CAESAREAN SECTION

CONTENT

• Definition• Type of caesarean section• Comparing both types• Indication• Preparation and procedure for caesarean

section• complication

DEFINITON OF CAESAREAN SECTION

• Operative procedure• To deliver fetus/baby• Via transabdominal

Brief history

• Caesarean believe take from Julius caesar who deliver via an operation

caesar= kizar(latin) mean to cut• Classically they been done through vertical

incision• 1920s, Munro Kerr introduce lower segment

incision.

Type of caesarean section

Classified by type of incision1. Skin incision - pfannenstiel incision: suprapubic, transverse

incision - midline incision: below umbilicus until just

above symphisis pubis, vertical incision2. Uterine incision - lower segment incision (transverse) - classsical incision(vertical)

• Lower segment incision usually done after lower segment of uterus is well formed >28 weeks

• Vertical skin incision done if quick access to abdomen is required such as in cord prolapse and also done in:

- post mortem caesarean section - patient with ovarian cyst - patient with previous midline scar

Classical vs lower segment cut LOWER SEGMENT INCISION CLASSICAL INCISIONAvascular part- Low risk of bleeding intraoperatively

Very vascular and thick part- High risk of bleeding intraoperatively

Lower part of uterus not active (not conttract & retract) during labour

- lower risk of uterine rupture in subsequent pregnancy

Upper part of uterus is active ( contract & retract) during labour

- Higher risk of uterine rupture in subdequent pregnancy

Ready access to presenting part Does not give access to presenting part

Lower part of uterus does not involve in pospartum involution

- The suture can heal well

Upper part of uterus involve in postpartum involution

- The suture tend to loose and poor heal

When to perform classical incision

1. if lower segment of uterus is not accessible - fibroid at lower uterus - adhesion between bladder and uterus2. Tranverse lie fetus with the back at inferior part of uterus3. Placenta previa or abruptio placenta which the great

vessel at lower part4. Plan to proceed with radical hysterectomy (for cervical

carcinoma ) after delivery the baby5. Post mortem caesarean section6. Preterm delivery less than 28 weeks

INDICATION

• EMERGENCY LSCS1. Fetal distress (commonest)2. Cephalo-pelvic disproportion / dystocia3. Umbilical cord prolapse4. Abruptio placenta5. Failed instrumental delivery6. Failed induction of labour ( poor progress of labour

despite time and induction was given)7. Placenta praevia with significant bleeding8. Eclampsia and severe pre eclampsia

INDICATION

• ELECTIVE LSCS1. cephalo-pelvic dispropotion 2. 2 or more previous LSCS scars3. 1 previous classical caesarean section incision4. Breech presentation5. Intrauterine growth restriction - which fetus may not withstand stress of labour6. Obstructed passage by tumor(eg. fibroid or cervical

carcinoma

7. Elderly primigravida(especially who has history of long subfertility)

- > 35 years old * not absolute indication

8. Multiple pregnancy9. malpresentation/ malposition10. Mother with genital herpes and HIV11. Uncontrolled diabetes mellitus and

hypertension

Pre operative preparation

• Consult patient about the decision of performing caesarean section

• Take consent• Set intravenous line for mother• Put in urinary catheter• Order blood • Monitor mother and fetus closely• Call anesthesiology and paediatrician

Intra operative procedure

• Anaesthesia - epidural/ spinal - general (especially in emergency)• Incision - lower segment incision - midline vertical incision

Lower segment anatomy

• Delivery of baby

• Clamp cord

• Delivery of placenta ( continuous cord traction)

• Closing the suture

COMPLICATION

• Anaesthesia complication - aspiration / Mendelson’s

syndrome(aspiration of acidic content of gastric content)

especially in general anaesthesia for emergency caesarean section

• Surgical complication1. Thromboembolism2. Bleeding3. Infection4. Poor wound healing5. Injury to bladder and ureter

• Obstetric complication(later)- High risk of scar dehiscence and uterine

rupture in subsequent labour- Care and caution for spontaneous delivery careful estimation if mother wish for vaginal

delivery 1. fetus weight via ultrasound2. Pelvic capacity : erect lateral pelvicmetry(ELP) anterior posterior diameter for inlet and

outlet of pelvic cavity is favourable if > 11.5cm

• If they are allowed for vaginal delivery, close monitoring sign and symptom of scar dehiscence or uterine rupture pain between contraction(at lower abdomen)Tender over the scar mother is tachycardia and/or hypotension exessive per vaginal bleeding poor progress of labour fetal distress may associated with haematuria( due to adhesion of

previous scar to wall of bladder)

Vaginal delivery in patient with 1 previous scar

• Succession rate :70%• Risk of scar rupture: 0.5% (1 in 200)• High cautios should be taken if require

induction as it will increase risk of scar rupture to 3%

# patient with 2 previous scar should not be allowed for vaginal delivery

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