1. Cesarean Delivery Op Dr A Cenk Özay
Near East University Faculty of Medicine Department of Obstetrics and Gynecology

2. Definition
C/S is an attempt to deliver a fetus, placenta and membrane after the gestational age of viability, through an incision on the abdominal wall and the intact uterus.
Removal of a fetus outside the uterus (abdominal pregnancy) or through a ruptured uterus or before the gestational age of viability is not a CS.

3. Objective To reduce infant and maternal morbidity
To reduce infant and maternal mortality

4. Cesarean Delivery Rates
It describes the proportion of women undergoing cesarean delivery of all women giving birth during a spesific time period.
It may be subdivided into the primary (first time operation) and repeat cesarean delivery rate.
C/S rates have risen in US from less than 5 percent in 1960s to nearly 30 percent by 2004.

5. Why C/S rates are increasing?
Obstetric factors
Increased primary C/S rate
Failed induction/increased utilization of induction of labor
Decreased utilization of operative vaginal delivery
Increased macrosomia(elective C/S for macrosomia)
Decline in vaginal breech delivery
Increased repeated C/S rate
Decreased utilization of vaginal birth after CS

6. Why C/S rates are increasing?
Maternal factors
Increased proportion of women >age 35
Increased nulliparous women
Increased elective primary C/S
Physician factors
Malpractice litigation concerns

7. Indications
Maternal
Spesific cardiac disease (Marfan's syndrome, unstable coronary artery disease)
Spesific respiratory disease (Guillian-Barre syndrome)
Conditions associated with increased intracranial pressure
Mechanical obstruction of the lower uterine segment(tumor, fibroids)
Mechanical vulvar obstruction (condylomata)

8. uterine scar with weak myometrium
Indications
Maternal
Operations
Abdominal cerclage operation
Repair of vesicovaginal fistula
Repair of stress incontinence
Myomectomy
Hysterotomy
Cesarean section
uterine scar with weak myometrium

9. Indications Fetal Nonreassuring fetal status Breech or transvers lie
Maternal herpes/condylomas
Congenital anomalies
Fetal macrosomia (>4500g)
Low birth weight (<1500g)

10. Indications Maternal-fetal Cephalopelvic disproportion
Placental abruption
Placenta previa
Elective C/S
Arrest of labor (dystocia)
Failed induction of labor
Multiple pregnancy

11. Risks and Benefits of Elective Cesarean Delivery
Potential Benefits
Reduction in perinatal morbidity and mortality
Elimination of intrapartum events associated with perinatal asphyxia
Reduction in traumatic birth injuries
Reduction in stillbirth beyond 30 weeks’ gestation
Possible protective effect against pelvic floor dysfunction

12. Risks and Benefits of Elective Cesarean Delivery
Potential Risks
Increased short-term morbidity
Increased endometritis, transfusion, venous trombosis rates
Increased length of stay and longer recovery time
Increased long term morbidity
Increased risk for placenta accreata, hysterectomy with subsequent cesarean delivery

13. TECHNIQUE OF C/S

14. Site preparation
It is performed in order to reduce the risk of wound infection by decreasing the amount of skin flora and contaminants at the incision site.
It is accomplished in the operating room through application of a surgical scrub.
Before scrub, hair is removed from operation site.
C/S wounds are considered to be clean contaminated.

15. Administration of prophylactic antibiotics
Prophylactic antibiotics are of clear benefit in reducing the frequency of postcesarean endomyometritis and wound infection.
The preferred agents cefazolin or cefotetan (1g).
Penicilin allergic patiens may receive a single dose of 500mg of metronidazole.

16. Classifications of C/S
According to urgency
Category Emergency C/S
Immediate threat to life of woman or fetus
Category Urgent C/S
Maternal or fetal compromise which is not immediately life-threatening
Category Scheduled C/S
Needing early delivery but no maternal or fetal compromise
Category Elective C/S
At optimal time for women and maternity team

17. Classifications of CS According to Gestational Age
Before the age of viability hysterotomy
After the age of viability cesarean section
According to Uterine Incision
Transverse LSCS (Kerr incision)
Vertical LSCS (De-Lee İncision)
Upper segment CS
Others; inverted-T, Hockey-stick incision

18. Incision Type Skin incision Vertical (midline)
Transverse (more cosmetic, less painful)
Phannenstiel incision (most common)
Maylard incision
Cherney incision
Joel-Kohen incision

19. Incision Type

20. Incision Type Factors influence the type of incision
Urgency of the delivery,
Prior incision type,
Potential need to explore the upper abdomen for nonobstetric pathology.
*The skin incision used in previous procedure is usually repeated in most C/S.

21. Incision Type Uterine incisions
Low transverse (Kerr İncision- in more than 90 percent of cases)
Low vertical
Classic
J incision
T incision

22. Incision Type

23. Potential Indications for Vertical Uterine Incision
Underdeveloped lower uterine segment
Breech or transvers lie with undeveloped lower uterine segment
Inability to develop bladder flap with repeat C/S
Lower segment anterior myoma
Anterior placenta previa

24. Extraction of Fetus
If the head is not easily delivered, the uterine incision may be extended( Rarely a T incision can be made to facilitate delivery)

25. Extraction of Placenta
Following the delivery of the infant, prophylactic antibiotics are administrated along with iv oxytocin as a drip (20 units/L)

26. Uterine Repair Transvers and vertical uterine incisions
Single-layer closure
Three-layer closure

27. Abdominal Closure
Closure of subcutaneous tissue decreases the risk of wound disruption by 34 percent in women with excessive subcutaneous fat.

28. Evidence Based Recommendations for C/S Techniques
The aim of proper technique at C/S should be to minimize complications and morbidity associated with the procedure.
The recommendations are
Prophylactic antibiotic for all C/S
Use of blunt uterine incision expansion
Spontaneous placental removal
Nonclosure of both visceral and parietal peritoneum
Suture closure or drainage of subcutaneous tissue when the thikness is greater than 2cm

29. Complications Intraoperative Anesthesia complications
Bleeding-more than the average (>1000ml)
Retained placental tissue
Uterine lacerations
Fetal injury
Bladder, ureter, gastrointestinal injury
Uterine atony
Hysterectomy
Maternal mortality

30. Complications Postoperative Gaseous distension Paralytic ileus
Endomyometritis
Wound infection
Thromboembolic disease
Septic pelvic thrombophlebitis
Vesicouterine fistula

31. Thank you for your attention.