cesarean section

By

Ahmed Mowafy Ibrahim

Resident of obstetrics and gynecology

Qena University Hospital

South Valley University

List of Content Definition

Historical Aspects

Incidence

Indications and contraindications

Classifications

Operative techniques

Complications

C.S versus V.D

VBAC

RCOG Guidlines

Definition It is the delivery of the fetus through an incision in

the abdominal wall (laparotomy) and uterine wall (hysterotomy) after the age of viability.

It is the third common surgical operation in the world. (WHO 2006)

1st is appendicectomy

2nd is cataract surgery

3rd is cesarean section

Historical Aspects Cesarean section has been part of human culture

since ancient times and there are tales in both Western and non-Western cultures

Numerous references to cesarean section appear in ancient Hindu, Egyptian, Grecian, Roman, and other European folklore depict the procedure on apparently dead women.

Historical Aspects In the ancient roman age. The king numa pomphilus

(2nd king of Rome 762 – 715 B.C) issued a group of laws called “Lex Regia” which prevent to bury a dead pregnant women before the child had been extracted from her abdomen.

In the age of Julius Cesar this law became known as “Lex Césara” and hence the name cesarean … The legend that the Cesar himself was born by this way is not sure.

Others say that the word cesarean is derived from the latin word “caedere” whisch means “to cut”.

Historical Aspects Year 1500 : Jacob Neufer, a Carpenter asked

permission of local mayer to cut open abdomen of his wife who was in prolonged labor with his saw. First request was not granted. He went second time and his request was granted. He opened his wife abdomen.

The term “Caesarian section” was first used by “James Gullimeau”, in his midwifery book published in 1598.

Historical Aspects Lots of attempts were carried out in the 19th century

but the majority failed Year 1876: Eduardo Porro an Italian obstetrician

introduced a technique of amputation of body of uterus after C.S. at this time this technique achieved a major imrovement of abdominal delivery. Even to day Caesarian hysterectomy is called Porro’s section.

Historical Aspects In the second half of the 19th century cesarean

section became a possible method in treatment of major obstetric problems due to:

1. Introduction of ether anesthesia 2. Carbolic acid antisepsis 3. Technique of suturing the uterus introduced by

Sanger in 1882

Historical Aspects 1912: Lower segment caesarian segment section was

first performed by Kronig and latter by Monro kerr. and popularized in the USA by DeLee in 1922.

1926: The transverse uterine incision was described by Munro Kerr

Historical Aspects With further improvement in antibiotic therapy ,

blood transfusion and attention to fine operative details the cesarean section is rising since the nineteen sixties to present time .

Incidence It is the third common surgical operation in the world

(WHO 2006) .

1st is appendicectomy

2nd is cataract surgery

3rd is cesarean section

20% - 25% of deliveries anually by C.S.

In USA the incidence increased from 4.5% in 1965 to 25% in 1988 then declines to 20.7% in 1996 due to increased VBAC.

Incidence Causes of increased incidence :

1. Attempt to perinatal mortality

2. Medical malpractice

3. use of midpelvic ventose and forceps

4. use of electronic fetal monitorng

5. Delivering most of breech presentation by C.S

6. Repeat CS

7. Non-medical consideration of obstetrician

8. Women selection (C.S on demand)

Incidence Causes of increased incidence :

9. In western societies , women marry late and end in becoming elderly primigravida this the need for C.S

Incidence Situation in Egypt :

1. National income can not afford having one-third of annual birth by C.S

2. Difficulties in availability of blood banks, anesthesiology and incubators

3. The increased need for repeat C.S

4. Maternal mortality and morbidity is higher in C.S than vaginal delivery especially with repeat C.S when not all facilities are available

Incidence How to the increased C.S rate ?

1. Training and education of obstetricians.

2. Encouraging VBAC

3. Obstetrician should be encouraged to give the patient a full operative report about C.S including the indication and complications occurred during the operation

Indications

I. Maternal indications

II. Fetal indications

III.Feto-maternal indications

Indications I. Maternal indications : Birth canal obstruction:

1. Contracted pelvis

2. Soft tissue obstruction.

3. Abdominal cerclage operation

herpes simplex virus : to decrease the risk of intrapartum transmission

Gynecologic operations :

o Rpair of vesico-vaginal fistula

o Fothergill’s operation

o Repair of stress incontinence

Indications I. Maternal indications : Third trimester bleeding

1. Placenta previa

2. Placental abruption

Maternal disease:

Indicated but difficult delivery:

o hypertensive disorders

o D.M

o IUGR

Indications I. Maternal indications : Uterine scar with weak myometrium:

1. Myomectomy with opening of the cavity.

2. Hysterotomy

3. Cesarean section scar in the following conditions

Decision During labour:

a. Signs and symptoms of uterine scar dehiscence.

b. Arrest of satisfactory progress during labor.

c. Development of fetal distress during labour

Indications I. Maternal indications : Uterine scar with weak myometrium:

3. Cesarean section scar in the following conditions

Decision before labour:

a.previous classic C.S.

b.Previous uterine rupture

c. previous vertical LSCS that extended into the upper uterine segment.

d.previous LSCS that extended laterally or downwards.

e.recurrent indication for C.S

f. multiple pregnancy.

Indications II. Fetal indications : Fetal Asphyxia: fetal scalp pH <7.2.

Malpresentation: examples

1. Occipto-posterior position (DTA , POP)

2. Face presentation: all cases of M.P. and impacted cases of M.A. position.

3. Breech presentation

4. Brow presentation

5. Cord presentation and prolapse if fetus is living

Indications II. Fetal indications : Fetal anomalies:

1. Hydrocephalus:

2. Abdominal wall defects e.g. omphalocele to avoid its rupture during vaginal delivery.

Abnormal fetal weight:

1. Fetal macrosomia >4500gm.

2. Low-birth weight infant: < 1500 gm.

A precious baby:

1. Elderly primigravida.

2. Bad obstetric history.

3. Long period of infertility

Indications III. FETOMATERNAL INDICATIONS:

1. Arrest of labour " dystocia“.

2. Failed induction of labour.

3. Inadequate uterine contractility despite oxytocin administration.

4. Arrest of cervical dilatation or fetal descent.

5. Impending rupture uterus.

Indications Most common indications for C.S.:- 1. Repeat C.S

2. Severe degree contracted pelvis.

3. Malpresentations

4. Fetal distress

5. Woman demand (elective C.S)

Indications Absolute indications of C.S : 1. Previous classic C.S. or CS extending to upper

segment

2. Previous ≥2 LSCS

3. Previous LSCS with malpresentation

4. Previous repair of vesicovaginal fistula

5. Extreme degree of contracted pelvis

6. Placenta previa centralis

Contraindications

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

C.S should be performed on dead fetus in the following conditions ( SAME ABSOLUTE INDICATIONS )

1. Severe degree of contracted pelvis

2. Placenta previa centralis

3. Presence of abdominal cerclage

4. Soft tissue obstruction

5. Previous 2 or more C.S

6. Prvious repair of vesicovaginal fistula

Classifications and Types of CS

According to Urgency : RCOG classification of CS according to urgency

Proposed by “Lucas et al “ April 2010

Classifications and Types of CS According to Urgency : Category I → Emergency CS :

Immediate threat to life of woman or fetus

Category II → Urgent CS :

Maternal or fetal compromise which is not immediately life-threatening

Category III → Scheduled CS :

Needing early delivery but no maternal or fetal compromise

Category IV → Elective CS :

At optimal time for woman and maternity team

Classifications and Types of CS 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)

Vertical LSCS (De-Lee incision)

Upper segment C.S.

Others : Inverted –T , Hockey- stick incision

By

Ahmed Mowafy Ibrahim

Resident of obstetrics and gynecology

Qena University Hospital

South Valley University

List of Content Definition Historical Aspects

Incidence

Indications and contraindications

Classifications

Operative techniques

Complications

C.S versus V.D

VBAC

RCOG Guidlines

Operative Techniques Before CS you should : Take a patient consent

Be sure that FHS are still audible

Be sure that the indication is still valid

Do routine U/S → (site of placenta - presenting part)

Do preoperative testing (HB , Co-agulation profile )

Ensure availability of blood

Be sure that neonatal resuscitation team is available

Give IV fluids (preload)

Give a prophylactic antibiotics

Fix a Foley’s catheter in the bladder

Operative Techniques Steps : I. Position

II. Anesthesia

III.Surgical draping

IV. Abdominal wall incision

V. Uterine wall incision

VI. Extraction of the fetus and afterbirth

VII.Repair of uterine wall

VIII.Repair of abdominal wall incision

Operative Techniques I. Position

a. Supine

b. 15 left lateral tilt of theatre table

Operative Techniques II. Anesthesia

II. general

III. spinal

IV. Epidural

V. Combined spinal and epidural

VI. local


Spinal anesthesia : Advantages:

1. Simple and rapid onset

2. Minimal fetal exposure to drug . Allow time for careful abdominal wall incision and good haemostasis

3. Does not cause uterine atony

4. Patient is awake and take part in birth occasion

5. Small doses of intrathecal morphia could be given to ensure post-operative analgesia

6. Avoidance of complication of

general anesthesia uterine atony and

pulmonary aspiration


Spinal anesthesia : Disadvantages :

1. Hypotension

2. intrapartum nausea and vomitting

3. spinal headache

4. Post-operative shivering


Epidural anesthesia : Advantages

1. Less incidence of hypotension because of slow onset of sympathetic block

2. Less incidence of spinal headache

3. Allow repeated administration through epidural catheter if the surgery is prolonged

4. Epidural catheter allow administration of post-operative analgesia


contra indication to regional anesthesia (spinal – epidural) : 1. Severe maternal hypertension

2. Severe hypovolemia

3. Hypotension due to any cause

4. Morbid obesity

5. Tocolysis with terbutaline

6. Congenital maternal heart disease where hypotension increase rt. to lt. shunt

7. Coagulation disorders

8. Emergency CS

9. Patient refusal


General anesthesia : advantages

1. Can be given quikly (suitable for emergency CS)

2. Blood pressure and breathing are easily controlled

3. Better with bleeding and clotting abnormalities

4. Better in patient with psychological problems

5. Can be used in presence of infection that can spread to spinal area


General anesthesia : disadvantages

1. Extraction of the fetus should be within 15 min. Nitous oxide can cross placental blood barrier cardiodepressant effect on the fetus

2. Acid aspiration syndrome

3. High incidence of uterine atony (Effect of halothan)

4. The patient doses not take apart in birth occasion

Operative Techniques II. Anesthesia Local anesthesia (extremely rare): Indications

Patient with bad general condition that not suitable neither to general nor to regional anesthesia ; severe coagulopathy , difficult airway with the following precautions

1. Midline incision

2. No exteriorisation of the uterus

Drawbacks

1. Need long time

2. Patient discomfort

3. Does not provide satisfactory operating conditions

Operative Techniques III.Surgical draping and toweling

Apply antiseptic solution three times to the incision site using a high-level disinfected ring forceps and cotton or gauze swab then toweling that allows good exposure

Operative Techniques IV.Abdominal wall incision

a. Longtudinal abdominal incisions Sub-umblical vertical midline incision

b. Transverse abdominal Incisionc 1. Pfannenstiel incision

2. Joel Cohen incision

3. Maylard incision

4. Cherny incision


Pfannenstiel incision: Low transverse incision that curves gently upward, placed in a natural skin fold, this incision is located two finger breadths above the pubic symphysis

Advantages:

1. Early movement of the patient

2. Excellent cosmetic results

3. Less incidence of incisional hernia

Disadvantages:

1. More bleeding

2. Limited exposure of adnexae


Sub-umblical vertical midline incision The incision is made in the midline extending tow fingers below the umblicus to the symphysis pubis

Advantages:

1. Takes less time

2. Less bleeding

3. Good exposure of pelvic viscera and adnexae

Disadvantages:

1. Higher incidence of wound infection

2. Poor cosmetic result

3. Higher incidence of Hernia

Operative Techniques V. Uterine wall incision

1. Low transverse incision

2. Classical incision

3. Low vertical incision

4. J-shaped incision

5. T-shaped incision


Differences between upper & Lower uterine segment

Upper segment Lower segment

Perit. covering Firmly attached Loosely attached

Muscle layer Thick ; arranged in 3 layers outer longtudinal , inner

circular and middle interlacing fibers forming figure of 8 around blood

vessels

Thin ; arranged in 2 layers outer longtudinal and inner

circular

decidua Well developed Poorly developed

Fet. membranes Firmly attached Loosely attached

Role in labour Active ; contraction + retraction

Passive ; stretched


1. Low transverse lower segment incision (standard)

( kerr incision ) Advantages:

1. Easy to perform.

2. Less bleeding.

3. Easier to repair.

4. If infection occurs, it is limited to

extraperitoneal space.

5. Lower incidence of ileus, intestinal obstruction

6. Lower incidence of adhesions to intestine and omentum


1. Low transverse lower segment incision (standard) Advantages:

7. Better healing =lower risk of rupture as:

a. Proper coaptation of the edges during suturing as they are thin.

b. LUS contains more fibrous tissue - easy placement of sutures without cutting.

c. Not subjected to stresses during healing

d. Lower possibility of placental implantation on LUS.

e. Less tension on it in future pregnancies.


2. Upper segment (classical type) → rarely used Indications :

1. Difficult access to lower segment due to presence of ( fibroids , varicose veins and extensive adhesions )

2. Repaired vesicovaginal fistula

3. Impacted shoulder presentation

4. Postmortem C.S

5. Cancer cervix


3. Low vertical incision (De-Lee incision) Indications :

1.Underdeveloped lower uterine segment (Preterm fetus)

2.Transverse lie with back down.

3.Hydrocephalus.

4.Varicosities on LUS

5.Contraction ring

Operative Techniques VI.Extraction of the fetus and afterbirth

Operative Techniques VII.Aspirate nose and mouth of newborn

VIII.Cord Clamping Delayed cord clamping benefits include:

1. decreased neonatal anaemia

2. Better systemic and pulmonary perfusion

3. better breastfeeding outcomes

4. Decrease incidence of neonatal jundice

IX.Give Newborn To Pediatrician

X. Repair of uterine wall incision

XI.Repair of abdominal incision

Complications

I. Intra opertaive complications

II. Early postoperative complications

III.Delayed " long-term“ complications

Complications I. Intra opertaive complications

A. Anesthetic

1. usually with general anesthesia

2. failure of endotracheal intubation

3. inhalation of gastric contents "Mendelson syndrome “

4. amniotic fluid embolism

5. cardiac arrest

6. severe convulsions.

B. Bleeding: more than the average (1000 ml)

Failure of blood coagulation mechanisms: DIC, HELLP syndrome


C. Uterine abnormalities: 1. Atony.

2. Uterine incision:

Lateral extension to uteine vessels.

Downward extension to cervix, vagina, or bladder.

3. Presence of uterine myomata.

D. Placental abnormalities: Placenta previa.

Abruptio placentae

Incomplete removal of the placenta: accreta, anomalies.


E. Trauma: Urinary tract injury:

Bladder injury: due to

o Difficult dissection off the lower uterine segment

o Bladder trauma during uterine incision

o Extension of uterine incision to the bladder

Ureteric injury: due to

o Extension of the uterine incision.

o Secondary to hemostatic sutures in the base of the broad ligament.


E. Trauma: Bowel injury: Due to

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.

Complications

II. Early postoperative complications

1. Post anesthetic complications:

Respiration difficulties.

Paralytic ileus and intestinal obstruction.

Deep venous thrombosis and pulmonary embolism

2. Uterine bleeding: reactionary or secondary.

3. Trauma: fistula.

4. Infection: endometritis, peritonitis, cystitis, chest infection, wound infection.

5. Psychological complications.

Complications

III.Delayed " long-term“ complications

1. Adhesions: • Tubo-peritonal leading to infertility. • Bladder adhesions making subsequent surgeries difficult. • Intrauterine adhesions if the anterior and posterior walls

of the uterus were sutured together Asherman syndrome. • Intestinal adhesions leading to intestinal obstruction • Chronic pelvic pain

2. Weak uterus: • Perforation if D&C is done in the presence of a weak scar. • Rupture of the uterus at the site of the scar in future

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

Vaginal Birth After CS “VBAC” Definition : It is the trial of vaginal birth after C.S. in previous pregnancy.

• In the past → once cesarean, always cesarean

• Now → Once CS always hospital delivery

• Risk of uterine dehiscence of LSCS is 0.2%

Vaginal Birth After CS “VBAC” Conditions that should be fulfilled before trial of VBAC

A. Non-recurrent indication.

B. Previous C.S.:

o Known type; single transverse LSCS type.

o Proper surgical technique: use of delayed absorbable sutures is preferred.

o Smooth postoperative course. No infection.

o A long interval between C.S. and current pregnancy.

C. Current pregnancy:

o Single fetus.

o Vertex presentation.

o Average fetal weight.

o No medical risks.

o No other indication for C.S

Vaginal Birth After CS “VBAC” Conditions that should be fulfilled before trial of VBAC

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

1. Available anesthesia

2. Good nursing

3. Available operation room

4. Available blood

5. Available neonatal resuscitation team

Vaginal Delivery vs CS Fetal outcome

Vaginal Delivery vs CS Maternal outcome 1. Physical problems in mothers: due possible complications

2. Hospitalization of mothers: If a woman has a cesarean there is a more hospital stay

3. 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.

4. Health of babies: Babies born by cesarean are more likely to: a. be cut during the surgery (usually minor) b. have breathing difficulties around the time of birth c. experience asthma in childhood and in adulthood.

Vaginal Delivery vs CS Maternal outcome 5. Future reproductive problems for mothers:

a. ectopic pregnancy: pregnancies that develop outside her uterus or within the scar

b. reduced fertility, due to either less ability to become pregnant again or less desire to do so

c. placenta previa: the placenta attaches near or over the opening to her cervix

d. placenta accreta: the placenta grows through the lining of the uterus and into or through the muscle of the uterus

e. placental abruption: the placenta detaches from the uterus before the baby is born

f. rupture of the uterus: the uterine scar gives way during pregnancy or labor.

RCOG Guidelines Timing of planned CS The risk of respiratory morbidity is increased in babies born by CS before labour, but this risk decreases significantly after 39 weeks. Therefore planned CS should not routinely be carried out before 39 weeks.

Delivery time for emergency CS Delivery at emergency CS for maternal or fetal compromise should be accomplished as quickly as possible, taking into account that rapid delivery has the potential to do harm. A decision-to-delivery interval of less than 30 minutes is not in itself critical in influencing baby outcome, but remains an audit standard for response to emergencies within maternity services.

RCOG Guidelines Preoperative testing and preparation for CS grouping and saving of serum

cross-matching of blood

a clotting screen

preoperative ultrasound for localisation of placenta

Anesthesia for CS Pregnant women having a CS should be given information on

different types of post-

Women who are having a CS should be offered regional anaesthesia because it is safer and results in less maternal and neonatal morbidity than general anaesthesia. This includes women who have a diagnosis of placenta praevia.

RCOG Guidelines Maternal request for CS ( C.S on demand ) When a woman requests a CS in the absence of an identifiable

reason, the overall benefits and risks of CS compared with vaginal birth should be discussed and recorded.

When a woman requests a CS because she has a fear of childbirth, she should be offered counseling (such as cognitive behavioural therapy) to help her to address her fears in a supportive manner, because this results in reduced fear of pain in labour and shorter labour.

An obstetrician has the right to decline a request for CS in the absence of an identifiable reason. However the woman’s decision should be respected and she should be referred for a second opinion.

RCOG Guidelines Abdominal-wall incision

CS should be performed using a transverse abdominal incision because this is associated with less postoperative pain and an improved cosmetic effect compared to a midline

Use of separate surgical knives The use of separate surgical knives to incise the skin and the deeper tissues at CS is not recommended because it does not decrease wound infection.

RCOG Guidelines Uterine dissection

When there is a well formed lower uterine segment, blunt rather than sharp extension of the uterine incision should be used as it reduces blood loss, incidence of postpartum hemorrhage and the need for transfusion at CS.

Cord clamping Suggested benefits of delayed cord clamping include decreased neonatal anaemia; better systemic and pulmonary perfusion; and better breastfeeding outcomes. Possible harms are polycythaemia, hyperviscosity, hyperbilirubinaemia, transient tachypnoea of the newborn and risk of maternal fetal transfusion in rhesus negative women

RCOG Guidelines Use of uterotonics

Oxytocin 5 IU by slow intravenous injection should be used at CS to encourage contraction of the uterus and to decrease blood loss

Method of placental removal At CS, the placenta should be removed using controlled cord traction and not manual removal as this reduces the risk of endometritis.

RCOG Guidelines Exteriorisation of the uterus

Intraperitoneal repair of the uterus at CS should be undertaken. Exteriorisation of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes such as haemorrhage and infection.

One- vs. two-layer closure of uterus The effectiveness and safety of single layer closure of the uterine incision is uncertain.

Except within a research context the uterine incision should be sutured with two layers

RCOG Guidelines Closure of the peritoneum

Neither the visceral nor parietal peritoneum should be sutured at CS as this reduces operating time, the need for postoperative analgesia and improves maternal satisfaction.

Closure of subcutaneous tissue Routine closure of the subcutanoues tissue space should not be used, unless the woman has more than 2 cm subcutaneous fat, because it does not reduce the incidence of wound infection.

RCOG Guidelines Hospital stay after C.S

Length of hospital stay is likely to be longer after a CS (an average of 3–4 days) than after a vaginal birth (average 1–2 days). However, women who are recovering well, are apyrexial and do not have complications following CS should be offered early discharge (after 24 hours) from hospital and follow up at home, because this is not associated with more infant or maternal readmissions.

cesarean section

Health & Medicine

increased c

repeat c

cesarean section scar

historical aspects year

women selection c

porros section

word cesarean

incidence situation