2. DEFINITION
• Delivery of a baby through surgical incision in
the abdomen and uterus after 28 wk of GA
• SYNONYMS
– CESAREAN SECTION
– CESAREAN BIRTH
• NOTE
– Hysterotomy if less than 28 wks of GA
– Laparatomy if uterus ruptured
3/16/2024
3. • PREVALENCE OF CD
• USA,2005
– 30% of all deliveries(62% are primary)
– The highest rate ever recorded
• World wide=15%
– Highest(29%) in latin america and caribean
– Lowest(3.5%) in africa
• Mean CD in developed countries=21%
• Only 2% in least developed countries
• OPTIMAL RATE OF CD
• Can not be determined
• Rate of 5-15% appears to give best maternal outcome
– The rate for best infant outcome is less clear but is likely
far higher
3/16/2024
4. • CLASSIFICATION:
• Many ways
– Type of uterine incision
– Timing of operation
– Number of C/S
• TYPE OF UTERINE INCISION
– CLASSICAL C/S
– LUST C/S
– De Lee incision
• Vertical incision over LUS
– J incision(Right or left)
– Inverted T incision
3/16/2024
6. TYPE OF UTERINE INCISION
• LUST C/S
– Adv
• Low risk of rupture,infection,hemorrhage,post op complication and
better healing
– Dis adv
• More technically difficult
• Extension as to the bladder
• Classical C/SVertical incision over the fundus
– Indications
• LUS:vascular,dense adhesion
• PP totalis
• Transverse lie with impacted shoulder
– disadv:high risk of rupture,infection,blood loss,intestinal
obstruction
3/16/2024
7. • NUMBER OF CD:
• Primary
– 1st CD
• Repeat
– After previous CD
– TOTAL CD=SUM OF ABOVE TWO
• TIMING OF OPERATION:
• EMERGENCY VS ELECTIVE CD
– Most useful
• Elective CD
– Planned during ANC
– Adequate patient preparation
• Blood,NPO,fetal maturity assured,treatment of intercurrent
disease
3/16/2024
8. • TIMING OF OPERATION:
• Elective CD
– Indications
• Gross CPD
• Previous classical CD
• Previous CD + other obstetric
complication(DM,APH,breech)
• Two previous CD (commonest)
• Tumor previa
• Repaired VVF
• Previous
myomectomy,metroplasty
• Previous hysterotomy
• Cornual implantation of the
tube
• Colporrhaphy
• High risk pregnancy
• Elective CD
– Adv:less risk of complication
– Prerequisities
• Assure fetal maturity by ACOG
criteria
• Emergency CD
– High risk of complication
– Indications
• Obstructed labor
• AP,PP
• NRFHRP
• Cord presentation or prolapse
• Malpresentation
• Footling
• Failed VBAC
– I-D time=less than 4 min
– D-D time=15 min
3/16/2024
9. • FACTORS INCREASING CD RATE IN DEVELOPED
COUNTRIES
• Change in physician and patient expectation
and attitudes about the risk
• Changes in clinical practice
– Fewer VBAC,ABD,instrumental deliveries
– more induction of labor
• Medicolegal issues,financial issues
• Increasing maternal age at delivery,increasing
incidence of multiple pregnancy and maternal
obesity
3/16/2024
10. • There are many different reasons for
performing a delivery by caesarean section.
The four major indications accounting for
greater than 70% of operations are:
• 1.Previous caesarean section.
• 2.Malpresentation (mainly breech).
• 3.Failure to progress in labour.
• 4.Suspected fetal compromise in labour.
3/16/2024
11. • LESS COMMON INDICATIONS
• Abn.placentation(PP,vasa previa,placenta accreta)
• Maternal infection(HSV,HIV)
• Fetal bleeding diathesis
• Feto-pelvic disproportion
• Increased risk of tissue trauma 2o to descent and
expulsion of fetus
– Invasive cervical cancer
– Repaired RVF or pelvic organ prolapse
• CONTROVERSIAL INDICATIONS
• EVLBW OR VLBW(less than 1000 gm and 1500 gm
respectively)
• Congenital anomalies(open NTD etc0
• Patient choice
3/16/2024
12. • No list can be truly comprehensive and
whatever the indication, the overriding
principle is that whenever the risk to the
mother and/or the fetus from vaginal delivery
exceeds that from abdominal delivery, a
caesarean section should be undertaken
• Absolute indications for recommending
delivery by caesarean section are few, almost
all indications are relative
3/16/2024
13. • Maternal request caesarean section needs to
differentiate between women who request
caesarean section because of a previous
traumatic birth experience (e.g. emergency
caesarean section, difficult OVD or third-degree
tear) and women who request caesarean section
because they wish to avoid labour. There is also
increasing recognition of a condition termed
‘tocophobia’, which describes an irrational fear of
childbirth that can be very incapacitating for the
woman. Lack of consent in a woman with
capacity to give consent will prohibit caesarean
section regardless of the perceived clinical need
3/16/2024
14. • PREOPERATIVE ISSUES
– Assess fetal pulmonary maturity
– Laboratory testing
– Antibiotic prophylaxis
– Bladder catheterization
– Patient preparation
• Fetal lung maturity can be inferred(by ACOG) if
– Confirmation of GA of 39 wks by at least one of the following
• FHR documented for more than or equal to 20 wks by fetoscope or greater
or equal to 30 wks by doppler
• Positive HCG documentation for greater or equal to 36 wks
• u/s CRL at 6-11 wks that indicate current GA of greater or equal to 39 wks
• u/s measure at 12-20 wks that supports GA greater or equal to 39 wks
– AF tests for lung maturity
• Neonatal morbidity decrease as GA increases from 37 to 39 wks
• At 37 wks =4x increase
• At 38 wks=3x increase
• At 39 wks=2x increase
• At 40 wks =0.9x
3/16/2024
15. • Need preoperative anesthesiology consultation
• not to eat anything for 12 hours prior to the procedure
• Baseline hematocrit
– May not be needed to repeat if normal value in the past one
month in uncomplicated patient
• Blood group and Rh
• ANTIBIOTIC PROPHYLAXIS
– To decrease post operative infection
• Recommendation
– Single,IV dose of a narrow spectrum antibiotic
– eg:ampicillin 2 gm,cefazolin 2 gm preoperatively to all woman
undergoing CD
• Evidences
– Decrease significantly in post op fever,endometritis,wound
infection,UTI than controls not taking antibiotic
– Eg:endometritis decrease by 60%
3/16/2024
16. • BLADDER CATHETERIZATION
– To prevent bladder distension,which could impede exposure of the LUS
– For instilling dye if a cystotomy is suspected and to facillitate postop voiding
• PATIENT PREPARATION
• Hair shaving
– Increase surgical site infection
– If need:should be clipped than shaved
– Otherwise
• No difference in the rate of surgical site infection in patients who had hair removed prior
to surgery and those who did not in 11 randomized trials
• Skin antiseptics prior to clean surgery
– Insufficient evidence to support or refute the use of skin antiseptics or the use
of one antiseptic over another
• Standard abdominal scrub alone vs with vaginal iodine scrub
– So no recommendation for vaginal preparation now
• Non adhesive drapes
– Lower rate of wound infection than adhesive tapes
• Uterus is displaced 10-15 degrees to the left to avoid compression of the
vena cava
3/16/2024
17. • EMERGENCY CD
• The ability to begin with in 30 min of decision
is a reasonable bench mark for monitoring
quality of labor and delivery units
• But,sudden complete anoxia as in total AP or
complete cord occlusion probably necessitates
delivery with in 5 min
• Risks of emergency CD
– Anesthesia complication
– Hemorrhage in patients with DIC
– Accidental injury to the fetus,abdominopelvic
organs
3/16/2024
18. Procedure steps in brief
1. Skin and subcutaneous incision
2. Uterine incision
3. Rupture of membranes
4. Fetal delivery
5. Oxytocic drug administration
6. Placental delivery
7. Closure of the uterus
3/16/2024
19. • SURGICAL PROCEDURE OF CD
• ABDOMINAL INCISIONS
– Transverse
• Pfannesteil
• Joel-Cohen
• Advantages
- Better cosmetic appearance
- Better healing
- Less incidence of incisional hernia
• Disadvantages
- More time consuming
- More blood loss
- Gives less exposure
• The infra-umbilical incision
- extreme obesity
- Access to uterine fundus may be
required (classical C/S)
• Faster abdominal enter
• Less bleeding and nerve injury
• Can be easily extended cephalad if
more space is neede for access
3/16/2024
20. Uterine
incision
• Transverse lower
segment incision
- Reduced blood loss
- Low incidence of
dehiscence
- Low incidence of rupture
in subsequent
pregnancies
• Classical caesarean
section incision
- Increased blood loss
- Risk of uterine rupture
prior to or during labour in
a subsequent pregnancy
3/16/2024
21. • BLADDER FLAP
– Omission is ass.with decrease in operation time ,I-D
time,blood loss and need for analgesia
– Recommended to do if time permits and no severe
adhesion that are likely to increase the risk of incidental
cystotomy
• Transverse incision over LUSLUS(Monrore-kerr or kerr
incision)
– Disadv
– Lateral extension is not possible w/o risking laceration of
major blood vessels(major risk)
• J or inverted T incision required if larger incision is needed
• Problematic b/c the J extension goes in to the lateral fundus and
the angles of the inverted T incision are poorly vascularized
• Both of which potentially result in weaker uterine scar
3/16/2024
22. • Vertical incision:Two types
• Low vertical(De Lee or Cornell)
• Classical
– Low vertical
• Done over LUS
• Major disadv:extension cephalad in to the uterine fundus(classical)
and caudally in to the bladder,cervix or vagina
• Vertical incision
– Differentiation of classical and low vertical incision is subjective
– Classical incision
• Extend in to UUS or fundus
• Rarely done b/c of higher risk of uterine rupture in future
pregnancy(4-9%)
– But low vertical =1-7% risk of rupture
– Low transverse=0.2-1.5% risk of rupture
• Objective method of differentiation of the two has not been
determined
3/16/2024
23. - Lower uterine segment containing
fibroid
- Lower segment covered with dense
adhesions
- Transverse lie with the back down
- Placenta praevia
- Fetal abnormality
- Carcinoma of the cervix
Indication for classical
incision
3/16/2024
24. • When entry in to uterine cavity is achieved,the incision
can be extended employing bandage scissors or using
blunt expansion with the surgeons fingers
– Blunt preffered than sharp as it is
• Quick
• less inadvertent trauma to the fetus
• less blood loss
• Less extension
• Cephalic presentation
– Insert hand in to the uterine cavity and flex the fetal head
and bring it to the level of uterine incision from which it
can be extrated
– A set of forceps or vacum device should be available in the
OR to assisst with flexing the head and guiding it through
the incision if this is difficult
3/16/2024
25. • Deeply impacted head can be hard to disengage and deliver
– The “push”method
» The operator or an assisstant pushing the head back through the
vagina and out of the pelvis
– The”pull ”method
» Grasp the fetal legs in the UUS and extract the fetus by the breech
» Lower maternal and neonatal morbidity than the push method
» stm. May need to extend the hysterotomy incision in to an inverted T
or a J shape to deliver the fetus as a large incision is needed
• Methods of placental extraction
– Spontaneous delivery
• Gentle traction on the cord and use of oxytocin to enhance
uterine contractile expulsive effort
• Prefferable as it has less postop endometritis and blood loss
– Manual removal
• Oxytocin administered IV to promote uterine
involution
3/16/2024
26. • CLOSURE OF UTERINE INCISION
• Many surgeons exteriorize the uterus to improve exposure
and facillitate the repair
– Risk
• Longer hospital stay
• More postop pain
• Increased rate of postop nausea and vomitting
• Transient hemodynamic changes w/o signif decrease in operation
time or blood loss
– But trials were small and do not provide strong evidence
• Uterine incision can be closed in single layer
– Increased risk of uterine rupture than two layer(3% vs 0.5%)
– And at least increase in asymptomatic dehiscence
• Uterine window i.e myometrial defect with intact peritoneum
• Single vs two layer closure still warrants further
investigation like factors which can affect strength of
closure as choice of suture material,closure technique,and
prescence of postop infections
3/16/2024
27. • Two layer recommended if we would consider VBAC
• A double or even triple layer closure is necessary when the
myometrium is thick,as with classical and some low vertical
incisions
• Intra abdominal irrigation after closure of the uterus does
not decrease maternal morbidity beyond the reduction
achieved with the prophylactic antibiotics alone
• Closing the peritoneal bladder flap or parietal peritoneum is
not recommended
– No short term benefit as decreasing in infectious
morbidity,analgesia,or bowel function
– Less certain effect on adhesion formation
– But still most studies(but not all) reported fewer adhesion
• CLOSURE OF RECTUS MUSCLE
• Not necessary to reapproximate the rectus muscles by
suturing them together
3/16/2024
28. • CLOSURE OF THE FASCIA
• Closed with delayed absorbable monofilament
continous suture
– So,care should be taken to avoid too much tension when closing
the fascia=1cmx1.5cm
– Reapproximation not strangulation is the appropraite goal
• CLOSURE OF SC TISSUE
• Closure with plain cat gut recommended if the depth is
more than 2 cm(not less or equal to 2 cm)
– Closure of dead space seems to inhibit accumulation of serum
and blood,which can lead to a wound seroma and subsequent
wound break down which
• is a major cause of morbidity
• can be costly and lengthens the recovery time for the
patients
• Routine use of wound drains is not beneficial even in obese
women
3/16/2024
29. • CLOSURE OF SKIN
• Can be approximated with suture
• In clean surgical wound
– Epithelial cells migrate downward to meet deep in the dermis
• Migration ceases when the layer is rejuvenated
– Completed with in 48 hrs of surgery
• Makes superficial layer of epithelium and this creates a barrier to
bacteria and other forign bodies
• But,this is very thin,easily traumatized and gives little tensile strength
• POST OPERATIVE ISSUES
• Recovery room
• The standard immediate postoperative care
• Well-trained and well-equiped personnel
• An anesthetist ,recovery nurse ,midwife or other properly
trained individual
• Vital signs monitered every 5 min for the first 30 min , then
every 30 min for 2 hours and hourly thereof
3/16/2024
30. • Pain management
• Intrathecal analgesia :-diamorphine (0.3–0.4 mg
intrathecally)
• Patient controlled analgesia:-
• NSAIDs
• opioids (Diclofenac)
• Wound infiltration with local anasthetic :- 20 ml
of 0.1% Bupivacaine
• Women who are recovering well after CS and
who do not have complications can eat and drink
when they feel hungry or thirsty (6-8hr).
• Delayed oral intake :- a minimum of 12-24 hours
3/16/2024
31. • Removal of the urinary bladder catheter should be
carried out once a woman is mobile after a regional
anaesthetic and not sooner than 12 hours after the last
epidural ‘top up’ dose
• Discharge require or usual hospital discharge (requires
the woman to be mobile , voiding, tolerating a normal
diet, passing flatus, normal uterine involution, afebrile
for 24 hours, uncomplicated wound healing, removal of
skin sutures or stapes and an adequate blood count
• An average of 3-4 days
• 3 % of patient with C/S are readmitted
• Most common causes include infection and bleeding
• Other serious complaints include manifestation of DVT
and pulmonary emblolism
3/16/2024
32. • COMPLICATIONS
• There are no randomized trials comparing outcomes of planned
vaginal versus planned cesarean delivery for the term cephalic
gestation.
• Moderate quality evidence shows that planned cesarean delivery is
associated with
– less maternal hemorrhage
– longer maternal hospital stay
– greater mild neonatal respiratory morbidity than planned vaginal
delivery
• The risks of severe maternal morbidity are generally higher in
women with an unplanned cesarean delivery during labor
• Cesarean delivery in the second stage of labor is associated with
slightly higher maternal composite morbidity than cesarean
delivery in the first stage of labor
– neonatal morbidity rates are similar for first and second stage
cesareans
3/16/2024
33. Late:
o Bowel obstruction
due to fibrous
adhesions
o Incisional hernia
o Persistent sinus
o Recurrence of the
reason for surgery
o Keloid formation
Immediate:
o Primary haemorrhage
o Atelectasis
o Shock
o Low urine output
Early:
o Acute confusion
o Fever
o Nausea and vomiting
o Pneumonia
o Secondary
haemorrhage
o Wound infection
o Wound or anastomotic
dehiscence
o Acute urinary retention
o Urinary tract infection
(UTI)
o Paralytic ileus
o Bowel obstruction due
to fibrinous adhesions
o Deep venous
thrombosis (DVT)
Postoperative complications in o
3/16/2024
34. causes of postoperative fever
The many causes of postoperative fever are best remembered as the “5 W’s:”
o Wind (postoperative days 1–2): This is often the result of atelectasis. Reasons include
ventilator support and shallow inspiration due to incisional pain.
o Water (postoperative days 3–5): Urinary tract infection (UTI). This is frequently
secondary to urinary catheters used during and after surgery.
o Walking (postoperative days 4–6): Deep venous thrombosis and superficial
thrombophlibitis
o Wounds (postoperative days 5–7): Wound infections or abscess formation must be
considered.
o Wonder drugs (postoperative day 7+): Medications commonly used postoperatively -
such as heparin, β-lactam and sulfonaminde antibiotics- may cause a rash,
eosinophilia, or drug fever.
3/16/2024
35. • Of note, fevers prior to postoperative day 3
are unlikely to be infectious unless caused by
Clostridium difficile or β-haemolytic
streptococci.
• INFECTIONS
• Endometritis
• Wound infection
• OVT and DSPT
3/16/2024
36. ENDOMETRITIS
• If prophylactic antibiotics are not administered,
postoperative endometritis occurs in up to 35 to 40
percent of patients delivered by cesarean
– This rate is as low as 4 to 5 percent after scheduled
delivery with intact membranes, and as high as 85 percent
after an extended labor with ruptured membranes.
• By comparison, use of prophylactic antibiotics reduces
the overall rate of infection by approximately two-
thirds.
• Surgical technique also affects the incidence of
postpartum endometritis.
3/16/2024
37. WOUND INFECTION
• Wound infection is diagnosed in 2.5 to 16 percent of
patients , generally four to seven days after the
cesarean.
• In a large case-control study of risk factors for surgical
site infection, 5 percent of 1605 low transverse
incisions for cesarean delivery became infected
– Approximately 40 percent of the infections were
diagnosed after hospital discharge, and the major
independent risk factor was development of a
subcutaneous hematoma (OR 11.6).
• Prophylactic interventions, such as antibiotic
administration and good surgical technique, decrease
the incidence of wound infection and disruption.
3/16/2024
38. WOUND INFECTION
• Early wound infections (in the first 24 to 48 hours) are
usually due to group A or B beta-hemolytic
streptococcus and are characterized by high fever and
cellulitis.
• Later infections are more likely to be due to
Staphylococcus epidermidis or aureus, Escherichia coli,
Proteus mirabilis, or cervicovaginal flora
• Initial treatment consists of opening the wound to
allow drainage, cleansing with irrigation, sharp
debridement as needed, placement of wet-to-dry
packs, and close attention to subsequent wound care.
3/16/2024
39. OVT AND DSPT
• There are two types of septic pelvic thrombophlebitis (SPT):
– ovarian vein thrombophlebitis (OVT)
– deep septic pelvic thrombophlebitis (DSPT).
• These two entities share common pathogenic mechanisms and
often occur together
– but they may differ in their clinical presentations and diagnostic
findings.
• Patients with OVT usually present with fever and abdominal pain
within one week after delivery or surgery
– thrombosis of the right ovarian vein is visualized radiographically in
about 20 percent of cases.
• Patients with DSPT usually present within a few days after delivery
or surgery with unlocalized fever that persists despite antibiotics, in
the absence of radiographic evidence of thrombosis.
3/16/2024
40. • HEMORRHAGE
• The mean blood loss at cesarean is approximately 1000 Ml
– however, estimates of blood loss are not very reliable
– About 2 to 3 percent of all patients undergoing cesarean delivery
require blood transfusion
• Good surgical technique can decrease the incidence of hemorrhage.
• Hemorrhage may be due to
– uterine atony
– placenta accreta
– extensive uterine injury
– extension of the incision into the uterine vessels.
• Lacerations extending into the lateral vagina and broad ligament
should be thoroughly evaluated and repaired with meticulous
attention to the position of the ureter.
– It may be necessary to divide the round ligaments and open the broad
ligament to isolate and ligate the bleeding vessel.
3/16/2024
42. INJURY
• Urinary and gastrointestinal tract injuries are
uncommon, occurring in fewer than 1 percent of pelvic
surgical procedures
• The incidence of bladder injury in a series of almost
15,000 cesareans was 0.28 percent (incidence in
primary and repeat cesareans: 0.14 and 0.56 percent,
respectively)
– The risk of cystotomy is higher for cesareans performed in
the second stage compared to the first stage
• Ureteral injury is rare, occurring in less than 0.1
percent of cesareans
3/16/2024
43. INJURY
• Risk factors for visceral injury include
– scarring from previous pelvic surgery
– unplanned cesarean
– cesarean hysterectomy
• The occurrence of bladder injuries may be
minimized by
– continuous bladder drainage during surgery
– careful avoidance of operating near the bladder
– assuring transparency of the parietal peritoneum
before cutting when sharp dissection is necessary
3/16/2024
44. INJURY
• Early diagnosis and immediate repair of urinary tract
and bowel injuries are important to prevent serious
sequelae, such as sepsis, renal damage, and fistulae.
• Small cystotomies in the dome of the bladder are easily
approached with a two-layer closure of absorbable
suture and catheter drainage.
– However, large cystotomies and those in the posterior wall
of the bladder or near the trigone may involve the ureter.
– Large lateral uterine or cervical extensions may also
involve the ureter.
– In these cases, placement of ureteral stents can aid in both
diagnosis and repair, which are performed according to
standard procedures described in detail separately.
3/16/2024
45. VTE AND EMBOLISM
• After cesarean delivery, the American College of Chest
Physicians practice guidelines recommend early
mobilization in postpartum women with no risk factors for
DVT other than the postpartum state and the operative
delivery
• For women with at least one additional risk factor, they
suggest pharmacologic thromboprophylaxis (prophylactic
low molecular weight heparin or unfractionated heparin) or
mechanical prophylaxis while the patient is in the hospital.
• For women with multiple risk factors for
thromboembolism, they suggest pharmacologic
thromboprophylaxis combined with graduated compression
stocking and/or intermittent pneumatic compression.
3/16/2024
46. WOUND DISRUPTION
• Disruption (or opening) of the cesarean laparotomy wound is not
uncommon, especially in women with risk factors (eg, obesity,
diabetes, history of wound disruption, vertical incision, etc).
• Reclosure with sutures is more effective than healing by secondary
intention and is associated with success in over 80 percent of
women, as well as faster healing times and fewer office visits
• Reclosure with permeable adhesive tape may be both faster and
associated with less pain than reclosure with sutures
• Optimal timing of reclosure is controversial, but probably four to six
days after disruption is reasonable if the wound is not infected.
3/16/2024
47. LONG TERM COMPLICATIONS
• Abnormal placentation
• Unexplained stillbirth
• Subfertility
• Scar complications
• Uterine rupture in subsequent term
pregnancy
3/16/2024
Cesarean delivery in the second stage of labor is associated with slightly higher maternal composite morbidity than cesarean delivery in the first stage of labor
neonatal morbidity rates are similar for first and second stage cesareans
