CESAREAN SECTION Dr.R.alyamani

Definition: Abdominal delivery, commonly known as cesarean section (cesarean birth), is a surgical procedure that permits delivery of the infant through incisions in the abdominal and uterine wall. Cesarean hysterectomy is a hysterectomy performed at the time of cesarean de­livery. The technique was not widely used until the 1920s.The adjective cesarean describing this procedure did not emanate from Julius Caesar's reign but rather from Pompilius II, who in 730 BC decreed that no pregnant woman who died would be buried until the baby was removed from the abdomen. The term may arise from a combination of the latin verbs (caedere) and (Seco) both meaning to cut.

Incidence and Trends: For many years, the incidence of the procedure was stable (3-5%) yet since 1960s, the rate of CS was rising steadily reaching (20-25%) in late 1980s. Causes for increase CS rates include: Dystocia (30% increase). Breech presentation. Fetal distress (10-15% increase). repeat CS (>50% increase). Malpractice suites.

Maternal Indications: 1-Antepartum hemorrhage (placenta praevia, severe abruptio- placentae), Contracted pelvis. 2-Pelvic tumors obstructing labor. 3-Pelvic fracture. 4-Previous successful vaginal surgery for stress incontinence or urinary fistula. 5-Invasive carcinoma of the cervix. 6-Previous Cesarean Sections or other uterine scar threatening uterine rupture. 7-Severe maternal hypertension. 8-Cerebral aneurysm or arterio-venous malformations.

Fetal Indications: 1-Fetal distress (with or without dystocia). 2-Certain cases of Malpresentations (face, brow, compound presentation, persistent OP or DTA, transverse lie as no place for internal version with living single fetus and CS for breech presentation is increasing). 3-Multiple pregnancies. 4-Fetal anomalies (with associated dystocia or due to worsening conditions in utero). 5-Macrosomia and extreme prematurity are examples of fetal indications for CS. Maternal genital Herpes infection and thrombocytopenia are also fetal indication for CS due to risk of fetal infection and hemorrhage.

Contraindications of Cesarean Section: There are no absolute contraindications, yet CS is better avoided in cases of fetal demise, major anomalies incompatible with life and in some maternal diseases as cardiac diseases and coagulopathy.

Types of Cesarean Section: It may be Elective or Non-Elective procedure i.e; (failed labor induction, trial or forceps) according to its indication and timing. It may be Primary (first performed) or Repeat CS. The uterine incision either in the lower segment (LSCS) or upper segment (USCS) usually through a transperitoneal route rarely through extraperitoneal route. 1 - The classical uterine incision is a vertical incision that involves the upper uterine segment. Although this incision al­lows rapid uterine entry. Complications encountered include: A - increased blood loss. B - risk of uterine rupture prior to or during labor in a subsequent pregnancy. Indication of classic uterine incision include: Maternal condition whereby lower segment is not accessible or not developed, cancer cervix, previous successful repair of vaginouterine fistula, or when the procedure is to be followed by hysterectomy or done postmortem. It may be also performed for transverse lie, fetal major malformation (sacrococcygeal tumor, severe hydrocephalus), or to fetal distress (due to rapidity of the procedure).

2 -The Lower uterine segment incision: It is the most commonly performed. It has the advantage of: 1-having less bleeding unless extended (as the lower segment is less vascular and away from implantation), 2-the scar is stronger and less incidence of subsequent rupture ( %). 3- less ileus, stomach dilatation, 4-infection and adhesions is anticipated with lower segment incisions compared to upper segment incisions. Low cervical incision may be a low cervical transverse (LCT) incision (Monroe/Kerr) or a low cervical vertical (LCV) incision (Kronig/Selheim). In general, the LCV incision tends to have increased blood loss because it extends into the upper uterine segment and has been thought to have a greater incidence of rupture during subsequent pregnancies when compared with the LCT incision, although this has not been substantiated. Its main disadvantage is possible downward extension with bladder injury. On the other hand, the LCT uterine incision has a greater tendency to extend laterally into the uterine vessels at the time of operation.

Preoperative Preparation: Preoperative visit by the anesthesiologist is important to assess the patient's anesthesia status and risk for untoward events during and after surgery. Patients scheduled for elective procedure should be kept fasting for at least 8 hours. Plans to decrease potential morbidity associated with aspiration of gastric contents should be carried out in non-elective procedure including administration of oral antacid (Magnesium Citrate within 1h of start of anesthesia). A large intravenous line is begun prior to the anesthetic administration and an infusion of crystalloid solution started. A recent Hb and Hct is checked and blood type and screen is done. Blood should be available in high risk parturient. Urinary bladder should be empty, either by a catheter or allowing the woman to empty her bladder immediately before operation. Preparation of the abdominal and perineal area include shaving just prior to surgery, 5-min scrubbing with a suitable detergent (hexachlorophene, povidone- iodine, and chlorhexidine) and covered with a sterile draping. The operating team should comply with all phases of universal precautions to avoid exposure to infectious agents. Anesthesia for cesarean birth is usually divided into two categories: general endo­ tracheal technique and regional anesthesia. Local anesthesia is rarely performed is critically ill patients only with the midline incision. Regional techniques usually entail either spinal or epidural blocks.

Postoperative care: Regardless of the type of abdominal wound 1 - The incision should be covered with a compression dressing and should be checked when the vital signs are measured for signs of hemorrhage through the bandage. In general, the morning of the first postoperative day, bandages are removed whether skin clips, subcuticular closure, or mattress silk sutures have been used. 2 - Care is taken to assess for the development of hematomas, seromas, or wound infections. Areas of redness and palpable masses or extraordinary tenderness or induration are carefully assessed twice daily. Signs of cellulitis require cultures and antibiotic therapy. 3 - The notation of a watery discharge from the wound may herald impending wound dehiscence and should be treated as an emergency. 4 -With primary transverse CS, the skin clips and mattress sutures are removed on the fourth or fifth postoperative day or according to wound condition. 5 - As after any major surgical procedure, the potential for severe maternal postoperative complications is present. Because of the hypercoagulable state of pregnancy, the hazard of postoperative embolization is increased: * Patients are encouraged to ambulate on the first postoperative day and are made to turn, cough, and deep-breathe immediately after surgery. * The diet is progressed from clear liquids on the evening of the operative day if surgery was in the morning, usually beginning about 8 to 12 hours after surgery. * Adequate pain medication is an essential component of postoperative management.

Complications of Cesarean Section: A - Maternal Mortality : Improved surgical and anesthesia skills, antibiotics, aseptic techniques, and blood product availability have decreased the risks of this procedure. However, ce­sarean birth still holds a much greater risk for the mother, with a maternal mortality rate of 20 per 100,000 births in the United States compared with a maternal mortal­ity rate from vaginal delivery of 2.5 per 100,000 births. Anaesthetic accidents, including aspiration pneumonia, severe sepsis and thromboembolic and hemorrhagic complication are the main cause of maternal death.

B - Maternal Morbidity: Although maternal morbidity has decreased significantly with cesarean section, it is still between eight and 12 times higher than for a vaginal birth. It may result from similar postpartum etiological factors, anesthetic complications, or those that arise in the intraopertative period as injury (bladder, ureter, bowel), bleeding with consequent anemia, infectious or thromboembolic complications. Remote morbidity include adhesive intestinal obstruction, ruptured uterine scar in next pregnancy, placenta accerta to previous scar and incisionnal hernia more common with midline subumbilical vertical incision. Postoperative febrile morbidity (10%-50%), depending on whether the cesarean birth is performed electively or during labor with ruptured membranes, is markedly decreased with vaginal deliv­ery (1% ‑ 3%). Endometritis, urinary tract infection, and wound infections are the major causes of postoperative morbidity following cesarean births.

C - Fetal/Neonatal Mortality and Morbidity. The safety of cesarean birth for the neonate has increased dramatically over the past 2 decades. Elective cesarean sections are the major cause of iatrogenic preterm delivery (1% to 20% of hyaline membrane dis­ease (HMD) cases are products of elective cesarean delivery). When abdominal deliv­ery must be performed prior to fetal maturity, it is imperative to document, confirm or be assured of pulmonary maturity. Elective cesarean delivery no earlier than 39 weeks is advised by the American College of Obstetricians and Gynecologists. If the pa­tient has insulin ‑ requiring diabetes mellitus during pregnancy, or dating cannot be firmly established, an amniocentesis is recommended to confirm lung maturity via a series of lung phospholipid studies if delivery is to be undertaken prior to 39 weeks' gestation.

D - Family, Maternal-Infant attachment : attitudes toward cesarean births among women. This is not surprising, since maternal anxiety and disappointment at not having a "normal birth," as well as a sense of failure and loss of autonomy, are associated with the operations. E - Obstetrician and Medico-Legal aspects : Legally, obstetricians and hospitals are at risk if the outcome of any birth is less than perfect, particularly if a cesarean birth was not performed.

Vaginal Delivery after Cesarean Section: Because more than 25% of cesarean sections are repeat procedures, vagi­nal births after cesarean section (VBAC) have become increasingly supported by the medical community. The success rate for VBAC has been reported to be from about 60% for patients who were previously delivered for pelvic dystocia to more than 70% for patients who were delivered by cesarean birth for nonrecurring conditions; such as breech presentation or fetal distress. The advantages of vaginal birth include decreased maternal and neonatal morbid­ity as well as decreased hospital time for both mother and baby. The use of oxytocin or epidural anesthesia is not contraindicated in VBAC. A trial of labor should be of­fered for all with a nonclassical uterine incision. The risk of uterine rupture for which the dictum "once a cesarean section, always a cesarean section" was once used has been noted to be approximately 0.5% as compared with 10% in patients with prior classical incisions.