CESAREAN SECTIONCESAREAN SECTION

By Zahraa majeed

DEFINITIONDEFINITION

The delivery of a viable fetus through an The delivery of a viable fetus through an incision in the abdominal wall and uterus. incision in the abdominal wall and uterus. Definition does not include removal of fetus Definition does not include removal of fetus from abdominal cavity in case of rupture from abdominal cavity in case of rupture uterus.uterus.

WHO recommends an ideal caesarean rate WHO recommends an ideal caesarean rate of 10- 25%..........of 10- 25%..........

WHY RATES INCREASED?WHY RATES INCREASED?

Increase in repeat caesareans.Increase in repeat caesareans. Difficult instrumental delivery and vaginal Difficult instrumental delivery and vaginal

breech deliveriesbreech deliveries Increased diagnosis of intrapartum fetal Increased diagnosis of intrapartum fetal

distress Caesarian on demanddistress Caesarian on demand Identification of risk of mothers and fetusesIdentification of risk of mothers and fetuses Increase in pregnancies by invitro Increase in pregnancies by invitro

fertilization fertilization

TYPES OF CSTYPES OF CS Lower uterine segment incision (LSCS) :Lower uterine segment incision (LSCS) : This is the commonest CS procedure. Involved This is the commonest CS procedure. Involved

horizontal incision after reflecting visceral horizontal incision after reflecting visceral peritoneum. the abdomen is opened by a low peritoneum. the abdomen is opened by a low midline ,paramedian and more commonly by a midline ,paramedian and more commonly by a pfannenstiel incision and peritoneal cavity pfannenstiel incision and peritoneal cavity opened. the bladder is reflected from the lower opened. the bladder is reflected from the lower segment and transverse incision is made on the segment and transverse incision is made on the lower uterine segment care being taken not to lower uterine segment care being taken not to injured the fetus.injured the fetus.

The forceps can be used to assist delivery in a The forceps can be used to assist delivery in a cephalic presentation.cephalic presentation.

(LSCS) is commonest procedure because it (LSCS) is commonest procedure because it easier to incise the lower segement , deliver the easier to incise the lower segement , deliver the fetus from point of incisionfetus from point of incision

and to approximate the layers because of thin and to approximate the layers because of thin muscle layers compared with upper muscle layers compared with upper segement .in addtion the peritoneal layer can segement .in addtion the peritoneal layer can be closed and was thought to provid be closed and was thought to provid advantage against infection .also blood loss advantage against infection .also blood loss with LSCS is less.with LSCS is less.

Midline vertical incisionMidline vertical incision

Commonly starts in the lower segment as a small Commonly starts in the lower segment as a small buttonhole incision till the uterine cavity is reached buttonhole incision till the uterine cavity is reached and is extended upwards .because the difficulty the and is extended upwards .because the difficulty the making the incision , increased blood loss , making the incision , increased blood loss , inadequate approximation at closure , increase post- inadequate approximation at closure , increase post- operative morbidity and inability to offer a trial of operative morbidity and inability to offer a trial of vaginal delivery in the next pregnant due to possible vaginal delivery in the next pregnant due to possible higher incidence of scar rupture .higher incidence of scar rupture .

Indications for classical incision:Indications for classical incision: Transverse lie with SROMTransverse lie with SROM Structural abnormality that makes lower segment Structural abnormality that makes lower segment

approach difficultapproach difficult Constriction ring with neglected labourConstriction ring with neglected labour

Fibroids in the lower segmentFibroids in the lower segment Ant PP & abnormally vascular lower segmentAnt PP & abnormally vascular lower segment Mother dead & rapid delivery is requiredMother dead & rapid delivery is required Very preterm fetus in breech presVery preterm fetus in breech pres

INDICATIONS FOR ELECTIVE CSINDICATIONS FOR ELECTIVE CS

Known CPD Known CPD Fetal macrosomia Fetal macrosomia > >

4500 gm4500 gm Placenta previaPlacenta previa VV fistula repairVV fistula repair HIVHIV Active herpesActive herpes Repeat CSRepeat CS

Uterine surgery eg. Uterine surgery eg. Hystrotomy, Hystrotomy, myomectomymyomectomy

Severe IUGRSevere IUGR Breech Breech Multiple pregnancyMultiple pregnancy Transverse lieTransverse lie Ca of the Cx/ TR Ca of the Cx/ TR

obstructing the birth obstructing the birth canalcanal

INDICATIONS FOR EMERGRENCY CSINDICATIONS FOR EMERGRENCY CS

Severe PETSevere PET Abruptio placntaeAbruptio placntae Fetal distressFetal distress Failure to progress in the first stage of labourFailure to progress in the first stage of labour Cord prolapseCord prolapse Obstructed labourObstructed labour Failed inductionFailed induction Malpresentation Malpresentation brow, chin post, shoulder brow, chin post, shoulder

& compound presentations, breech& compound presentations, breech Compromised fetus 2ry to DM, HPT, Compromised fetus 2ry to DM, HPT,

isoimmunization isoimmunization APHAPH

Urgent CSUrgent CS

There is maternal and fetal compromised but There is maternal and fetal compromised but not life threatening .here delivery should be not life threatening .here delivery should be complteted within 60-75 min and cases with complteted within 60-75 min and cases with FHR abnormalities are those of concern.FHR abnormalities are those of concern.

Sechualed CSSechualed CS The mother need early delivery but not The mother need early delivery but not

maternal or fetal compromised there may maternal or fetal compromised there may concern that continuation of pregnancy is concern that continuation of pregnancy is likely affect the mothe or fetus in hours or likely affect the mothe or fetus in hours or days to comedays to come..

COMPLICATIONSCOMPLICATIONS

INTRAOPERATIVEINTRAOPERATIVE Bleeding & the need for bl transfusionBleeding & the need for bl transfusion HysterectomyHysterectomy Complications of anaesthesiaComplications of anaesthesia Damage to the bladder, ureter, colon , retained Damage to the bladder, ureter, colon , retained

placental tissueplacental tissue Fetal injuryFetal injuryPOSTOPERATIVE POSTOPERATIVE Gaseous distensionGaseous distension Paralytic ileusParalytic ileus Wound dehiscence & infectionWound dehiscence & infection Infectins Infectins UTI, pulmonary UTI, pulmonary DVT & pulmonary embolismDVT & pulmonary embolism DeathDeath Vesico uterine fistulaVesico uterine fistula

POSTNATAL CAREPOSTNATAL CARE

V/S & blood loss must be moniteredV/S & blood loss must be monitered Uterine fundus palpated Uterine fundus palpated Effective parentral analgesicsEffective parentral analgesics Deep breathing & coughing encouragedDeep breathing & coughing encouraged Early mobilizationEarly mobilization Fluid therapy &dietFluid therapy &diet Bladder & bowel functionBladder & bowel function Wound careWound care LabLab Breast careBreast care Prophylaxis for thrombembolismProphylaxis for thrombembolism

MODE OF DELIVERY IN NEXT MODE OF DELIVERY IN NEXT PREGNANCYPREGNANCY

CRITERIA FOR VBACCRITERIA FOR VBAC Pt must agree to the procedurePt must agree to the procedure A low transverse uterine incisionA low transverse uterine incision Non recurrent cause of the previous CSNon recurrent cause of the previous CS No macrosomia, malposition, multiple No macrosomia, malposition, multiple

gestation, breechgestation, breechContraindicationContraindication Previous classical CSPrevious classical CS 2 or more previous CS2 or more previous CS Previous other uterine surgeryPrevious other uterine surgery Hx of scar ruptureHx of scar rupture Placentaprevia or transverse liePlacentaprevia or transverse lie

SCAR RUPTURESCAR RUPTURE O.2-1.5% for LSCSO.2-1.5% for LSCS 4-9% for classical4-9% for classical

INDICATIONS OF SCAR RUPTUREINDICATIONS OF SCAR RUPTURE Fetal distressFetal distress Ease of fetal palpationEase of fetal palpation Cessation of contractionsCessation of contractions Elevation of presenting partElevation of presenting part Scar painScar pain Bleeding / shockBleeding / shock

The endThe end