Caesaean Section 2

7/31/2019 Caesaean Section 2

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CAESAEAN SECTION

SR.ELIZABETH M.A

LECTURERFMCON


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Nomenclature and History

Name derived from lex cesarea-a Roman

law promulgated in 715 B.C.

Abdominal delivery in a dying woman to get a

baby.

Or to perform postmortem abdominal

delivery for separate burial.


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Latin Verb caedere which means to cut.

French Obstetrician, Francois Mauriceau firstreported caesarean section in 1668.

Kronig in 1912,introduced lower segment

vertical incision.

Kehrer in 1881 did the transverse lower

segment operation for the first time.

Munro Kerr in 1926 not only reintroduced thepresent technique of lower segment operation

but also popularized.


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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.


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Primary caesarean section

Repeat caesarean section (subsequentpregnancies)


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Incidence

Factors for increasing caesarean section

Identification of at risk fetuses before term

Identification of at risk mothers. Wider use of repeat C.S. in cases with previous

caesarean delivery.

Rising incidence of elderly pimigravidae. Decline in difficult operative or manipulative

vaginal deliveries.


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Decline in vaginal breech delivery

Increased diagnosis of fetal distress and fear

of litigation.

Adoption of small family norm


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Indications

1.Absolute Indications

Vaginal delivery is not possible, CS is needed

even with a dead fetus.

1. Central placenta praevia

2. Contracted pelvis or CPD

3. pelvic mass causing obstruction

4. Advanced carcinoma cervix5. Vaginal obstruction (atresia, stenosis)


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2.Relative Indications

Vaginal delivery may be possible with or without

aids. But risks to the mother and /or to thebaby are high.

1. CPD

2. Previous caesarean delivery(CPD, previoustwo CS, scar dehiscence, previous classicalC.S)

3. Non reassuring FHR

4. Dystocia

5. Antepartum Haemorrhage


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6. Malpresentations

7. Failed surgical induction

8. Bad obstetric history9. Hypertensive disorders

10.Medical and gynaecological disorders


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3. Common Indications

Primigravidae

CPD Fetal distress

dystocia


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Multigravidae

Previous CS

APH malpresentations


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Maternal Indications

CPD and contracted pelvis

Inadequate uterine force

Previous classical cesarean section

Previous LSCS

Placenta praevia

Eclampsia or pre-eclampsia

Dystocia

Carcinoma cervix


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Fetal indications

Fetal distress

Prolapse of umbilical cord

Mal presentation

Bad obstetrical history and habitualintrauterine death of fetus

Abruption placenta

Multiple pregnancy

Maternal HIV infection


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Time of operation

Elective

Emergency

Elective When the operation is done at a pre arranged

time during pregnancy to ensure the best

quality of obstetrics, anaesthesia, neonatal

resuscitation and nursing services.


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Time

Maturity is certainthe operation is done aboutone week prior to the expected date of

confinement.

Maturity is uncertain

Ultrasound assessment in first or second

trimesters.

Amniocentesis to ensure fetal maturity. Spontaneous onset of labour is awaited and

then CS is done.


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Type of operation

Lower segment

Classical or Upper segment


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Lower segment caesarean section

The extraction of the baby is done through an

incision made in the lower segment through

trans peritoneal approach.


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Classical

The baby is extracted through an incision

made in the upper segment of the uterus.

Indications

A. Lower segment approach is difficult

1. Dense adhesions due to previous abdominal

operation

2. Severe contracted pelvis with pendulous

abdomen


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B. Lower segment approach is risky

1. Big fibroid on the lower segment

2. Carcinoma of cervix3. Repair of difficult and high VVF

4. Severe degree of placenta praevia with

engorged vessels in the lower segment


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Lower segment Caesarean Section

Pre operative preparation

Informed written permission for the

procedure, anaesthesia and blood transfusion

is obtained.

Abdomen is srubbed with soap and non

organic iodide lotion. Hair may be clipped.

Pre medicative sedation

Antacid before transferring to the theatre


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PremedicationRanitidine or Metaclopramide

NG tube if needed

Emptying the bladder, Keep catheter in place Checking of FHS

Presence of Neonatologist


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Anaesthesia

Spinal

Epidural

General


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Position

Supine

15 tilt


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Incision

Vertical

Infraumbilical or paramedian

Transverse 3cm above the symphisis pubis


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Advantages of transverse incision

More post operative comfort

Fundus of the uterus can be better palpated

during immediate post-operative period.

Less chance of wound dehiscence

Cosmetic value

Less chance of incisional hernia.


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Disadvantages

Takes a little longer time and as such

unsuitable in acute emergency operation.

Blood loss is little more

Requires competency during repeat section

Unsuitable for classical operation.


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Packing

The Doyens retractor is introduced.

The peritoneal cavity is now packed of using

two taped large swabs. The tape ends are

attached to artery forceps. This will minimize

spilling of the uterine contents in to the

general peritoneal cavity.


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Uterine incision

Peritoneal incision

The loose peritoneum of the utero-vesical

pouch is cut transversely across the lower

segment with convexity downwards at about

1.25cm below its firm attachments to the

uterus.

The lower flap of the peritoneum is pushed

down a little.


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Muscle incision

The most commonly used incision is low

transverseAdvantages

1. Ease of operation.

2. less bladder dissection3. less blood loss

4. easy to repair

5. complete reperitonisation6. less adhesion formation

7. less risk of scar rupture


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Other type of Incisions

Lower segment transverse

Lower segment vertical

J incision

Classical incision

Inverted T incision


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Low transverse incision

A small transverse incision is made in the

midline by a scalpel at a level slightly below

the peritoneal incision until the membranes of

the gestation sac are exposed.

Two index fingers are then inserted through

the small incision down to the membranes

and the muscles of the lower segment are

split transversely across the fibers.


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The method minimizes the blood loss but

requires experience.

Alternatively the incision may be extended on

either sides using a pair of a curved scissors to

make it a curved one of about 10cm in length,

the concavity directed upwards.


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Delivery of the head

The membranes are ruptured if still intact

The blood mixed amniotic fluid is sucked out

by continuous suction. The Doyens retractor is removed.

The head is delivered by hooking the head

with the fingers which are carefully insertedbetween the lower uterine flap and the head

until the palm is placed below the head.


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As the head is drawn to the incision line the

assistant is to apply pressure on the fundus.

If the head is jammed, an assistant may push

up the head by sterile gloved fingers

introduced in to the vagina.

The head can be also delivered using either

wrigleys forceps


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Delivery of the trunk

As soon as the head is delivered, the mucus

from the mouth ,pharynx and nostrils is

sucked out using rubber catheter attached to

a electric sucker.

After the delivery of the shoulders intravenous

oxytocin 20 units or metergin0.2mg is to be

administered.


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The rest of the body is delivered slowly and

the baby is placed in a tray placed in between

the mothers thigh and with the head tilted

down for gravitational drainage.

The cord is cut in between two clamps and the

baby is handed over to the nurse.

The Doyens retractor is reintroduced.


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Delivery of the placenta

The placenta is extracted by traction on the

cord with simultaneous pushing the uterustowards the umbilicus per abdomen using the

left hand .

the membranes are to be carefully removedpreferably intact and even a small piece, if

attached to the decidua should be removed

using a dry gauze. dilatation of the internal os is not required.

Exploration of the uterine cavity is desirable.


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Suture of the uterine wound

the margins of the wound are picked up by

Alis tissue forceps or Green Armytage

haemostatic clamps.

The uterine incision is sutured in three layers.


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First layer the first stitch is placed on the far

side in the lateral angle of the uterine incision

and is tied with 0 chromic catgut or vicryl. A

continuous running suture taking deepermuscles excluding the decidua ensures

effective apposition.


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Second layer -the superficial muscles and

fascia by continuous suture.

Third layer-the peritoneal flap by continuous

inverting suture.

Concluding part

The mops placed inside are removed and the

number verified. Peritoneal toileting is done

and the blood clots are removed meticulously.


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The tubes and ovaries are examined. Doyen's

retractor is removed.

After being satisfied that the uterus is well

contracted, the abdomen is closed in layers.

The vagina is cleansed of blood clots and a

sterile vulval pad is placed.


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Post operative care

First 24 hours

Meticulous observation for 6-8 hours

TPR, BP, amount of bleeding, and behaviour of

uterus.

Fluid- 2 to 2.5 litres

Blood transfusion in cases of anaemia orexcessive blood loss.

oxytocics


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Prophylactic antibiotics

Analgesics

Breast feeding

Ambulation and exercises- leg, ankles, deep

breathing ,sitting or walking-prevent deep

vein thrombosis and pulmonary embolism


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Day 1

Observe for bowel sound

Oral feeding-clear liquid, coffee tea.

Day 2

Light solid diet

Laxatives

Day 5-6

Stitches are removed


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Transverse D-5

Longitudinal D-6

Discharge

Patient is discharged on the day following

removal of the stiches.

Health education


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Classical caesarean section

Abdominal incision is longitudinal about 15cmin length, 1/3rd of which extends above theumbilicus.

After opening the peritoneal cavity, the uterusis centralized and packs are placed on eachsides

A longitudinal incision of about 12.5 cm ismade on the midline of the anterior wall ofthe uterus starting from below the fundus.


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The incision is deepened along its entire length

until the membranes are exposed which are

punctured.

The baby is delivered as breech extraction

Methergin

Placental removal

Suture of the uterine incision

Uterus is returned back into the abdominal cavity


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Packings are removed

Peritoneal toileting is done

The abdomen is closed in layers

Merits and demerits


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Lower segment Classical

techniques Slight difficult

Blood loss is less

The wall is thin and assuch apposition is

perfect

Perfect peritonisationis possible

Technical difficulty in

placenta praevia or

transverse lie

Technically easy

Blood loss is more

The wall is thick andapposition of the

margins is not perfect

Not possible

Comparatively safer in

such circumstances.

Post - Haemorrhage and More


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operative

g

shock-less

Peritonitis is less

Peritoneal adhesion

and intestinal

obstruction are less

Convalescence is better

Morbidity andmortality are lower

More

More because of

imperfect

peritonisation

Relatively poor

Morbidity andmortality are

higher

Wound The scar is better healed The scar is weak because


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Wound

healing

The scar is better healed

because of :Perfect muscle apposition

due to thin margins

Minimal wound

heamatoma

The wound remainsquiescent during healing

process

Chance of gutter formation

is unlikely

The scar is weak because

of:Imperfect muscle apposition

because of thick margins

More wound haematoma

formation

The wound is in a state oftension due to contraction

and relaxation of the upper

segment. As a result, the

knots may slip or the suturesmay become loose

Chance of gutter formation

on the inner aspect is more


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During future

pregnancy

Scar rupture is

less 0.5-1.5%

More risk of scar

rupture 4-9%


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Complications

Due to operation or anaesthesiaIntra operative complications

Extension of uterine incision to one or both

the edgesinvolve uterine vessels broadligament haematoma

Uterine lacerations-laterally or inferiorly to

vagina Bladder injurytwo layer closure with 2-0

chromic catgut, continuous bladder drainage

for 7-10 days


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Urethral injury

Gastrointestinal tract injury

Uterine atony and primary post partum

haemorrhage

Morbid adherent placenta


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Post operative complications

Maternal-immediate

Post partum haemorrhage

Shock

Anaesthetic hazards

Infections

Intestinal obstructions Thromboembolic disorders


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Wound complications

Wound sepsis, sanguineous or frank puss,

haematoma, dehiscence, burst abdomen.

Post mortem cesarean birth


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Post mortem cesarean birth

If a pregnant woman does not survive serious

trauma, it may still be possible for her child to

be born safely by postmortem CS birth.

This is usually attempted if the fetus is past 24

weeks and less than 20 minutes has passed

since the mother died.

Infant survival is best in these circumstances ifno longer than 5 minutes has passed.


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No consent

Classical incision

Personnel to resuscitate the baby.


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THANK YOU

Documents

Caesaean Section 2