Caesarean Section

Indications and types

VISHNU AMBAREESH M S

2007 BATCH

• According to legend, Julius Caesar was born by

this operation and hence the origin of the term

caesarean. ????

• Used to be

invariably fatal

• Most important modification was the lower

segment transverse incision. First done by kehrer

and popularized by Munro Kerr

DEFINITION

• CAESAREAN SECTION is the removal of a child

through an incision in the abdominal wall of an

intact uterus.

• Term not applied to removal of a child from the

abdomen after rupture of the uterus with or

without protrusion of the whole or part of the child

into the peritoneal cavity, nor to an operation for

abdominal pregnancy.

INCIDENCE

• It is the most commonest operation performed

worldwide.

• Ideal CS rate is 10 to 15 % (WHO)

• Increased incidence worldwide during last 25

years.

Why has the incidence increased?

• Mainly due to 3 factors

1. Repeat caesarean

2. Dystocia

3. Fetal distress

• Increased safety of the surgery

• Increased demand

INDICATIONS

• Divided into

1. Maternal indicators

2. Fetal indicators

3. Fetomaternal indicators- coexist

MATERNAL INDICATORS

PREVIOUS CS

DYSTOCIA due to

1. -CPD

2. -tumours complicating pregnancy

3. -non progressive labour

4. -threatened rupture and obstructed labour

5. -failed forceps or vacuum

6. -deep transverse arrest

Antepartum hemorrhage

1. -placenta praevia

2. -abruptio placenta

3. -vasa praevia

4. -carcinoma cervix

Medical disorders

1. -pre-eclampsia and eclampsia

2. -coarctation of aorta

Maternal obstetric problem

1. -elderly nullipara

2. -prolonged period of infertility or

pregnancy following IVF

3. -bad obstetric history

4. -previous repair of nulliparous prolapse

5. -stress incontinence or fistula

6. -failed induction

FETAL INDICATION

• Fetal distress and cord prolapse

• Breech presentation –[footling, knee presentation,

complicated breech]

• Malpresentation [ brow, transverse lie persistent

mentoposterior ]

• Sever IUGR

• Macrosomia

• Multiple pregnancy[first twin non -vertex and

monoamniotic twin]

• HIV complicating

CAESARIAN SECTION - TYPES

CAESARAEAN SECTION -TYPES

• Lower Segment Caeserean Section(LSCS)

• Lower segment vertical incision

• Classical CS

• Extraperitoneal caeserean

• Caeserean hysterectomy

LSCS

• Most commonly employed type

• Involves lower segment transverse incision

LOWER SEGMENT VERTICAL INCISION

Indications:

• Constriction ring

• Lower segment not formed as in transverse lie

Disadvantages:

• Extension downwards may involve the

cervix,vagina and even the bladder

• Extension into the upper segment increases the

chance of rupture in next pregnancy

Classical Caesarean section

• Lower segment is not approachable

• Uterine incision –on the anterior uterine wall in the

upper segment above the reflection of the UV fold

of peritoneum

• Fetal foot grasped and baby delivered as breech

Classical CS - Indications

• Lower segment is unapproachable due to severe

adhesions or myomas

• Ca cervix

• Some cases of anterior placenta praevia with a

previous caeserean

• Some cases of transverse lie with ruptured

membranes

• Conjoined twins

Classical CS - Disadvantages

• Chance of scar rupture more

• General peritonitis ,if infection occurs

LSCS SCAR CLASSICAL SCAR

Apposition Better Difficult

Healing in

puerperium

Better as the Lower

segment is quiscent

Imperfect due to

contraction and

retraction of upper

segment

Placental

implantation

May be over the scar much more likely

Rupture .5-2% 4-8%

Timing of rupture In labour In pregnancy and

labour

Infection Less chance More chance

Extraperitoneal Caesarean section

• In severe infection

• Uterus opened through an extraperitoneal

approach

• Through the space of Retzius beneath the

bladder

Caesarean Hysterectomy

• Life saving measure for severe atonic PPH

Indications

• Severe atonic PPH

• Placenta accreta , increta, percreta

• Severe sepsis

• Multiple large myomas

• Carcinoma in situ of the cervix

Cesarean section is safe, but it’s not as

safe as a planned vaginal delivery

• Many pregnant women believe that undergoing a cesarean section is a no risk surgery

• They suffer more than three times the number of cardiac arrests, blood clots and major infections than those who deliver vaginally