CS by Berihu.Gebre yohannes.ppt presentations

CESAREAN SECTION (C/S)
Berihu.G

CESAREAN SECTION (C/S): Def
Cesarean section is delivery of fetus or fetuses
along with the placenta and membranes by an
incision made through the abdominal and intact
uterine wall after the fetus has reached viability.
The correct terminology for the surgical delivery
of a previable fetus is hysterectomy.

CESAREAN SECTION (C/S): Timing
Elective : before Labor or the appearance of any
complication that mandates an urgent delivery
emergency : cesarean section that is performed
after the onset of labor or appearance of a
complication that mandates urgent delivery

CESAREAN SECTION (C/S): Number
Primary cesarean section is one that is done for
the first time
Repeat cesarean section is the one that is done for
more than one time.

History
 Not exactly known
 At first it was done just to deliver the fetus
 Later greater care was given to the techniques
 Maternal mortality was great ,in 1970 70-80%
 Major cause of death
Hemorrhage and infection
Anesthesia related

……..History
• Modifications done later
– Amputation the body of the uterus and securing
cervical stamp to the lower abdominal wound
;to control bleeding by pressure
• Mortality decreased by half
• By removing the uterus both bleeding & infection
could be decreased

……..History
• Stitching of the uterus before replacement
– Advocated by Lebas (1769) but opposed by pundits
until kehrer in 1981 and Sanger 1982 adopted it and
proved its efficiency
• By the end of the century mortality ↓ to 6-10%
– By the beginning of the 20th century
• technique Much improved & more rigid aseptic technique
• But results were good for clean cases
• Other modification were extrperitoneal technique
– Lateral and medial

Incidence & indications
• Vary from place to place
• Population based survey report=6% but Can be even >
15%
• Rate has increased as indication for dystocia and fetal
distress
• Extension of the rate of C/S is because of decreased
mortality to the mother & fetus
• Reasons for the fall in the fall in mortality
– Technique of the operation is increased
– Blood transfusion has been used if needed
– Attention has been given as to the choice & administration of
the anesthetic
– Aseptic technique
– Choice of antibiotics if needed

Incidence & indications
 But it seems that the method is regarded as the
legitimate method of delivery with each & every
obstetric abnormality
 Even though low the mortality is not negligible
Pulmoneary embolism , sepsis, and hemorrhage still take their
roll
 Mortality from C/S is 10-20x greater than vaginal
delivery
 Future obstetric is prejudiced by uterine scar
 The problem today is to select the cases best suited for
delivery by C/S ,having regarding not only to the
immediate need of the mother & baby but to the more
obstetric future

Indications
Cesarean section is done in cases in which
• vaginal delivery either is not possible or
• vaginal delivery would pose undue risks to mother
or baby or both.
Some of the indications
• are clear and absolute
• others are relative.

... Indications
• Cephalopelvic disproportion Gross CPD /CPD
diagnosed during labor):
• Except in very few cases correct decision is made after a
trail of labor
• Malpresentation/ malpositions
– Persistent brow, mento posterior
– Deep transverse arrest
– Persistent occiput posterior
– transverse lie,
– breech
• Extended head
• Footling
• Big baby (EFW=>3.5kg
• Poor progress of labor
• Contracted pelvis

... Indications
• Major degree of pp
– Minor degree could be dealt by SVD
• Multiple pregnancy
– Triple
– 1st non vertex
– Monozygotic
– Conjoint twin
– Poor progress of labor
• Cord presentation and prolapse
• Failed induction/ augmentation and
instrumental delivery

... Indications
• Fetal distress if delivery is not imminent
became more common indication
– Know the warning signs
– Use back up methods
• Failure to progress of labor :Abnormal patterns
are a combination of factors
– Minor degree of CPD
– Inefficient contraction
– Soft tissue resistance
– Malpositions

... Indications
 Conditions with unripe cervix where rapid delivery is
needed like preeclampsia, eclampsia.
 Sever IUGR
 2 previous c/s
 Previous cesarean section after failed trail of scar or
electively

... Indications
 Carcinoma of the cervix
 The X-factor relative indications, which considered
separately, might not warrant cesarean section but
when taken together constitute a valid indication.
Example is post term plus elderly primigravida or
prior infertility.

... Indications
• Pre eclampsia
– With the presence of a effective method of induction
,hypertension controlling vaginal delivery Done in the
interest of fetal factor
• Eclampsia
– Vaginal delivery for at least 12-24 hrs
– For fulminates cases which are responding indifferently to
medical treatment are cases for C/S

Cesarean section incision: Types
Types
Lower uterine c/s
Classical c/s
Low vertical
Inverted T
J shape

Preliminary to operation
• Imaging
– Exclude gross fetal malformations
– Specially in
• malpresentations
– Face & brow= 10-12%
– Breech
• Placenta previa
– Timing
• At the start of labor if elective
• Make sure term
• Maturity test

Anesthesia
• General anesthesia
– Risk of aspiration
– More bleeding
– More risk of respiratory depression
– More freedom of action
• Spinal anesthesia
– Easier
– Supine hypotension syndrome
• Local anesthesia
– Less risk
– For operator who is careful at each and every step

Procedure
Informed consent should be obtained.
An intravenous line is opened and crystalloids
started.
Hematocrite and blood group should be
determined.
Blood should be cross matched and be readily
available.

…..Procedure
Self catheter assisted bladder emptying is
done.
Prophylactic antibiotics, if indicated, are given.
 Administration of non particulate antacids
with gastric decompression by nasogastric
tube should be done in emergency cases.

…..Procedure
 Instrument preparation
 Laparatomy instrument including Delee retractor
 Green-armytage
 Suction
 Large gauzed square
 Left tilt till operation started to avoid supine
hypotension
 Both inhalational (general) and regional (spinal,
epidural) anesthesia can be used

Procedure ….abdominal wall incision
Proper preparation of the operative site is done.
Abdomen is opened by midline , Para median
or pfannenstein (transverse suprapubic)
incisions.
Commonly midline From just from the 2.5cm
umbilicus to upper border of the pubis( never on
the pubis)
Size depends on the size of the fetus, configuration of the
patients abdomen
The abdomen is then opened in layers.

Procedure …..abdominal incision
 Once in the fascia small incision to expose the rectus
muscle
 Cut the fascia anterior wall up and downward
 Make the muscle to one side / split it
 Peritoneum is opened blunt/cutting in the upper third
o Avoids bladder damage

Procedure ….. intra abdominal
• Packing
– Two large taped gauze swabs are inserted into the Para
colic gutter/lateral recesses of the wound
– Tapes are attached to artery forceps
– Never use free swap
• Detecting uterine rotation
– By Identifying the round ligament
– From this the exact position and extent of transverse
uterine incision will be determined
– Common error is to extend the incision to left broad
ligament because of uncorrected position and the
surgeons stance of the patients right side

Procedure ….. uterine incision
• The vesicouterine fold of peritoneum is opened
transversely and bladder pushed down
– Loose part is lift up with dissecting forceps ,snipped with
scissors and divided out to both sides
– The retractor should be moved from side to side in accordance
of the need of the operator
– The lower peritoneal flap is lifted up with forceps and ,by
finger pressure with the other hand ,is stripped downwards for
about 5 cm together with the incorporated bladder
– The separation must extend well out to both sides

• Further exposure of uterus is improved by
reapplying the retractor to hold back the lower
peritoneal flap and the bladder
• Opening the uterus
– Using a knife make small transverse incision in the
uterine muscle and cut down
– The level of the incision depends upon the level of the
head should be as near as practical to the widest
diameter
• Too low incision results in uterine wall disappearance
below the bladder with danger during repair of inadvertent
including bladder & urether or both in the stitches
• There is also hazard if the head is high and the segment is
poorly formed ,as the size is small there is extension to the
broad ligament profuse bleeding
• There is problem also in extracting the head

• After opening the uterus incision is extended
– By means of scissors while using the forefinger of the
other hand as elevator
– By inserting the index finger into the incision and
stretching it from side to side
• Not recommended to do for the whole width of the
incision

Procedure ….. Extracting the fetus
 Useful method is to hook the chin forward and apply
forceps with the concavity of the pelvic curvature
towards the pubis
 The upper half of the trunk is now extracted by
hooking the fingers into the axilla and delivering the
shoulder and the arm
 The fetus now half born ,but the breech in the uterus
,maintains the uterine incision in a stretched condition
allowing to prevent bleeding and by time to give
ergometrine

 Give ergometrine /oxytocin
 Clear air way
 Completely extract the fetus & clamp the cord
 The cord is clamped and cut. The placenta is
delivered. The endometrial cavity is mapped of any
remnants by sterile moist pack

• If breech the full breech is extracted by grasping
the anterior foot
• Premature breech is difficult for delivery
– The unformed lower uterine segment is thick and
narrow and retractile
• Extraction of the trunk and arms may involve undesirable
forcefulness and the after coming head may be trapped by
the retracting uterus

Procedure ….. Controlling hemorrhage
• IV ergometrine /oxytocin while the fetus half
born ,but the breech in the uterus
• Bleeding sinus is controlled by use of green
armytage
• Serious bleeding from the angle wound
– Insert two finger behind the broad ligament and
bring the uterus forward
• This compresses the vasculature and elevates the site of
the torn vessels ,so that they can be more readily located
and quickly clamped with out injury to the urether or
bladder

Procedure ….. Removing the placenta
 Extracted by traction if needed by finger hooked into
the placenta substances ( never express)
 If necessary remove by inserting the whole hand into
the uterus
 Strip the membrane completely from the lower
uterine segment and this obviously requires the
momentary removable of green armytage
 Remove all flecks of vernix caseosa and stray
portions of amniotic membrane

Procedure ….. uterine closure
• The lower margin of the incised uterus & the edges of
the uterine incision are caught by Green armytage
forceps
– should be secured at once as it quickly lost in the pool of
blood
– If lost, pinch the lateral angle of the uterine wall between his
fingers and thumb ,then slipping his hold downward ,quickly
identify the lower margin of the incision and grasp it with a
green armytage
• Dilating the cervical canal
– Not as such important

 Atraumatic No 1 /0 chromic cut gut half circle rounded
body
 1st stitch is applies at the lateral angle of the uterine
incision on the far side from the operator and is tied
 Avoiding the decidua repair the muscle
 Care at the lateral angle to avoid bladder suturing ;if not
formed earlier

 Clean the area and commence second suturing
 The second row pick up any unstitched muscle tissue on
the upper uterine segment
 By bringing a fold of muscle and fascia on the lower side
it shuts the inner row of the sutures completely from
sight
 Tie the second row of the suture to the 1st strand
 If one or more holes at may persistently ooze blood
Sutured with fine N0 20 on atraumatic half circled needle. One
transverse bite should be made below the bleeding spot and
another above it

• Once sutured clean the field and remove any
clotted blood in the sides behind the uterus
• Bladder peritoneum closed by continuous
chromic 2/0.( Recovering the lower uterine
segment)
– Loose above and below the exposed uterine
segment is brought together with a fine &
continuous cut gut suture
– Can also anchored to the underlying wound

Procedure ….. Closing the abdomen
• Remove gauze
• Inspect to the ovary grossly
• Clean the abdomen
• Close abdomen layer by layer
– Peritoneum with No 0
– Fascia with No 1
– Subcutaneous 20
– Skin clip ,proline ,silk ,
• Apply dry dressing

Procedure
Press firmly the fundus to expel the blood clot
that always formed in the vagina
Clean vagina

Procedure …Lower segment
transverse (Kerr) C/S
• Most commonly done type of C/S and has long been the
standard operation
• has the following advantages
• Less vascularized Less blood loss, easy to repair
• Good wound healing, Not under tension during repair
,accurate apposition and a strong union can be secured
• less risk of future rupture
• Less risk of adhesion formation because of its
peritoneal coverage.
• No risk of infected material to be disseminated to the
peritoneal cavity

Procedure …Lower segment
transverse (Kerr) C/S
• The major disadvantages are:
• Lateral extension with damage to uterine
vessels and Urethers
• Bladder injury especially in repeat cases and
needs expertise.
• Not appropriate for patients with lower uterine
segment pathology

Difficulties dangers and alternatives
:Preparation
 Front of the thigh is included in the antiseptic to
reduce contaminated from the contents of fluids
 Water proof drape
 The drapes should come in close to the edge of the
proposed incision

Difficulties, dangers and alternatives
:Abdominal wall incision
Pfannenstien incision
Longer to make and longer to repair
Many bleeding to be controlled
Low APGAR score
Little space to open the peritoneum in prolonged
labor with distended bladder
More difficult in repeat C/S

• Dividing the loose peritoneum
– Never cut through with knife pressed against the
uterine surface ,rather pickup and snip
– If there are large bleed vessels double cut before
proceeding
• Opening the uterus
– Bleeding could be reduced if you make enlarge the
cut wall of uterus by finger from side to side
• Difficult in identifying for uterine wall from the
endometrial lining
• Stitching become a blind procedure

Difficulties, dangers and alternatives:
Low Vertical (Sellheim)
• Advantage
– Less bleeding no danger to large blood vessels in the broad
ligament
– Can be extended to upper part
– In poorly developed and engorged vessels at both sides is safe
and easy to make and extract the fetus
• Disadvantage
– Impossible to make large incision unless there is well formed
formation of lower uterine segment
– Extension to the upper segment and to the down ward with
danger of bladder injury

:Classical (Sanger) C/S
 Uterine incision is made vertically through the
corpora uteri highly muscular and contractile
part of the uterus (upper segment)
not a routine method of c/s :done upon specific
indications.

:Classical (Sanger) c/s
indications
• When fast delivery is indicated (fetal distress)
• Lower uterine segment pathology
– Highly vascularized
– Myoma
– dense Adhesion from previous cesarean section
• Unformed lower uterine segment
– GA <32 weeks
– Transverse lie with back down

:Classical (Sanger) c/s
Indications
Pp anterior
Fetal malformations like conjoined twin and
Cervical ca
Transverse lie lower segment is narrow and the re is neglected
shoulder with arm prolapse
Constriction ring dystocia

Advantage
• It is simple and fast to perform but is associated with a
number of
Disadvantages
• More blood loss and difficult to close (repair)
• Poor healing of the incision,
• Extension to bladder
• high chance of future rupture
• Risk of adhesion formation with bowel and omentum
high

Procedure
• Make correction of rotated uterus
• Make the incision exactly on the mid line
• Size 12-15cm
• Control bleeding by artery forceps ,green-armytage
• In 40 % of the cases there is placenta encounter
– Should slip fingers between it and the uterine wall enlarge
the incision and deliver the fetus
– Passing via the placenta is another possibility but danger

Procedure
• Fetus is extracted by grasping the feet
• Too small incisions
– Uterine wound will contracted firmly around the
neck and while it is extracted
• Needs slight extension of the incision upwards and
imparting flexion to the head will overcome this

Procedure
• Very rarely a constricting ring may have formed in
the groove between the head and shoulder and
prevent extraction of the fetus
– Needs to extend the incision downwards through the
obstructing ring
– spinal anesthesia to prevent vomiting oxytocin rather than
ergometrine
• Placenta is removed by sweeping movements of the
fingers with in the uterus

• Suturing
– Material is Cut gut
– To prevent knot slipping in the tissue tie each knot
most securely using three casts and that at least 5
mm length stamp left
– Exclude decidua stitching
– Inner most layer = continuous 0 cut gut
– For second layer = interrupted cut gut of no 1
– Third layer = continuous no 0 cut gut the
peritoneum with the superficial muscle

Difficulties, dangers and
alternatives: Less common types
• T-shaped incision
• Securing suturing is never possible
• Delee incision – J-shaped upward extension of
the lower segment transverse incision
• Inverted T lower segment incision

Extracting the fetus
• Insert the hand below the head and scoop the
head out of the pelvis like a shoe horn
– Quick and easy
• But high risk of extension of uterine incision by
both the head and hand
• Use one blade of obstetric forceps
• Use special extractor device

Extracting the fetus
• More difficult is in deeply engaged head
– Needs deep anesthesia
– Instruct assistant to press the fetal shoulder upwards
– Push from below
– If an arm is prolapsed try to insert into the uterus
,never proceed to extraction while /pull the on the arm

Suturing the uterus
• If bladder is not sufficiently displaced risk of including
in the stitching
• In incision is extended there is risk of puncturing the
dilated veins in the brood ligament and there is a risk of
injuring the ureter if there is hematoma
• Stitching the upper segment to posterior retracted wall of
the uterus mistaking it for the lower edge of the uterine
incision
• Avoid three rows which can necrotizing the muscle

peritoneal covering
• Recovering the lower uterine segment
– Never drawn up the peritoneum tightly for it
makes future C/S difficult
– Cm
• My be left with out repairing
– Heels with in 24 hr
– Less time
– Less adhesion

Rupture
 No matter what precautions are taken or how
carefully is stitched there is always risk of rupture
during pregnancy or labor after C/s
 The risk is not eliminated if after the C/S the patient
has one or more vaginal delivery
 The scar on the active contractile is more liable

Rupture
Reasons
• Difficulty in coapting the muscle fiber exactly ,accumulation
of blood make weak scar
• Contraction and relaxation during the early days of the
operation make the stitch disrupted and dragged upon ,the it
become relaxed and results the two surface of the wound tend
to be in less intimate apposition

Rupture
Reasons
• If decidua has not been excluded a gutter run
along the scar on its inner lower uterine surface.
This constituted a permanent weakness and in a
subsequent pregnancy occurrence of hernia of
membranes through the walls
• Wound may be infected
• If placenta is situated in the inner part of the
uterine wound the edges are difficult to coapt
exactly
• If the placenta is implanted in the previous scar
destructive action of the chroinic villa on fibrous
tissue becomes pronounced and very decidedly
predisposes to rupture

Rupture
• There is less risk of rupture When
operation result is good
–The wound accurately secured
–are done early in labor
–Sutures remain firm at the end of the
operation
–The contain no decidua, muscle , vernix
–If the wound is stitched in two row
–Not grossly infected

Rupture
• Rupture occur 10-14 days prior to labor in
classical C/S
• lower uterine C/S
– Less risk of rupture
– Not catastrophic
– Occur During labor

infection
• Techniques done to lesson the danger of local
or generalized infection is
– Perfecting the technique of the operation
– free employment of antibiotics, and drainage of the
wound
– Shutting of the general peritoneal cavity before
opening into the lower uterine segment
– Genuine extrperitoneal section
– Hysterectomy
– Limit the head down position to the least
– Apply pack
– Short stap of incision 1st to suck amniotic

Patient care
• Postoperatively,
• the level of consciousness,
• vital signs and degree of vaginal bleeding
should be monitored frequently.
• Intravenous fluids are continued until the woman
is taking fluids.
• Do not give anything orally until bowel sound
returns.
• Antibiotics and transfusion are given if indicated.
• Encourage early ambulation.

Patient care
• Upon discharge ensure that she is taking
• regular diet,
• wound is clean, dry and not infected and
• there is no fever.
• Counsel on future risks and need to have
hospital delivery in future pregnancies.

Complications
• Complications could occur during the operation
,Intra operative or in the postoperative period.
• Complications include
– bladder laceration especially in repeat cases.
– Urethral injury,
– hemorrhage from damaged uterine vessels,
– anesthetic complications like mendelsons syndrome,
– fetal blood lose from incision through placenta or
laceration at the time of incision,

Complications
– trauma at time of extraction and
– fetal hypoxia from venacava compression and
anesthetic drugs.

Complications
Postoperative complications include
• Paralytic ileus
• hemorrhage from uterine atony or from
incision site,
• pelvic hematoma,
• endomyometritis,
• wound site infection,
• Pulmonary collapse

Complications
Postoperative complications include
• deep vein thrombosis and
thromboembolism and
• risk of rupture of the scar in subsequent
pregnancies.
• Other post operative complications seen in
any surgical patient can be encountered.
– Incisional hernia
– Intestinal obstruction

Vaginal birth after cesarean (VBAC)
• Increasing
• Solution is
– Great care at 1st C/S decision
– Securing of a uterine wound which can stand
future labor
• Once c/s hospital delivery and trail of scar
/VBAC

Vaginal birth after cesarean (VBAC)
• In the absence of absolute contraindications a
woman with cesarean section scar can be given the
chance to deliver vaginally.
– Non recurrent one
– Operation technique is non satisfactory
– Convalescence was aprexial
Prerequisite
• Spontaneous labor
• One c/s (lower uterine type or low vertical)
• vertex presentation
• No CPD
• Single
• Should be conducted in a hospital

…Vaginal birth after cesarean (VBAC
– Sign of dehiscence
• Pain and tenderness over the scar
• Slight vaginal bleeding
• Slight raise in PR
• Fetal tachycardia 1st later deceleration
– Declare failed VBAC/trail of scar if the alert
line is crossed for 2 hrs
– Avoid prolonged 2nd stage and assist delivery
– Explore the uterus if there is sever bleeding
and deranged V/S

…Vaginal birth after cesarean (VBAC)
Those contraindications which mandate
elective cesarean section are
• Classic or inverted T or low vertical
incision with extension to the corpus
• Two or more lower segment incisions or
• Previous repair of uterus /transfundal
surgery
• when the type of incision is unknown

…Vaginal birth after cesarean (VBAC)
Those contraindications which mandate
elective cesarean section are
• Gross CPD from macrosomia (estimated fetal
weight of more than 4000 grams).
• considerable degree of pelvic contracture
• Multiple pregnancies
• Malpresentation
• Conditions that preclude vaginal delivery or
need induction
• If the indication for primary cesarean section is
recurrent

C/S in previous C/S
• If the old scar is wide or irregular should be
excised
• Open the peritoneum with care to avoid adhered
bladder damage
• If adhered bladder careful blunt dissection may
be done to mobilize the bladder
• It is unwise to do blunt dissection with gauze –
tearing is possible
• Incise via the old scar and trim the edge before
repair ,until a reasonable depth of myometrium
is available for suturing

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