Cesarean section (CS)

• Caesarean section or c-section, is a delivary of the foetus through incisions in anterior abdominal (laparotomy) and uterine wall (hysterotomy)

• It is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk.

• The following indications are the most frequent:

1. Extreme dgree of contracted pelvic (one or more of the diameters is reduced and interferes with normal mechanism of labour.

Degrees of contracted pelvis: Minor degree: the true conjugate is 9-10 cm. Modrate degree: the true conjugate is 8-9 cm. Sever degree: the true conjugate is 6-8 cm. Extreme degree: the true conjugate is less than 6 cm.2. Cephalopelvic disproportion: the head of the foetus is too largeto

come through the pelvis.3. Uterine Inertia: Inefficient uterine contraction.4. Placenta pravia: Implamtation of placenta in the lower uterine

segment.

5. Premature separation of placena: Cesarean section is indicated when,the foetel distress occurs, when effective labour does not follow rupture of membrane and when vaginal can not be anticipeted within 2 hours.

6. Malposition and malpresentation7. Pre-eclamsia8. Diabetes ( causes over size of the foetus. Cesarean

section should be done in the 1st four weeks in primigravidae.

9. Cardiac diseases.10. Vaginal scaring.11. Carcinoma of the cervix.

12. Cervical dystoctia (failure of the cervix to dilate in spite of strong contraction of the uterus). 13. A previous uterine incision.14. Prolapse of the umbilical.15. Foetal distress.16. Bad post obstetric history (baby habitually dies in

the uterus.17. Failure of labour to progress despite adequate

stimulation.

Dead of foetus

1) Elective timing: (before the onset of labour by one week.

2) Selective timing: (after the onset of labour, it is preferred.

• The classical caesarean section:• A midline longitudinal (vertical) incision which allows a

larger space to deliver the baby. However, it is rarely performed today as it is more prone to complications.

• The lower uterine segment section: • It is the a procedure most commonly used today; it involves a

transverse cut just above the edge of the bladder and results in

less blood loss and is easier to repair.

Indications of classical caesarean section

1. when the lower segment is abnormally vascular.2. when the lower segment can not identified due to

adhesion.3. when caesarean section is done after motherיs death.4. Cases needs rapid delivery.5. When the foetus lie is transverse and can not be

corrected.6. When hysterectomy will follow caesarean section

Advantages of the lower segment:• The wound is extra peritoneal so less risk of infection.• Healing scar is better.• The risk of rupture of the scar is less.• Hemorrhage is less.• Placenta is away from the incision. Disadvantages of the lower segment:• The operation requires more skill and experience.• The incision may extend down to the bladder.Disadvantages of classical operation:• More liable to chest infection.• More liable to intestinal distension.• The scar is more liable to rupture.

• Respiratory complications: due to inhibitory effects of pain, immobilization in post operative period and anaesthesia.

• So encourage deep breathing exercises. teach the patient huffing and coughing (the abdomen must be supported by the patientיs hands and/or towel)• Excessive abdominal pain due to: Wound infection. Haematoma. Excessive localized edema. Nerve entrapment syndrome (ilioinguinal or iliohypogastric nerve)• Deep venous thrombosis due to (hypercoagulability, decrease

venous tone

Signs and symptoms of DVT: in about 50%

• Edmatous limb.• Erythrocyanotic appearance.• Dilated superficial veins.• Elevated skin temperature. Prophylactic role to prevent DVT:o Application of compression stocking.o Early ambulation.o Avoidance of pressure under thighs and calveso Avoidance of sitting with knees acutely flexed.o Deep breathing exercises.

o Circulatory and leg exercises.

• Dependent edema. (generalized retension of fluid) aggravated by decreased movements of the lower limb muscles.

• to prevent dependent edema: Vigorous foot and ankle exercises. elevation of L.L.

If sever apply stoking and intermittent pressure.• Intestinal complications.• Haemorrhage.

• It is done when there is inability to stop bleeding from the uterine incision or multiple fibroids in old patient.

• It is an excision of a portion of both fallopian tube.

• It is done after 3rd or 4th cesarean section.

• It is done after motherיs death, to save the life of a living foetus, It is done within 10 minutes of maternal death.

• For elective cases, prior to surgery the mother is pain free and alert, to prepare her emotionally and physically for post operative delivery.

Pre-operative goals:1. Improve pulmonary function and prevent post operative

pulmonary complications( pneumonia….)2. Improve circulation and prevent post operative circulatory

complications (DVD, edema ….)

3. Prepare patient emotionally and physically

Methods: Discussion to minimize or eliminate negative feeling about delivery. Demonstrate the patient how to mobilize early with minimum amount of

strain or pain. Teach the patient how to cough and huff to get red of expectoration. Deep breathing exercises. Circulatory exercise. Post- operative management: In recovery area. Observation of level of consciousness, blood

pressure, heart rate, respiration and vaginal blood loss. Nursing care, including regular assessment of temperature, blood

pressure, heart rate, color, lochia, wound appearance, bleeding, bladder function and urine output, oral fluid intake.

Post-operative goals:1. Improve pulmonary function and prevent post operative

pulmonary complications( pneumonia….)2. Improve circulation and prevent post operative

circulatory complications (DVD, edema ….)3. Decrease incisional pain associated with coughing,

movement or breast feeding.4. Improve healing of incision and prevent adhesion

formation.5. Prevent pelvic floor dysfunction.6. Improve lactation and prevent sagging of the breast.7. Correct posture.

Methods: Deep breathing exercises. Circulatory exercise. Early ambulation. Arm exercises. Postural correction. Pelvic floor exercises. Abdominal strengthening exercises. Electrotherapy to decrease incisional pain and to

promote wound healing. Positioning instruction.

Physical therapy forearly post-operative days

1st day: Breathing exיs. Circulatory exיs. Leg exיs. Static abdominal contraction. 2nd day: Repeat previous exיs, add the following: Early ambulation to: Prevent muscle wasting. Prevent constipation. Prevent retension of urine Prevent respiratory and vascular complication. Arm exיs. Half lying position. 3rd day: Repeat previous exיs, add the following: Pelvic floor exיs

4th day: Repeat previous exיs, add the following: Pelvic rocking exיs Scapular retraction. 5th day: Repeat previous exיs, add the following: Hip shrugging. Postural correction exיs. 6th day: Repeat previous exיs, add the following: Pelvic rotation exיs. 7th day: Repeat previous exיs, add the following: Lateral flexion (1st step) Trunk rotation (1st step) Trunk flexion (1st step).