Cesarean SectionPresented By: Richard Lim

Caesarean SectionDefinition Removal of a fetus from the uterus by

abdominal incision, After 28 weeks of pregnancy Its called hysterotomy, if removal is

done before 28 weeks of pregnancy

Cesarean Section The word cesarean is derived from the

Latin “caedore” which means “to cut” At one time , there was a popular belief

that Julies Caesar was born by a cesarean birth and the procedure was named from him

Assessment Assessment as to whether a woman will

be a good candidate for surgery is sometimes done throughout pregnancy and sometimes done very quickly in an emergency.

Either way, assessment must include both physiologic and psychological stays and preparedness

Nursing Diagnosis Risk for infection related to a surgical

incision Fear related to impending surgery Pain related t0 a surgical incision Deficient fluid volume related to blood

loss from surgery Powerlessness related to medical need

of cesarean birth

Outcome Identification and Planning The sane outcome applies to a woman

giving birth by cesarean as a woman giving birth vaginally: a healthy mother and a healthy child

Because cesarean birth decisions can be made suddenly, planning can be limited to only a few minutes.

Implementation Many interventions focus on teaching

and support, because the more a woman understands about what is happening to her, the more she can accept and cooperate with the procedure.

Outcome Evaluation Patient state that she understands the

reason for a cesarean birth Patient state that she felt well prepared

for cesarean birth even in a light of an emergency

Patient remains free of signs and symptoms of infection after cesarean birth

Patient states that incisional pain is controlled and tolerable

Cesarean Birth1. Scheduled Cesarean Birth2. Emergency Cesarean Birth

Scheduled Cesarean Birth In the 1950’s, cesarean birth became a

status symbol when Hollywood stars asked to have cesarean births to save themselves the strain of labor and in some instance to schedule the birth conveniently between movie contracts.

Average woman came to think that a Cesarean birth not a surgical procedure but as an east method of painless birth

Emergency Cesarean Birth Done for reason such as; Placenta previa Abruptio placentae Fetal distress Failure to progress in labor

Emergency Cesarean Birth An Emergency Cesarean Birth carries with it the risk of any emergency surgery: The woman may not be a prime candidate for

anesthesia Psychologically unprepared for the

experience The woman may have a fluid and electrolytes

imbalance and be both physically and emotionally exhausted from long labor

Cesarean Birth May reduce the transfer of Human

Immunodeficiency Virus (HIV) Hepatitis C Herpes type 2 from mother to new bornSo its recommended for woman who are HIV positive.It can reduce mortality among infants presenting breech

Risk of Cesarean SectionBecause the cesarean delivery involves major surgery and anesthesia, there are some disadvantage compared to vaginal delivery Cesarean is associated with a higher rate of

injury to abdominal organs( bladder, bowel, blood vessels) infections (wounds, uterus, urinary track) and thromboembolic (blood clotting) complication than vaginal delivery

Risk of Cesarean Section Cesarean surgery can interfere with mother-

infant interaction in the delivery Recover take longer than vaginal delivery Cesarean delivery is associated with a higher

risk that the placenta will attach to uterus abnormally in subsequent pregnancies, which can lead to serious complications

Cutting the uterus to deliver the baby weakens the uterus, increasing the uterine rupture in future pregnancy

Cesarean Delivery on Maternal Request After previous cesarean – Mothers who

have previously had a cesarean section are more likely to have cesarean section for future pregnancies than mother who have never had cesarean section.

Twins – for otherwise twin pregnancies were both twins are head down a trial of vaginal delivery is recommended at between 37 and 38 weeks

Cesarean Delivery on Maternal Request Breech birth – is the birth of the baby

from breech presentation, in which the baby exists the pelvis with the buttocks or feet first as opposed to the normal head first presentation. Breech presentation, the fetal heart sound are heard above the umbilicus

Infant RiskThere are few risk of cesarean delivery for the infant. One risk is birth trauma. Temporary respiratory problems are more common after cesarean birth because baby is not squeezed through the mother’s birth canal. This reduces the reabsorption of fluid in infant’s lungs.

Potential ComplicationThe most common complications related to cesarean delivery include Infection hemorrhage, injury to pelvic organs, and blood clots

Potential Complication1. Infection - The risk of postoperative

uterine infection (endometritis) varies according to several factors, such as whether labor had started and whether the water was broken. Endometritis is treated with antibiotics.

Potential Complication2. Hemorrhage -  One to two percent of all women having cesarean deliveries require a blood transfusion because of hemorrhage (excessive bleeding). Hemorrhage usually responds to medications that cause the uterus to contract or procedures to stop the bleeding. In rare cases, when all other measures fail to stop bleeding, a hysterectomy (surgical removal of the uterus) may be required.

Potential Complication3. Injury to Pelvic Organ -  Injuries to the bladder or intestinal tract occur in approximately one percent of cesarean deliveries.

Potential Complication4. Blood Clots -  Women are at increased risk of developing blood clots in the legs (deep vein thrombosis or DVT) or the lungs (pulmonary embolus) during pregnancy and the postpartum period. This risk is further increased after cesarean delivery. The risk can be reduced by using a device that gently squeezes the legs during and after surgery, called an intermittent compression device. Women at high risk of DVT may be given an anticoagulant (blood thinning) medication to reduce the risk of blood clots.

Types of Anesthesia Spinal General Epedural Local

Spinal Anesthesia It is best and the cheapest Patient remains conscious Less incidence of cardiac arrest Sometimes difficult for anesthetist to find space due

to lumbar lordosis of pregnancy Sometimes there is fall of blood pressure Post operative spinal headache Spinal anesthesia should not be given if patient has

already low BP or baby has transverse presentation or deeply engaged head or failed forceps or vacuum delivery

General Anesthesia Many times patient demand GA Drug used is I.V Pentothal Sodium with

Oxygen and Nitrous Oxide and muscle relaxant

If the patient has taken food, regurgitation complication like aspiration pneumonia may occur

Deeply anesthesia, only to be given after baby has been deliver

Epidural Anesthesia These days patient are asking for

painless delivery and for that, many time continuous epidural anesthesia is given. Ig the trial of labor fails, the patient may be taken cesarean section or forceps delivery. In that case cesarean may be performed in the same epidural anesthesia. It is good anesthesia with less of a fall of blood pressure

Local Anesthesia In this anesthesia, the surgery may not

be as comfortable as spinal or general anesthesia.

Very rarely used and is not even briefly mention.

Procedure After being admitted to the hospital, a

woman may be given an oral dose of an antacid to reduce the acidity of the stomach contents. Another medication may be given to reduce the secretions in the mouth and nose. An intravenous line will be placed into the hand or arm, and an electrolyte solution will be infused. Monitors will be placed to keep track of blood pressure, heart rate, and blood oxygen levels.

Procedure Anesthesia — The woman is usually

accompanied to an operating room before anesthesia is administered. A spouse or partner can usually stay with the woman in the operating room.

Procedure There are two types of anesthesia used

during cesarean delivery: regional and less commonly, general. For a planned cesarean delivery, regional anesthesia is usually performed. Meeting with the anesthesiologist allows the woman to ask specific questions about anesthesia, and allows the anesthesiologist to identify any medical problems that might affect the type of anesthesia that is recommended.

Procedure With epidural and spinal anesthesia, the

anesthetic is injected near the spine, which numbs the abdomen and legs to allow the surgery to be pain-free while allowing the mother to be awake.

Procedure General anesthesia, now infrequently used for

cesarean, induces unconsciousness. This means that the mother will not be awake or aware during the procedure. After the anesthesia is given, the woman will fall asleep within 10 to 20 seconds and a tube will be placed in the throat to assist with breathing. General anesthesia carries a greater risk of complications than epidural or regional anesthesia because of the need for an endotracheal (breathing) tube and because drugs given to the mother affect the infant.

Procedure Women who have general anesthesia will not be

awake during the cesarean delivery. Regional anesthesia is generally preferred because it allows the mother to remain awake during the procedure, enjoy support from staff and a family member, experience the birth, and have immediate contact with the infant. It is usually safer than general anesthesia.

After the anesthesia is given, a catheter is placed in the bladder to allow urine to drain out during the surgery and reduce the chance of injury to the bladder. The catheter is usually removed within 24 hours after the procedure.

Procedure Skin incision — There are two basic types

of incision: horizontal (transverse or "bikini line") and vertical (midline). Most women have a transverse skin incision, which is made 1 to 2 inches above the pubic hair line. The advantages of this type of incision include less postoperative pain, more rapid healing, and a lower chance that the wound will separate during healing.

Procedure Less commonly, the woman will have a

vertical ("up and down") skin incision in the midline of the abdomen. The advantages of this type of incision include a slightly more rapid access to the uterus 

Procedure Uterine incision — The uterine incision

can also be either transverse or vertical. The type of incision depends upon several factors, including the position and size of the fetus, the location of the placenta, and the presence of fibroids. The main consideration is that the incision must be large enough to allow delivery of the fetus without causing trauma.

Procedure The most common uterine incision is transverse.

However, a vertical incision may be required if the baby is breech or sideways, if the placenta is in the lower front of the uterus, or if there are other abnormalities of the uterus.

After opening the uterus, the baby is usually removed within seconds. After the baby is delivered, the umbilical cord is clamped and cut and the placenta is removed. The uterus is then closed. The abdominal skin is closed with either metal staples or reabsorbable sutures.

After the mother and baby are stable, she or her partner may hold the baby.

Postoperative Care After surgery is completed, the woman will

be monitored in a recovery area. Pain medication is given, initially through the IV line, and later with oral medications.

When the effects of anesthesia have worn off, generally within one to three hours after surgery, the woman is transferred to a postpartum room and encouraged to move around and begin to drink fluids and eat food.

Postoperative Care Breastfeeding can usually begin anytime

after the birth. A pediatrician will examine the baby within the first 24 hours of the delivery. Most women are able to go home within three to four days after delivery

Staples are usually removed within three to seven days of delivery, while reabsorbable sutures, which are now recommended over staples, are absorbed by the body and do not need to be removed.

Postoperative Care The abdominal incision will heal over the

next few weeks. During this time, there may be mild cramping, light bleeding or vaginal discharge, incisional pain, and numbness in the skin around the incision site. Most women will feel well by six weeks postpartum, but numbness around the incision and occasional aches and pains can last for several months.

Postoperative Care After going home, the woman should

notify her healthcare provider if she develops a fever (temperature greater than 100.4º F [38º C]), if pain or bleeding worsens, or there are other concerns.

A Team Performing a Cesarean Section

Transvaginal Ultrasonography

Of a uterus years after a Cesarean Section, showing characteristic scar formation

A 7 Week Old Cesarean Section scar and linea nigra visible

Suturing of the Uterus

Closed Incision for low transverse abdominal incision after stapling has been complete

Pulling out of the Baby