Associate Prof.Dr Aisha Elbareg lecture on CS.

CESAREAN SECTION
Associate Clinical Prof. Dr. Aisha M. El-Bareg, MD, PhD
Senior Consultant in (Obs & Gyn)/ Reproductive Medicine
Faculty of Medicine, Misurata University. LIBYA

DEFINITION:
 The delivery of a fetus, placenta and membranes after
28 weeks gestation through an incision in both, the
anterior abdominal and uterine walls!
 Removal of a fetus outside the uterus (abdominal
pregnancy) or through a ruptured uterus or before 28
weeks is then not a CS!

• References to Cesarean Section appear in ancient
Chinese, Persian, Hindu, Egyptian, Grecian, Roman,
Muslims, and others.
• Early time, C-sections are performed on dying or dead
women
• The purpose of C-section is differ from time to time as
the technique advanced.
History

History
 Commonly known that Julius Caesar was born from C-
section,(was born from the procedure. Ab utero caeso
(to cut open uterus).
 Caesar’s Law : dying or dead pregnant mother must be
cut open to save the infant to increase population, and
for religious view.
 Derived from term caedere (to cut), caesones.

History
 320 BC: mother of Bindusara (second emperor of India)
accidentally drank poison. Advisor and teacher of first
emperor, Chanakya made up his mind and perform
C-section to save the infant: (In order to save Bindusara
life, Chanakya rushed to her and cut off her head! to stop
the flow of blood through her body and then cut open her
abdomen and pulled out the baby Bindusara. But a drop of
poison fell on baby head and it left a black mark on his
forehead hence he was named Bindusara).

History
 The Islamic scholars of the Middle ages were, in
fact, the first to not only write about this operation
but to illustrate it in pictures and describe it in
poetry.
 Abū Hanīfa (699-767 CE), a highly respected
Islamic jurist, who was of the opinion that
Caesarean section was allowed on living or dead
pregnant women.

A fourteenth century Persian manuscript, showing the
birth of Rustam.

History
 1580s: First recorded woman surviving the procedure.
 Jacob Nufer, Swiss pig-gelder performed C-section on his
wife after prolonged labour. His wife and his child
survived. His wife allegedly bore five more children,
including twins, and the baby delivered by Caesarean
section purportedly lived to the age of 77!! C-section was
done at an earlier stage in failing labor when the mother
was not near death and the fetus was less distressed.
Chances of one or both surviving were greater!

History
 Between 1815 and 1821, first successful C-section in
British Empire was performed.
 1865: In Great Britain and Ireland, mortality rate for C-
section was as high as (85%).
 1879 R.W. Felkin witnessed cesarean section performed
by Ugandans:
 Banana wine was used to semi-intoxicate the woman
and to cleanse hands and her abdomen.
 A midline incision and applied cautery to minimize
blood loss, and massaging the uterus to make it
contract but did not suture.

History
 The abdominal wound was pinned with iron needles and
dressed with a paste prepared from roots
 The patient recovered well and Felkin concluded that
this technique was well-developed and had clearly been
employed for a long time
C-section performed by Ugandan as depicted by RW Felkin (1879)

History
 1881 First modern C-section performed by German
Gynecologist, Ferdinand Adolf Kehrer. He introduced
transverse incision of Uterus.
 1882 Max Saenger introduced uterine suture.
 1888: First C-section under modern antiseptic condition
was performed by Murdoch Cameron.
 1900: Pfannenstiel introduced Pfannenstiel’s incision
(bikini-line incision).

History
First description of Pfannenstiel's incision:
Hermann Johannes Pfannenstiel (1862-1909)

History
 By mid 20th century, C-section became to be one of the
safest and most successful surgical operation.
 On 5th March, 2000: A Mexican woman named (Inés
Ramírez Pérez ) successfully performed Caesarean
Section on herself after 12 hours of continual pain with a
kitchen knife and 3 glasses of hard liquor while her
husband away from home!! She and her son, Orlando
are still alive today.

Objectives:
 1. To reduce infant and maternal morbidity
 2. To reduce infant and maternal mortality

Section:-Indications of C
 It is usually performed when a vaginal delivery
would put the baby's or mother's life or health at
risk.
 Most frequent indications are:
 Extreme degree of contracted pelvic (one or more
of the diameters is reduced and interferes with
normal mechanism of labour).
 Cephalo-pelvic disproportion: the head of the fetus
is too large to come through the pelvis.
 Uterine Inertia: Inefficient uterine contraction.
 Placenta previa: Implantation of placenta in the
lower uterine segment.

:Section-Indications of C
 Premature separation of placenta/APH
 Malposition and malpresentation(Brow presentation,
Shoulder presentation).
 Previous caesarian section.
 Fetal distress/Fetal Asphyxia: ominous intrapartum signs
or scalp pH <7.2
 Pre-eclampsia.
 Breech presentation.
 Diabetes . Cardiac diseases
 Vaginal scaring.
 Failure of labour to progress despite adequate stimulation.
 Cervical dystocia (failure of the cervix to dilate in spite of
strong contraction of the uterus).

Section:-Indications of C
 Ca Cervix.
 Prolapse of the umbilical cord.
 Bad obstetric history.
 Fetal anomalies: Hydrocephalus, Abdominal wall defects
e.g. omphalocele to avoid its rupture during vaginal
delivery.
 Caesarian section on demand!!

Absolute indications for C.S
 It should be done even in the presence of
dead fetus:
• Previous classic C.S. or CS extending to upper
segment.
• Previous ≥2 LSCS
• Previous LSCS with malpresentation.
• Previous repair of vesicovaginal fistula.
• Extreme degree of contracted pelvis.
• Placenta previa centralis.

Contraindications:
 Severe Chorioamnionitis.
 Very poor fetal prognosis, expt: extremely
premature, severe congenital anomaly.
 Fetal death, except in case of placenta previa
 No adequate facilities for surgical procedure!

Decision-to-delivery interval for CS:
 Emergency: Immediate threat to life of woman or fetus:
Within 30 minutes.
 Urgent: Maternal or fetal compromise which is not
immediately life threatening Within 75 minutes.
 Scheduled: Needing early delivery but no maternal or
fetal compromise. Rapid delivery may be harmful in
certain circumstances.
 Elective: At a time to suit the patient and the maternity
team.
The risk of respiratory morbidity is increased in babies born
by CS before labour, but this risk decreases significantly
after 39 weeks : planned CS should not routinely be carried
out before 39 weeks.

 Medically or obstetrically indicated CS are performed
when clinically indicated, without assessment of fetal
lung maturity. RDS can be prevented by giving
dexamethasone 6mg/12 h for 4 doses.

?WHY RATES INCREASED
 The incidence of Caesarean deliveries is increasing
every day, passing faraway beyond WHO recommended
rate of 15% for all deliveries .
 United States cesarean rate increased from 20.7% in
1996 to 32.2% in 2014, while it is 40.5% in
Latin America and 25% in Europe.
 In Japan was 37.3% in the year of 2016.
 At Misurata Medical Centre, reached 48% !! (almost 1 in
2 women giving birth by CS appears to be too high!).

WHY RATES INCREASED?
 Possible factors leading to rising rates (complex factors):
 Main: Previous CS, PET, Breech, Multiple pregnancy,
Elderly PG, Obesity and Maternal medical conditions.
 Others:
 Fear of labour pains.
 Intolerance of labour pains.
 Misconception about genital damage after vaginal
delivery.
 Misconception about safety of CS delivery for the baby;
 Lower tolerance to any complications or outcomes other
than the perfect baby!
 Cesarean section on request!

WHY RATES INCREASED?
 Financial issues.
 Ignorance of vaginal delivery arts.
 Ignorance of CTG, Partogram or increased use of
electronic fetal monitoring!
 Intolerance to long lasting deliveries.
 Fear of rupture uterus.
 Malpractice.
 Medico-legal responsibilities if fetus was lost in
normal labour.
 Increase in pregnancies by in vitro fertilization.
 Social factors.

:Impact of increased rates
 Increase in C-S rates does not indicate better maternal
or perinatal care : Data for 106,546 births found rate of
cesarean delivery was positively associated with:
 Postpartum antibiotic treatment.
 Severe maternal morbidity and mortality.
 Increase in fetal mortality rates.
 Increase in babies admitted to neonatal intensive care.
 Rates of preterm delivery and neonatal mortality both
rose at rates of C-S between 10% and 20%.
(Haberman 2013; Shah 2009; Boyle 2012; Villar 2006)

Impact of increased rates:
 Caesarean delivery is associated with an increased risk
of placenta praevia & placenta accreta in subsequent
pregnancies. This risk rises as the number of prior
caesarean sections increases, therefore, Women
requesting elective caesarean delivery for non-medical
indications should be informed of the risk of placenta
accreta spectrum and its consequences for subsequent
pregnancies (RCOG Green-top Guidelines, No. 27a,
September 2018).
 incidence of placenta praevia increases from 10 in 1000
deliveries with one previous caesarean delivery to 28
in 1000 with 3 or more caesarean deliveries

Impact of increased rates:
 Women having a caesarean section for placenta praevia
are at increased risk of blood loss of more than1000 ml
compared with women having a caesarean section for
other indications.
 Placenta praevia is often associated with additional
complications, including fetal malpresentation
(transverse or breech presentation) requiring complex
intraoperative manoeuvres to deliver the baby.

INTERVENTIONS TO DECREASE CS Rates:
 Practices that have become standard over decades
should be carefully questioned and replaced by
standardized, evidence-based practices (clinical practice
guidelines for CS). This may safely decrease the
cesarean rate and without any adverse effects on
neonatal outcome (physician motivation to make a
change!!).
 The healthcare system will need to adopt systems
approaches to decrease the national cesarean delivery
rate:-
 Audit and feedback, second opinions and culture
change.

 VBAC:
 Should be offered and encouraged for all patients
unless there is a separate complicating risk factor that
justifies CS.
 Safer for both mother and infant, in most cases, than
is routine elective CS, which is major surgery.
 Patient acceptance of VBAC is important.
 Maternal request:
 On its own, not an indication! reasons for the request
should be explored, discussed, and recorded.

 Inducing first-time mothers at 39 weeks lowers the risk
of cesarean delivery and other serious ‎complications,
compared to those induced after 41 weeks‎: Using data
collected by the National Institute of Health on 100,000
patients, researchers at the ‎University of South Florida,
US, found that waiting to induce labour ‎until after 41
weeks resulted in increased C-section rates to 35.9 %
compared to 13.9 % in cases of elective induction at 39
weeks.‎
 Similarly, maternal complications, such as preeclampsia
and uterine rupture, were more likely ‎‎(21.2 % vs
16.5%), as were stillbirths and newborn deaths.‎

 A higher rate of IV fluids provided to women in labour
can reduce the number of caesarean ‎sections as well as
shorten the length of labour by an hour, according to a
study by ‎researchers at Thomas Jefferson University,
Pennsylvania, US.‎

Positive Impact of Cesarean on Maternal &
Neonatal Health:
 Protective against perineal lacerations.
 Evidence suggests that vaginal delivery may be
associated with pelvic organ prolapse and fecal and
urinary incontinence but CS has not.
 Cesarean delivery is associated with lower rates of
intra-partum hypoxic injury.
 With vaginal delivery, there is also always a risk of
shoulder dystocia and permanent brachial plexus
injury.

Negative Impact of Cesarean on Maternal &
:Neonatal Health
 Cesarean delivery has been associated with higher rates
of maternal hemorrhage, DIC, Injury to internal organs,
Injury to the baby, Difficulty in delivery of the head,
Bladder injury, Anaesthetic complications , and
postoperative complications:-
 Paralytic ileus. Respiratory complications
 Infections/Peritonitis/Pelvic abscess.
 Pelvic thrombophlebitis.
 Deep vein thrombosis and pulmonary embolism.
 Wound dehiscence.
 Hospitalization of mothers: women are more likely to
stay in the hospital longer and are at greater risk of being
re-hospitalized.

Neonatal Health:
 Increased risk of abnormal placentation that can lead to
a need for preterm delivery and cesarean hysterectomy.
 Future fertility may be affected by CS.
 Neonates delivered via cesarean appear to experience
higher rates of transient tachypnea and possibly primary
pulmonary hypertension.
 Infants born to mothers who have had prior cesareans
are at increased risk of stillbirth.
 LATE SEQUELAE : Secondary PPH, Incisional hernia, Scar
endometriosis, Adhesions, Vesico-vaginal fistula, ectopic
pregnancy, Scar rupture in the next pregnancy.

Neonatal Health:
 Emotional well-being of mothers: A woman who has a
cesarean section may be at greater risk for poorer
overall mental health and some emotional problems.
She is also more likely to rate her birth experience
poorer than a woman who has had a vaginal birth.
 Early contact with, feelings toward babies: A woman
who has a cesarean usually has less early contact with
her baby and is more likely to have initial negative
feelings about her baby.

trial of a scar
 It is the trial of vaginal birth after C.S. in previous
pregnancy. The dictum once cesarean, always cesarean
is no longer present.
Conditions that should be fulfilled before trial of
scar:
 Non-recurrent indication.
 Previous C.S.: single transverse LSCS type, Proper
surgical technique, Smooth postoperative course, A
long interval between C.S. and current pregnancy
 Current pregnancy : Single fetus, Vertex presentation,
Average fetal weight, No medical risks, No other
indication for C.S.

trial of a scar
 Competent obstetrician to follow the patient in a
well-equipped hospital capable of performing urgent C.S
once uterine dehiscence is detected.
Signs of dehiscence:
 Lower abdominal pain in between uterine contractions.
 Lower abdominal tenderness in between contractions.
 Vaginal bleeding.
 Sudden changes in FHR pattern: variable decelerations.

:Preoperative management
 The patient is told not to eat or drink anything 8hrs
prior to surgery (if it is a scheduled Caesarean).
 Basic investigations required : CBC, Hb min. 10 g/dL,
Blood Grouping and Rh typing, viral screen: HIV,
Hepatitis(B&C). Serum Electrolyte, LFTs & RFTs,
Clotting screen (for complicated cases), FBS, Urine
analysis.
 Risk factors for requiring Blood transfusion : Placental
abnormalities, Eclampsia or HELLP syndrome,
Preoperative hematocrit<25 %(HB 8.5g/d), History of
≥5 CS.
 Indwelling Urinary Catheter (to prevent over-distension
of the bladder).

Preoperative management
 IV line to be taken with large bore needle (minimum 16
/18 gauge).
 Prophylactic antibiotics : Preoperative (given 0 to 60
minutes before making the incision). Cefazolin :2 gm for
patients <120 kg, 3 gm for patients ≥120 kg,
Clindamycin and Gentamicin for women with serious
penicillin allergy(to prevent post-operative infection).
 combination of heartburn relief medication between
2 hours and not less than 30 minutes prior to surgery, to
prevent Mendelson’s syndrome.
 Preoperative requisites: Theatre should be clean with
adequate sterile linen, gowns, emergency drugs and
equipments in working condition.

Preoperative management:
 For the newborn, arrangements should be made for
suction machine, sterile tubing, laryngoscope, endo-
tracheal tubes overhead light /warmer.
 For all women undergoing CS, mechanical
thromboprophylaxis is advisable, high risk of DVT:
mechanical thromboprophylaxis + pharmacological
thromboprophylaxis (to start 6 to 12hrs post) and
continued postoperatively until the woman is fully
ambulating.
 The operating table for CS should have a lateral tilt of
15 degrees (reduce aortocaval compression/reduce risk
of supine hypotension).

 Type of Anesthesia: Choices influenced by:
1.Urgency of the procedure.
2.Maternal status.
3.Specific contraindications.
4.Physician and patient preference.
 Spinal anesthesia : (needle, in the lumbar region,
between the vertebrae through the epidural, beyond
the dura, and just before the spinal cord. This injection
is directly into the spinal fluid.), it is reliable, has rapid
onset, patient is awake and there is less risk of
aspiration.

 Epidural anesthesia (needle tip is placed in the epidural
space, which lies just outside the membrane covering
the spinal fluid, less hypotension).
 The main difference between the two is how it is
administered and that the spinal anesthetic has a higher
incidence of spinal headaches which can be treated with
painkillers and oral fluids.
 General :mostly used when regional is contraindicated,
in cases of sepsis, hypotension, thrombocytopenia,
coagulation disorders, CHD. Unusual complications
include aspiration, neonatal depression.
In an exceptional situation, CS may be performed under
local anesthesia.

C-Section Technique:
 Types of Cesarean Section:
 1. Classical (vertical incision).: allows a larger
space to deliver the baby, is rarely performed today as
it is more prone to complications.
 2. Low segment (transverse incision).
(Pfannenstiel, Maylard, Joel Cohen)‎
It is the a procedure most commonly used today
 3. Extraperitoneal CS.
 4. Cesarean hysterectomy: It is done when there is
inability to stop bleeding from the uterine incision or
multiple fibroids in old patient, Placenta accreta, increta,
Uterine rupture that can not be repaired.

Types of Cesarean Section:
 Classic CS, Indications :
 Poorly developed L US + Extr. Preterm.
 Fetal abnormality as conjoined twins.
 Cancer Cervix.
 Postmortem delivery.
 Back down transverse lie.
 Lower U segment leiomyoma.
 Densely adherent bladder(lower segment can not
identified due to adhesions).
 Anterior placenta previa or accreta.
 When hysterectomy will follow caesarean section.

 Classic CS, Advantages:
 Faster
 Easier
 Classic CS, disadvantages:
 Profuse bleeding.
 More liable to chest infection and intestinal distension.
 Increased Risk of rupture during future pregnancy.

 Skin Incision:
 Joel Cohen Incision: Straight, slightly higher than
Pfannenstiel, 3 cm above the pubic symphysis,
subsequent tissue layers are opened bluntly (scissors
used for extension), has shorter operating time and
reduced postoperative febrile morbidity.
 Pfannenstiel Incision: It is curved skin incision, two
fingers above the symphysis pubis. It is associated with
less postoperative pain, has cosmetic appeal, low
wound dehiscence and less chances of herniation
 Vertical Incision:(infraumbilical vertical /paramedian )
usually avoided, more post op pain, low cosmetic
appeal, more chances of hernia.

 Maylard incision:
 Option when more exposure is needed in
transverse incision, recti muscles are divided.
 Low segment CS (Advantages):
 Less bleeding
 Easy to luxate fetal head
 Easy to close (suture)
 Good reperitonization
 Risk of rupture in the next pregnancy is minimal

 Low segment CS (Disadvantages):
 Takes more time.
 Bleeding may be more severe, if the incision runs too
laterally.
 Injury to the bladder may happen, if the incision is too
low.
 During repeated CS, post laparotomy, or post infection,
LUS may be too difficult to identify.

:O P E R A T I V E STEPS-I N T R A
 Incision is made into the lower abdomen with a scalpel.
 Dissection is made until a shiny, fibrous layer called the
fascia is seen which lies over the abdominal muscles.
 Fascia is opened and dissected away using curved Mayo
scissors.
 The peritoneum, a film-like layer is the lining of the
abdominal cavity, 2 curved hemostats are used to grasp
this layer and separated with a curved Metzenbaum
scissor.
 Once the opening is made into the peritoneum, (Doyen
Retractor) is placed to pull the lowest part of the
opening downward, care is taken not to injure the
bladder.

O P E R A T I V E STEPS:-I N T R A
 The uterus is then exposed, with the other half of the
bladder riding up to the lowest part of the uterus and a
bladder flap is created.
 Bladder is pushed away from the rest of the surgery.
 The uterine incision is made , If the patient’s amniotic
sac has not broken it will protrude through the uterine
incision, bag of water is artificially ruptured using a blunt
instrument.
 The baby’s head is delivered first, (suctioning of the
infant’s nose and throat) followed by the rest of the
baby’s body

I N T R A -O P E R A T I V E STEPS:
 The cord is clamped with an infant cord clamp and one
Kocher clamp and dissected between the two with a
pair of curved Mayo scissors freeing the baby from
placenta.
 Newborn will then be taken to an infant warmer to be
assessed by a neonatal nurse and/or pediatrician.
 Cord blood specimen is obtained to get baby’s blood
type
 Placenta should be removed using controlled cord
traction.
 Twenty units of oxytocin usually is administered through
the IV so the uterus will contract and help control
bleeding.

 uterine incision is then closed typically using polyglactin
2-0.(two-layer uterine closure).
 If there is no further bleeding after re-approximation of
incision line, the uterus is allowed to fall back into the
pelvis.
 The peritoneum is left open(reduces operating time,
quicker return of bowel activity) or closed, If so usually
with 3-0 polyglactin. (studies have indicated if closed it
might lead to internal scarring called adhesions).
 Sponges counting.
 Abdominal muscles, are usually left open because they
usually fall together by themselves, sometimes tying
them together at spots using a 3-0 polyglactin.

 Fascia layer is the most important layer to close since
it is the support layer for the abdomen. Use of delayed
or non absorbable suture is recommended.
 Subcutaneous tissue : Routine closure is not advocated
except when fat is more than 2 cm.
 Subcutaneous drain Does not reduce wound morbidity.
 SKIN closed with- mattress sutures of silk, subcuticular
suture or clips.
 Dressing is applied to stapled or sutured incision using
sterile pads and abdominal dressings.

 Fundus is compressed with the hand to make sure
the uterus is nice and firm and to check for any
bleeding, Pt to receive 600µgm misoprostol PR to
ensure uterine contraction.
 Pt transferred to post surgery care unit and later on
into postpartum ward.

 Difficult baby deliveries:
 High floating head : Rupture of membranes followed by
suctioning of liquor, allow vertex to descend to incision
site, then flexion and delivery. Use of vacuum or short
forceps is also possible.
 Deeply engaged head: Disimpaction manually,
(abdomino -vaginal method ).
 Breech : should be delivered with same care as in
vaginal breech delivery.
 The most important pre-requisite to any difficult delivery
is that it should be conducted by an experienced
operator.

:O P E R A T I V E STEPS-I N T R A
 Myomectomy may be considered: if myoma size<6cm,
Pedunculated myoma, myoma in lower segment to
avoid upper segment incision.
 Abdominoplasty not recommended.
 Appendectomy or hernia repair can be combined with
CS when indicated.
 Single-layer closures were associated with a higher
uterine rupture risk than double-layer closure in women
attempting VBAC.
 Extraperitoneal repair of the uterus is not
recommended.

 IN MANAGEMENT OF DEEPLY IMPACTED HEAD:
 A hand in the lower uterine segment in the standard
fashion to cup and then disengage the fetal head.
 An assistant can place a sterile, gloved hand into the
vagina from the introitus and disengage the fetal head
from below.
 T-shaped incisions: If required J-shaped or U-shaped
incisions are preferred to T incision. These incisions
may be required in case of difficult delivery. It is
associated with poor healing and increased
postoperative morbidity thus should be reserved in
special situations only.

CS in Morbidly obese pregnant women:
 Increased risk of pregnancy complications.
 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.
 The dose of thromboprophylaxis needs to be higher.
 Prophylactic antibiotics reduce postoperative
infections.
 Breast feeding, which may promote further weight
reduction, must be encouraged.

Postoperative Care:
 Oxytocin, ergometrin, misoprostol to prevent PPH.
 Patient is kept nil by mouth for 4-6 hours only. Early
ambulation should, oral fluids should be started as early
as possible.
 Chewing Gum, Coffee might lead to quicker return of
bowel activity.
 Patient should be offered analgesia whenever she
demands.
 IV fluids are given and soft diet is advised once bowel
sounds appear and/or patient feels hungry.

:Postoperative Care
 Monitor –Pulse, blood pressure, respiratory rate ½ hrly
for first 2 hours and hourly thereafter for 6 hours if
these are normal. Woman should be catheterized to
monitor urinary out put.
 Breast feeding is initiated as early possible. Emphasis
must be given on correct breast feeding practices.
 Patient can be discharged after 2or 3 days if ok (pulse,
BP, temperature, lochia and breast examination are
normal). Wound is checked prior to discharge.
 To prevent surgical site infection : strict glycemic
control in DM, IV antibiotic prophylaxis.
 Routine follow up is advised after a week for
examining the wound and assess breast feeding.

Postoperative Care:
 In Summary, Post-operative goals are:
 Improve pulmonary function and prevent post
operative pulmonary complications( pneumonia….).
 Improve circulation and prevent post operative
circulatory complications (DVD, edema ….).
 Decrease incisional pain associated with coughing,
movement or breast feeding.
 Improve healing of incision and prevent adhesion
formation.
 Prevent pelvic floor dysfunction.
 Improve lactation.
 Correct posture.

Associate Prof.Dr Aisha Elbareg lecture on CS.

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Associate Prof.Dr Aisha Elbareg lecture on CS.