CAESAREAN SECTION

MEGHA S KABEER
MEGHA UNNI
O4 unit
1. Definition
2. Incidence
3. Indication
4. Types
5. LSCS
 DEFINITION
• Operative procedure whereby fetuses after
the end of 28th week are delivered through
an incision on the abdominal and uterine
wall.
• These excludes the cases where abdominal
incision is made to remove fetus lying freely in
the abdominal cavity after uterine rupture or
in abdominal pregnancies.
 Incidence
• Rate = 15-20%
• Most common operation done world wide
• Rates steadily rising
• Primary : 1st C-section on a patient
• Secondary : C-section done on a patient with
past h/o of C-section
 INDICATIONS
• Previous C-section
• Dystocia or dysfunctional labour
1. Cepahalopelvic disproportion
2. Tumors complicating pregnancy
3. Fetal macrosomia
4. Malpresentations like brow , transverse lie and
persistent mentoposterior
5. Deep transverse arrest
6. Abnormal uterine action
7. Threatened rupture and obstructed labour
8. Failed forceps or vacuum
• Failed induction
• Fetal distress and cord prolapse
• Breech presentation (selected cases)
• Other fetal indications :
– Severe IUGR
– Multiple pregnancy ( non vertex and
monoamniotic twins)
• Antepartum hemorrhage
– Placenta previa
– Abruption placentae
– Vasa previa
• Maternal problems
 Elderly nullipara
 Prolonged period of infertility following IVF.
 Bad obstetric history
 Previous history of nulliparous prolapse , stress
incontinence or fistula
 HIV complicating pregnancy
 Severe preeclampsia and diabetes
• C section on maternal request
 MOST COMMON

1. Previous C –section
2. Dystocia
3. Fetal distress
4. Breech presentation
 TYPES
• Based on time of • Based on type of
operation : operation-
Elective – When LSCS
operation is done at Classical
prearranged time during
pregnancy to ensure the
best quality obstetrics,
anesthesia and neonatal
resuccitation
Emergency – Operation
done for acute obstetric
emergency
 LOWER SEGMENT C-SECTION
(LSCS)
• In this operation extraction of the baby is
done through an incision made in the lower
segment through a transperitoneal approach’
• Most practiced . Unless specified
 Preoperative Preparation
Informed written consent of the patient, anesthesia and
blood transfusion is obtained.
• Antiseptic painting - Abdomen is scrubbed with soap
and inorganic iodine lotion (7.5% Povidone iodine or
Savlon lotion). Hair maybe clipped. Then properly
draped with sterile towels.
• IV Canula – Sited to administer fluids (Ringer’s solution)
• Position of patient : placed in dorsal position . To
reduce venacaval compression ,a 15 degree tilt to left
using a wedge is maintained till the delivery of the
baby
 Anesthesia :
• Regional (better)- spinal or epidural , or general
• Complications of general anesthesia
 If woman is not fasting there is risk of aspiration and
chemical pneumonitis (Mendelson syndrome).
 Gastric emptying is delayed in pregnancy
• Measures to counteract the risk
 Antacids are given and oral fluids withheld
 30mL of 0.3 molar sodium citrate , orally, recommended
half an hr before surgery to neutralise acid contents of
stomach
 Ranitidine injection to inhibit gastric secretion
 Sellick manoeuvre
 After intubation nasogastric tube is passed to empty the
stomach of it’s contents
 ABDOMINAL INCISIONS:
• Pfannensteil incision –
Most common. Transverse curviliniear incision made just
above pubic hairline . Deepened down s/c fat upto rectus
sheath , which is incised transversly. After separating two
recti in midline parietal peritoneum is opened.
• Joel Cohen
Modified transverse incision placed 3cm above the line
joining two ASIS. Higher and more curved. Sharp dissection
minimized. Recti separated by finger traction.
• Maylard incision –
More exposure in transverse incision. Recti are divided.
• Midline vertical incision
INCISION TRANSVERSE VERTICAL

1. Cosmetic appeal More Less

2. P/o pain Less More

3. Wound dehiscence Less More

4. Incisional hernia Less More

5.Technical skill and time More Less

required

6. Access to upper abdomen Less access Good , can be extended if

needed
 UTERINE INCISION
• Abdomen is opened, any dextrorotation of the uterus is
corrected.
• A Doyen retractor is used to visualise the lower segment.
• After identifying the loose peritoneum over the lower
segment , it is divided transversely and separated from the
bladder by blunt dissection.
• A small incision is made in the lower segment and extended
later ,using scissors or by stretching with fingers .
• If there is inadequate space rarely a J-shaped or inverted T
incision may be needed. Care should be taken not to injure
the uterine vessels laterally.
 Delivery of Baby
• Cephalic presentations : the hand is slipped into the uterine
cavity and the head is gently levered out of the incision .
• The assistant may exert fundal pressure on the fetal buttocks
to aid in delivery of the head.
• Obstetric forceps is used to deliver the head, in case of a
floating head.
• The mouth and nostrils are suctioned to prevent aspiration
and the rest of the body is delivered by gentle traction.
• The umbilical cord is doubly clamped and the baby handed
over to a person trained in neonatal resuscitation.
• Breech : the feet are first hooked out and the rest of the body
delivered as in case of a vaginal breech delivery.
 DEEPLY IMPACTED HEAD
• If the operation is done late in labour, the head may be
deeply impacted in midpelvis, with a thinned out lower
segment.
• It may be necessary for an assistant to dislodge the fetal
head from below, with a hand inserted into the vagina.
• Patwardhan method : shoulder is usually at the level of the
uterine incision and pops out. It is gently extracted through
the uterine incision. Posterior shoulder is also delivered
out. The surgeon then hooks the fingers through both the
fetal axillae and with gentle traction, deliver the fetal body
outside the uterus. This is aided by the assistant giving
fundal pressure. The head is finally delivered by traction on
the legs.
 TRANSVERSE LIE
• Lie is corrected to a longitudinal one before the uterine
incision is made. Then the baby is delivered as such.
• If it can’t be corrected , the operator’s hand is introduced
into the uterus and after locating the foot, it is gently pulled
out and the rest of the delivery conducted as in breech.
• In cases of transverse lie with ruptured membranes and an
undeveloped lower segment, there may be difficulty in
delivery of the baby and extension of the uterine incision
may be needed. In such cases, a J or U-shaped incision may
be needed and sometimes an inverted T.
 CLOSURE OF UTERINE INCISION
• As soon as baby is delivered , oxytocin infusion is started
• Uterine fundus contracts and the placenta and membranes
are removed by controlled cord traction
• Manual removal of placenta isn’t recommended
• Uterine edges are held with Allis forceps and uterine
incision is closed in two layers of continuous sutures.
• Usually delayed absorbable sutures like Polyglactin (vicryl)
is used
• Two angles and other bleeding points are carefully ligated
• Bleeding points controlled by figure of eight sutures
• Tubes and ovaries are inspected and concurrent tubal
sterilisation is done if indicated
 CLOSURE OF ABDOMEN
• Peritoneal cavity is cleaned and after confirming mop
and instrument count , the abdominal wall is closed in
layers.
• The parietal peritoneum need not be closed
• Rectus sheath is carefully approximated with
nonabsorbable or delayed absorbable sutures to
minimise the chance of wound dehiscence and future
incisional hernia
• In case of vertical incision , a mass closure if necessary
and then the skin approximated with mattress sutures
of silk , a subcuticular suture or clips
 POSTOPERATIVE CARE

Observation for the first 6-8 hours is important. Periodic checkup

of pulse, BP ,amount of vaginal bleeding and behavior of the
uterus etc are recorded.
Fluid: Sodium chloride (0.9%) or Ringer's lactate drip is
continued until at least 2-2.5 L of the solutions is in fused.
Blood transfusion is helpful in anemic mothers for a speedy
post-operative recovery. Blood transfusion is required if the
blood loss is more than average during the operation (average
blood loss in cesarean section is approximately 0.5l.0 L).
Oxylocin: Injection oxytocin 5 units IM or IV (slow) is given and
may be repeated.
Prophylactic antibiotics (cephalosporins. metronidazole) for all
cesarean delivery is given for 2-4 doses.
Analgesics in the [form of pethidine hydrochloride 75 100
mg] is administered and may have to be repeated.
Ambulation: patient can sit on the bed or even get out to
evacuate the bladder, provided the general condition
permits. She is encouraged to move her legs and ankles
and to breathe deeply to minimize leg vein thrombosis
and pulmonary embolism.
Breast feeding :Baby is put to the breast for feeding after
3-4 hours when mother is stable and relieved of pain.
• Day 1: Oral feeding can be started and bowel
sounds are observed at the end of the day.
• Day 2: Liquid solid diet of patient’s choice. 3-4
teaspoons of lactulose is given if bowels don’t
move spontaneously
• Discharge: If otherwise fit , discharged on the
day following stitch removal.
 Advantages
• Better healing as the lower segment is
quiescent
• Tensile strength is more and chance of scar
rupture in next pregnancy is minimal