CAESAREAN SECTION “YET ANOTHER WAY TO GET OUT!”

WHY CALLED SO??

According to legend ,julius caesar was born by this operation

It was a fatal operation until beginning of 20th century.

Now the most common operation performed worldwide

DEFINITION

The delivery of a viable fetus through an incision in the abdominal wall and uterus.

Definition does not include removal of fetus from abdominal cavity in case of rupture uterus.

WHO recommends an ideal caesarean rate of 15-20%.

But in most countries it is 15-20%

WHY RATES INCREASED?

Increase in repeat caesareans. Difficult instrumental delivery and

vaginal breech deliveries Increased diagnosis of intrapartum fetal

distress Caesarian on demand Identification of risk of mothers and

fetuses Increase in pregnancies by invitro

fertilization

INDICATIONS

Previous caesarian section

Dystocia or dysfunctional labour

Fetal distress

Breech presentation

Antepartum haemorrhage

Maternal problems

Caesarian section on demand

LSCS

• Cross matched blood• Catheter introduced• Antibiotic prophylaxis• Heparin as thromboprophylaxis• Parts cleansed with antiseptic solution• Left lateral position- reduce aortocaval

compression. reduce risk of supine hypotension

ANAESTHESIA• GA or REGIONAL• REGIONAL - Spinal or Epidural• Mendelson’s syndrome- GA given as

emergency- risk of aspiration- chemical pneumonitis.

• To counteract- antacids given during labour, oral fluids withheld

• 30 ml 0.3 molar sodium citrate orally -1/2 hr before surgery.

• Sellick’s manoeuvre- endotracheal intubation accompained by pressure on cricoid cartilage

ABDOMINAL INCISIONS

Pfannensteil incision-MC used. Transverse curvilinear incision above pubic hairline

Deepened through s/c tissue upto rectus sheath

Rectus sheath divided transversely

Two recti muscles seperated in midline

Maylard incisionOption when more exposure is needed in transverse incisionRecti muscles are divided

Midline vertical incision

Transverse incision

Vertical incision

Cosmetic appeal More Less

Postoperative pain

Less More

Wound dehiscence

Less More

Incisional hernia Less More

Technical skill More Less

Time taken More Less

Access to upper abdomen

Less Good, can be extended

PROCEDURE• Once abdomen opened- dextrorotation of

uterus corrected• Doyen retractor- visualize lower segment• Peritoneum over lower segment identified-

divided transversely- seperated from bladder by blunt dissection

• Small incision in lower segment-extended laterally

• Inadequate space- J shaped or inverted T incision

• Do not injure uterine vessels lying laterally

DELIVERY OF BABY

Cephalic presentationHand slipped into uterine cavity

Head is levered out gentlyFloating head- use forceps to deliver

the baby.

Breech presentationfeet hooked out first

rest delivered as vaginal breech delivery

Transverse or oblique liecorrected to longitudinal lie before making uterine incision.

Transverse lie with ruptured membranes & undeveloped lower segment

extension of uterine incision required

CLOSURE OF UTERINE INCISION OXYTOCIN infusion started as soon as

baby is delivered Uterine fundus contracts-placenta and

membranes extrudes spontaneously- removed

Wipe with moist pad- ensure uterine cavity is empty and cervical canal is open

Uterine edges- held with ALLIS forceps or GREEN ARMYTAGE forceps- incision closed in 2 layers- continuous sutures

Chromic catgut or polyglactin used

Any bleeding points- controlled with figure-of-eight sutures

CLOSURE OF ABDOMEN

• PERITONEUM- closed or not closed• RECTUS SHEATH-non absorbable

sutures-proline- to reduce wound dehiscence & incisional hernia

• SUBCUTANEOUS TISSUE-closed• SKIN- mattress sutures of silk,

subcuticcular suture or clips

POST OPERATIVE CARE

Close monitoring for 1st 6-8 hrs Parenteral fluids Blood transfusion if needed Analgesics and sedatives Oral fluids Early ambulation and deep breathing

exercises Light solid diet n laxatives Discharged –day following suture

removal/if transverse or subcuticular-5th/6th day

ADVANTAGES OF LSCS

Healing better

Scar rupture minimal

OTHER TYPES OF CS

1. Low segment vertical incision 2.Classical CS 3.Extra peritoneal CS 4.Caesarean hysterectomy

LOWER SEGMENT VERTICAL INCISION Indications:Constriction ring,lower

segment not formed Disadv:

injury to cervix, vagina,bladder increased chance of rupture in next pregnancy

CLASSICAL CAESAREANIndicationslower segment unapproachableCA cervixAnterior placenta praevia with prev caesarianTransverse lie with ruptured membranesConjoint twinsDisadvantagesDifficult healingScar ruptureGeneral peritonitis

EXTRAPERITONIAL CAESAREAN Severe infection Extraperitoneal approach Space of Retzius

CAESAREAN HYSTERECTOMYIndicationsSevere atonic PPHPlacenta accreta,increta,percretaSepsisMultiple large myomasCA cervix

COMPLICATIONS OF CAESAREAN SECTION

INTRAOPERATIVE COMPLICATIONS

Primary haemorrhage

Injury to internal organs

Injury to the baby

Difficulty in delivery of the head

Anaesthetic complications

PRIMARY HAEMORRHAGE

Atonic- oxytocin 20units in 500ml ergometrine0.25mg im or iv prostaglandin F2 alpha 250micgram im and intramurally PGE1 200micgram rectally

Traumatic-ligation of concerned vessels

Placenta accreta

POSTOPERATIVE COMPLICATIONS Paralytic ileus Respiratory complications Infections Peritonitis Pelvic abscess Pelvic thrombophlebitis Deep vein thrombosis and pulmonary

embolism Wound dehiscence

LATE SEQUELAE Secondary PPH Incisional hernia Scar endometriosis Vesico-vaginal fistula Scar rupture in the next pregnancy Placenta praevia and placenta

accreta Bladder injury