Caesarean section

Mahmoud Abdel-Aleem, 2010

Caesarean Section

Dr/ Mahmoud A. Abdel-AleemDiploma in Reproductive medicine, Geneva.

M.D Obstetrics and Gynecology


Objectives • Definitions.• History.• Types.• Incidence.• Indications.• Contraindications.• Technique.• Complications.• Peripartal hysterectomy.• Postmortem CS.• CS hysterectomy.• Hysterectomy en-toto.• VBAC• Vaginal delivery Vs Cesarean section


Definition

• It is the delivery of the fetus through an incision in the abdominal wall and uterine wall. It is one of the most commonly done operations worldwide.

• First operation is --------

• Second operation is -------

• Third operation is -------


• The word cesarean is probably derived either from the Lex Regia, later called Cesarea, which allowed, in ancient Rome, the postmortem abdominal delivery of the child, or from the Latin caesare, which means ‘to cut’ .

• Until the late 1800s, most cesarean deliveries (CDs) were done after maternal death, for attempt at fetal salvage.

• In 1882, the era of the modern CD began when Saenger advocated closing all uterine incisions immediately after surgery.

• The lower uterine segment incision was introduced by Kronig in 1912 and popularized in the USA by DeLee in 1922.

• The transverse uterine incision was described by Munro Kerr in 1926.

• CD has been associated with relatively low maternal mortality for about 100 years. Safety has improved in the last 50 years, as the above techniques have become more widely used, and antibiotics have been introduced.


Indications• MATERNAL INDICATIONS:

• Third trimester bleeding: – Placenta previa.– Placental abruption.

• Birth canal obstruction:– Contracted pelvis. – Soft tissue obstruction.– Abdominal cerclage operation.– Previous repair of vesicovaginal fistula. Also, rectovaginal fistula if the

repair was difficult or recurrent.

• Maternal active genital herpes simplex virus infection: to lessen the infection of the newborn.


• Maternal disease:

– Indicated but difficult delivery: hypertensive disorders, D.M., IUGR.

– Dangerous delivery: cerebral hemorrhage, cerebral aneurysm, diabetic retinopathy.


• Uterine scar: with weak myometrium.– Myomectomy with opening of the cavity.– Hysterotomy done in the upper segment.– Cesarean section scar in the following conditions:

• Decision before labour:– Previous classic C.S.– Previous vertical LSCS that extended into the upper uterine

segment.– Previous LSCS that extended laterally or downwards.– Recurrent indication for C.S. as contracted pelvis.– Associated fetal Malpresentation or malposition.– Multiple pregnancy.– Associated PIH.

• Decision During labour:– Signs and symptoms of uterine scar dehiscence.– Arrest of satisfactory progress during labor.– Development of fetal distress during labour.


• FETAL INDICATIONS:

• Fetal Asphyxia: ominous intrapartum signs or scalp pH <7.2.

• Malpresentations:– Occipto-posterior position:– Face presentation: all cases of M.P. and impacted

cases of M.A. position.– Brow presentation: after R.O.M.– Breech presentation: the 10 indications– Shoulder presentation: if ECV fails or cannot be done.– Cord presentation and prolapse if fetus is living and

delivery cannot be effected rapidly


• Fetal anomalies: – Hydrocephalus:– Abdominal wall defects e.g. omphalocele to

avoid its rupture during vaginal delivery.

• Abnormal fetal weight:– Fetal macrosomia: >4500gm.– Low-birth weight infant: < 1500 gm.

• A precious baby:– Elderly primigravida.– Bad obstetric history.


• FETOMATERNAL INDICATIONS:

– Arrest of labour " dystocia“.– Failed induction of labour.– Inadequate uterine contractility despite oxytocin administration.– Arrest of cervical dilatation or fetal descent.– Impending rupture uterus.


Absolute indications for C.S

• It should be done even in the presence of dead fetus:

• Previous classic C.S. or CS extending to upper segment.

• Previous ≥2 LSCS • Previous LSCS with malpresentation.• Previous repair of vesicovaginal fistula.• Extreme degree of contracted pelvis.• Placenta previa centralis.


Contraindications

• THERE IS NO CONTRAINDICATIONS TO C.S. IF THE FETUS IS LIVING.

• It should be performed cautiously in the presence of any of the following conditions:– Severe intrauterine infection. – Women with severe DIC.– In the presence of intra-abdominal infection.– Dead woman. However, women died within 4-5 minutes may

undergo C.S. to save the living viable fetus inside "postmortem C.S."


According to timing:– Elective C.S. : done before the start of labour pains:

1.20 weeks of documented FHS by Pinard or 30 weeks by Doptone.

2.36 weeks or more passed since a +ve urine pregnancy test.3.US of CRL between 6-12 weeks = 39 weeks or more.4.US scan between 13-20 weeks = at least gestational age of

39 weeks as verified by clinical history and physical examination.

– Emergency C.S.: done after the start of labour pains.

According to gestational age:– Before the age of viability: hysterotomy.– After the age of viability: cesarean section.


• According to uterine incision:

– Transverse LSCS (Kerr incision): first choice: Advantages

– Vertical LSCS (De-Lee incision)• Underdeveloped lower uterine segment (Preterm fetus)• Transverse lie with back down.• Hydrocephalus.• Varicosities on LUS• Contraction ring

Disadvantages


• Upper segment C.S.

– Now it is rarely done: Disadvantages• Myoma on LUS• Severely adherent bladder to LUS• Perimortem C.S.• Cancer cervix.• Repaired high V.V.F.


Avoidable Incisions

• A surgical fault i.e. transverse incision done but it doesn't accommodate for the fetus, so the incision is extended into the upper uterine segment either:

– Inverted –T: if extended from the center of the transverse incision.

– Hockey- stick incision: if extended at either end; i.e. L- or J- shaped.


• Preoperative:– Be sure that FHS are still audible.– Be sure that the indication is still valid.– A Foley catheter is fixed in the bladder.

• Operative:1. Dorsal position.2. Anesthesia.3. Surgical draping.4. Abdominal wall incision.

i. Midline.ii. Transverse.

5. Uterine wall incision.i. First step: dissection of vesical peritoneum.ii. Key step: identification of site of incision.iii. Essential step: identification of round ligament.

6. Extraction of the fetus and afterbirth.7. Repair of uterine wall.8. Repair of abdominal wall incision.

• Postoperative:1. Early care:2. Delayed care:


• Intra-operative complications: ABT– Anesthetic complications: almost all are associated with general

anesthesia. Due to failure of endotracheal intubation or inhalation of gastric contents into the lungs "Mendelson syndrome ", amniotic fluid embolism, cardiac arrest, severe convulsions.

– Bleeding: more than the average (1000 ml)• Uterine abnormalities:

– Atony.– Uterine incision:

» Classical C.S. incision.» Lateral extension to uteine vessels.» Downward extension to cervix, vagina, or bladder.

– Presence of uterine myomata.– Placental abnormalities:

» Placenta previa.» Abruptio placentae: due to premature separation and couvlaire

uterus.» Incomplete removal of the placenta: accreta, anomalies.

• Failure of blood coagulation mechanisms: DIC, HELLP syndrome.


• Trauma:– Urinary tract injury:

• Bladder injury: due to – Difficult dissection off the lower uterine segment.– Bladder trauma during uterine incision.– Extension of uterine incision to the bladder.

• Ureteric injury: due to– Extension of the uterine incision.– Secondary to hemostatic sutures in the base of the broad

ligament.

– Bowel injury:• Causes:

– Blunt dissection of thick adhesions due to previous surgery, PID.

– Putting a clamp on the bowel.– Needle or suture passing through it.– Sharp dissection by a scalpel or scissors.


• Early postoperative complications: ABTI– Post anesthetic complications:

• Respiration difficulties.• Paralytic ileus and intestinal obstruction.• Deep venous thrombosis and pulmonary embolism

– Uterine bleeding: reactionary or secondary.– Trauma: fistula.– Infection: endometritis, peritonitis, cystitis,

chest infection, wound infection.– Rare: Psychological complications.


• Delayed " long-term" sequelae of C.S.:1. Adhesions:

i. Tubo-peritonal leading to infertility.ii. Bladder adhesions making subsequent surgeries difficult.iii. Intrauterine adhesions if the anterior and posterior walls of

the uterus were sutured together leading to Asherman syndrome.

iv. Intestinal adhesions leading to intestinal obstruction.v. Adhesions and pelvic pain may need an operation to treat

them.

2. Weak uterus:i. Perforation of the uterus is more common if D&C is done in

the presence of a weak scar.ii. Rupture of the uterus at the site of the scar in future

pregnancies.

3. Risk of incisional hernia.4. Higher risk of placenta accreta.


• It is the trial of vaginal birth after C.S. in previous pregnancy.

• The dictum once cesarean, always cesarean is no longer present.

• Once CS always hospitalization.• Risk of uterine dehiscence of LSCS is 0.2%


• Conditions that should be fulfilled before trial of scar:– Non-recurrent indication.– Previous C.S.:

• Known type; single transverse LSCS type.• Proper surgical technique: use of delayed absorbable

sutures is preferred.• Smooth postoperative course. No infection.• A long interval between C.S. and current pregnancy.

– Current pregnancy:• Single fetus.• Vertex presentation.• Average fetal weight.• No medical risks.• No other indication for C.S.


Competent obstetrician to follow the patient in a well-equipped hospital capable of performing urgent C.S. once uterine dehiscence is detected.


• Signs of dehiscence:1. Lower abdominal pain in between uterine

contractions.

2. Lower abdominal tenderness in between contractions.

3. Vaginal bleeding.

4. Sudden changes in FHR pattern: variable decelerations.


• Hysterectomy en toto.

• CS hysterectomy.

• Peripartum hysterectomy.

• Postmortem CS.


Fetal OutcomeVaginal deliveryCesarean delivery

MortalityMortality1-3/4000<1/1000

IC HgeIC Hge1/20001/2000

Facial nerve palsyFacial nerve palsy1/30001/2000

Brachial palsyBrachial palsy1/13001/2400

ConvulsionsConvulsions1/15601/1160

Feeding difficultiesFeeding difficulties1/1501/90

TTNTTN1/901/30

RDSRDS1/6401/470

Mechanical ventilationMechanical ventilation1/3901/140

CNS depressionCNS depression1/32301/1500

Persistent pulmonary HTPersistent pulmonary HT1/12401/270


Maternal outcome1. Physical problems in mothers: potentially life-threatening problems, including hemorrhage (severe

bleeding), blood clots, and bowel obstruction, to much more common concerns such as longer-lasting and more severe pain and infection. Even after recovery from surgery, scarring and adhesion tissue increase risk for ongoing pelvic pain and for twisted bowel.

2. Hospitalization of mothers: If a woman has a cesarean, she is more likely to stay in the hospital longer and is at greater risk of being re-hospitalized.

3. Emotional well-being of mothers: A woman who has a cesarean section may be at greater risk for poorer overall mental health and some emotional problems. She is also more likely to rate her birth experience poorer than a woman who has had a vaginal birth.

4. Early contact with, feelings toward babies: A woman who has a cesarean usually has less early contact with her baby and is more likely to have initial negative feelings about her baby.

5. Breastfeeding: Recovery from surgery poses challenges for getting breastfeeding under way, and a baby who was born by cesarean is less likely to be breastfed and get the benefits of breastfeeding.

6. Health of babies: Babies born by cesarean are more likely to: 1. be cut during the surgery (usually minor) 2. have breathing difficulties around the time of birth3. experience asthma in childhood and in adulthood.

7. Future reproductive problems for mothers: 1. ectopic pregnancy: pregnancies that develop outside her uterus or within the scar 2. reduced fertility, due to either less ability to become pregnant again or less desire to do so 3. placenta previa: the placenta attaches near or over the opening to her cervix 4. placenta accreta: the placenta grows through the lining of the uterus and into or through the muscle of the uterus 5. placental abruption: the placenta detaches from the uterus before the baby is born 6. rupture of the uterus: the uterine scar gives way during pregnancy or labor.


• Contact information:– E-mail: [email protected]– Phone: 0101022820.– Fax: 2371461

Caesarean section

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