Cesarea

n
Section

Dr Khaled Baiomy
.Prof. Ob/GynOb/Gyn

Oldest surgical procedures in

history, with literature dating back
to at least
800 BC (Duer, 1879).

An operative procedure to deliver

a viable fetus or more (after 28
weeks
or 20 weeks according to the ACOG)
through an abdominal and uterine
incisions.

Cesarean section is performed by moving the

other abdominal organs out of the way, then
making a slit in the uterus. After removal of
the baby and the placenta, the uterus is
sutured, and the abdominal organs are
arranged back in place.
The cut can be made vertically (classical
incision) or across the lower part of the
abdomen at the bikini line (transverse).

Cesarean Delivery
Cesarean Section

It is commonly believed to be
derived from the surgical birth of
Julius Caesar, however this seems
unlikely since his mother Aurelia
is reputed to have lived to hear of
.her son's invasion of Britain

Cesarean sections are

performed instead of
vaginal delivery, if
vaginal delivery is
judged to be
impossible or unsafe.

Incidence
5% in 1970 & 25% in 1990
.increased 0.6% to 3%( Chicago),1910-1928
.In 1965,United States was 4.5%
In 1980,16.5%, and it peaked at 24.7% in
. 1988
In 1985, the cesarean delivery rate in
America was 22.7%; 19% in Canada, 13% in
.Denmark, 10% in England, and 7% in Japan

In KAASH, 16-18%

Why the rate of cesarean delivery has

increased so dramatically in the United
States is not entirely clear

1. Increased repeated C.S due to increased

primary C.S..
2. Delay in childbirth and reduced parity
3. Increased C.S delivery in breech presentation.
4. Procedures as high forceps and difficult
mid forceps are abandoned in favour of C.S.
5. Destructive operations are abandoned in
favour of C.S.
6. Decreased perinatal mortality
7. Non-reassuring fetal heart rate testing
8. Fear of malpractice litigation:Unfortunately, many
obstetricians admit that their practice of medicine has become
more defensive. Given the fear of inquiry regarding how a
particular patient's labor was managed, many obstetricians
may have a lower threshold to perform a cesarean delivery.

Indications of CS
Maternal indications
Cont. pelvis and CPD -Pelvic
tumors
APH - HDP - Abnormal uterine
action
Previous uterine scar.
Previous successful repair of
vesico-vaginal fistula.
Previous caesarean section if,
.etc

?Why CS

 Malpresentations
and
Foetal indications
malpositions
Prolapsed pulsating cord or
foetal distress
Diabetes mellitus
Bad obstetric history as
recurrent IUFD
Post-mortem C.S. done within
10 minutes
of maternal death

Types of Cesarean Section

)A( According to timing
1. Elective cesarean
2. Selectivecesarean

 Pre - operative good preparation

sterilization
fasting and bowel preparation.
The risk of puerperal sepsis is
minimized
The operation is scheduled and
working is in ease.

Disadvantages of elective
C.S

Risk of immaturity, respiratory distress

syndrome.
The lower segment may be not well
formed.

Types of Cesarean Section

)B( According to the site of uterine incision
Upper segment cesarean section (Classical C.S.)
Lower segment cesarean section (LSCS)

Types of Cesarean Section

)C( According to number of the operation
Primary cesarean section
Repeated cesarean section

Types of Cesarean Section

According to opening the peritoneal cavity

Transperitoneal CS
Extraperitoneal CS

Procedure of Lower Segment

C.S

Preoperative details
NPO at least 8 hours prior to arriving.
IV line
CBC and type and screen (Blood).
Cross-match blood to be available
IV FluidLactated Ringer solution or saline with
5% dextrose.
The patient is placed on an external fetal
monitor.
Evaluation by the operating physician &
anesthesiologist.

Intra-operative details

Anesthesia: General / epidural/ spinal or

rarely local infiltration anesthesia.
Position : Tilting the patient 15 dgree to
the left in the dorsal position
minimize the aorto-caval compression.
Skin incision :
Pfannenstiel
Midline
Paramedian vertical

Pfannenstiel
Longer to enter the
peritoneal cavity,
Less painful,
Smaller risk of
incisional hernia,
Cosmetically.

Less blood loss,

Easier examination
of the upper abd,
Easy extension
cephalad around
the umbilicus

The subcutaneous fat is incised

The anterior rectus sheath is incised
transversely or vertically
The rectus muscles : are separated in the
midline (pfannenstiel) or retracted laterally
.(vertical)
The parietal peritoneum: is opened vertically
The uterus is centralized, the bowel and
omentum are packed of with moist laparotomy
pads
The loose peritoneum over the lower uterine
segment is held and incised transversely, for
about 10 cm in a semilunar fashion with its

The bladder : is dissected downward

and is retained behind a Doyne
.retractor placed over the symphysis
The uterus is incised : in the same
semilunar fashion. A short (3cm) cut &
completed by the 2 index fingers along
the incision mark or by a bandage
scissors over 2 fingers introduced into
.the uterus to protect the fetus
Membranes are ruptured : by toothed
.or Kockers forceps

The emergent nature of the procedure: FHR, urinarycatheter, & scrub and shave abdomen
The fetus should be protected from lacerationsThe infant should be immediately handed to someonetrained in infant resuscitation
Closure should be undertaken based on maternalcircumstances
Avoiding needless blood lossThe rules of dirty surgery should apply, and any broad-spectrum
.antibiotics )cephalosporin( in a single dose should be adequate

Opening uterus

:The head is delivered by*

i. introducing the right hand gently
below it and lifting it up helped by
fundal pressure done by the
,assistant
,ii. using one blade of the forceps or
.iii. using Wrigleys forceps
iv. deep in the pelvis (push
.vaginally)
Suction for the fetus*
In breech or transverse lie the*
foetus is extracted as breech
*****The placenta is removed *****

U.C Clamping

Closure of the uterine incision is done

in 3 layers
The first is a ContinuousThe second is a continuous or Interrupted.one inverting the first layer
The third is a Continuous or interrupted- layer to close the visceral peritoneum of the
.uterus
Closure of visceral and/or parietal .peritoneum is omitted by some surgeons
. The abdomen is then closed in layers-

Skin

Procedure of Upper Segment

C.S

Upper Segment Caesarean Section

:

Indications

Dense adhesions, extensive varicosity or

myoma in the lower uterine.
Impacted shoulder presentation.
Anterior placenta praevia.
Defective scar in the upper segment.
Cancer cervix.
Rapid delivery is indicated.
If a concomitant tubal sterilisation will be
done.
Previous successful repair of high vesicovaginal or
Cervico-vaginal fistula.
Post-mortem hysterectomy

Procedure
. Abdominal incision: is vertical
Uterine incision : 10 cm vertical incision is made in the midline
of upper uterine segment without incising the peritoneal coat
.separately as it is adherent in the upper segment
. Extraction of the foetus: as a breech in cephalic presentation
The last layer of the uterine incision closure includes the
superficial part of the myometrium with the peritoneal
. covering
.The remainder of the procedure is as lower segment C.S

BTL

Caesarean
Hysterectomy
.Un-controllable postpartum hge-1
.Un-repairable rupture uterus-2
.Operable cancer cervix-3
.Couvelaires uterus-4
Placenta accreta cannot be-5
.separated
.Severe uterine infection Cl. Welchii-6
Multiple uterine myomas in a woman-7
.not desiring future pregnancy

Postoperative details
In the recovery room :
Vital signs / 15 minutes for the first 1-2 hours, urine output /
hourly basis.

Palpate the fundus to ensure that it feels firm. Check amount

of vaginal bl.

Pain control usually is not an issue in the first 24 hours

Fluid 3-4 L of intravenous fluid from initiation of the
intravenous line through the first 24 hours.

Liquid diet 12-24 hours after an uncomplicated procedure,

and diet can be advanced accordingly.

D/C, IVF

When the patient is able to tolerate good oral

intake,

Catheter can be removed 12-24 hours postoperatively

Discharge safely 3-4 days after surgery.

Complications
I Operative
1- Primary maternal mortality
is 4 times that of vaginal
delivery
i- Shock .
ii- Anesthetic complications
particularlyMendelsonsynd.
iii- Haemorrhage usually
due to extension of the
uterine
incision to the uterine
vessels, atony of the uterus
or DIC.
2- Injuries to the bladder or
ureter.
3- Foetal injuries

II Post-operative:
(A) Early:
Thrombosis and pulmonary
embolism.
Acute dilatation of the
stomach and paralytic
ileus.
Wound infection, puerperal
sepsis and burst abdomen.
Chest infection.
(B) Late :
Rupture of the uterine scar.

An atonic uterus

Multiple gestation,
Polyhydramnios, or
Failed attempt at a vaginal delivery
(prolonged).
Massage and Intravenous oxytocin, Consider
Intramuscular injections of prostaglandin (15methyl-prostaglandin, Hemabate) or
methylergonovine and repeat as appropriate.