History of Caesarean delivery

The origin of the Caesarean section is somewhat

uncertain.
The hypothesis that Julius Casear was the product
of a Caesarean delivery is unlikely to be true in
view of the probability of fatality associated with
the procedure in the ancient times and the
observation that his mother, Aurelia, corresponded
with him during his campaigns in Europe many
years later.
History Contd
The term may have as its origin the Latin verb
cadere, to cut; the children of such birth were
referred to as caesones.
It is also possible that the term stems from the
Roman law known as Lex Regis, which mandated
postmortem operative delivery so that the mother
and child could be buried separately; the specific
law is referred to historically as Lex Cesare.


CAESAREAN SECTION IN UGANDA DURING
ANCIENT DAYS
Historical Advances

By the mid seventeenth century, in 1668
French obstetrician F. Mauriceau first
reported sections on living woman.
Although surgeons possessed the anatomic
knowledge necessary to perform a Caesarean
delivery
Historical Advances Contd

In 1800s, they were limited by their
inability to provide anesthesia and
control infection.
The introduction of diethyl ether and
later chloroform as anesthetic agents
increased the feasibility of major
abdominal surgery.

Historical Advances Contd

Surgical techniques were also a limiting factor

Surgeons were hesitant to reapproximate the
uterine incision for fear that permanent sutures
would increase the likelihood of infection and cause
uterine rupture in subsequent pregnancies.

Not surprisingly, women continued to die from
blood loss and infection.

Historical Advances Contd

In 1882, Max Sanger in Germany first sutured uterine
wall in Caesarean section using silver wire and silk
with careful attention to haemostasis.
Frank (1907) described extraperitoneal lower segment
operation to avoid peritonitis.
Beck (1919) and De Lee (1922) introduced lower segment
operation by vertical incision.
Munro Kerr (1926) gave the transverse lower segment
incision for Caesarean delivery the world today.

Caesarean delivery: Definition
Caesarean delivery is defined as the
birth of a foetus through incisions in the
abdominal wall (laparotomy) and the
uterine wall (hysterotomy) after 28
weeks of pregnancy.
Definition
It is an operative procedure
whereby the fetuses after the end
of 28
th
week, are delivered
through an incision on the
abdominal and uterine walls.

Incidence
Last decade 2-3 fold rise in C/s
from the initial rate of 10%
Incidence
Factors for increasing caesarean section
Identification of at risk fetuses before term
Identification of at risk mothers.
Wider use of repeat C.S. in cases with previous
caesarean delivery.
Decline in difficult operative or manipulative
vaginal deliveries.
Decline in vaginal breech delivery
Increased diagnosis of fetal distress
and fear of litigation.
Adoption of small family norm
Incidence
Reduced parity: almost half of the pregnant
women are nulliparous, thus an increased number
of caesarean births might be expected for
conditions which are more common in
primigravida.
Older women are having children and frequency of
caesarean deliveries increases with advancing age.
Incidence Contd
Extensive use of electronic foetal monitoring and
increased caesarean deliveries for non-reassuring foetal
heart rate picked up by this technique is compared with
intermittent foetal heart rate auscultation.
By 1990, 83% of all breech presentations were
delivered abdominally.
The incidence of mid pelvic vaginal deliveries (high
presentation) has decreased.


Incidence Contd
Concern for malpractice litigation has
contributed significantly to the present
caesarean delivery rate
Socioeconomic and demographic factors
may play a role in caesarean birth rate.

INDICATIONS

Absolute
Relative


ABSOLUTE INDICATIONS
Central placenta praevia
Contracted pelvis or cephalopelvic
disproportion
Pelvic mass causing obstruction (cervical or
broad ligament fibroid)
Advanced carcinoma cervix
Vaginal obstruction (atresia, stenosis)

RELATIVE INDICATIONS
Cephalo-pelvic disproportion (relative)
Previous caesarean delivery
Non reassuring FHR (fetal distress)
Dystocia may be due to (three Ps) relatively
large fetus (passenger), small pelvis (passage) /
or inefficient uterine contractions (power).
Antepartum haemorrhage (a) placenta
praevia and (b) abruption placenta.

RELATIVE INDICATIONS CONTD
Malpresentations
Failed surgical induction of labour,
Failure to progress in labour.
Bad obstetric history
Hypertensive disorders
Medical-Gynaecological disorders
Common Indications

Primigravidae:
Cephalopelvic
disproportion (CPD)
Fetal distress (non-
reassuring fetal FHR)
Dystocia (three Ps)


Multigravidae:
Previous caesarean
delivery (28%)
Antepartum
hemorrhage (Placenta
Previa, placental
abruption)
Malpresentation
(Breech)

Maternal Indications
CPD and contracted pelvis
Inadequate uterine force
Previous classical cesarean section
Previous LSCS
Placenta praevia
Eclampsia or pre-eclampsia
Dystocia
Carcinoma cervix






Fetal indications
Fetal distress
Prolapse of umbilical cord
Mal presentation
Bad obstetrical history and habitual
intrauterine death of fetus
Abruption placenta
Multiple pregnancy
Maternal HIV infection
Contraindications

Very low birth weight baby
Maternal coagulation defects

Time of Operation in Caesarean

Elective CS
Emergency CS
Criteria for timing of elective repeat
caesarean delivery
When the operation is done at a pre
arranged time during pregnancy to ensure
the best quality of obstetrics, anaesthesia,
neonatal resuscitation and nursing
services.



An ultrasound obtained at 12 to 20 weeks
confirms the gestational age of at least 39 weeks
determined by clinical history and physical
examination.


Types of caesarean section

Lower segment caesarean section
(99.8%)
Classical or Upper segment 0.02%.
Caesarean hysterectomy 0.18%.
Extra peritoneal lower segment
operation.

Lower segment caesarean section
The extraction of the baby is done
through an incision made in the
lower segment through trans
peritoneal approach.
Classical
The baby is extracted through an incision made
in the upper segment of the uterus.
Indications
A. Lower segment approach is difficult
1. Dense adhesions due to previous abdominal
operation
2. Severe contracted pelvis with pendulous
abdomen
Contd..
B. Lower segment approach is risky
1. Big fibroid on the lower segment
2. Carcinoma of cervix
3. Repair of difficult and high VVF
4. Severe degree of placenta praevia with
engorged vessels in the lower segment
Lower segment Caesarean Section
Pre operative preparation
Informed written permission for the
procedure, anesthesia and blood transfusion is
obtained.
Abdomen is scrubbed with soap and non
organic iodide lotion. Hair may be clipped.
Pre medicative sedation
Antacid before transferring to the theatre
Contd..
Premedication Ranitidine or
Metaclopramide
NG tube if needed
Emptying the bladder, Keep catheter
in place
Checking of FHS
Presence of Neonatologist
Anesthesia
Spinal
Epidural
General
Position
Supine
15 tilt
Incision
Vertical
Infraumbilical or paramedian
Transverse
3cm above the symphisis pubis


Features of Transverse and Vertical
Incision
Transverse (Pfannnensteil) Vertical
More popular due to cosmetic
purposes
Less popular
Limited exposture Rapid entry and good exposure
Cherny/maylard modification may
be needed, in the presence of
previios similar surgery
Median/ paramedian incision can
be made
Hernia less common (this usually
occurs at the angles)
Post-operative hernia more
common (this can occur
anywhere along the incision)
Advantages and Disadvantages of Transverse
Incision
Advantages Disadvantages
Postoperative comfort is more Takes a little time and as such
unsuitable in acute emergency
operation
Fundus of the uterus can be better
palpated during immediate post-
operative period
Blood loss is little more
Less chance of wound dehiscence
Cosmetic value Requires competency during repeat
section
Less chance of incisional hernia Unsuitable for classical operation
Preparation of the mother

Psychological Preparation
Physical Preparation
Anesthesia
Position

Incision on the Abdomen
A low transverse incision is made about two
fingers breadth above the symphysis pubis
(modified pfannenstiel) or above the
symphysis pubis (pfannenstiel or bikini line
incision)
Some obstetricians make a vertical
infraumbilical or paramedian incision, which
extends from about 2.5 cm below the
umbilicus to the upper border of the
symphysis pubis.

Contd
The anatomic layers incised are:
Fat
Rectal sheath
Muscle (rectus abdominis)
Abdominal peritoneum
Uterine muscle.

Packing
The Doyens retractor is introduced.
The peritoneal cavity is now packed
of using two taped large swabs.
The tape ends are attached to artery
forceps. This will minimize spilling of
the uterine contents in to the general
peritoneal cavity.
Uterine incision
Peritoneal incision
The loose peritoneum of the utero-vesical
pouch is cut transversely across the lower
segment with convexity downwards at about
1.25cm below its firm attachments to the
uterus.

The lower flap of the peritoneum is pushed
down a little.
contd,..
Muscle incision
The most commonly used incision is low
transverse
Advantages
1. Ease of operation.
2. less bladder dissection
3. less blood loss
4. easy to repair
5. complete reperitonisation
6. less adhesion formation
7. less risk of scar rupture
Other type of Incisions
Lower segment transverse
Lower segment vertical
J incision
Classical incision
Inverted T incision


Low transverse incision
A small transverse incision is made in the
midline by a scalpel at a level slightly below
the peritoneal incision until the membranes of
the gestation sac are exposed.

Two index fingers are then inserted through
the small incision down to the membranes and
the muscles of the lower segment are split
transversely across the fibers.
Contd
The method minimizes the blood loss but
requires experience.

Alternatively the incision may be extended
on either sides using a pair of a curved
scissors to make it a curved one of about
10cm in length, the concavity directed
upwards.
Delivery of the head
The membranes are ruptured if still intact

The blood mixed amniotic fluid is sucked out by
continuous suction.

The Doyens retractor is removed.

The head is delivered by hooking the head with the
fingers which are carefully inserted between the lower
uterine flap and the head until the palm is placed below
the head.
Contd
As the head is drawn to the incision line the assistant
is to apply pressure on the fundus.

If the head is jammed, an assistant may push up the
head by sterile gloved fingers introduced in to the
vagina.

The head can be also delivered using either wrigleys
forceps
Delivery of the trunk
As soon as the head is delivered, the mucus
from the mouth ,pharynx and nostrils is
sucked out using rubber catheter attached
to a electric sucker.

After the delivery of the shoulders
intravenous oxytocin 20 units or
metergin0.2mg is to be administered.

Contd..
The rest of the body is delivered slowly and the
baby is placed in a tray placed in between the
mothers thigh and with the head tilted down
for gravitational drainage.
The cord is cut in between two clamps and the
baby is handed over to the nurse.
The Doyens retractor is reintroduced.





Delivery of the placenta
The placenta is extracted by traction on the cord
with simultaneous pushing the uterus towards the
umbilicus per abdomen using the left hand .
the membranes are to be carefully removed
preferably intact and even a small piece, if attached
to the decidua should be removed using a dry gauze.
dilatation of the internal os is not required.
Exploration of the uterine cavity is desirable.
Suture of the uterine wound
The margins of the wound are
picked up by Alis tissue
forceps or Green Armytage
haemostatic clamps.
The uterine incision is sutured
in three layers.
Contd
First layer the first stitch is placed
on the far side in the lateral angle
of the uterine incision and is tied
with 0 chromic catgut or vicryl. A
continuous running suture taking
deeper muscles excluding the
decidua ensures effective
apposition.

Contd..
Second layer -the superficial muscles and
fascia by continuous suture.
Third layer-the peritoneal flap by
continuous inverting suture.
Concluding part
The mops placed inside are removed and
the number verified. Peritoneal toileting is
done and the blood clots are removed
meticulously.
The tubes and ovaries are
examined. Doyen's retractor is
removed.
After being satisfied that the
uterus is well contracted, the
abdomen is closed in layers.
The vagina is cleansed of blood
clots and a sterile vulval pad is
placed.

BLUNCH SUTURE FOR CAESAREAN SECTION:
BLUNCH SUTURE FOR CAESAREAN
SECTION


Postoperative Care

Immediate Care (4-6 hours):
In the immediate recovery period, the blood
pressure is recorded every 15 minutes.
Temperature is recorded every two hours.
The wound must be inspected every half hour
to detect any blood loss.
Immediate Care (4-6 hours)

The lochia are also inspected and drainage should
be small initially.
Following general anesthesia, the woman is
nursed in the left lateral or recovery position
until she is fully conscious, since the risks of
airway obstruction or regurgitation and silent
aspiration of stomach contents are still present.
Analgesia is given as prescribed.

First 24 hours

IV fluids (5% dextrose or Ringers lactate) are
continued.
Blood transfusion is helpful in anemic mothers
for speedy postoperative recovery.
Injection methergine 0.2 mg may be repeated
intramuscularly.
Parenteral antibiotic is usually given for the
first 48 hours.

First 24 hours Contd

Analgesics in the form of pethidine 75-
100 mg are administered as required.
Ambulation is encouraged on the day
following surgery and baby is brought
to her.

After 24 Hours Contd
The blood pressure, pulse and temperature are
usually checked every four hours.
Oral feeding is started with clear liquids and
then advanced to light and regular diet.
IV fluids are continued for about 48 hours.
Urinary catheter may be for about 48 hours.

Urinary catheter may be removed on the
following day when the woman is able to get up
to the toilet
The woman is helped to get out of bed as soon
as possible and encouraged to become fully
mobile.
The mother must be encouraged to rest as
much as possible and needed help is to be given
with care for the baby.


This should preferably take place at the
mothers bedside and should include support
with breastfeeding.
The mother is usually discharged with
the baby after the abdominal skin
stitches are removed by the 4
th
or 5
th

day.( Depends on policy or varies )

Postpartum pain Relief after
Cesarean Birth
Incisional Pain:
Splint incision with a pillow hen
moving or coughing.
Use relaxation techniques such as
music, breathing and dim lights
Intestinal Gas:
Walk as often as you can
Do not eat or drink gas-forming foods,
carbonated beverages, or whole drink
Do not use straws for drinking fluids.
Take anti flatulence medication if
prescribed
Lie on your left side to expel gas
Rock in a rocking chair
Home Care
Signs of postoperative complications after
discharge:
Report the following signs to your health care provider.
Temperature exceeding 38
0
c
Painful urination
Lochia heavier than a normal period
Wound separation
Redness or oozing at the incision site
Severe abdominal pain
Classical caesarean
section
Abdominal incision is longitudinal about
15cm in length, 1/3
rd
of which extends
above the umbilicus.
After opening the peritoneal cavity, the
uterus is centralized and packs are
placed on each sides
A longitudinal incision of about 12.5 cm is
made on the midline of the anterior wall
of the uterus starting from below the
fundus.
Contd..
The incision is deepened along its entire
length until the membranes are exposed
which are punctured.
The baby is delivered as breech
extraction
Methergin
Placental removal
Suture of the uterine incision
Uterus is returned back into the
abdominal cavity
Contd
Packings are removed
Peritoneal toileting is done
The abdomen is closed in layers

Merits and Demerits of Lower Segment Operation
over classical
Lower segment Classical
1.Techniques Slight difficult

Blood loss is less

The wall is thin and as
such apposition is
perfect

Perfect peritonisation is
possible
Technical difficulty in
placenta praevia or
transverse lie
Technically easy

Blood loss is more

The wall is thick and
apposition of the
margins is not
perfect

Not possible

Comparatively safer
in such
circumstances.

2.Post -
operative
Haemorrhage and
shock-less

Peritonitis is less

Peritoneal adhesion
and intestinal
obstruction are less

Convalescence is
better

Morbidity and
mortality are lower
More


More

More because of
imperfect
peritonisation

Relatively poor

Morbidity and
mortality are
higher
3.Wound
healing
The scar is better
healed because of :
Perfect muscle
apposition due to thin
margins

Minimal wound
heamatoma

The wound remains
quiescent during
healing process




Chance of gutter
formation is unlikely
The scar is weak
because of:
Imperfect muscle
apposition because of
thick margins

More wound haematoma
formation

The wound is in a state of
tension due to contraction
and relaxation of the
upper segment. As a
result, the knots may slip
or the sutures may
become loose

Chance of gutter
formation on the inner
aspect is more

Contd
4.During future
pregnancy
Scar rupture is less
0.5-1.5%
More risk of scar
rupture 4-9%
Complications
Due to operation or anaesthesia
Intra operative complications
Extension of uterine incision -to one or both
the edgesinvolve uterine vessels broad
ligament haematoma
Uterine lacerations-laterally or inferiorly to
vagina
Bladder injury two layer closure with 2-0
chromic catgut, continuous bladder drainage
for 7-10 days
Contd
Urethral injury
Gastrointestinal tract injury
Uterine atony and primary post
partum haemorrhage
Morbid adherent placenta
Postoperative Complications
Maternal



Immediate Remote
Postpartum hemorrhage Gynaecological:
Menstrual excess or
irregularities
Chronic pelvic pain or
backache
Shock General Surgical:
Incisional hernia
Intestinal obstruction due
to adhesions and bands
Immediate Remote
Anesthetic hazards Future Pregnancy:
There is risk of scar
rupture
Infections
Intestinal obstruction
Thromboembolic
disorders
Wound complications
Secondary postpartum
hemorrhage
Fetal Complications
Iatrogenic prematurity and
development of RDS is not
uncommon following caesarean
delivery. This is seen when fetal
maturity is uncertain.
Post mortem cesarean birth

If a pregnant woman does not survive
serious trauma, it may still be possible
for her child to be born safely by
postmortem CS birth.
This is usually attempted if the fetus is
past 24 weeks and less than 20 minutes
has passed since the mother died.
Infant survival is best in these
circumstances if no longer than 5
minutes has passed.
No consent
Classical incision
Personnel to resuscitate the baby.
Nursing diagnosis
Pain related to surgical incision
Ineffective individual coping related to
surgical intervention ,perceived loss of
birthing experience and fatigue
Activity intolerance related to delivery
and secondary to anesthetic
administration surgical incision and pain
Constipation related to anticipated
abdominal pain
Contd
Knowledge deficit related to post
partum course and implication of
subsequent pregnancy
Self esteem disturbance related to
perceived inability to birth naturally
Risk for impaired parenting related
pain and effect of anesthesia and
postponing to secondary to touch
hold and care for infant

Contd..
Risk for fluid volume deficit R/t to
blood loss associated with surgery
Risk for maternal infection R/t delivery
and secondary to surgical incision

Evidence based practice

Doshi Haresh, Tripathi Jagruti, Maheshwari
Sonal, Gupta Arti (2009) conducted a national survey
in Cesarean section changing trends with the
objectives to study the changing trends in indications
and techniques of cesarean section in various parts of
India.
Methods: A clinical survey was carried out amongst
253 obstetricians from all over India selected at
random regarding their practices of cesarean section
in terms of indications and technique.

Results: Result showed that previous
cesarean section, severe pregnancy induced
hypertension, failed induction of labor and
infertility treated cases is now increasing
amongst the indications for cesarean section.
In techniques, single layer closure (41.11%
doctors) and non suturing of peritoneum,
visceral or both, (35.96% doctors) are now
increasing among obstetricians. Polyglycolic
acid sutures (vicryl, centicryl, dexon) are
replacing catgut for uterine closure.

Conclusion:
Changes in indications are mainly due to
litigation fear and better neonatal facilities.

Conclusion
Low caesarean section rates are associated
with low levels of intervention and high levels of
psychological support. It is difficult to decipher
whether caesarean section rates have been
affected by interventions such are proactive
management of labour.