The document provides a comprehensive overview of caesarean sections (c/s), including their history, types, indications, surgical preparation, and post-operative care. It emphasizes the increasing prevalence of c/s globally and details various complications associated with both caesarean and vaginal births after caesarean (VBAC). Additionally, it outlines criteria for trial of labor after caesarean (TOLAC) to facilitate successful vaginal deliveries.

1. Halder Jamal September 24th, 2023
Caesarean Section

2. VBAC-TOLAC
Complications
Post-Operative Care
Surgery
Preparation
Incisions
Why?
Categories
Caesarean Section

3. Caesarean Section
• A surgical procedure in which delivery is done via a
laparotomy & a hysterotomy.
• WHO: globally, 1 of 5 babies delivered by C/S,
expected to rise to 1 of 3 by 2030.

4. • Roman law (Lex Caesarea) in 715 BC
• Caedere is a latin word = to cut
• The first woman surviving a C/S was
around 1500, in Switzerland, done by
Jakob Nufer on his wife for prolonged
obstructed labour.
• Thereafter, it had a high mortality and
was performed only when the mother
was already dead or considered to be
beyond help.
• Inés Ramírez is supposably the only
women who did C/S on herself on
march 5th, 2000, and succeeded (she
and her baby survived)
From antiquity to nowadays

5. Inés Ramírez Pérez:
"I couldn't stand the pain
anymore. If my baby was
going to die, then I decided I
would have to die, too. But if
he was going to grow up, I
was going to see him grow
up, and I was going to be with
my child. I thought that God
would save both our lives."

6. Categories
• Emergency C/S (category 1)
• Urgent C/S (category 2, 3)
• Elective C/S (category 4)
• Caesarean Hysterectomy
• Emergency Caesarean Hysterectomy

7. Why?
• Either for fetal or maternal interest or both.
• Often ≥ 2 risk factors.
• No list can be fully comprehensive.

8. Indications
• Previous C/S: 2 LSCS or 1 classical C/S
• Dystocia
• Maternal medical conditions
• Mal-presentations
• Suspected fetal compromise
• Multifetal gestation
• Fetal disease
• Placental disorders (previa, accreta)
• Cephalopelvic disproportion

9. Abdominal Incisions
Pfannenstiel
Midline Vertical
Maylard
Joel-Cohen

10. Midline Vertical Pfannenstiel

11. Midline Vertical Pfannenstiel

12. Uterine Incisions

13. LSCS is the standard method (98.5%).
• Advantages:….
• Disadvantage: longitudinal lie & a developed lower segment
Classical C/S Indications:
Uterine Incisions
• Transverse lie with the fetal back inferior.
• Preterm delivery with poorly formed lower segment
• Placenta Praevia with large vessels in lower segment.
• Severe adhesions in lower segment reducing accessibility.
• Large cervical fibroid
• Previous classical C/S
• Preliminary to caesarean hysterectomy e.g cervical cancer
• Postmortem C/S

14. Preparation
• Hx
• Ex
• Ix: US, CBC, Blood group, FBS, GUE, LFT, RFT, Virology.
• Informed written consent for surgery, anesthesia &
transfusion.
• Ensure availability of blood & neonatal resuscitation
• Fasting: 6-8 h for foods, 2 h for liquids.
• Stop anti-thrombotics (antiplatelets & anticoagulants)
accordingly.

15. • Anesthesia: mainly regional (spinal/epidural), but can also
use general anesthesia or local infiltration.
• Positioning: supine position 15 degree tilting to left lateral
position.
• Foley’s catheter should be put.
• Medications: injection of PPI, start antibiotics, oxytocin 5
IU infused IV slowly.
• youtu.be/VkxwN8xQz80?si=hdT6YiiRy2cEEh6h
Surgery

16. Post-Operative Care
• Send the patient to ward if stable or HDU/ICU if complicated.
• Observation Chart: consciousness, vitals, bleeding, uterus.
• Fluids or Transfusion.
• Prophylactic antibiotics: cephalosporins, metronidazole.
• Analgesics.
• Wound care.
• Breastfeeding.
• Vitamin C (dietary or medication).

17. • Start oral intake: when bowel sounds positive (often 4-6 h)
• Remove catheter: when she can move lower limbs.
• Remove wound dressing: after 24 h
• Remove stitches: after 7-10 days.
• Go home: after 24-48 h if no problems
• Shower: after 72 h
• Do housewife activities: after 7 days.
• Start sexual intercourse: after 40 days (puerperium)
• Exercise: after 3 months
• Heavy lifting: after 6 months
Frequently asked questions; when can I:

18. Complications
Maternal:
• Intra-operative:
• Post-operative:
• Early:
• Late:
Fetal:
• Iatrogenic prematurity
• Accidental scalpel injury.

19. Intra-operative:
• Hemorrhage; Atony, Lateral extension of incision, broad ligament hematoma.
• Extension to cervix or vagina
• Placenta accreta seen with placenta previa often ends up with hysterectomy.
• Nearby organ injuries; Bladder, Bowel, Ureteral
Post-operative:
• Early:
• Late:
Complications

20. Intra-operative:
Post-operative:
• Early:
• PPH & Shock
• Anesthetic hazards: N&V, Hypotension, Aspiration, spinal headache.
• Infections: endometritis, UTI, peritonitis, pneumonia, septic pelvic thrombophlebitis.
• GIT: Constipation, Intestinal obstruction (paralytic ileus or mechanical)
• DVT & PE.
• Wound: infection, dehiscence, evisceration, delayed healing, bleeding.
• Late:
Complications

21. Intra-operative:
Post-operative:
• Early:
• Late:
• General surgical; Incisional hernia, intestinal obstructions, keloid scar.
• Gynecological; Menstrual irregularities, chronic pelvic/back pain.
• Obstetrical; scar rupture, placenta previa/accreta, scar ectopic.
Complications

22. Vaginal Birth After Cesarean (VBAC): Successful vaginal delivery
rate is up to 80% in carefully selected patients.
Criteria for a trial of labor a after caesarean (TOLAC) include:
• Patient consent
• 1 LSCS
• No repeat indication of C/S
• Clinically adequate pelvis.
• Advanced staff for TOLAC & emergency C/S when needed.
VBAC-TOLAC