CAESARIAN SECTION Dr. Madhavi Karki

DEFINITION : The term CAESARIAN SECTION denotes the delivery of a viable fetus, placenta and membranes through an incision in the abdominal wall and the uterine wall. The first caesarian section performed on a patient is known as PRIMARY CAESARIAN SECTION.

An elective is one which is performed before the onset of labour or before the occurrence of any complication which calls for an emergency intervention. EMERGENCY CS: PERFORMED IMMEDIATELY AFTER UNFORESEEN COMPLICATION DURING PREGNANCY OR LABOUR

INDICATIONS Pelvic contraction and dystocia Previous uterine surgery Hemorrhage maternal medical disorders Maternal obstetrics and health problems Fetal indications

Pelvic contraction and dystocia due to Cepahalo-pelvic disproportion Fetal malpresentation and malposition Incoordinate uterine action Non-progress of labour Soft tissue dystocia constriction ring, vaginal stenosis, cervical rigidity Neoplasms – fibroids , impacted ovarian cysts or non-pregnant horn of bicornuate uterus – obstructing labour Failed forceps and threatened uterine rupture

Previous uterine surgery Caesarian section Myomectomy Hysterotomy

HEMORRHAGE: Placenta praevia Abruptio placenta Vasa praevia Cancer cervix

MATERNAL MEDICAL DISORDERS: Severe hypertension Pre- eclampsia and eclampsia Renal disease diabetes mellitus Co- arctation of the aorta Herpes gestationalis Malignant disease, eg: leukemias, prior to chemotherapy

Maternal obstetrics and health problems Elderly primi gravida Prolonged previous infertility Previous repair of vagina – genital prolapse Bad obstetric history Previous difficult vaginal delivery Congenital uterine anomaly

FETAL INDICATIONS (i) Fetal distress (ii)Previous unexplained fetal death (iii)Umbilical cord prolapse (iv)Placental insufficiency (IUGR) (v) Macrosomia (maternal diabetes, postmaturity) (vi) Rh iso-immunization (vii) Multiple pregnancy(triplets and over)

Types of Operations: Lower Segment Caesarian Section: Classical Caesarian Section: Incision is made in the upper uterine segment. Lower Segment Caesarian Section: Incision over the lower uterine segment.

BEFORE CS: Informed Consent Inform Anesthetist, OR staff, Pediatrician 100% oxygen mask in case of fetal distress Transfer the patient to the OR, open IV line with wide bore cannula, take Blood for hemoglobin and blood grouping cross matching

FHS should be done one more time at this stage Indwelling catheter PREOPERATIVE PREPARATION: FHS should be done one more time at this stage Indwelling catheter Metoclopramide10mg IV Ranitidine: 150mg is given orally night before and repeated 50mg IV/IM one hour before surgery. Administration of 30ml of 0.3 molar sodium citrate orally half an hour before the surgery. The abdomen, back, private parts and upper parts of thighs are cleaned and shaved.

3 METHODS : EPIDURAL ANESTHESIA: GENERAL SPINAL

POSITION: The patient is placed in dorsal/ supine position. If spinal anesthesia has been given, a 15 degrees tilt to her left using sandbags till the delivery of the fetus is beneficial.

The patient is then draped with sterile towel ANTISEPTIC PAINTING: Savlon Betadine Spirit The patient is then draped with sterile towel

SKIN INCISIONS : Vertical: PROCEDURE : The incision extends from about 2.5cms below the umbilicus to the upper border of symphysis pubis. Vertical: The delivery of the baby can be accomplished more quickly Easy to extend the incision Simplicity ADVANTAGES: Since the midline is least vascular, healing maybe poor. Occurring at a later date is considerable. Risk of wound dehiscence are higher and the incidence of incisional hernia Postoperative pain is considerable particularly on coughing or sneezing There is more side-to-side tension on the scar The scar is very apparent so cosmetically not very acceptable DISADVANTAGES:

Pfannensteil (Transverse) Incision: The incision is semilunar and is made about two finger breadths above the symphysis pubis. Cosmetic value Less chance of incisional hernia Less chance of wound dehiscence Post operative comfort is more ADVANTAGES : Requires more technical skill Blood loss is more Takes longer time DISADVANTAGES:

PACKING : Apply Doyen’s retractor and push the bladder down. The peritoneal cavity is now packed using two large swabs . This will minimize Spilling of the uterine contents into the abdominal cavity.

Uterine Incision: Peritoneal Incision: Identify the lower uterine segment The loose peritoneum is picked with the help of dissecting forceps and incised transversely with the scissors.

(b) Muscle Incision: A small transverse incision is made in the midline. Extend with two index fingers.

Delivery of the Head: The membranes are ruptured if still intact. Suction of amniotic fluid and blood. The Doyen’s retractor is removed. The head is delivered by hooking the head with the fingers which are insinuated between the lower uterine flap and the head until the palm is placed below the head. Apply fundal pressure

Delivery of the Trunk: Suction of the mouth, pharynx and nostrils. Delivery of the shoulder. Administer 0.2mg methergin Deliver the rest of the baby Cord clamped and cut The Doyen’s retractor is reintroduced.

Removal of the Placenta and Membranes: - By controlled cord traction - Exploration of the uterine cavity

The uterine incision is sutured in three layers. Suturing of the uterine wound: The uterine incision is sutured in three layers. 1. CONTINUOUS SUTURE : DEEP MUSCLES 3. PERITONEAL CLOSURE 2.CONTINUOUS SUTURE : SUPERFICIAL MUSCLES

Concluding Part: Mops placed inside are removed. Vagina cleaned and vulval pad placed Abdomen closed in layers . Doyen’s Retractor removed Peritoneum washed and clots removed Instrument and mop count performed. Mops placed inside are removed.

POSTOPERATIVE CARE NPO TILL BOWEL SOUND RETURNS(24hrs) IV FLUDS: AS PER REQUIREMENT IV ANTIBIOTICS PARENTRAL ANALGESICS VITALS CHARTING WATCH FOR PPH EARLY MOBILISATION SWITCH TO ORAL FEEDING AFTER BS+ STITCH REMOVAL ON 8TH DAY

COMPLICATIONS OF CAESARIAN SECTION: MATERNAL : REMOTE: Incisional Hernia Intestinal obstruction Scar rupture in future pregnancy IMMEDIATE: Hemorrhage and shock Infections Extension of incision and hematoma formation Injury to the urinary bladder, ureter and bowel. Paralytic ileus and peritonitis Formation of pelvic abscess Thromboembolism Anesthetic complications: aspiration, hypotension

FETAL COMPLICATIONS: Iatrogenic prematurity Respiratory distress syndrome Injury to the baby due to surgical knife Birth asphyxia due to anesthetic problems Birth injury due to difficult extraction