last 30 years there has been a decreased
use of GA and epidural were “all the rage” in the
70’s
Spinal or Epidural are now preferred anaesthesia
method.
SPINAL ANAESTHESIA –Advantages
Uniquely appropriate in CD (happy event)
Patient is awake and smiling
Quick, solid, simple, reliable and pretty safe.
Can give long lasting analgesia
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25. CHOICE OF ANAESTHESIA
It lacks the potential for serious systemic drug
toxicity
More rapid and predictable onset
Decreased risk of maternal pulmonary aspiration
DISADVANTAGES
Longer to perform
Hypotension especially with high doses
Not suitable for surgery lasting >2hrs
Postdural puncture headache
Requires skill
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26. CHOICE OF ANAESTHESIA
GA –ADVANTAGES
Fast,reliable and flexible duration
Greater comfort for parturient who have morbid
fear for needle or surgery
Can be given despite coagulopathy
Control over the airway and ventilation
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27. CHOICE OF ANAESTHESIA
GA-DISADVANTAGES
Patient not awake for birth
Unprotected airway
Possible “can’t intubate, can’t ventilate” scenario
Nausea, post-operative pain, sorethroat.
Aspiration pneumonitis
Drug induced foetal depression
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28. CHOICE OF ANAESTHESIA
SPINAL ANAESTHESIA AGENTS;
Bupivacaine .5%, 2-2.5mls. Lasts 2-3hrs
Lignocaine 5%+- adrenalin. 1.2-1.6mls. Lasts 45-
90min
GENERAL ANAESTHESIA AGENT
Thiopentone is currently the drug of choice
4mg/kg. Others are propofol, ketamine,halothane
and isoflurane
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29. INCISION
Skin incision ;
Vertical incision;sub umblical,less vascular,good
exposure
Pfannenstiel incision;cosmesis,early
ambulation,low incidence of wound
disruption,dehiscence and herniation.
Disadvantages-longer time to perform,injury to
ilioinguinal,iliohypogastric vessels leading to blood
loss.
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33. INCISION…
Advantages of TRANVERSE over CLASSICAL
uterine incision
Less risk of entry into the upper segment
Greater ease of entry
Less repair
Reperitonealization is higher
Less likelyhood of adhesion formation
Less likelyhood of rupture
VBAC is possible
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34. PROCEDURE
Place the patient on the table with a left lateral tilt
Scrub
Under anaesthesia, clean the abdomen with
antiseptic solution and drape
Perform abdominal incision
Perform uterine incision
Delivery of the foetus
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42. PROCEDURE..
Clean and sunction mouth and nostrils
Clamp the umblical cord
Maintain haemostasis
Deliver the placenta by control cord traction
Close uterine incision in two layers
Inspect ovary,tube,and uterine wall
Close the abdominal incision in layers
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44. POST-OPERATIVE CARE
Nil per Oral
IV Fluid
Analgesic
Antibiotic
Catheter
Vital signs
Graded oral sips
Early ambulation
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45. POST-OPERATIVE CARE
Return activity when comfortable
Breastfeeding
Post-op PCV
Avoid heavy lifting for two weeks
Misoprostol
Wound care
Discharge
Post natal clinic
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46. COMPLICATIONS
Anaesthetic complications
Early or Late
Surgical complications
Early or late
Maternal morbidity rate has increased twofold
with caeserean delivery compared with vaginal
delivery.
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47. COMPLICATIONS…
EARLY SURGICAL
Bleeding leading to anaemia
Injury to internal organs (bladder laceration with
caeserean delivery was 1.4 per 1000 precedure
and ureteral injury was 0.3 per 1000 procedure.
Injury to neonate
Infections - wound, UTI, GIT
Deep Venous thrombosis
Maternal mortality rates 2.2 per 100,000 CD
which could be from complications or surgery
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49. COMPLICATIONS….
Early anaesthetic
Failure of technique
Hypotension
High motor block
Loss of consciousness
Fever with chills and rigor
Myocardial infarction
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51. PREVENTION OF CAESAREAN
DELIVERIES
Educating healthcare providers
Childhood nutrition
Girl child education
Immunization in childhood
Ante natal care …Preconception, counseling, haematinics
,Treating anemia, DM, HTN, Cardiac diseases
Discourage induction of labour in nulliparas with an unengaged
vertex
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52. PREVENTION OF CAESAREAN
DELIVERIES
Discourage CD for patients presenting with
breech
Encourage use of forceps and vacuum
Early detection and treat hypertensive disorders
Encourage marriage before 35years of age
Encourage Vaginal birth after caesarean delivery
[VBAC] despite lack of fetal electronic monitoring
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53. PSYCHOLOGICAL ASPECT OF
POST CAESAREAN DELIVERY
Maternal happiness with child birth
Post partum depression/psychosis
Post surgery stress disorder
Relationship of the mother with the infant
Breastfeeding practices and sexual relationship
with the husband
The stress of coping with the baby and other
siblings at same time
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54. PSYCHOLOGICAL ASPECT OF
POST CAESAREAN DELIVERY
Loss of idealized vaginal birth they had hoped for
during pregnancy
Caesarean scar as a form of deformity or
mutilation
Anger at hospital staff
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55. CONTROVERSIES
Use of betamethasone 12mg @37wks
Skin cleansing techniques…povidone iodine vs
spirit for scrub
Pre-op metronidazole gel insertion
Adhesive drapes for caesarean delivery
associated with a higher incidence of wound
infection, it should not be used.
Early vs delayed cord clamping
Control cord traction vs manual removal
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56. CONTROVERSIES
GA vs epidural anaesthesia
Skin incision ….joel cohen is faster
Exteriorization of uterus not recommended as it
increases pain, fever and infection
Closure of uterus - 1layer vs 2layers
Forceps only used in delivery of head
Use of same or separate surgical knife
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57. CAESAREAN HYSTERECTOMY
Defined as hysterectomy performed at CD
Placenta increta percreta
Ruptured uterus
Markedly hypotonic uterus
Severe intrauterine infection
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58. CONTRAINDICATIONS
Congenital anomaly not compatible with extra-
uterine life
Severe cardiopulmonary disease..
MAXIMUM NUMBER OF CS
4 but up to 6 with increasing risk of morbidity in
the mother
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59. Conclusion
CD subjects both mother and neonate to
increasing risk of complications, hence
optimal pre-operative care, surgical
technique and post operative care should
be employed to reduced morbidity in the
present and future deliveries.
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61. REFERENCES
Cunningham FG,Leveno KJ,Spong CY,Bloom
SL,Hauth JC,Rouse DJ.Caesarean delivery and
caeserean hysterectomy in williams obstetrics 23rd
ed.2010 (25);544-564
American College of Obstetritians and
Gynecologists.Task Force on Cesearean Delivery
Rates. Evaluation of Cesarean Delivery. American
College of Obstetricians and Gynecologists.
Washington, D.C. 2000.
Kwawukume EY,Emuveyan EE,Caesarean section in
comprehensive obstetric in the tropics 1st
ed.2002(42);321-329
Flamm BL,Operative delivary in current diagnosis
nd
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