SECTIO CESAREAN CASE PRESENTATION

INTRODUCTION
Cesarean delivery is defined as the birth of a fetus through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterotomy).

The reasons why the cesarean rate quadrupled between 1965 and 1988
1. Women are having fewer children, thus, a greater percentage of births are among nulliparas, who are at increased risk for cesarean delivery. 2. The average maternal age is rising, and older women, especially nulliparas, are at increased risk of cesarean delivery 3. The use of electronic fetal monitoring is widespread. This technique is associated with an increased cesarean delivery rate compared with intermittent fetal heart rate auscultation 4. The vast majority of fetuses presenting as breech are now delivered by cesarean 5. The incidence of midpelvic forceps and vacuum deliveries has decreased 6. Rates of labor induction continue to rise, and induced labor, especially among nulliparas, increases the risk of cesarean 7. The prevalence of obesity has risen dramatically, and obesity also increases the risk of cesarean delivery

Indications

Technique for Cesarean Delivery

Abdominal Incisions
Vertical Incision Transverse Incisions Uterine Incisions
midline vertical or a suprapubic transverse incision is used

An infraumbilical midline vertical incision The incision should be of sufficient length to allow delivery of the infant without difficulty

The incision is made at the level of the pubic hairline and is extended beyond the lateral borders of the rectus muscles. After the subcutaneous tissue has been separated from the underlying fascia for 1 cm or so on each side, the fascia is incised transversely the full length of the incision

For most cesarean deliveries, the transverse incision is the operation of choice advantages : (1) easier to repair, (2) located at a site least likely to rupture during a subsequent pregnancy, and (3) does not promote adherence of bowel or omentum to the incisional line

Transverse Cesarean Incision

Delivery of the Infant

head is elevated gently with the fingers and palm through the incision

The shoulders then are delivered using gentle traction plus fundal pressure

The rest of the body readily follows

I.V infusion containing about two ampules or 20 units of oxytocin per liter of crystalloid is infused at 10 mL/min until the uterus contracts satisfactorily

Delivery of the Infant

The cord is clamped, and the infant is given to the team member who will conduct resuscitative efforts as needed

The placenta is then delivered unless it has already done so spontaneously

Fundal massage, begun as soon as the fetus is delivered, reduces bleeding and hastens placental delivery

Delivery of the Infant

Delivery of the Infant

Repair of the Uterus

1. The uterine incision is then closed with one or two layers of continuous 0 or number 1 absorbable suture. Chromic suture is used by most surgeons, but some prefer synthetic nonabsorbable sutures

Subsequent Care
Analgesia
For the woman of average size, meperidine, 75 to 100 mg, is given intramuscularly as often as every 3 hours as needed for discomfort, or morphine sulfate, 10 to 15 mg, is similarly administered

Vital Signs
assessed at least hourly for 4 hours and thereafter. Blood pressure, pulse, temperature, uterine tone, urine output, and amount of bleeding are evaluated

Fluid Therapy and Diet

3 L of fluid should prove adequate during the first 24 hours after surgery

Bladder and Bowel Function

The bladder catheter most often can be removed by 12 hours postoperatively. In uncomplicated cases Solid food may be offered within 8 hours of surgery

Subsequent Care
Ambulation
The woman should get briefly out of bed with assistance at least twice Early ambulation lowers the risk of venous thrombosis and pulmonary embolism

Wound Care
the skin sutures or clips often can be removed on the fourth day after surgery By the third postpartum day, bathing by shower is not harmful to the incision

Laboratory
when there was unusual blood loss or when there is oliguria or other evidence to suggest hypovolemia

Breast Care
After delivery, the breasts begin to secrete colostrum, which is a deep lemonyellow-colored liquid. It usually can be expressed from the nipples by the second day

Sources
Williams Obstetrics Medscape