W Cesarean sect|on s|mp||f|ed techn|que

(1he S||ent kn|fe )

W r Muhammad L| nennawy
W $yn spec|a||st
W Street kass e| arr dumyat eypt
W wwweoc|t|escom$mmhennawy
W wwweoc|t|escom$ac_oyn
W Mo||e 012203011
W A large number of Lechnlques and maLerlals for cesarean secLlon have been proposed Lo
reduce Lhe operaLlng Llme Lhe hosplLal cosLs and Lo make Lhe procedure easler for Lhe
surgeon
Powever
W ew of Lhese lnLervenLlons have been rlgorously evaluaLed before belng lncorporaLed
lnLo pracLlce
W @he flve MosL Common Causes of Cesarean SecLlon
W CS on 8equesL
W 8ouLlne repeaL cesareans
W ysLocla (nonprogresslve labor)
W Abnormal feLal presenLaLlon eg breech Lranseverse cord presenLaLlon
W eLal dlsLress
W 8easons suggesLed for Lhe lncrease ln caesarean secLlon raLes
W Advanclng maLernal age Socloeconomlc facLors 8educed parlLy
W mprovemenLs ln surglcal Lechnlques ecreased morbldlLy and morLallLy
W ncreased repeaLed CS due Lo lncreased prlmary CS
W @ype of healLh lnsurance wheLher Lhe hosplLal ls prlvaLe or publlc wheLher or noL Lhere
ls a neonaLal resusclLaLlon unlL Lhe slze of Lhe clLy
W @he obsLeLrlclan's experlence and Lype of Lralnlng
W Choose Lhe Llme and day of dellvery
W 9rocedures as hlgh forceps and dlfflculL mld forceps are abandoned ln favour of
Caesarean SecLlon (CS)
W esLrucLlve operaLlons are abandoned ln favour of CS
W @he lnLroducLlon of epldural anaesLhesla has reduced Lhe anaesLheLlc rlsks of Lhe
procedure @hls has led Lo a lower Lhreshold for dolng a Caesarean secLlon ln Lhe second
sLage of labour raLher Lhan performlng roLaLlonal/hlgh cavlLy forceps dellverles whlch
led Lo maLernal and neonaLal morbldlLy
W @he lncreased use of elecLronlc feLal monlLorlng has lncreased our awareness of feLal
dlsLress alLhough Lhe ma[orlLy of bables are born ln good condlLlon desplLe an abnormal
C@ and/or low pP aL feLal blood sampllng
W @he reducLlon ln Lhe number of roLaLlonal forceps dellverles has led Lo a deskllllng of
obsLeLrlclans who do noL feel confldenL Lo carry ouL Lhese procedures
W @he evldence LhaL breech presenLaLlon bables have a reduced morbldlLy and morLallLy
lf dellvered by elecLlve Caesarean secLlon
W An lncreaslng demand from women for elecLlve Caesarean secLlons wlLh no medlcal
reason
W Avoldlng lrsL CSecLlon Should 8e 9rlorlLy
W Avoldlng prlmary cesarean secLlons unless Lhere ls a medlcal necesslLy
W once a cesarean always a cesarean has been changed Lo Cnce a cesarean always a
PosplLallsaLlon also has been changed @o Cnce a cesarean always a conLroversy
W or Lhe physlclan elecLlve repeaL cesarean offers advanLages lncludlng convenlence
Llme savlngs and someLlmes lncreased compensaLlon even physlclans earnesLly wanL
Lo avold unnecessary repeaL cesarean operaLlons buL fear LhaL Lhey wlll be found legally
llable lf any unLoward evenL occurs durlng a Lrlal labor speclally lf lL ls noL posslble Lo
perform a crash cesarean wlLhln 1013 mlnuLes of Lhe onseL of an omlnous feLal
monlLor paLLern
W LlecLlve repeaL cesarean also ls convenlenL for Lhe paLlenL and her famlly even Lhe
paLlenL who sLrongly requesLs a v8AC buL Lhen demands a cesarean ln Lhe mldsL of
labor
W Cesarean SecLlon 8y Cholce
Cr Cesarean SecLlon Cn emand
Cr 9rophylacLlc Caesarean SecLlon
W Lhe women are requesLlng elecLlve caesarean secLlon by cholce as a mode of dellvery ln
Lhe absence of any speclflc lndlcaLlon as nonverLex presenLaLlon prevlous CsecLlon or
prlor perlneal or pelvlc reconsLrucLlve surgery
W 8ecause women are afrald from vaglnal dellvery LhaL can cause pudendal ln[ury whlch
leads Lo perslsLenL fecal and sLress lnconLlnence and genlLal prolapse and affecL sex
W Cesarean secLlon ls safe buL lL's noL as safe as a planned vaglnal dellvery
W Many pregnanL women belleve LhaL undergolng a cesarean secLlon ls a no rlsk surgery
W @hey suffer more Lhan Lhree Llmes Lhe number of cardlac arresLs blood cloLs and ma[or
lnfecLlons Lhan Lhose who dellver vaglnally
W ocLors mldwlves and chlldblrLh educaLors musL glve full and honesL advlce based on
Lhe avallable lnformaLlon Lhey may persuade buL never coerce AcLlve parLlclpaLlon by
paLlenLs should be encouraged Lo arrlve aL a safe and loglcal lnformed declslon abouL
meLhod of dellvery wlLh carers recommendlng whaL Lhey percelve Lo be Lhe besL course
of acLlon ln keeplng wlLh Lhe avallable evldence
W AsslsL Lhe woman and her famlly Lo prepare emoLlonally and psychologlcally for Lhe
procedure
W Consent for CS
ConsenL for CS should be requesLed afLer provldlng pregnanL women wlLh evldence based
lnformaLlon and ln a manner LhaL respecLs Lhe woman's dlgnlLy prlvacy vlews and culLure
whllsL Laklng lnLo conslderaLlon Lhe cllnlcal slLuaLlon
W Materna| Sat|sfact|on dur|n CS
W Jomen's preferences for Lhe blrLh
such as
W muslc playlng ln LheaLre
W lowerlng Lhe screen Lo see baby born or
W sllence so LhaL Lhe moLher's volce ls Lhe flrsL baby hears and
W lowerlng Lhe llghLs ln LheaLre
durlng CS are needed should be accommodaLed where posslble
f CS ls dolng under reglonal anasLhesla
W @lmlng Cf CS
W Cesarean dellverles may be performed because of maLernal or feLal problems LhaL arlse
durlng labor or Lhey may be planned before Lhe moLher goes lnLo labor
W LlecLlve cesarean dellvery
W elecLlve caesarean secLlon may be [usLlfled buL declslons musL Lake lnLo accounL Lhe
rlsk Lo Lhe lnfanL assoclaLed wlLh dellvery before 39 weeks gesLaLlon
W L ls now clear LhaL resplraLory dlsLress syndrome ls lndeed seen ln Lerm lnfanLs and ls
a conslderable source of morbldlLy and morLallLy ln Lhls group
W mechanlcal venLllaLlon Lo LreaL presumed surfacLanL deflclency ls 120 Llmes more llkely
Lo be needed afLer elecLlve dellvery aL 3738 weeks Lhan afLer dellvery aL 3941 weeks
W Lmergency cesarean secLlon
W n cases of suspecLed or conflrmed acuLe feLal compromlse
W dellvery should be accompllshed as soon as posslble
W @he accepLed sLandard ls wlLhln 30 mlnuLes
W 9reoperaLlve LesLlng and preparaLlon for CS
W 9regnanL women should be offered a haemoglobln assessmenL before CS Lo ldenLlfy
Lhose who have anaemla AlLhough blood loss of more Lhan 1000ml ls lnfrequenL afLer
CS (lL occurs ln 4 Lo 8 of CS) lL ls a poLenLlally serlous compllcaLlon
W 9regnanL women havlng CS for anLe parLum haemorrhage abrupLlon uLerlne rupLure
and placenLa praevla are aL lncreased rlsk of blood loss greaLer Lhan 1000 ml and should
have Lhe CS carrled ouL aL a maLernlLy unlL wlLh onslLe blood Lransfuslon servlces
W 9rescrlbe anLlbloLlcs (one dose of flrsLgeneraLlon cephalosporln or amplclllln)
W Assess rlsk for Lhromboembollc dlsease (offer graduaLed sLocklngs hydraLlon early
moblllsaLlon and low molecular welghL heparln)
W @o reduce Lhe rlsk of asplraLlon pneumonlLls LmpLy sLomach 9remedlcaLlon wlLh lve
an anLacld (sodlum clLraLe 03 30 mL or magneslum LrlslllcaLe 300 mg) + C|met|d|ne v
1 hr before CS
W Jomen havlng CS wlLh reglonal anesLhesla requlre an lndwelllng urlnary caLheLer Lo
prevenL overdlsLenslon of Lhe bladder because Lhe anaesLheLlc block lnLerferes wlLh
normal bladder funcLlon
W MaLernal 9oslLlon urlng CS
W All obsLeLrlc paLlenLs undergolng CS should be poslLloned wlLh lefL laLeral LllL Lo avold
aorLocaval compresslon
W 8y LllLlng Lhe operaLlng Lable Lo Lhe lefL
or place a plllow or folded llnen under her rlghL lower back
W Catheter|sat|on
kout|ne catheter|sat|on vs no catheter|sat|on
Indwe|||n vs |nandout catheter
Indwe|||n catheter for durat|on of CS vs for 24 hrs
no evldence
Cochrane rotoco|s ndwelllng bladder caLheLerlsaLlon as parL of posLoperaLlve care for
caesarean secLlon
W 9reoxygenaLlon 8efore nducLlon for Cesarean SecLlon
W 4 maxlmally deep lnsplraLlons
were demonsLraLed Lo be as effecLlve
as a 3mln lnhalaLlon of 100 C2
for preoxygenaLlon
before lnducLlon of a general anaesLhesla
for Cesarean secLlon
W AnaesLhesla
W 1 eneral anaesLheLlc
W 2 8eglonal anaesLhesla ( Lpldural block Splnal block )
W 3 nfllLraLlon of local anaesLheLlc agenLs

W 8eglonal anaesLhesla ls regarded as conslderably safer Lhan general anaesLhesla wlLh
respecL Lo maLernal morLallLy
W 8eglonal anesLhesla ls generally preferred because lL allows Lhe moLher Lo remaln
awake experlence Lhe blrLh and have lmmedlaLe conLacL wlLh her lnfanL L ls usually
safer Lhan general anesLhesla Many pracLlLloners prefer splnal or CSL Lo epldural
Lechnlques because of more rapld onseL and beLLer blockage of paln
W 9repare @he skln
W Jash Lhe area around Lhe proposed lnclslon slLe wlLh soap and waLer
W o noL shave Lhe woman's publc halr as Lhls lncreases Lhe rlsk of wound lnfecLlon @he
halr may be Lrlmmed lf necessary
W SLerllze @he Skln
W at|ents sk|n at the operat|on s|te |s rout|ne|y c|eaned w|th ant|sept|c so|ut|ons efore
surery Ant|sept|c sk|n c|eans|n efore surery |s thouht to reduce the r|sk of
postoperat|ve wound |nfect|ons
W Apply anLlsepLlc soluLlon Lhree Llmes Lo Lhe lnclslon slLe uslng a hlghlevel dlslnfecLed
rlng forceps and coLLon or gauze swab f Lhe swab ls held wlLh a gloved hand do noL
conLamlnaLe Lhe glove by Louchlng unprepared skln
W 8egln aL Lhe proposed lnclslon slLe and work ouLward ln a clrcular moLlon away from
Lhe lnclslon slLe
W AL Lhe edge of Lhe sLerlle fleld dlscard Lhe swab
W never go back Lo Lhe mlddle of Lhe prepared area wlLh Lhe same swab keep your arms
and elbows hlgh and surglcal dress away from Lhe surglcal fleld
W ut 1here |s |nsuff|c|ent ev|dence on whether c|ean|n pat|ents sk|n w|th ant|sept|c
efore c|ean surery reduces wound |nfect|ons after surery
W rape @he Skln
W rape the woman |mmed|ate|y after the area |s prepared to avo|d contam|nat|on
W If the drape has a w|ndow p|ace the w|ndow d|rect|y over the |nc|s|on s|te f|rst
W Unfo|d the drape away from the |nc|s|on s|te to avo|d contam|nat|on
W @he use of separaLe surglcal knlves Lo lnclse Lhe skln and Lhe deeper Llssues aL CS ls noL
recommended because lL does noL decrease wound lnfecLlon
W 8C@s are needed Lo evaluaLe Lhe effecLlveness of lnclslons made wlLh dlaLhermy
compared wlLh surglcal knlfe ln Lerms of operaLlng Llme wound lnfecLlon wound Lenslle
sLrengLh cosmeLlc appearance and women's saLlsfacLlon wlLh Lhe experlence
W Adom|na| entry
W C lnclslon (C)
W @he C lnclslon ls performed by a superflclal Lransverse cuL ln Lhe cuLls abouL 3 cm
below an lmaglnary llne connecLlng Lhe splnae lllacae anLero superlor cuLLlng only
Lhrough Lhe cuLls
W n Lhe mldllne whlch ls free from large blood vessels Lhe cuL ls deepened Lo Lhe fascla
W A small Lransverse openlng ls made ln Lhe fascla and Lhen Lhe fascla ls opened
Lransversely underneaLh Lhe faL Llssue and blood vessels by pushlng Lhe sllghLly open Llp
of a palr of sLralghL sclssors flrsL ln one dlrecLlon and Lhen ln Lhe oLher
W @he fascla ls sLreLched caudally and cranlally uslng Lhe lndex flngers Lo make room for
Lhe nexL sLep
W @he surgeon and hls asslsLanL each lnserL Lhelr lndex and Lhlrd flngers under Lhe
muscles and sLreLch Lhe muscles blood vessels and Lhe faL Llssue by manual bllaLeral
LracLlon
W
Sharp (fannenst|e|) vs |unt (Ioe| Cohen)
lmprovemenL ln febrlle morbldlLy wlLh C
@here was llLLle dlfference ln wound lnfecLlon
no daLa avallable for endomeLrlLls
@he baslc prlnclples of Lhe blunL oel Cohen lnclslon lnclude a shorLer surglcal
Llme mlnlmlsaLlon of Llssue damage operaLlng ln harmony wlLh bodys anaLomy
physlology and mlnlmal use of lnsLrumenLsless fever less paln and less
analgeslc requlremenLs less blood loss and shorLer hosplLal sLay
ar|eta| er|tonea| Inc|s|on
W Dse flngers Lo make an openlng ln Lhe perlLoneum near Lhe umblllcus Lhen lengLhen Lhe
lnclslon up and down ln order Lo see Lhe enLlre uLerus
W Cr Dse sclssors Lo lengLhen Lhe lnclslon up and down ln order Lo see Lhe enLlre uLerus
Carefully Lo prevenL bladder ln[ury use sclssors Lo separaLe layers and open Lhe lower parL of
Lhe perlLoneum
W 9acks
W @he uLerus ls cenLrallsed Lhe bowel and omenLum are packed off wlLh molsL laparoLomy
pads
W however
W Lhls ls usually unnecessary
W V|scera| er|tonea| Inc|s|on
W 9lace a bladder reLracLor over Lhe publc bone
W Dse forceps Lo plck up Lhe loose perlLoneum coverlng Lhe anLerlor surface of Lhe lower
uLerlne segmenL and lnclse wlLh sclssors
W LxLend Lhe lnclslon by placlng Lhe sclssors beLween Lhe uLerus and Lhe loose serosa and
cuLLlng abouL 3 cm on each slde ln a Lransverse fashlon
W Dse Lwo flngers Lo push Lhe bladder downwards off of Lhe lower uLerlne segmenL
8eplace Lhe bladder reLracLor over Lhe publc bone and bladder
W DLerlne nclslon
W Abdomlnal cesarean secLlon
W LxLraperlLoneal cesarean secLlon LaLzko operaLlon
W lnLraperlLoneal cesarean secLlon
1Cervlcal A a Lransverse or curved (horlzonLal) kerr operaLlon
Low Lransverse lf cx ls dllaLed less Lhan 3 cm
Plgh Lransverse lf cx ls dllaLed more Lhan 3 cm
8verLlcal lnclslon ln Lhe lower uLerus Selhelm operaLlon
2 Classlcala verLlcal lnclslon ln Lhe maln body of Lhe uLerus Sanger operaLlon
3nverLed @shaped lnclslon elee operaLlon
4 shaped
W vaglnal cesarean secLlon
W
W Sharp vs |unt uter|ne entry
W noL enough evldence
W A sem||unar mark |s made y the sca|pe| cutt|n part|a||y throuh the myometr|um for
10 cm
W A short (3cm) cut |s made |n the m|dd|e of th|s |nc|s|on mark reach|n up to ut not
throuh the memranes
W 1he |nc|s|on |s comp|eted y the 2 |ndex f|ners a|on the |nc|s|on mark
W If the |ower uter|ne sement |s very th|n |n[ury of the foetus can e avo|ded y us|n
the hand|e of the sca|pe| or a haemostat (an artery forceps) to open the uterus
W 1he short (3cm) m|dd|e |nc|s|on may e en|ared y a andae sc|ssors over 2 f|ners
|ntroduced |nto the uterus to protect the foetus
W narrow uLerlne lnclslon
W LxLenslon of Lhe lower uLerlne segmenL lnclslon may be done by
W 1 shaped or hockeysLlck lnclslon le exLenslon of one end of Lhe Lransverse
semllunar lnclslon upwards
W 2 D shaped or Lrapdoor lnclslon le exLenslon of boLh ends upwards
W 3 An lnverLed @ lnclslon le cuLLlng upwards from Lhe mlddle of Lhe Lransverse lnclslon
@hls ls Lhe worsL cholce because of lLs dlfflculL repalr and poor heallng
W Membranes are rupLured by LooLhed or kocher's forceps
W LLIVLk 1nL A
W 1o de||ver the ay p|ace one hand |ns|de the uter|ne cav|ty etween the uterus and
the ay's head
W J|th the f|ners rasp and f|ex the head
W ent|y ||ft the ay's head throuh the |nc|s|on tak|n care not to extend the |nc|s|on
down towards the cerv|x
W J|th the other hand ent|y press on the adomen over the top of the uterus to he|p
de||ver the head
W f Lhe ay's head |s deep down |n the pe|v|s or va|na
Ask an asslsLanL (wearlng hlghlevel dlslnfecLed gloves) Lo reach lnLo Lhe vaglna and push Lhe
baby's head up Lhrough Lhe vaglna @hen llfL and dellver Lhe head
W Safe de||very of the feta| head dur|n cesarean sect|on
W JlLh Lhe goals of mlnlmlzlng delay head compresslon and sLraln on Lhe uLerlne
lnclslon a sequence of maneuvers Lhe elevaLe roLaLe and reduce (L88) Lechnlque for
expedlLlous dellvery of Lhe head from a deep pelvlc sLaLlon @o prevenL exLenslon of Lhe
uLerlne lnclslon and rlsk ln[ury Lo Lhe uLerlne vessels and bladder
W 9oslLlon yourself so your upper Lrunk arm and hand move as a unlL Lo elevaLe Lhe head
W L|evate Lock the f|ners |nto a quarterc|rc|e around the vertex App|y tract|on out of
the pe|v|s w|th the hand and the ent|re extended arm
W kotate rasp the feta| head etween the thum and f|ners and rotate |t so the
occ|put faces the |nc|s|on
W keduce ush the |ower ede of the uter|ne |nc|s|on down unt|| |t |s poster|or to the
feta| head
W AsplraLe nose and mouLh of newborn
W Cord Clamplng
W SuggesLed beneflLs of delayed cord clamplng lnclude decreased neonaLal anaemla
W 8eLLer sysLemlc and pulmonary perfuslon and beLLer breasLfeedlng ouLcomes
W 9osslble harms are
polycyLhaemla hypervlscoslLy hyperblllrublnaemla LranslenL Lachypnoea of Lhe
newborn and rlsk of maLernal feLal Lransfuslon ln rhesus negaLlve women
W lve newborn @o 9edlaLrlLlon
W resence of paed|atr|c|an at CS
W An approprlaLely Lralned pracLlLloner skllled ln Lhe resusclLaLlon of Lhe newborn should
be presenL aL CS performed under general anaesLhesla or where Lhere ls evldence of
feLal compromlse
W lnfanLs born by CS wlLh general anaesLhesla are aL an lncreased rlsk of havlng 1 and 3
mlnuLe Apgar scores of less Lhan 7 when compared wlLh Lhose born by CS wlLh reglonal
anaesLhesla (1mlnuLe Apgar less Lhan 7
W Materna| contact (sk|n to sk|n)
W Larly sklnLoskln conLacL beLween Lhe woman and her baby should be encouraged
and faclllLaLed because lL lmproves maLernal percepLlons of Lhelr lnfanL moLherlng
skllls maLernal behavlour breasLfeedlng ouLcomes and reduces lnfanL crylng
W reastfeed|n
W Jomen who have had a CS should be offered addlLlonal supporL Lo help Lhem Lo sLarL
breasLfeedlng as soon posslble afLer Lhe blrLh of Lhelr baby
W @hls ls because women who have had a CS are less llkely Lo sLarL breasLfeedlng ln Lhe
flrsL few hours afLer Lhe blrLh buL when breasLfeedlng ls esLabllshed Lhey are as llkely
Lo conLlnue as women who have a vaglnal blrLh
W @he placenLa was manually removed or sponLaneously dellvered
W AL CS Lhe placenLa should be removed uslng conLrolled cord LracLlon and noL manual
removal as Lhls reduces Lhe rlsk of endomeLrlLls
W SponLaneous dellvery of Lhe placenLa may reduce blood loss and decrease Lhe chance of
posLoperaLlve endomeLrlLls
W y keep|n ent|e tract|on on the cord and massae (ru) the uterus throuh the
adomen
W e||ver the p|acenta and memranes
W |ve xytoc|n
W lve oxyLocln 20 unlLs ln 1 L v flulds (normal sallne or 8lnger's lacLaLe) aL 60 drops per
mlnuLe for 2 hours
W Lo encourage conLracLlon of Lhe uLerus and Lo decrease blood loss

W 9rophylacLlc anLlbloLlcs wlLh cesarean secLlon
(lmmedlaLely afLer Lhe cord ls clamped versus preoperaLlve)
W lve a slngle dose lnLravenously of prophylacLlc anLlbloLlcs afLer Lhe cord ls clamped and
cuL
W amplclllln 2 g v C8 cefazolln 1 g v provldes adequaLe prophylaxls
W no addlLlonal beneflL has been demonsLraLed wlLh Lhe use of mulLlpledose reglmens
W however no consensus on Lhe opLlmal Llmlng of admlnlsLraLlon and doses
W 1here |s a|so no ev|dence that the transp|acenta| passae of prophy|act|c amp|c||||n
|ncreases |mmed|ate or de|ayed neonata| |nfect|ons
W LxLerlorlsaLlon of uLerus for repalr vs lnLraabdomlnal repalr
LxLerlorlsaLlon assoclaLed wlLh reducLlon ln febrlle
morbldlLy and dlagnosls of uLerlne anomalles
buL no effecL on endomeLrlLls wound
compllcaLlon sepsls or blood Lransfuslon
DLerlne swabblng vs no swabblng prlor Lo uLerlne closure
no evldence
Slngle vs double layer uLerlne closure
no dlfference found beLween Lhe groups
no effecL on endomeLrlLls or blood Lransfuslons
W @he effecLlveness and safeLy of slngle layer closure of Lhe uLerlne lnclslon
ls uncerLalnLxcepL wlLhln a research conLexL Lhe uLerlne lnclslon should
be suLured wlLh Lwo layers
W DLerlne repalr
chromlc caLguL vs vlcryl
locklng vs nonlocklng suLure
conLlnuous vs lnLerrupLed suLures
no sLudles found
W er|tonea| C|osure
perlLoneal closure vs nonclosure (9elvlc parleLal boLh )
nonclosure assoclaLed wlLh less posLop fever
buL no slgnlflcanL effecL on wound lnfecLlon or endomeLrlLls
new Lrlal fewer adheslons ln closure
W nelLher Lhe vlsceral nor parleLal perlLoneum should be suLured aL CS as Lhls reduces
operaLlng Llme Lhe need for posLoperaLlve analgesla and lmproves maLernal
saLlsfacLlon
W none of Lhe 8C@s reporLed long Lerm ouLcomes relaLed Lo heallng and scarrlng or
lmpllcaLlons for fuLure surgery
Mater|a|s for c|osure of the per|toneum
plaln caLguL vs vlcryl vs chromlc caLguL
no evldence
W Sheath
Chromlc caLguL vs plaln caLguL vs vlcryl for sheaLh repalr
no sLudles found
Locked conLlnuous vs nonlocked conLlnuous closure
no sLudles found
W Lhe subcuLaneous Llssue
Lhe subcuLaneous Llssue (faL and/or camper fascla) closure vs no closure
W no effecL on wound lnfecLlon alone (buL closure assoclaLed wlLh less wound
compllcaLlon" and no effecL on endomeLrlLls)
W 8ouLlne closure of Lhe subcuLanoues Llssue space should noL be used unless Lhe
woman has more Lhan 2 cm subcuLaneous faL because lL does noL reduce Lhe
lncldence of wound lnfecLlon
W SubcuLaneous conLlnous absorbable suLure vs
lnLerrupLed absorbable suLure
no effecL on lnfecLlon
W llberal vs resLrlcLed use of a subsheaLh draln
Superflclal wound draln should noL be used aL CS because Lhey do noL decrease Lhe lncldence of
wound lnfecLlon or wound haemaLoma
W Sk|n c|osure
W Compared sLaples vs absorbable subcuLlcular suLure
no effecL on lnfecLlon
CbsLeLrlclans should be aware LhaL Lhe effecLs of dlfferenL suLure maLerlals or
meLhods of skln closure aL CS are noL cerLaln
More 8C@s are needed Lo deLermlne Lhe effecL of sLaples compared Lo
subcuLlcular suLures for skln closure aL CS on posLoperaLlve paln cosmeLlc
appearance and removal of suLures and sLaples
mmedlaLe posLoperaLlve care
W AfLer surgery ls compleLed Lhe woman wlll be monlLored ln a recovery area
W Lo ensure LhaL Lhe uLerus remalns conLracLed LhaL Lhere ls no excesslve vaglnal bleedlng
or bleedlng aL Lhe lnclslon slLe LhaL Lhere ls adequaLe urlne ouLpuL and Lo monlLor
rouLlne vlLal slgns (blood pressure LemperaLure breaLhlng) 9aln medlcaLlon ls also
glven lnlLlally Lhrough Lhe v llne and laLer wlLh oral medlcaLlons
W Jhen Lhe effecLs of anesLhesla have worn off abouL four Lo elghL hours afLer surgery
Lhe woman ls Lransferred Lo a posLparLum room
W Analgesla AfLer Cesarean SecLlon
AdequaLe posLoperaLlve paln conLrol ls lmporLanL A woman who ls ln severe paln does noL
recover well
Avold over sedaLlon as Lhls wlll llmlL moblllLy whlch ls lmporLanL durlng Lhe posLoperaLlve
perlod
W Jomen should be offered dlamorphlne (0304 mg lnLraLhecally) for lnLra and
W posLoperaLlve analgesla because lL reduces Lhe need for supplemenLal analgesla afLer
W a CS
W deally a mulLlmodal approach Lo posLoperaLlve analgesla ls employed ln order Lo besL
conLrol Lhe paLlenL's paln synerglsLlcally
W n Lhls manner ldeally less of each lndlvldual drug ls requlred Lo conLrol paln
W nSAs have been shown Lo poLenLlaLe Lhe effecLs of oplolds
W Addlng aceLamlnophen also poLenLlaLes Lhe effecLs of Lhe oLher medlcaLlons wlLh very
llLLle addlLlonal adverse rlsk
W analgeslc recLal supposlLorles for rellef of paln ln women followlng caesarean secLlon
W Jound lnfllLraLlon wlLh local anaesLheLlc may furLher asslsL wlLh posLoperaLlve
analgesla and cerLalnly carrles mlnlmal rlsk alLhough sLudles of beneflL are confllcLlng Lo
daLe
W AnLlbloLlcs afLer cs
W f Lhere were slgns of lnfecLlon or Lhe woman currenLly has fever conLlnue anLlbloLlcs
unLll Lhe woman ls feverfree for 48 hours
W Cral flulds and food afLer caesarean secLlon early versus delayed lnlLlaLlon
W f Lhe surglcal procedure was uncompllcaLed glve Lhe woman a llquld dleL
W f Lhere were slgns of lnfecLlon or lf Lhe cesarean was for obsLrucLed labour or uLerlne
rupLure walL unLll bowel sounds are heard before glvlng llqulds
W Jhen Lhe woman ls passlng gas begln glvlng her solld food
W f Lhe woman ls recelvlng v flulds Lhey should be conLlnued unLll she ls Laklng llqulds
well
W f you anLlclpaLe LhaL Lhe woman wlll recelve v flulds for 48 hours or more lnfuse a
balanced elecLrolyLe soluLlon (eg poLasslum chlorlde 13 g ln 1 L v flulds
W f Lhe woman recelves v flulds for more Lhan 48 hours monlLor elecLrolyLes every 48
hours 9rolonged lnfuslon of v flulds can alLer elecLrolyLe balance
W Lnsure Lhe woman ls eaLlng a regular dleL prlor Lo dlscharge from hosplLal
W Jomen who are recoverlng well and who do noL have compllcaLlons afLer CS can eaL
and drlnk when Lhey feel hungry or LhlrsLy
W rlnklng afLer cs
W oral lnLake was lnlLlaLed earller ln Lhe slmpllfled Lechnlque group (68 hoursop vs 1012
hours posLop)
W 8emoval of Lhe urlnary bladder caLheLer should be carrled ouL once a woman ls moblle
afLer a reglonal anaesLheLlc and noL sooner Lhan 12 hours afLer Lhe lasL epldural 'Lop up'
dose
W AmbulaLlon afLer cs
W AmbulaLlon sLarLed earller ln Lhe slmpllfled Lechnlque group (68 hours posLop vs 1012
hours posLop)
W AmbulaLlon enhances clrculaLlon encourages deep breaLhlng and sLlmulaLes reLurn of
normal gasLrolnLesLlnal funcLlon Lncourage fooL and leg exerclses and moblllze as soon
as posslble usually wlLhln 24 hours
W A pedlaLrlclan wlll examlne Lhe baby wlLhln Lhe flrsL 24 hours of Lhe dellvery
W resslng and wound care
W @he dresslng provldes a proLecLlve barrler agalnsL lnfecLlon whlle a heallng process
known as reeplLhellallzaLlon" occurs keep Lhe dresslng on Lhe wound for Lhe flrsL day
afLer surgery Lo proLecL agalnsL lnfecLlon whlle reeplLhellallzaLlon occurs @hereafLer a
dresslng ls noL necessary
W f blood or fluld ls leaklng Lhrough Lhe lnlLlal dresslng do noL change Lhe dresslng
8elnforce Lhe dresslng
MonlLor Lhe amounL of blood/fluld losL by ouLllnlng Lhe blood sLaln on Lhe dresslng wlLh a
pen
W f bleedlng lncreases or Lhe blood sLaln covers half Lhe dresslng or more remove Lhe
dresslng and lnspecL Lhe wound 8eplace wlLh anoLher sLerlle dresslng
W f Lhe dresslng comes loose relnforce wlLh more Lape raLher Lhan removlng Lhe
dresslng @hls wlll help malnLaln Lhe sLerlllLy of Lhe dresslng and reduce Lhe rlsk of
wound lnfecLlon
W Change Lhe dresslng uslng sLerlle Lechnlque
W Lenth of hosp|ta| stay
W LengLh of hosplLal sLay ls llkely Lo be longer afLer a CS (an average of 34 days) Lhan
afLer a vaglnal blrLh (average 12 days) Powever women who are recoverlng well are
apyrexlal and do noL have compllcaLlons followlng CS should be offered earlydlscharge
(afLer 24 hours) from hosplLal and follow up aL home because Lhls ls noL assoclaLed wlLh
more lnfanL or maLernal readmlsslons
W vomlLlng afLer cs
W nel uan (9 6) polnL ls locaLed 2 cun or abouL 3 cm above Lhe Lransverse crease of Lhe
wrlsL beLween Lhe Lendons of m polmotls looqos and m flexot cotpl toJlolls @he name
of Lhe polnL means nner 9ass" or nner aLe
W SLlmulaLlon of nelguan (9C 6) lnduced favorable regulaLlon of boLh Lhe perlpheral
nervous sysLem and cenLral nervous sysLem and changes of Lhe gasLrolnLesLlnal
hormone secreLlon may conLrlbuLe Lo lLs effecLs ln LreaLlng varlous dlsorders
W @here ls sclenLlflc evldence from numerous sLudles supporLlng Lhe use of wrlsL
acupressure aL Lhe 96 acupolnL (also known as -elqooo) ln Lhe prevenLlon and
LreaLmenL of nausea and vomlLlng n parLlcular Lhls research has reporLed
effecLlveness for posLoperaLlve nausea lnLraoperaLlve nausea (durlng splnal
anesLhesla) chemoLherapylnduced nausea and moLlonrelaLed and pregnancyrelaLed
nausea (mornlng slckness) LffecLs have been noLed ln boLh chlldren and adulLs @hls
Lherapy has grown ln popularlLy because lL ls nonlnvaslve ls easy Lo selfadmlnlsLer has
no observable slde effecLs and ls low cosL
W Success of acupuncLure and acupressure of Lhe pc 6 acupolnL ln Lhe LreaLmenL of
hyperemesls gravldarum
W Lhe PemosLaLlc Cesarean SecLlon
W as a new surglcal Lechnlque Lo manage pregnanL women lnfecLed wlLh Pv1
W @hls ls an elecLlve cesarean secLlon wlLh Lechnlcal modlflcaLlon L ls used ln all paLlenLs
plus anLlreLrovlral LreaLmenL(A8v) and breasL feedlng perlod has been lnhlblLed
W @he PemosLaLlc Cesarean SecLlon (programmed aL 38 weeks from gesLaLlon ln lnLacL
membranes and noL ln labour) and consenL of paLlenLs L conslsL ln Lhe managemenL of
lower uLerlne segmenL keeplng lnLegrlLy of membranes avoldlng Lhe masslve conLacL
beLween maLernal blood and Lhe feLus
W @hls Lechnlque has shown Lo be useful as lL decreases verLlcal Lransmlsslon Lo less Lhan
2
W Caesarean SLerlllzaLlon
W @ubal llgaLlon (sLerlllzaLlon) may also be performed durlng cesarean dellvery
W 1ua| ||at|on can e done |mmed|ate|y fo||ow|n caesarean sect|on |f the woman
requested the procedure efore |aour ean (dur|n prenata| v|s|ts) Adequate
counse|||n and |nformed dec|s|onmak|n and consent must precede vo|untary
ster|||zat|on procedures th|s |s often not poss||e dur|n |aour and de||very
W kev|ew for consent of pat|ent
W rasp the |east vascu|ar m|dd|e port|on of the fa||op|an tue w|th a acock or A|||s
forceps
W no|d up a |oop of tue 2 cm |n |enth (| 24 A)
W Crush the ase of the |oop w|th artery forceps and ||ate |t w|th 0 p|a|n catut suture
(| 24 )
W Lxc|se the |oop (a sement 1 cm |n |enth) throuh the crushed area (| 24)
W kepeat the procedure on the other s|de
W Caesarean myomecLomy
W Lhere ls no slgnlflcanL dlfference ln lnLraoperaLlve and posLoperaLlve morbldlLy and
blood loss ln performlng caesarean secLlon alone and caesarean secLlon wlLh
myomecLomy when a LournlqueL ls applled
W Caesarean secLlon ln A8@
W @he average lncldence of CS ls 20
W Caesarean secLlon ls 3 Llmes hlgher ln A8@ due Lo
Advanced age of Lhe moLher
9reclous baby
More lncldence of plural pregnancy
W Cesarean PysLerecLomy
W PysLerecLomy ls carrled ouL afLer caesarean secLlon ln Lhe same slLLlng for one of Lhe
followlng reasons
W DnconLrollable posLparLum haemorrhage
W Dnrepalrable rupLure uLerus
W Cperable cancer cervlx
W Couvelalre uLerus
W 9lacenLa accreLa cannoL be separaLed
W Severe uLerlne lnfecLlon parLlcularly LhaL caused by Cl welchll
W MulLlple uLerlne myomas ln a woman noL deslrlng fuLure pregnancy alLhough lL ls
preferred Lo do lL 3 monLhs laLer
W 9erlmorLem Cesarean ellvery( 9MC)
W 9MC has evolved Lhrough 23 cenLurles from a means of provldlng approprlaLe burlal
and/or rlLual for boLh moLher and baby Lo a way of savlng a chllds llfe when maLernal
deaLh ls lnevlLable Lo a meLhod of opLlmlzlng resusclLaLlon for boLh moLher and baby
W 8epeaLed CS ls safer Lhan v8AC
W should we be promoLlng v8AC whlch may carry greaLer rlsks
W Lo Lhe lndlvldual for Lhe purposes of reduclng an undeslrable sLaLlsLlc"?
W n our counLry where famlly slzes are now volunLarlly llmlLed
W ls lL ln Lhe woman's lnLeresLs Lo Lry for a v8AC?
W Causes of a weak scar
1 mproper haemosLasls
2 mperfecL coapLaLlon (Dndue hasLe)
3 nverslon of decldua
4 LxLenslon of Lhe angles
3 nfecLlon durlng heallng
6 9lacenLal lmplanLaLlon
7 CverdlsLenslon of Lhe uLerus
W AssessmenL of scar lnLegrlLy
W PysLerogram
efect |n the |atera| v|ew
W DlLrasonlc measuremenL
Scar defecLs
Scar Lhlckness
W CuLoff value of 33 mm aL 36 weeks (n9v of 993 (8ozenberg eL al
1996)
W Manual exploraLlon
W 8leedlng
W @hlrd sLage Lroubles
W mpendlng scar rupLure
W 9aln over Lhe scar
W MaLernal Lachycardla
W eLal dlsLress
W 9oor progress
W vaglnal bleedlng
W v8AC should be lndlvlduallzed
W @he moLher should share ln Lhe declslon
W Cnly Lrled ln well equlpped hosplLals
W lfflculL vaglnal Lrlal endlng ln fallure uLerlne rupLure or pelvlc floor dysfuncLlon leaves
ln Lhe paLlenL's mlnd a scar more worse Lhan Lhe scar on her abdomen
W Surglcal Lechnlques for cesarean secLlon
W Cesarean secLlon ls probably one of Lhe oldesL and cerLalnly one of Lhe mosL commonly
performed surglcal procedures ln obsLeLrlcs and gynecology @here ls always a rlsk ln
aLLempLlng Lo elaboraLe excesslvely on such a common operaLlon Lach of us wlll
develop our own personal blases based on lndlvldual experlence and experLlse @hese
dlfferences are superflclally dlsLlncL buL usually have underlylng slmllarlLles LhaL allow us
Lo achleve slmllar ouLcomes and expecLaLlons AL Lhe same Llme however lL ls
lmporLanL Lo recognlze LhaL Lhere ls a dlfference beLween repeLlLlon and hablL as
opposed Lo alLerlng a Lechnlque ln order Lo meeL a speclflc end Cbvlously wlLh
cesarean secLlon Lhere can be several ways Lo accompllsh Lhe same resulL and cerLaln
slLuaLlons wlll dlcLaLe Lhe lndlvlduallzaLlon (paLlenL noL physlclan) of Lechnlque
CerLalnly one has Lo be aware of hls or her own experLlse and aL Lhe same Llme know
hls or her opLlons L seems besL noL Lo llmlL oneself Lo Lhe same Lechnlque under all
clrcumsLances buL Lo be able Lo anLlclpaLe problems and know how Lo recLlfy Lhem ln a
manner LhaL wlll avold undue ln[ury or compromlse Lo Lhe lnfanL and moLher
W o
W Jear double gloves for CS for women who are PvposlLlve
W Dse a Lransverse lower abdomlnal lnclslon (oel Cohen lnclslon)
W Dse blunL exLenslon of Lhe uLerlne lnclslon
W lve oxyLocln (3lu) by slow lnLravenous ln[ecLlon
W Dse conLrolled cord LracLlon for removal of Lhe placenLa
W Close Lhe uLerlne lnclslon wlLh Lwo suLure layers
W Check umblllcal arLery pP lf CS performed for feLal compromlse
W Conslder women's preferences for blrLh (such as muslc playlng ln LheaLre)
W aclllLaLe early sklnLoskln conLacL for moLher and baby
W on't
W on'L Close subcuLaneous space (unless 2 cm faL)
W on'L Dse superflclal wound dralns
W on'L Dse separaLe surglcal knlves for skln and deeper Llssues
W on'L Dse rouLlnely use forceps Lo dellver bables head
W on'L SuLure elLher Lhe vlsceral or Lhe parleLal perlLoneum
W on'L LxLerlorlse Lhe uLerus
W on'L Manually remove Lhe placenLa
W Conslder CS compllcaLlons
W LndomeLrlLls lf excesslve vaglnal bleedlng
W @hromboembollsm lf cough or swollen calf
W Drlnary LracL lnfecLlon lf urlnary sympLoms
W Drlnary LracL Lrauma (flsLula) lf leaklng urlne
W Cesarean secLlon
slmpllfled Lechnlque
vS convenLlonal Lechnlque
W @he cesarean secLlon slmpllfled Lechnlque ls a safe procedure fasL and easy Lo perform
LhaL decreases Lhe posLoperaLlve paln and decreases Lhe appearance of posLoperaLlve
paralyLlc lleum