The document details the definitions, history, incidence, types, indications, and complications of caesarean sections (C-sections) and trial of labor after cesarean delivery (TOLAC). It discusses the rise in C-section rates over the years, the types of incisions used, and the benefits and risks associated with VBAC. Additionally, it outlines the eligibility criteria for TOLAC and potential complications while offering insights into preoperative preparation and techniques for conducting a C-section.

1. Caesarian section and trial of
labor/VBAC
Supervisors
 Dr. Kelil
 Dr. Abdurazak

2. Presenters
1. Chala Abera
2. Dembi Endalu

3. Outline
Caesarian section
 Definition
 History
 Incidence
 Types
 Indication
 Contraindication
 Complication
 Techniques of caesarean delivery
VBAC
• Benefit
• Risk
• Eligability
• Contraindication
• Success rate
• complication
• Elective repeat CS indication

4. Cesarean section
Cesarean delivery defines the birth of a fetus from the uterus through an
abdominal incision and uterine incision
Does not include removal of the fetus
from the abdominal cavity:
In the case of rupture of the uterus .
 In the case of an abdominal pregnancy(ectopic pregnancy)
The name evolved from being
• Cesarean operation
• Section(by 1598 publication of Guillimeau,)
• Currently cesarean delivery or cesarean birth.

5. history
It is said that the term is related to the manner of the birth of Julius
Caesar. But some suggest that the procedure's name derives from the
Latin verb caedere "to cut," in which case the term "Caesarean
section" is redundant.
In Caesar’s time, surgical delivery was reserved for when the mother
was dead or dying because of religious requirements for separate
burial for the infant and mother
The procedure was associated then with high mortality due to sepsis
(lack of antibiotics) and no anesthesia.

6. Incidence
• CD rate has risen in the USA in a dramatic fashion from less than 5%
in the 1960s to 32.7% by 2013 with stable rates around 32% - 33% in
the last 5 years
• Most common major surgical procedure undertaken today in the USA and
around the world
Causes of these increments are thought to be:
• Obstetrical factors:
•Increased primary CD rate
•Failed induction, increased use of induction
•Decreased use of operative vaginal delivery
•Increased macrosomia and Malpresentation
•Increased electronic fetal monitoring

7. Incidence cont….
• Maternal factors:
•Increased proportion of women >35 yr.
High risk of preeclampsia
Gestational diabetes
•Increased proportion of nulliparous women.
•Increased primary CDs on maternal request
•Increased obesity
Physician factors:
•Malpractice litigation concerns

8. Incidence cont….
• 10% - 15% CD incidence is the target of WHO to optimize maternal
and perinatal outcomes.
• However, CD rate is not appropriate measure of these outcomes.

9. Types of caesarean section
By timing and urgency of operation
1.Elective caesarean delivery
 before any complication that is in need of urgent indication.
 Is a planned cesarean delivery
 performed before the onset of labor.

10. Types cont
2. Emergency CS
 done in labor
In complication that necessitates immediate delivery.

11. Comparison

12. It can be:
• Primary CD: in a woman without a prior cesarean birth.
• Secondary (repeat) CD: in a woman who had a cesarean birth in a
previous pregnancy.

13. By incision type
1.Classical caesarean section (sanger) – is longitudinal
incision in the anterior fundus.
- there is a risk of greater adhesion formation and uterine rupture with
subsequent pregnancy.
- It is indicated for
- transverse lie in labor with impacted shoulder.
- extensive adhesion in the lower segment
- Myoma in the lower uterine segment
- Placenta previa with anterior implantation

14. Type cont….
2.Lower transverse caesarean section (Kerr) – is the most commonly used and preferred
incision.
- It has less risk of hemorrhage, rupture, infection.
- It is easy to perform and repair.
- but there may be risk of bladder injury and the lower uterine segment must be developed
in order to be performed.

15. Type cont….
3.Lower vertical caesarean section (Selheim or Kronig) - is done in the non contractile
lower segment. It is advised unless the lower segment is extremely well developed. Indicated for:
-Underdeveloped lower uterine segment
- Breech or transverse lie with undeveloped lower uterine segment
- Inability to develop bladder flap with repeat cesarean delivery
-Lower segment anterior myoma
-Anterior placenta previa

16. Type cont…..
Additional incisions – Inverted T – a vertical extension to a lower transverse incision and J incisions
on either side of a transverse incision

17. Uterine incision
A. Low transverse incision
B. Low vertical incision
C. Classical incision
D. J incision
E. T incision

18. Indications for primary cesarean delivery

19. Indications…
Maternal-Fetal
• Cephalopelvic disproportion
• Placental abruption
• Placenta previa
• Repeat cesarean delivery

20. Indications cont….
Maternal
• Specific cardiac disease (e.g., Marfan syndrome with dilated aortic
root
• Cerebral aneurisms and atriovenous malformations: raised ICP
• Cesarean delivery on maternal request

21. Indications cont….
Fetal
• Nonreassuring fetal status.
Fetal tachycardia
Variable deceleration
Late deceleration
Brady cardia
•

22. • malpresentation (Breech or transverse lie ).
• Fetal macrosomia.
• Congenital anomaly
neural tube defect (best possible outcome for the baby)

23. contraindications
oThe presence of dead fetus.
Its complication could affect future fertility rate.
o An immature fetus that could not survive out side the uterine
environment.

24. complications
• - The intraoperative complications are hemorrhage,injury the
adjacent organs(uterine laceration,bladder injury,ureteral
injury and GI injury) and uterine atony
• Maternal post operative morbidity like ( endometritis, wound
infection, thromboembolic disease and septic pelvic
thrombophlebitis)
• The late complications are placental previa,placental
accreta ,abdominal hernia, intestinal obstruction due to
adhesions, and vague abdominal pain .

25. Potential benefits
• Reduction in perinatal morbidity and mortality
• Elimination of intrapartum events associated with perinatal asphyxia
• Reduction in traumatic birth injuries
• Reduction in stillbirth beyond 39 weeks’ gestation
• Possible protective effect against pelvic floor dysfunction
• Less postpartum hemorrhage

26. Potential risks
• Increased short and longterm maternal and neonatal morbidity
- Increased endometritis, transfusion, and venous thrombosis rates
- Increased length of stay and longer recovery time
- Increased risk for placenta accreta and hysterectomy with
subsequent cesarean delivery.

27. TECHNIQUE OF CESAREAN DELIVERY
• preoperative preparation
1.informed consent
2.Assessment of fetal pulmonary maturity
3.Preoperative anesthesiologist consultation
4.Lab testing

28. preoperative preparation cont….
5.Precesarean Antibiotics
• given approximately 30 to 60 minutes before the skin incision ( cefazolin or ampicillin)
• anaphylactic allergic reaction to penicillin ;metronidazole or clindamycin and gentamicin
6. Thromboprophylaxis
7. Vaginal Preparation by Povidone Iodine
6.FHR monitoring
7.Bladder catheterization

29. preoperative preparation cont….
8.Site Preparation
Hair removal and sterilization on skin
- The hair should be clipped rather than shaved.
- Apply antiseptic solution (dine,chlorhexidine) on incision
and surrounding area
9.Drapes
10.In case of Emergency Cesarean Delivery, The operation
should be started within 30 min of the decision to operate.

30. steps
• Site Preparation
• Abdominal Skin Incision and Abdominal Entry
• Uterine Incision
• Delivery of the Fetus
• Prevention of Postpartum Hemorrhage
• Placental Extraction
• Uterine Repair
• Abdominal Closure

31. Abdominal Skin Incision and Abdominal Entry
Abdominal incision: − Incise the skin and subcutaneous tissue. Skin
incision types include
• Pfannensteil incision
• Subumbilical midline incision
Pfannensteil incision: Strong op site, less risk of dehiscence and hernia
Sub Umbilical midline incision: Fast, less hemorrhagic and can easily be
extended

32. Uterine Incision
The uterus is often dextrorotated, and its position must be
appreciated to plan the incision site.

33. Uterine incision
A. Low transverse incision
B. Low vertical incision
C. Classical incision
D. J incision
E. T incision

34. Delivery of the Fetus
• extracted by elevation and flexion using the operator’s hand as a
fulcrum
• Adequate fundal pressure by the assistant is often critical to obtain
delivery.

35. Prevention of Postpartum Hemorrhage
• intravenous (IV) oxytocin is started as a drip.
• 10 to 80 IU of oxytocin in 1 L crystalloid infused over 4 to 8 hours.
• prevents uterine atony and postpartum hemorrhage.

36. Placental extraction
• spontaneous expulsion with gentle cord traction and uterine massage
should be performed for delivery of the placenta.

37. Uterine repair
• the uterus is lifted through the
incision and onto the draped
abdominal wall.
• We favor exteriorizing and believe a
relaxed, atonic uterus can be
recognized quickly and massage
applied.

38. Abdominal Repair
• Prior to abdominal closure, correct
sponge and instrument counts are
verified.
• The parietal and visceral peritoneum
are not reapproximated because
spontaneous closure will occur within
days.

39. TRIAL OF LABOR AFTER CESERIAN DELIVERY
• Trial of labor after cesarean section (TOLAC )refers to planned attempt
to deliver vaginally by a woman who had previous CS history
regardless of outcome
• VBAC is a successful delivery after TOLAC,

40. Benefits
• High success rate (72 to75%).
• Less postpartum febrile morbidity.
• Reduced anesthesia related risk.
• Shorter hospital stay and recovery.
• Early smooth mother-infant interaction.

41. Risks
• Uterine rupture is the most common risk:depends on
previous vaginal delivery
type of incision (location)
No of prior CS
Interdelivery interval
Induction of labor
• Maternal hemmorhage
• hysterectomy

42. Candidates for a trial of labor after CD
• One or two previous low transverse cesarean deliveries
• Clinically adequate pelvis
• No other uterine scars or previous rupture
• Physicians immediately available throughout active labor
capable of monitoring labor and performing an emergency
cesarean delivery

43. Relative CI for TOLAC
• Maternal obesity
• Macrosomic fetus(>4000gm)
• Malpresentation
• Multifetal pregnancy
• Short interdelivery interval

44. Absolute CI for TOLAC
• Prior hx of uterine rupture
• Prior Lower segment incision type other than transverse
• Contraindication to vaginal delivery
• CPD of current pregnancy

45. Potential complications of TOLAC
• Uterine rupture : (acute signs)
fetal bradycardia(70%)
Vaginal bleeding
Loss of fetal station
New onset of intense uterine pain
• Perinatal death and/or encephalopathy
• Hysterectomy (_x0000_

46. Increased Maternal Morbidity With Failed TOLAC
Transfusion
Endometritis
Length of stay
Other Risks With TOLAC
Potential risk for perinatal asphyxia with labor (cord
prolapse, abruption)
Potential risk for antepartum stillbirth beyond 39 weeks’
gestation

47. SUCCESS RATE

48. Predictors of successful TOLAC includes
- Maternal demographics
- Prior vaginal delivery or VBAC, and
- Prior indication for the cesarean delivery
- Birthweight
-Labor status and Cervical examination

49. • When to declare failed TOLAC:- The length of TOLAC should be
individualized to declare failure: - If labor doesn‘t progress as
expected or If any evidence of scar dehiscence develops

50. Elective repeat CS indication
• Women whose first c/s was done b/c of CPD due to contracted pelvis
• Those whose labor is long and tedious
• Ruptured membrane
• Uneffaced and rigid cervix
• Those who, after viability is reached, experience persistent pain in the
region of uterine incision

51. REFERENCE
• Gabbe Obstetrics 7th edition.
• Williams_Obstetrics__26thEdition
• Uptodate 2024

52. THANKYOU