1. CAESARIAN SECTION
Dr. Madhavi Karki

2. 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.

3. 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

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

5. 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

6. Previous uterine surgery
Caesarian section
Myomectomy
Hysterotomy

7. HEMORRHAGE: Placenta praevia Abruptio placenta Vasa praevia
Cancer cervix

8. 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

9. 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

10. 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)

11. 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.

12. 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

13. 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.

14. 3 METHODS :
EPIDURAL
ANESTHESIA:
GENERAL
SPINAL

15. 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.

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

17. 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:

18. 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:

19. 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.

20. 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.

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

22. 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

23. 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.

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

25. 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

26. 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.

27. 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

28. 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

29. 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