CESAREAN SECTION

once a cesarean, always a cesarean has been changed to Once a cesarean

always a Hospitalization

CESAREAN SECTION

• is a surgical procedure in which one or more incisions are made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies, or, rarely, to remove a dead fetus.

The five Most Common Causes of Cesarean Section

• CS on Request• Routine repeat cesareans .• Dystocia (non-progressive

labor) .• Abnormal fetal presentation eg

breech , transeverse , cord presentation .

• Fetal distress .

TYPES OF CS

• The classical Caesarean section involves a midline longitudinal incision which allows a larger space to deliver the baby. However, it is rarely performed today, as it is more prone to complications.

• The lower uterine segment section is the procedure most commonly used today; it involves a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair.

• An unplanned Caesarean section is performed once labour has commenced due to unexpected labor complications.

TYPES OF CS

• A crash/emergent/emergency Caesarean section is performed in an obstetric emergency, where complications of pregnancy onset suddenly during the process of labour, and swift action is required to prevent the deaths of mother, child(ren) or both.

• A planned caesarean (or elective/scheduled caesarean), arranged ahead of time, is most commonly arranged for medical reasons and ideally as close to the due date as possible.

TYPES OF CS

• A Caesarean hysterectomy consists of a Caesarean section followed by the removal of the uterus. This may be done in cases of intractable bleeding or when the placenta cannot be separated from the uterus.

• Traditionally, other forms of Caesarean section have been used, such as extraperitoneal Caesarean section or Porro Caesarean section.

• a repeat Caesarean section is done when a patient had a previous Caesarean section. Typically it is performed through the old scar.

INDICATIONS FOR ELECTIVE CS

• Known CPD• Fetal macrosomia > 4500 gm• Placenta previa• VV fistula repair• HIV• Active herpes• Repeat CS

• Uterine surgery eg. Hystrotomy, myomectomy• Severe IUGR• Breech • Multiple pregnancy• Transverse lie• Ca of the Cx/ TR obstructing the birth canal

INDICATIONS FOR EMERGRENCY CS

• Severe PET• Abruptio placentae• Fetal distress• Failure to progress in the first stage of labour• Cord prolapse• Obstructed labour• Failed induction• Malpresentation brow, chin post, shoulder &

compound presentations, breech• Compromised fetus 2ry to DM, HPT,

isoimmunization • APH

Consent for CS

Consent for CS should be requested after providing pregnant women with evidence based information and in a manner that respects the woman’s dignity, privacy, views and culture whilst taking into consideration the clinical situation.

Before Emergency CS

• Explain to the Pt & husband & obtain consent

• Inform anesthetist, OR staff, ped

• 100% oxygen mask in case of fetal distress

• Sodium citrate 20 ml , metoclopramide 10 mg IV

• Transfer to the theatre, IV , take blood for Hb, x-match 2 U of blood

• Preferable to use spinal or epidural anaethesia

Before Emergency CS

• Catheterize the bladder • Tilt the mother 15 º by using wedge• Pneumatic inflatable boots or Ted stockings• Prophylactic Ab ↓↓ incidence of infection• Inform ped if the mother had opiates in the last 4

hrs• Halothane should not be used uterine relaxation

& bleeding

Maternal Position During CS

• All obstetric patients undergoing CS should be positioned with left lateral tilt to avoid aorto-caval compression

• By tilting the operating table to the left or place a pillow or folded linen under her right

lower back

Anaesthesia

• 1 General anaesthetic.• 2 Regional anaesthesia ( Epidural block. -

Spinal block ).• 3 Infiltration of local anaesthetic agents.

Abdominal entry

Uterine Incision

• Abdominal cesarean section– Extraperitoneal cesarean section Latzko operation– intraperitoneal cesarean section

1-Cervical A-- a transverse or curved (horizontal) Kerr operation

Low transverse– if cx is dilated less than 5 cm

High transverse– if cx is dilated more than 5 cm

B--vertical incision in the lower uterus Selheim operation

2 -Classical--a vertical incision in the main body of the uterus. Sanger operation

3-Inverted T-shaped incision Delee operation 4 -J shaped• Vaginal cesarean section

COMPLICATIONS

INTRAOPERATIVE• Bleeding & the need for bl transfusion• Hysterectomy• Complications of anaesthesia• Damage to the bladder, ureter, colon , retained

placental tissue• Fetal injury

COMPLICATIONS

POSTOPERATIVE • Gaseous distension• Paralytic ileus• Wound dehiscence & infection• Infectins UTI, pulmonary• DVT & pulmonary embolism• Death• Vesico uterine fistula

POSTNATAL CARE

• V/S & blood loss must be monitered• Uterine fundus palpated • Effective parentral analgesics• Deep breathing & coughing encouraged• Early mobilization• Fluid therapy &diet• Bladder & bowel function• Wound care• Lab• Breast care• Prophylaxis for thrombembolism