Caesarean Section Flashcards
(17 cards)
CESAREAN SECTION
It is an operative procedure to deliver a fetus/es after the end of 28th week of GA (age of fetal viability) via an
abdominal and uterine walls incision.
A Caesarean section, aka C-section or Caesar, is a surgical procedure in which incisions are made through a
mother’s abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies
Cesarean Hysterotomy
If its performed before age of fetal viability it is termed Cesarean Hysterotomy
Factors for rising cesarean section rate/incidence
Early identification of at risk fetuses before term (IUGR)
Early identification of at maternal risks
As indication in cases with previous cesarean delivery
Increasing of IOL and failure of induction
Decline in operative vaginal (mid forceps, vacuum) delivery and manipulative vaginal delivery (rotational forceps)
Decline in vaginal breech delivery
Increased martenal age > 30 and associated medical complications
Adoption of small family norm—neither the obstetriccians, nor the patients are ready to accept any risk of abnormal labor
Wider use of electronic fetal monitoring and increased diagnosis of fetal distress
Fear of litigation in obstetric practice
Maternal request (controversial)
absolute Indications for Ceaserian section
Vaginal delivery is not possible. Cesarean is needed
even with a dead fetus
Indications are few:
1. Central placenta previa
2. Contracted pelvis or CPD (absolute)
3. Pelvic mass causing obstruction (cervical or broad
ligament fibroid)
4. Advanced carcinoma of the cervix
5.. Vaginal obstruction (atresia, stenosis)
Common indications in:
Primigravidae:
(1) Failed indication
(2) Fetal distress (nonreassuring fetal FHR)
(3) Cephalo pelvic disproportion (CPD)
(4) Dystocia (dysfuctional labour) nonprogress of labour
(5) Malposition and malpresentation (occipitoposterior,
breech).
Multigravidae:
(1) Previous Caesarean delivery
(2)APH (placenta praevia, placental abruption)
(3) Malpresentation (breech, transverse lie).
RELATIVE INDICATIONS for c/s
Vaginal delivery may be possible but risks to the mother and/
or to the baby are high
More often multiple factors may be responsible
1. CPD (relative)
2. Previous cesarean delivery-
(a) If primary C/S was due to recurrent indication (contracted pelvis).
(b) Previous 2 CS
(c) Features of scar dehiscence.
(d) Previous classical CS
3. Non-reassuring FHR (fetal distress)
4. Dystocia may be due to (three Ps) relatively
a. (passenger), large fetus, Fetal distress, certain malpresentation
b. (passage)- contracted pelvis, soft tissues obstruction
c. (Power)- inefficient uterine contractions, retraction ring cervical dystocia
5. APH (a) Placenta previa and (b) Abruptio placenta
6. Malpresentation- Breech, shoulder (transverse lie), brow
7. Failed surgical IOL, Failure to progress in labor
8. Bad obstetric history- with recurrent fetal wastage
9. Hypertensive disorders- (a) SPE, (b) Eclampsia-uncontrolled fits even
with antiseizure therapy
10. Medical-gynecological disorders-
(a) Diabetes (uncontrolled), heart disease (coarctation of aorta,
Marfan’s syndrome.
(b) Mechanical obstruction (due to benign or malignant pelvic
tumors (carcinoma cervix), or following repair of VVF
Types of cesarean section
It’s based on time of operation:
1. Elective 2. Emergency
Elective cesarean section- When operation is done at a prearranged time during preg to
ensure best quality of obstetrics, anesthesia, neonatal resuscitation& nursing care
Emergency cesarean section- when operation is performed due to unforeseen or acute
obstetric emergencies and should be done within of 30 minutes
Based on operation approach:
1. Lower segment
2. Classical or upper segment
Classical cesarean section
Classical cesarean section- Baby is extracted through a vertical incision made in upper
segment of uterus through the myometrium. Has limited indications & only done when;
Lower segment approach is difficult- (Dense adhesions, Severe contracted pelvis (osteomalacic or rachitic)
Lower segment approach is risky.
This approach carries a 4-7% risk of uterine rupture and thus after classical uterine incision, subsequent
deliveries are destined for repeat cesareans
Indications for the classical caesarean section
- Structural abnormality makes lower segment approach difficult
- Transverse lie of the fetus with neglected shoulder
- Fibroids in lower segment
- Varicose veins in lower uterine segment
- Preterm breech in undeveloped lower uterine segment
- Postmortem caesarean section
- Dense adhesions due to previous abdominal op
- Severe contracted pelvis (osteomalacic or rachitic) with pendulous abdomen
- Carcinoma cervix
- Repair of high VVF
- Complete anterior placenta previa
Lower segment section
Lower segment section - extraction of the baby is done through an incision made in the lower segment through a
transperitoneal approach
Advantages of lower segmen C/S
- Less blood loss because the LUS is thin and less vascular
- Postoperative ileus and intestinal obstruction due to postoperative adhesions- is less frequent
- Rupture in subsequent pregnancy is less
- Lower segment is passive during labour
- Better coaptation of the wound
Casearian hysterectomy- done due to
- Uncontrolled PPH,
- Morbid adherent placenta,
- Atonic uterus,
- Big fibroid (parous)
- Extensive lacerations due to extension of tears with broad ligament hematoma,
- Grossly infected uterus and
- Rupture uterus
Perimortem C/ section
Perimortem C/ section- Is done to have a live baby (rare) following maternal death. Perimortem section is an
extreme emergency procedure. Classical section is done in a woman who has suffered a cardiac arrest. The infant
may survive if delivery is done within 10 minutes of maternal death.
Extraperitoneal C/ section
Extraperitoneal C/ section- Lower segment is approached extraperitoneally by dissecting through the space of
Retzius. Not practiced now
Peripartum hysterectomy
Peripartum hysterectomy- Surgical removal of uterus either at time of cesarean delivery or in immediate
postpartum period (even following SVD)
Complications of caesarean section
May be: 1. Intraoperative 2. Postoperative
Intraoperative
a. Shock
b. Haemorrhage due to injury to vessels, atony of uterus & coagulation defects as in abruptio placentae
c. Bladder injury- Rare in primary C/S but may occur in a repeat C/Section
d. Ureteral injury
e. Gastrointestinal tract (bowel) injury
f. Caesarean hysterectomy- uncontrollable maternal bleeding
g. Anaesthetic complications
h. Morbid adherent placenta (placenta accreta) - common in placenta previa with prior cesarean delivery. To
control hemorrhage Total hysterectomy is often needed
Post operative complication
Fetal complication:
a. Iatrogenic prematurity
b. Development of RDS
c. Injury to fetus: scalpel lacerations
Maternal complications
Immediate/intermediate
a. Postpartum haemorrhage
b. Shock- Related to bld loss
c. Anesthetic hazards- e.g., aspiration of gastric contents, resulting aspiration atelectasis or aspiration
pneumonitis (Mendelson’s syndrome): hypotension and spinal headache
d. Infections- uterus (endo- myometritis), UTI, wound infen, peritonitis Pneumonia etc
e. Intestinal obstruction- may be mechanical due to adhesions/ bands or paralytic ileus following peritonitis.
f. DVT & thromboembolic - disorders due to immobility
g. Secondary PPH
Remote complications
* Gynecological: Menstrual excess or irregularities, chronic pelvic pain or backache.
* General surgical: Incisional hernia, Intestinal obstruction due to adhesions and bands.
* Future pregnancies- Risk of scar rupture, Placenta praevia increases almost linearly after C/S, Morbid
adherent placenta (placenta accrete)
Procedure for caesarean section
- Abdominal skin prepared aseptically and draped; adequate anesthesia confirmed
- Skin incision made using scapel is;
a. Pfannenstiel incision (“bikini cut”): transverse incision ~ 2-3 cm above pubic symphysis
b. Midline vertical incision: often performed in emergent cases or when additional exposure may be needed
c. Maylard incision: similar to Pfannenstiel, but medial aspect of rectus abdominis muscle incised if additional
exposure needed - Subcutaneous fat is incised and rectus fascia exposed then incised
- Fascial incision extended using a mayo scissors and dissected off underlying rectus muscles
- Midline between rectus muscles identified and
peritoneum entered - Bladder blade positioned, vesicouterine peritoneum
incised and extended, bladder flap created, and bladder
blade replaced. Introduce Doyen’s retractor. Pack peritoneal cavity using 2 taped large swabs. - Hysterotomy made using scalpel
a. Low transverse uterine incision (most common)
b. Low vertical incision
c. Classical uterine incision (vertical hysterotomy)
i. Transverse lie (back down)
ii. Premature infant and poorly developed lower uterine segment
iii. Fibroids obstructing lower uterine segment
– Classical incision closed in multiple layers
d. J-incision and Inverted T-incision: performed after attempted low
transverse when additional room to deliver fetus is needed - In Low transverse incision- make a small transverse incision in midline
with a scalpel at a level slightly below the peritoneal incision until
membranes are exposed - Insert 2 index fingers in the small incision down to the membranes & split muscles transversely across the fibers
to minimize blood loss but requires experience. - ROM if intact, suck amniotic fluid by continuous suction & remove Doyen’s
retractor. - Deliver fetal head by hooking head with fingers carefully insinuated betwn lower
uterine flap & head until the palm is placed below the head. As the head is drawn to
incision line, +
/_ apply fundal pressure - by assistant - Delivery of the trunk: As soon as the head is delivered, suck out mucus from the
mouth, pharynx and nostrils using sucker. After the delivery of the shoulders, give IV oxytocin 20 units.
Rest of the body is delivered slowly and the baby is placed on mother’s abdomen with the head tilted down for
gravitational drainage. The cord is cut in between 2 clamps and baby is handed over to the nurse.
Optimum interval betwn uterine incision & delivery is < 90 secs. Interval > 90 secs is associated with poor
Apgar Scores due to reflex uterine vasoconstriction following uterine incision and manipulation. - Remove placenta and membranes by controlled cord traction: after spontaneous placenta
separation - The Doyen’s retractor is reintroduced.
- Mop the endometrial cavity with a dry tapped abdominal swab
- Hysterotomy closed using absorbable suture CGT 1 or 2, and hemostasis assured
- Fascia and other incised layers closed
- Dressing applied
- Massage fundal aspect of the uterus abdominally to stimulate contraction and expel clots
and then do vaginal toilet. Apply a pad - Take pt to recovery area
Postoperative care of C/S
First 24 hours:
* (Day 0)
* Observation for the first 6–8 hours is important- Periodic check up of
TPR+BP, amount of vaginal bleeding and behavior of the uterus
* Fluid- N/S (0.9%) or R/L IV 2.5 – 3L. BT PRN if pts Hb was low pre-op or pt signicantly bled
* Oxytocics: Inj oxytocin 5units IM or IV (slow) or methergin 0.2 mg IM
* Prophylactic antibiotic (cephalosporins, metronidazole) x 3days
* Analgesics- pethidine hydrochloride 75–100 mg Qid x ¹⁄7
* Ambulation- Can sit on bed or get out of bed to evacuate bladder as soon a condition allows
* Baby- breastfeed after 3-4 hrs when stable & pain rel
* Day 1: Give oral feeding- plain or electrolyte water or raw tea. And monitor for active bowel sounds.
* Day 2: Light solid diet, if bowels do not move spontaneously, do bowel care: 3–4 teaspoons of lactulose noc
* Depending on post-op recovery and availability of home care, pt may be discharged by 3rd day
* Review pt after 1 or 2 week depending co-exesting condition and remove stitches
