CESAREAN SECTIONDr shams reha

OBJECTIVESDEFINITIONINCIDENCEINDICATIONSTYPES OF CAESAREAN SECTIONPROCEDUREPREOPERATIVE PREPARATION7. PREPARATION IN THEATRE

8.ANESTHESIA9.VARIANTS OF C-SECTION10. COMPLICATIONS OF C-SECTION11.ANESTHESIA COMPLICATION12.PREGNANCY AFTER ONE C-SETION

THE TERM CESAREAN SECTION is derived from TWO LATIN WORDSCAEDERE means to cutSECTIO means an act of cutting

CESAREAN SECTION

NUMA POMPOLIS , King of Rome , in 715 BC, brought in a law which forbade the burial of a pregnant women unless her child has been removed & burried separatelyIn 200 BC , this practice was called Lex Caesarea, when the kings became Caesars(Used as a title and form of address for Roman emperors.

1- DEFINITIONCaesarean section the operation performed to deliver the baby after the age of viability (24 weeks) through an abdominal incisionIt is called HYSTROTOMY if performed before the age of viability

INDICATIONS FOR CSBASED ON THE TIMING OF CS AT THE TIME OF DECISION MAKING, THE INDICATIONS ARE GROUPED UNDER ONE OF FOUR CATEGORIESEMERGENCY C-SECTION:URGENT C-SECTION:SCHEDULED C-SECTION:ELECTIVE C-SECTION:

EMERGENCY C-SECTION:CATEGORY 1There is an immediate threat to the mother or the fetus. ideally c-section should be done with in next 30 mints e.g. cord prolapse scar rupture abruptionscalp pH

URGENT C-SECTIONCATEGORY 2

There is maternal or fetal compromise but was not immediately life threatening.Here the delivery should be completed within 6075 min and cases with FHR abnormalities are thoseof concern.

SCHEDULED CSCATEGORY 3 The mother needed early delivery but there was no maternal or fetal compromise.This group has a wide range of indicationsIt may be a case of failure to progress where the CS is planned within the next hour or twoor it may be a case of growth-restricted fetus in the preterm period with absent end diastolic flow but a normal CTG or

SCHEDULED CSCATEGORY 3 a case with pre- eclampsia where the liver or renal function tests are gradually deteriorating where the CS is planned for within hours to days. The timing of the CS would vary but some plan should be in place to deliver before further deterioration occurs

ELECTIVE CS CATEGORY 4

THE DELIVERY IS TIMED TO SUIT THE MOTHER AND STAFF. THESE ARE CASES WHERE THERE IS AN INDICATION FOR CS BUT THERE IS NO URGENCY placenta praevia with no active bleedingmalpresentations, (e.g. brow, breech) history of previous hysterotomy or vertical incision CS past history of repair of vesico-vaginal or recto-vaginal fistulae or stress incontinence HIV infection.

2-INCIDENCEThe incidence is 15-20 % of the deliveriesINDICATIONS: ABSOLUTE INDICATIONSRELATIVE INDICATIONSA- FETAL INDICATIONSB-MATERNAL INDICATIONSC-FETOMATERNAL INDICATIONS

ABSOLUTE INDICATIONSA- FETAL INDICATIONS: cord prolapse before 7 cm dilatationB-MATERNAL INDICATIONS:MAJOR DEGREE P-PREVIAUPPER SEGMENT C-SECTION SCARPREVIOUS 2 LOWER SEGMENT C-SCARPREVIOUS VVF REPAIRMATERNAL MEDICAL DISORDERS: Marfans SyndromeCARCINOMA CERVIX

ABSOLUTE INDICATIONSC-FETOMATERNAL INDICATIONS:GROSSLY CONTRACTED PELVISPERSISTENT TRANSVERSE LIEPERSISTENT MENTOPOSTERIOR POSITIONPERSISTENT BROW AND FOOTLING BREECH PRESENTATION

RELATIVE INDICATIONSA-FETAL INDICATIONS:Fetal distressIUGRPlacental abruptionFetal thrombocytopeniaMaternal infections e.g. HIV, genital herpesRh isoimmunizationCord prolapse beyond 7 cm

RELATIVE INDICATIONSMATERNAL INDICATIONS:P PREVIA TYPE 1 & 2PE & ECLAMPSIAPREVIOUS ONE C-SECTIONMATERNAL MEDICAL DISORDERS : DIABETES , CARDIAC DISEASE, RESPIRATORY DISEASEMATERNAL PREFFERENCE

RELATIVE INDICATIONSFETOMATERNAL INDICATION:CPDFETAL MALPRESENTATIONS : BROW PRESENTATION IN EARLY LABOUR, FLEXED BREECHFETAL MACROSOMIAPELVIC TUMORS: LOWER SEGMENT FIBROID, BIG OVARIAN CYST IN POD

TYPES OF CAESAREAN SECTION

THE CS IS DESCRIBED BASED ON THE TYPE OF INCISION ON THE UTERUS

CESAREAN SECTION. (A),CLASSIC;(B),LOW VERTICAL;(C),TRANSVERSE INCISIONS.

4-TYPES OF C-SECTION1- LOWER SEGMENT C-SECTION:2- UPPER SEGMENT C-SECTION: (classical c section)Postmartum c-sectionFibroid in lower uterine segmentCervical carcinomaPlacenta previaPoorly formed lower segmentExtensive bladder adhesions3- MODIFIED CLASSICAL (De-Lee incision)

COUNSELLINGSKILLFULLY, SYMPATHETICALLY AND PROFESSIONALLYINDICATION,PROCEDURE AND COMPLICATIONTYPE OF ANESTHESIASTERILIZATION DURING ANTENATAL PERIODBLOOD TRANSFUSIONTHE OBJECTIVE OF COUNSELLING IS TO MAKE THE WOMEN AND HER FAMILY AWARE NOT TO HORRIFY

PREOPERATIVE PREPARATIONPRE-OPERTIVE EVALUATION:ORAL INTAKE: MENDELSON SYNDROMECATHETERIZATIONBLOOD ARRANGEMENTS:ANTIBIOTICS:HEPARIN THERAPY: ONLY IN HIGH RISK GROUPSFAMILY/PERSONAL HISTORY OF THROMBO-EMBOLISMPOSITIVE ANTI-PHOSPHOLIPID ANTIBODY ETCGENERAL MEASURES:

PREPARATION IN THEATRELEFT LATERAL POSITIONO2 INHALATIONPEDIATRICIANUNDER SPINAL ANESTHESIA: ARRANGEMENTS IF MOTHER WANT TO HOLD THE BABY

GENERAL ANESTHESIA REGIONAL ANESTHESIALOCALNINFILTERATION

ANESTHESIA

GENERAL ANESTHESIAINDICATIONSURGENT DELIVERY e.g. cord prolapse , Ab placentaeSEVERE HAEMORRHAGECARDIAC DISEASES e.g. pulmonary/aortic stenosisANATOMICAL PROBLEMS: kyphoscoliosis , spina bifidaCOAGULOPATHY e.g. congenital/acquired

INDUCTION DELIVERY INTERVALA good fetus acid base status can be maintained up to 30 MINUTES AFTER THE INDUCTION OF ANESTHESIA , provided patient is nursed in left lateral position and oxygen is administered in 100 % concentrationThe uterine incision delivery interval when exceeds 3 MINUTES is associated with low Apgar score and fetal acidosis

REGIONAL ANESTHESIATHE MOTHER IS AWAKE AND STILL FEELS A PART OF PROCESS OF CHILD BIRTHNO RISK OF ASPIRATION/FAILED INTUBATIONLESS BLOOD LOSS QUICK RECOVERY , EARLY MOBILIZATION & ORAL INTAKEEARLY BONDING WITH NEWBORN

LOCAL INFILTREATIONIS ACHIEVED BY ADMINISTRATION OF LOCAL ANESTHETIC AGENT INTO THE FOLLOWING SITES

Subcutaneous injection towards the anterior edges of ribs 8-11 bilaterallyAdditional infiltration at incision areaInfilteration into retropubic space, rectus sheath and peritonium across lower segmentPatient must remain fully co operativeIt is effective only in skin and peritonium but manipulation of internal organs causes severe pain

TECHNIQUE OF LSCSABDOMINAL WALL INCISION: vertical midline vertical paramedian Pfannestiel incision

VARIANT OF C-SECTIONRHESUS NEGATIVE MOTHER packing the para-colic gutters avoid manual removal of placenta peritoneal lavageFETAL MALPRESENTATIONS / MALPOSITION Obstructed labour Preterm delivery Placenta previa

COMPLICATIONSINTRAOPERTIVE HAEMORRHAGEURINARY TRACT INJURIESBOWEL INJURIESPOSTOPERATIVE COMPLICATIONSPARALYTIC ILEUSTHROMBO EMBOLISMINFECTIONSURINARY COMPLICATIONSPSYCHOLOGICAL COMPLICATIONSANESTHESIA COMPLICATION

POST OPERATIVE CAREGENERAL CAREI/V FLUIDSANALGESIAMOBILIZATIONCARE OF CATHETERORAL INTAKEBABY CARECARE OF WOUNDPATIENT COUNSELLING

PREGNANCY AFTER ONE C-SECTIONPREGNANCY AFTER ONE C-SECTION

THE RISK OF SCAR RUTURE

LOWER SEGMENT C-SECTCLASSICAL C-SECTSCAR RUPTURE0.5 %2.2 %MATERNAL MORTALITY 0.05% 5 %FETAL MORTALITY12.5%73 %

MANAGEMENT DURING PREGNANCYA WOMEN SHOULD HAVE REPEAT CSECTION IFHAD PREVIOUS CLASSICAL CSECTIONDe-Lee OPERATIONEXTENSION OF LOWER UTERINE SEGMENT INCISION INTO UPPER SEGMENT

THE EVALUATION OF PATIENTREVIEW OF PREVIOUS CSECTION NOTES THE INDICATIONTHE TYPE AND PLACE OF C-SECTIONLEVEL OF SURGEONANY POST OPERATIVE COMPLICATIONPRESENCE OF ANY ADDITIONAL RISK FACTOR IN PRESENT PREGNANCY

THE EVALUATION OF PATIENT IN CURRENT PREGNANCY

ANY OTHER RISK FACTORSIZE AND LIE OF FETUSAMOUNT OF LIQOUR VOLUMELEVEL OF PRESENTING PARTPELVIC DIMENSION AND BISHOP SCORETHE CLINICAL AND RADIOLOGICAL( X-RAY,CT SCAN,MRI) PELVIMETRY IN THE EVALUATION OF PATIENTS WHERE PREVIOUS C-SECTION WAS CARRIED OUT FOR CPD ARE NOT GREATLY HELPFUL

IDEAL PATIENT FOR THE TRIAL OF LABOUR AFTER ONE C-SECTIONThe previous c-section is carried out in a hospital by a trained person & there was no intrapartum or postpartum complicationThe c-section was carried out for non-recurrent indication e.g. fetal distressNo risk factor in current pregnancyThe presenting part is well applied to the lower uterine segment & the labour starts spontaneously

TRIAL OF LABOURTRIAL OF UTERINE SCARis defined as giving chance to deliver vaginally by keeping a very low thresh hold for c-section.it should be allowed in a hospital fully equipped with facilities for emergency c-section

SIGNS OF SCAR RUPTURE: FETAL DISTRESS MATERNAL TACHYCARDIA FRESH VAGINAL BLEEDING

TRIAL OF UTERINE SCARScar tenderness alone is of less value in determining scar dehiscence , unless accompanied by any of the above featureContinuous electronic FHR monitoring should be used for early detection of fetal distressEpidural analgesia block can be used in patient with c-section as it do not block pathological painSyntocinon use (for labour augmentation) should be decided by a senior person & ideally be used in combination with intrauterine pressure catheter

A C-SECTION SHOULD BE PERFORMED IF ANY OF THE SIGNS OF SCAR DEHISCENCE APPERRS ORCERVIX FAILS TO DIALTE AT A RATE OF 1 CM/HR IN THE PRESENCE OF OPTIMAL UTERINE CAVITY