CONTENT

Definition Type of caesarean section Comparing both types Indication Preparation and procedure for caesarean section complication

DEFINITON OF CAESAREAN SECTION

Operative procedure To deliver fetus/baby Via transabdominal

Brief history
Caesarean believe take from Julius caesar who deliver via an operation caesar= kizar(latin) mean to cut Classically they been done through vertical incision 1920s, Munro Kerr introduce lower segment incision.

Type of caesarean section

Classified by type of incision 1. Skin incision - pfannenstiel incision: suprapubic, transverse incision - midline incision: below umbilicus until just above symphisis pubis, vertical incision 2. Uterine incision - lower segment incision (transverse) - classsical incision(vertical)

 Lower segment incision usually done after lower segment of uterus is well formed >28 weeks Vertical skin incision done if quick access to abdomen is required such as in cord prolapse and also done in: - post mortem caesarean section - patient with ovarian cyst - patient with previous midline scar

Classical vs lower segment cut

LOWER SEGMENT INCISION CLASSICAL INCISION

Avascular part - Low risk of bleeding intraoperatively

Lower part of uterus not active (not conttract & retract) during labour

Very vascular and thick part - High risk of bleeding intraoperatively

Upper part of uterus is active ( contract & retract) during labour

- lower risk of uterine rupture in subsequent pregnancy

Ready access to presenting part Lower part of uterus does not involve in pospartum involution

- Higher risk of uterine rupture in subdequent pregnancy

Does not give access to presenting part Upper part of uterus involve in postpartum involution

- The suture can heal well

- The suture tend to loose and poor heal

When to perform classical incision

1. if lower segment of uterus is not accessible - fibroid at lower uterus - adhesion between bladder and uterus 2. Tranverse lie fetus with the back at inferior part of uterus 3. Placenta previa or abruptio placenta which the great vessel at lower part 4. Plan to proceed with radical hysterectomy (for cervical carcinoma ) after delivery the baby 5. Post mortem caesarean section 6. Preterm delivery less than 28 weeks

INDICATION
EMERGENCY LSCS 1. Fetal distress (commonest) 2. Cephalo-pelvic disproportion / dystocia 3. Umbilical cord prolapse 4. Abruptio placenta 5. Failed instrumental delivery 6. Failed induction of labour ( poor progress of labour despite time and induction was given) 7. Placenta praevia with significant bleeding 8. Eclampsia and severe pre eclampsia

INDICATION
ELECTIVE LSCS 1. cephalo-pelvic dispropotion 2. 2 or more previous LSCS scars 3. 1 previous classical caesarean section incision 4. Breech presentation 5. Intrauterine growth restriction - which fetus may not withstand stress of labour 6. Obstructed passage by tumor(eg. fibroid or cervical carcinoma

7. Elderly primigravida(especially who has history of long subfertility) - > 35 years old * not absolute indication 8. Multiple pregnancy 9. malpresentation/ malposition 10. Mother with genital herpes and HIV 11. Uncontrolled diabetes mellitus and hypertension

Pre operative preparation

Consult patient about the decision of performing caesarean section Take consent Set intravenous line for mother Put in urinary catheter Order blood Monitor mother and fetus closely Call anesthesiology and paediatrician

Intra operative procedure

Anaesthesia - epidural/ spinal - general (especially in emergency) Incision - lower segment incision - midline vertical incision

Lower segment anatomy

 Delivery of baby

 Clamp cord

Delivery of placenta ( continuous cord traction)

 Closing the suture

COMPLICATION
Anaesthesia complication - aspiration / Mendelsons syndrome(aspiration of acidic content of gastric content) especially in general anaesthesia for emergency caesarean section

 Surgical complication 1. Thromboembolism 2. Bleeding 3. Infection 4. Poor wound healing 5. Injury to bladder and ureter

 Obstetric complication(later) - High risk of scar dehiscence and uterine rupture in subsequent labour - Care and caution for spontaneous delivery careful estimation if mother wish for vaginal delivery 1. fetus weight via ultrasound 2. Pelvic capacity : erect lateral pelvicmetry(ELP) anterior posterior diameter for inlet and outlet of pelvic cavity is favourable if > 11.5cm

 If they are allowed for vaginal delivery, close monitoring sign and symptom of scar dehiscence or uterine rupture
pain between contraction(at lower abdomen) Tender over the scar mother is tachycardia and/or hypotension exessive per vaginal bleeding poor progress of labour fetal distress may associated with haematuria( due to adhesion of previous scar to wall of bladder)

Vaginal delivery in patient with 1 previous scar

Succession rate :70% Risk of scar rupture: 0.5% (1 in 200) High cautios should be taken if require induction as it will increase risk of scar rupture to 3%

# patient with 2 previous scar should not be allowed for vaginal delivery