uncertain. The hypothesis that Julius Casear was the product of a Caesarean delivery is unlikely to be true in view of the probability of fatality associated with the procedure in the ancient times and the observation that his mother, Aurelia, corresponded with him during his campaigns in Europe many years later. History Contd The term may have as its origin the Latin verb cadere, to cut; the children of such birth were referred to as caesones. It is also possible that the term stems from the Roman law known as Lex Regis, which mandated postmortem operative delivery so that the mother and child could be buried separately; the specific law is referred to historically as Lex Cesare.
CAESAREAN SECTION IN UGANDA DURING ANCIENT DAYS Historical Advances
By the mid seventeenth century, in 1668 French obstetrician F. Mauriceau first reported sections on living woman. Although surgeons possessed the anatomic knowledge necessary to perform a Caesarean delivery Historical Advances Contd
In 1800s, they were limited by their inability to provide anesthesia and control infection. The introduction of diethyl ether and later chloroform as anesthetic agents increased the feasibility of major abdominal surgery.
Historical Advances Contd
Surgical techniques were also a limiting factor
Surgeons were hesitant to reapproximate the uterine incision for fear that permanent sutures would increase the likelihood of infection and cause uterine rupture in subsequent pregnancies.
Not surprisingly, women continued to die from blood loss and infection.
Historical Advances Contd
In 1882, Max Sanger in Germany first sutured uterine wall in Caesarean section using silver wire and silk with careful attention to haemostasis. Frank (1907) described extraperitoneal lower segment operation to avoid peritonitis. Beck (1919) and De Lee (1922) introduced lower segment operation by vertical incision. Munro Kerr (1926) gave the transverse lower segment incision for Caesarean delivery the world today.
Caesarean delivery: Definition Caesarean delivery is defined as the birth of a foetus through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterotomy) after 28 weeks of pregnancy. Definition It is an operative procedure whereby the fetuses after the end of 28 th week, are delivered through an incision on the abdominal and uterine walls.
Incidence Last decade 2-3 fold rise in C/s from the initial rate of 10% Incidence Factors for increasing caesarean section Identification of at risk fetuses before term Identification of at risk mothers. Wider use of repeat C.S. in cases with previous caesarean delivery. Decline in difficult operative or manipulative vaginal deliveries. Decline in vaginal breech delivery Increased diagnosis of fetal distress and fear of litigation. Adoption of small family norm Incidence Reduced parity: almost half of the pregnant women are nulliparous, thus an increased number of caesarean births might be expected for conditions which are more common in primigravida. Older women are having children and frequency of caesarean deliveries increases with advancing age. Incidence Contd Extensive use of electronic foetal monitoring and increased caesarean deliveries for non-reassuring foetal heart rate picked up by this technique is compared with intermittent foetal heart rate auscultation. By 1990, 83% of all breech presentations were delivered abdominally. The incidence of mid pelvic vaginal deliveries (high presentation) has decreased.
Incidence Contd Concern for malpractice litigation has contributed significantly to the present caesarean delivery rate Socioeconomic and demographic factors may play a role in caesarean birth rate.
INDICATIONS
Absolute Relative
ABSOLUTE INDICATIONS Central placenta praevia Contracted pelvis or cephalopelvic disproportion Pelvic mass causing obstruction (cervical or broad ligament fibroid) Advanced carcinoma cervix Vaginal obstruction (atresia, stenosis)
RELATIVE INDICATIONS Cephalo-pelvic disproportion (relative) Previous caesarean delivery Non reassuring FHR (fetal distress) Dystocia may be due to (three Ps) relatively large fetus (passenger), small pelvis (passage) / or inefficient uterine contractions (power). Antepartum haemorrhage (a) placenta praevia and (b) abruption placenta.
RELATIVE INDICATIONS CONTD Malpresentations Failed surgical induction of labour, Failure to progress in labour. Bad obstetric history Hypertensive disorders Medical-Gynaecological disorders Common Indications
Maternal Indications CPD and contracted pelvis Inadequate uterine force Previous classical cesarean section Previous LSCS Placenta praevia Eclampsia or pre-eclampsia Dystocia Carcinoma cervix
Fetal indications Fetal distress Prolapse of umbilical cord Mal presentation Bad obstetrical history and habitual intrauterine death of fetus Abruption placenta Multiple pregnancy Maternal HIV infection Contraindications
Very low birth weight baby Maternal coagulation defects
Time of Operation in Caesarean
Elective CS Emergency CS Criteria for timing of elective repeat caesarean delivery When the operation is done at a pre arranged time during pregnancy to ensure the best quality of obstetrics, anaesthesia, neonatal resuscitation and nursing services.
An ultrasound obtained at 12 to 20 weeks confirms the gestational age of at least 39 weeks determined by clinical history and physical examination.
Types of caesarean section
Lower segment caesarean section (99.8%) Classical or Upper segment 0.02%. Caesarean hysterectomy 0.18%. Extra peritoneal lower segment operation.
Lower segment caesarean section The extraction of the baby is done through an incision made in the lower segment through trans peritoneal approach. Classical The baby is extracted through an incision made in the upper segment of the uterus. Indications A. Lower segment approach is difficult 1. Dense adhesions due to previous abdominal operation 2. Severe contracted pelvis with pendulous abdomen Contd.. B. Lower segment approach is risky 1. Big fibroid on the lower segment 2. Carcinoma of cervix 3. Repair of difficult and high VVF 4. Severe degree of placenta praevia with engorged vessels in the lower segment Lower segment Caesarean Section Pre operative preparation Informed written permission for the procedure, anesthesia and blood transfusion is obtained. Abdomen is scrubbed with soap and non organic iodide lotion. Hair may be clipped. Pre medicative sedation Antacid before transferring to the theatre Contd.. Premedication Ranitidine or Metaclopramide NG tube if needed Emptying the bladder, Keep catheter in place Checking of FHS Presence of Neonatologist Anesthesia Spinal Epidural General Position Supine 15 tilt Incision Vertical Infraumbilical or paramedian Transverse 3cm above the symphisis pubis
Features of Transverse and Vertical Incision Transverse (Pfannnensteil) Vertical More popular due to cosmetic purposes Less popular Limited exposture Rapid entry and good exposure Cherny/maylard modification may be needed, in the presence of previios similar surgery Median/ paramedian incision can be made Hernia less common (this usually occurs at the angles) Post-operative hernia more common (this can occur anywhere along the incision) Advantages and Disadvantages of Transverse Incision Advantages Disadvantages Postoperative comfort is more Takes a little time and as such unsuitable in acute emergency operation Fundus of the uterus can be better palpated during immediate post- operative period Blood loss is little more Less chance of wound dehiscence Cosmetic value Requires competency during repeat section Less chance of incisional hernia Unsuitable for classical operation Preparation of the mother
Psychological Preparation Physical Preparation Anesthesia Position
Incision on the Abdomen A low transverse incision is made about two fingers breadth above the symphysis pubis (modified pfannenstiel) or above the symphysis pubis (pfannenstiel or bikini line incision) Some obstetricians make a vertical infraumbilical or paramedian incision, which extends from about 2.5 cm below the umbilicus to the upper border of the symphysis pubis.
Packing The Doyens retractor is introduced. The peritoneal cavity is now packed of using two taped large swabs. The tape ends are attached to artery forceps. This will minimize spilling of the uterine contents in to the general peritoneal cavity. Uterine incision Peritoneal incision The loose peritoneum of the utero-vesical pouch is cut transversely across the lower segment with convexity downwards at about 1.25cm below its firm attachments to the uterus.
The lower flap of the peritoneum is pushed down a little. contd,.. Muscle incision The most commonly used incision is low transverse Advantages 1. Ease of operation. 2. less bladder dissection 3. less blood loss 4. easy to repair 5. complete reperitonisation 6. less adhesion formation 7. less risk of scar rupture Other type of Incisions Lower segment transverse Lower segment vertical J incision Classical incision Inverted T incision
Low transverse incision A small transverse incision is made in the midline by a scalpel at a level slightly below the peritoneal incision until the membranes of the gestation sac are exposed.
Two index fingers are then inserted through the small incision down to the membranes and the muscles of the lower segment are split transversely across the fibers. Contd The method minimizes the blood loss but requires experience.
Alternatively the incision may be extended on either sides using a pair of a curved scissors to make it a curved one of about 10cm in length, the concavity directed upwards. Delivery of the head The membranes are ruptured if still intact
The blood mixed amniotic fluid is sucked out by continuous suction.
The Doyens retractor is removed.
The head is delivered by hooking the head with the fingers which are carefully inserted between the lower uterine flap and the head until the palm is placed below the head. Contd As the head is drawn to the incision line the assistant is to apply pressure on the fundus.
If the head is jammed, an assistant may push up the head by sterile gloved fingers introduced in to the vagina.
The head can be also delivered using either wrigleys forceps Delivery of the trunk As soon as the head is delivered, the mucus from the mouth ,pharynx and nostrils is sucked out using rubber catheter attached to a electric sucker.
After the delivery of the shoulders intravenous oxytocin 20 units or metergin0.2mg is to be administered.
Contd.. The rest of the body is delivered slowly and the baby is placed in a tray placed in between the mothers thigh and with the head tilted down for gravitational drainage. The cord is cut in between two clamps and the baby is handed over to the nurse. The Doyens retractor is reintroduced.
Delivery of the placenta The placenta is extracted by traction on the cord with simultaneous pushing the uterus towards the umbilicus per abdomen using the left hand . the membranes are to be carefully removed preferably intact and even a small piece, if attached to the decidua should be removed using a dry gauze. dilatation of the internal os is not required. Exploration of the uterine cavity is desirable. Suture of the uterine wound The margins of the wound are picked up by Alis tissue forceps or Green Armytage haemostatic clamps. The uterine incision is sutured in three layers. Contd First layer the first stitch is placed on the far side in the lateral angle of the uterine incision and is tied with 0 chromic catgut or vicryl. A continuous running suture taking deeper muscles excluding the decidua ensures effective apposition.
Contd.. Second layer -the superficial muscles and fascia by continuous suture. Third layer-the peritoneal flap by continuous inverting suture. Concluding part The mops placed inside are removed and the number verified. Peritoneal toileting is done and the blood clots are removed meticulously. The tubes and ovaries are examined. Doyen's retractor is removed. After being satisfied that the uterus is well contracted, the abdomen is closed in layers. The vagina is cleansed of blood clots and a sterile vulval pad is placed.
BLUNCH SUTURE FOR CAESAREAN SECTION: BLUNCH SUTURE FOR CAESAREAN SECTION
Postoperative Care
Immediate Care (4-6 hours): In the immediate recovery period, the blood pressure is recorded every 15 minutes. Temperature is recorded every two hours. The wound must be inspected every half hour to detect any blood loss. Immediate Care (4-6 hours)
The lochia are also inspected and drainage should be small initially. Following general anesthesia, the woman is nursed in the left lateral or recovery position until she is fully conscious, since the risks of airway obstruction or regurgitation and silent aspiration of stomach contents are still present. Analgesia is given as prescribed.
First 24 hours
IV fluids (5% dextrose or Ringers lactate) are continued. Blood transfusion is helpful in anemic mothers for speedy postoperative recovery. Injection methergine 0.2 mg may be repeated intramuscularly. Parenteral antibiotic is usually given for the first 48 hours.
First 24 hours Contd
Analgesics in the form of pethidine 75- 100 mg are administered as required. Ambulation is encouraged on the day following surgery and baby is brought to her.
After 24 Hours Contd The blood pressure, pulse and temperature are usually checked every four hours. Oral feeding is started with clear liquids and then advanced to light and regular diet. IV fluids are continued for about 48 hours. Urinary catheter may be for about 48 hours.
Urinary catheter may be removed on the following day when the woman is able to get up to the toilet The woman is helped to get out of bed as soon as possible and encouraged to become fully mobile. The mother must be encouraged to rest as much as possible and needed help is to be given with care for the baby.
This should preferably take place at the mothers bedside and should include support with breastfeeding. The mother is usually discharged with the baby after the abdominal skin stitches are removed by the 4 th or 5 th
day.( Depends on policy or varies )
Postpartum pain Relief after Cesarean Birth Incisional Pain: Splint incision with a pillow hen moving or coughing. Use relaxation techniques such as music, breathing and dim lights Intestinal Gas: Walk as often as you can Do not eat or drink gas-forming foods, carbonated beverages, or whole drink Do not use straws for drinking fluids. Take anti flatulence medication if prescribed Lie on your left side to expel gas Rock in a rocking chair Home Care Signs of postoperative complications after discharge: Report the following signs to your health care provider. Temperature exceeding 38 0 c Painful urination Lochia heavier than a normal period Wound separation Redness or oozing at the incision site Severe abdominal pain Classical caesarean section Abdominal incision is longitudinal about 15cm in length, 1/3 rd of which extends above the umbilicus. After opening the peritoneal cavity, the uterus is centralized and packs are placed on each sides A longitudinal incision of about 12.5 cm is made on the midline of the anterior wall of the uterus starting from below the fundus. Contd.. The incision is deepened along its entire length until the membranes are exposed which are punctured. The baby is delivered as breech extraction Methergin Placental removal Suture of the uterine incision Uterus is returned back into the abdominal cavity Contd Packings are removed Peritoneal toileting is done The abdomen is closed in layers
Merits and Demerits of Lower Segment Operation over classical Lower segment Classical 1.Techniques Slight difficult
Blood loss is less
The wall is thin and as such apposition is perfect
Perfect peritonisation is possible Technical difficulty in placenta praevia or transverse lie Technically easy
Blood loss is more
The wall is thick and apposition of the margins is not perfect
Not possible
Comparatively safer in such circumstances.
2.Post - operative Haemorrhage and shock-less
Peritonitis is less
Peritoneal adhesion and intestinal obstruction are less
Convalescence is better
Morbidity and mortality are lower More
More
More because of imperfect peritonisation
Relatively poor
Morbidity and mortality are higher 3.Wound healing The scar is better healed because of : Perfect muscle apposition due to thin margins
Minimal wound heamatoma
The wound remains quiescent during healing process
Chance of gutter formation is unlikely The scar is weak because of: Imperfect muscle apposition because of thick margins
More wound haematoma formation
The wound is in a state of tension due to contraction and relaxation of the upper segment. As a result, the knots may slip or the sutures may become loose
Chance of gutter formation on the inner aspect is more
Contd 4.During future pregnancy Scar rupture is less 0.5-1.5% More risk of scar rupture 4-9% Complications Due to operation or anaesthesia Intra operative complications Extension of uterine incision -to one or both the edgesinvolve uterine vessels broad ligament haematoma Uterine lacerations-laterally or inferiorly to vagina Bladder injury two layer closure with 2-0 chromic catgut, continuous bladder drainage for 7-10 days Contd Urethral injury Gastrointestinal tract injury Uterine atony and primary post partum haemorrhage Morbid adherent placenta Postoperative Complications Maternal
Immediate Remote Postpartum hemorrhage Gynaecological: Menstrual excess or irregularities Chronic pelvic pain or backache Shock General Surgical: Incisional hernia Intestinal obstruction due to adhesions and bands Immediate Remote Anesthetic hazards Future Pregnancy: There is risk of scar rupture Infections Intestinal obstruction Thromboembolic disorders Wound complications Secondary postpartum hemorrhage Fetal Complications Iatrogenic prematurity and development of RDS is not uncommon following caesarean delivery. This is seen when fetal maturity is uncertain. Post mortem cesarean birth
If a pregnant woman does not survive serious trauma, it may still be possible for her child to be born safely by postmortem CS birth. This is usually attempted if the fetus is past 24 weeks and less than 20 minutes has passed since the mother died. Infant survival is best in these circumstances if no longer than 5 minutes has passed. No consent Classical incision Personnel to resuscitate the baby. Nursing diagnosis Pain related to surgical incision Ineffective individual coping related to surgical intervention ,perceived loss of birthing experience and fatigue Activity intolerance related to delivery and secondary to anesthetic administration surgical incision and pain Constipation related to anticipated abdominal pain Contd Knowledge deficit related to post partum course and implication of subsequent pregnancy Self esteem disturbance related to perceived inability to birth naturally Risk for impaired parenting related pain and effect of anesthesia and postponing to secondary to touch hold and care for infant
Contd.. Risk for fluid volume deficit R/t to blood loss associated with surgery Risk for maternal infection R/t delivery and secondary to surgical incision
Evidence based practice
Doshi Haresh, Tripathi Jagruti, Maheshwari Sonal, Gupta Arti (2009) conducted a national survey in Cesarean section changing trends with the objectives to study the changing trends in indications and techniques of cesarean section in various parts of India. Methods: A clinical survey was carried out amongst 253 obstetricians from all over India selected at random regarding their practices of cesarean section in terms of indications and technique.
Results: Result showed that previous cesarean section, severe pregnancy induced hypertension, failed induction of labor and infertility treated cases is now increasing amongst the indications for cesarean section. In techniques, single layer closure (41.11% doctors) and non suturing of peritoneum, visceral or both, (35.96% doctors) are now increasing among obstetricians. Polyglycolic acid sutures (vicryl, centicryl, dexon) are replacing catgut for uterine closure.
Conclusion: Changes in indications are mainly due to litigation fear and better neonatal facilities.
Conclusion Low caesarean section rates are associated with low levels of intervention and high levels of psychological support. It is difficult to decipher whether caesarean section rates have been affected by interventions such are proactive management of labour.