CESAREAN SECTION CS

CESAREAN SECTION Cs Ghadeer Al-Shaikh, MD, FRCSC Assistant Professor & Consultant Obstetrics & Gynecology Urogynecology & Pelvic Reconstructive Surgery

TYPES OF CS Lower segment CS Classical CS

Indications for classical CS Transverse lie back down (with SROM) Structural abnormality that makes lower segment approach difficult (Fibroids) Anterior Placenta Previa & abnormally vascular lower segment Poorly developed lower segment in Very preterm fetus in breech presentation Cervical cancer

INDICATIONS FOR ELECTIVE CS Repeat CS Placenta previa VV fistula repair HIV (poor controlled) Active herpes Fetal macrosomia > 4500 gm Uterine surgery eg. Hystrotomy, myomectomy Severe IUGR Breech Multiple pregnancy Transverse lie Ca of the Cx/ TR obstructing the birth canal

INDICATIONS FOR EMERGRENCY CS Severe PET Abruptio placenta (APH) Fetal distress Failure to progress in the first stage of labour Cord prolapse Obstructed labour Failed induction Malpresentation  brow, chin post, shoulder & compound presentations, breech Compromised fetus 2ry to DM, HPT, isoimmunization

TIMING OF ELECTIVE CS Usually at 38-39 wks

Before Emergency CS Explain to the Pt & husband & obtain consent Inform anesthetist, OR staff, ped 100% oxygen mask in case of fetal distress Sodium citrate 20 ml , metoclopramide 10 mg IV Transfer to the theatre, IV , take blood for Hb, x-match 2 U of blood Preferable to use spinal or epidural anaethesia

Catheterize the bladder Tilt the mother 15 º by using wedge Pneumatic inflatable boots or Ted stockings Prophylactic Ab ↓↓ incidence of infection Inform ped if the mother had opiates in the last 4 hrs Halothane should not be used uterine relaxation & bleeding

COMPLICATIONS INTRAOPERATIVE Bleeding & the need for bl transfusion Hysterectomy Complications of anaesthesia Damage to the bladder, ureter, colon , retained placental tissue Fetal injury

COMPLICATIONS POSTOPERATIVE Paralytic ileus Wound dehiscence & infection Infectins  UTI, pnemonea DVT & pulmonary embolism Fistula Death

POSTNATAL CARE V/S & blood loss must be monitered Uterine fundus palpated Effective parentral analgesics Deep breathing & coughing encouraged Early mobilization Fluid therapy &diet Bladder & bowel function Wound care Lab Breast care Prophylaxis for thrombembolism

MODE OF DELIVERY IN NEXT PREGNANCY CRITERIA FOR VBAC Pt must agree to the procedure A low transverse uterine incision Non recurrent cause of the previous CS No macrosomia, malposition, multiple gestation, breech

MODE OF DELIVERY IN NEXT PREGNANCY Contraindication Previous classical CS 2 or more previous CS Previous other uterine surgery Hx of scar rupture Placentaprevia or transverse lie

CONDUCT OF LABOUR Observe for Progress Fetal wellbeing Maternal well being Epidural HOSPITAL SHOULD PROVIDE BLOOD , OPERATING ROOM 24 HRS, NEONATAL RESUSCITATION, NURSING ANAESTHESIA &SURGICAL PERSONNEL CAN START CS WITHIN 30 MIN

Risk of SCAR RUPTURE O.5% for LSCS 4-9% for classical

SCAR RUPTURE Signs OF SCAR RUPTURE Fetal distress Ease of fetal palpation Cessation of contractions Elevation of presenting part Scar pain Bleeding / shock

ABNORMAL LABOUR/DYSTOCIA/FAILURE TO PROGRESS IN LABOUR CAUSES 1-Abnormalities of the pasage Alteration in the shape of the pelvis Mass occupying the birth canal

ABNORMAL LABOUR/DYSTOCIA/FAILURE TO PROGRESS IN LABOUR 2-Abnormalities in the passenger Abnormal lie Abnormal presentation  occiput-postrior, occiput-transverse brow face breech Macrosomia , perinatal mortality 5* higher than N Wt Congenital malformation Multiple gestation

ABNORMAL LABOUR/DYSTOCIA/FAILURE TO PROGRESS IN LABOUR 3-Abnormalities in the powers Ineffective uterine activity Lack of voluntary expulsive efforts in the 2nd stage DYSTOCIA IS THE MOST COMMON INDICATION FOR CS