3. Introduction
DEFINITION:
• It is an operative procedure whereby the fetuses after the end of 28th
week are delivered through an incision on the abdominal and uterine
walls.
• This excludes delivery through an abdominal incision of a fetus, lying free in the abdominal
cavity following uterine rupture or in secondary abdominal pregnancy.
• The first operation performed on a patient is referred to as a primary
cesarean section.
• When the operation is performed in subsequent pregnancies, it is called
repeat cesarean section.
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4. Intro…..
• Nomenclature and history :
• Amidst controversy, it appears that the operation derives its name from the notification “lex
Cesarea” – a Roman law promulgated in 715 BC which was continued even during Caesar’s reign.
• The law provided either an abdominal delivery in a dying woman with a
hope to get a live baby or to perform postmortem abdominal delivery for
separate burial.
• The operation does not derive its name from the birth of Caesar, as his
mother lived long time after his birth.
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5. Intro…
• The other explanation is that
• the word cesarean is derived from the Latin Verb ‘Cedere’ which means ‘to cut’.
French obstetrician, Francois Mauriceau first reported cesarean section in 1668.
• In 1876, Porro performed subtotal hysterectomy.
• It was Max Sanger in 1882, who first sutured the uterine walls.
• In 1907, Frank described the extraperitoneal operation.
• Kronig in 1912, introduced lower segment vertical incision and it was popularized by
De Lee (1922).
• Although Kehrer in 1881 did the transverse lower segment operation for the first
time, Munro Kerr in 1926 not only reintroduced the present technique of lower
segment operation but also popularized it.
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6. Incidence
• The incidence of cesarean section is steadily rising.
• During the last decade there has been two to three fold rise in the
incidence from the initial rate of about 10%.
• Increased safety of the operation due to
• Improved anesthesia,
• Availability of blood transfusion and
• Antibiotics,
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7. Incidence….
Responsible factors for rise in c/s incidence….
• Identification of at risk fetuses before term (IUGR)
• Wider use of repeat CS in cases with previous cesarean delivery
• Rising rates of induction of labor and failure of induction
• Decline in operative vaginal (mid forceps, vacuum) delivery and
manipulative vaginal delivery (rotational forceps)
• Decline in vaginal breech delivery
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8. Incidence….
• Increased number of women with age > 30 and associated medical
complications
• Wider use of electronic fetal monitoring and increased diagnosis of fetal
distress
• Fear of litigation in obstetric practice
• Cesarean delivery on demand (controversial)
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9. Indication
• The indications are broadly divided into two categories :
• Absolute
• Relative (common)
• Cesarean delivery is done when labor is contraindicated
(central placenta previa) and/or vaginal delivery is found
unsafe for the fetus and/or mother.
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10. Absolute indications
• Vaginal delivery is not possible.
• Cesarean is needed even with a dead fetus Indications are few:
1. Central placenta previa
2. Contracted pelvis or cephalopelvic disproportion (absolute)
3. Pelvic mass causing obstruction (cervical or broad ligament fibroid)
4. Advanced carcinoma cervix
5. Vaginal obstruction (atresia, stenosis)
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11. Absolute indications…..
COMMONINDICATIONS
Primigravida :
(1) Failed induction
(2) Fetal distress (non reassuring fetal FHR)
(3) Cephalo pelvic disproportion (CPD)
(4) Dystocia (dysfuctional labour ) nonprogress of labour
(5) Malposition and malpresentation (occipitoposterior, breech).
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13. Relative indications
• Vaginal delivery may be possible but risks to the mother and/ or to the
baby are high More often multiple factors may be responsible
Cephalopelvic disproportion (relative)
Previous cesarean delivery
When primary C/S was due to recurrent indication (contracted pelvis).
Previous two C/S
Features of scar dehiscence.
Previous classical C/S
Non-reassuring FHR (fetal distress)
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14. Relative indications…..
Dystocia may be due to (three Ps): passenger, passage or Power
Malpresentation—Breech, shoulder (transverse lie), brow
Failed surgical induction of labor, Failure to progress in labor
Bad obstetric history—with recurrent fetal wastage
• Hypertensive disorders—
Eclampsia—uncontrolled fits even with antiseizure
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15. Relative indications…
Medical-gynecological disorders—
Diabetes (uncontrolled), heart disease (coarctation of aorta, Marfan’s
syndrome.
Mechanical obstruction (due to benign or malignant pelvic tumors
(carcinoma cervix), or following repair of vesicovaginal fistula
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16. Classification
Accordingto timing:
• Electivecaesareansection: The operation is done at a pre-selected time before onset
of labour, usually at completed 39 weeks.
• Selective caesareansection: The operation is done after onset of labor.
According to the site of uterine incision:
Upper segment caesarean section (classical C.S.):
The incision is done in the upper uterine segment and it is always vertical.
Lowersegment caesarean section (LSCS) :
It is the commoner type.
The incision is done in the lower uterine segment and may be transverse ( the usual) or vertical
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17. Classifications….
Accordingto numberof the operation:
Primarycaesarean section: for the first time.
Repeatedcaesarean section : with previous caesarean section(s).
Accordingto opening theperitoneal cavity:
Transperitoneal :
The ordinary operation where the peritoneal cavity is opened before incising the
uterus.
Extraperitoneal:
The peritoneal cavity is not opened and the LUS is reached either laterally or inferiorly
by reflecting the peritoneum of the vesico-uterine pouch.
It is indicated in case of infected uterine contents as chorioamnionitis.
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18. Time and types of CS
TIME OF OPERATION
• Elective
• Emergency
Elective—
When the operation is done at a prearranged time during pregnancy to ensure the
best quality of obstetrics, anesthesia, neonatal resuscitation and nursing services.
Time:
(a) Maturity is certain: The operation is done about one week prior to the expected
date of confinement.
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19. Time and types of CS….
Elective….
(b) Maturity is uncertain:
Ultrasound assessment in 1st or 2nd trimesters if available is corroborated.
Amniocentesis for L : S ratio is used to ensure fetal maturity.
Otherwise spontaneous onset of labor is awaited and then CS is done.
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20. Benefits and risks of elective operation
Maternal benefits
Reduction in perinatal morbidity and mortality as there is no hazard
from labor and delivery process.
No pelvic floor dysfunction.
Maternal risks are:
Longer recovery time and hospital stay.
Risks of placenta previa and hysterectomy are more in subsequent delivery .
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21. Types of operations
Abdominal incision
• The abdominal incision maybe midline, paramedian, or Pfannenstiel.
• Midline
• The infraumbilical vertical midline incision is less bloody and
allows more rapid entry into the abdominal cavity.
• Paramedian
• A vertical incision lateral to the umbilicus. It is rarely used.
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22. Types of operations….
Abdominal incision……
• Pfannenstiel
This low transverse incision near the symphysis pubis
Provides the most desired cosmetic effect and
Done most often.
However, it requires more time to perform.
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23. Types of operations
Uterine incision
• The type of uterine incision is selected depending on development of the
Lower uterine segment,
Presentation of the infant, and
Placental location.
Cesarean operations are classified
• According to the orientation (transverse or vertical) and
• According to the site of placement (lower segment or upper segment) of the uterine
incision.
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24. Types of operations
Low transverse(Kerr).
It is the preferred incision and the one most frequently used today.
Unless specified, cesarean section means lower segment operation.
Made in the non-contractile portion of the uterus, minimizing chances
of rupture or separation in subsequent pregnancies.
Requires creation of a bladder flap and lies behind the peritoneal
bladder reflection, allowing reperitonealization.
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25. Types of operations…
Low transverse(Kerr)……..
Uterine closure is accomplished more easily because of the thin muscle
wall of the lower segment, and
Potential for blood loss is lowest.
This incision may involve potential extension into the uterine vessels
laterally and into the cervix and vagina inferiorly.
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26. Types of operations….
Low vertical.
Incision begins in the non-contractile lower segment but usually extends into the contractile
upper segment.
• This incision is used when a transverse incision is not feasible.
• The LUS may not be developed if labor has not occurred; the transverse incision may
not provide enough room for delivery of the infant.
• Malpresentation of the term or premature infant may necessitate a vertical incision to
allow more room for delivery of the infant.
• Used when an anterior placenta previa is noted to facilitate delivery without cutting
through the body of the placenta.
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27. Types of operations….
Low ertical……
• Requires creation of a bladder flap and allows reperitonealization.
• The risk of uterine rupture in subsequent pregnancies is increased
when the upper segment of the uterus is entered.
• Uterine closure is more difficult, and blood loss is greater if the upper
segment is involved.
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28. Types of operations….
Classicincision(Sanger).
• It is a longitudinal incision in the anterior fundus.
• Its indications in present day obstetrics are very much limited because of the
significant risk of uterine rupture in subsequent pregnancies.
• It is the simplest and quickest incision to perform.
• The potential for intraperitoneal adhesion formation is greater.
• Uterine closure is more difficult because of the thick muscular upper segment, and
• The potential for blood loss is greater.
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29. Types of operations….
Classicincision (Sanger)….
• The operation is only done under forced circumstances such as :
• Invasive carcinoma of the cervix,
• Repair of high VVF
• Big fibroid on the lower segment—Blood loss is more and contemplating myomectomy may
end in hysterectomy
• Transverse lie with the back down (most cases).
• Complete anterior placenta previa with engorged vessels in the lower segment—risk of
hemorrhage
• Lower segment approach is difficult
(1) Dense adhesions due to previous abdominal operation
(2) Severe contracted pelvis (osteomalacic or rachitic) with pendulous abdomen
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30. Complications of cesarean section
• The complications are related either to the operations (inherent
hazards)‚ or due to anesthesia.
• The complications are grouped into:
• Maternal
• Fetal
• The complications may be :
• Intraoperative
• Postoperative
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31. Intraoperative complications
• Extension of uterine incision to one or both the sides. —may extend laterally or
inferiorly into the vagina.
• May involve the uterine vessels to cause severe hemorrhage and broad ligament
hematoma formation.
• Bladder injury
Is rare in a primary CS
but may occur in a repeat procedure.
Continuous bladder drainage is then maintained for 7–10 days.
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32. Intraoperative complications ….
• Ureteral injury is rare (1 in 1000 procedures).
• Injury occurs during control of bleeding from lateral extensions.
• Gastrointestinal tract injury is rare unless there is prior
pelvic/abdominal adhesions.
• Hemorrhage may be due to uterine atony or uterine lacerations.
• Blood transfusion is needed
• Total hysterectomy
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33. Postoperative Complications
MATERNAL :
• Immediate
• Remote
IMMEDIATE •
• Postpartum hemorrhage
• It is mostly related to uterine atony.
• Shock—While most often it is related to the blood loss, it may occur when the
operation is done following prolonged labor without correcting pre-existing
dehydration and ketoacidosis. •
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34. Postoperative complications….
• Infections—
• The common sites are uterus (endomyometritis), urinary tract,
abdominal wound, peritoneal cavity (peritonitis) and lungs.
Risk factors for infection are :
• Prolonged duration of labor and that of rupture of membranes,
• Repeated number of vaginal examinations.
• Prophylactic antibiotics reduces the risk significantly.
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35. Postoperative Complications….
Intestinal obstruction—
• The obstruction may be mechanical due to adhesions or bands, or
paralytic ileus following peritonitis.
• Deep vein thrombosis and thromboembolic disorders are more likely to
occur following cesarean section than following vaginal delivery.
• Septic thrombophlebitis is also a known complication
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36. Postoperative Complications…
• Wound complications—Abdominal wound sepsis is quite common.
The complications those are detected on removal of the skin stitches are:
(1) Sanguinous or frank pus
(2) Hematoma
(3) Dehiscence (peritoneal coat intact)
(4) Burst abdomen (involving the peritoneal coat).
Secondary postpartum hemorrhage.
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37. Postoperative Complications….
REMOTE:
• Gynecological
• Menstrual excess or irregularities, chronic pelvic pain or backache.
• General surgical
• Incisional hernia, Intestinal obstruction due to adhesions and bands.
• Future pregnancy
• There is risk of scar rupture
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38. Postoperative Complications….
• MATERNAL AND PERINATAL MORTALITY:
The causes of death are —
(1) Hemorrhage and shock
(2) Anesthetic hazards
(3) Infection
(4) Thromboembolic disorders.
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39. Postoperative Complications….
MATERNAL AND PERINATAL MORTALITY:
Fetal:
The causes of death are:
1. Asphyxia may be pre-existing
2. RDS
3. Prematurity
4. Infection and
5. Intracranial hemorrhage—attempting breech delivery through a small incision.
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40. Postoperative Complications…
Cesarean Hysterectomy :
• Cesarean hysterectomy refers to an operation where cesarean section is followed by
removal of the uterus.
• The common conditions are :
1) Morbid adherent placenta
2) Atonic uterus and uncontrolled postpartum hemorrhage
3) Big fibroid (parous)
4) Extensive lacerations due to extension of tears with broad ligament hematoma
5) Grossly infected uterus
6) Rupture uterus.
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41. Postoperative Complications…
• Peripartum hysterectomy is the surgical removal of the uterus either at the time of
cesarean delivery or in the immediate postpartum period (even following vaginal delivery).
• Subtotal hysterectomy is commonly done as an emergency (unplanned) procedure.
Benefits of subtotal hysterectomy are:
• Less operating time,
• Less blood loss,
• Less risk of injury to other organs (bladder, ureter) and
• Less post-operative morbidity.
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Adoption of small family norm—neither the obstetricians, nor the patients are ready to accept any risk of abnormal labor
The pregnant uterus is palpated and inspected for rotation.
Currently used infrequently because of the significant risk of uterine rupture in subsequent pregnancies, which can occur before labor begins, and higher complication rate.
