1. Cesarean Section

2. Definition
CS is an attempt to deliver a fetus, placenta and membrane after 28 weeks of gestation, 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 28 weeks is then not a CS.

3. Objective 1. To reduce infant and maternal morbidity
2. To reduce infant and maternal mortality

4. Indications A. Based on urgency Absolute or Relative
Emergency or Elective
B. Based on prognosis
Maternal indication
Fetal indication
Combined
C. General indications, based on certain clinical situation or diagnosis

5. General indications based on diagnosis
Fetopelvic or cephalo pelvic disproportion
Obstruction of birth canal
Uterine disfunction
Malposition or malpresentation
Maternal diseases
Scarred uterus or anomaly of the uterus
Cancer of the cervix

6. Fetal indications (I) Fetal distress Malpresentation or malposition
Failed vacuum or forceps
Expensive child
Cord prolapsed
Placental insufficiency (IUGR)

7. Fetal indications (II)
Incompatibility of rhesus
Post term pregnancy
Genital herpes
Diabetes mellitus
Elderly primigravida (>35 th)
Poor obstetric history
Giant fetus (> 4000 grams)

8. Maternal indication (Fetus already died)
Total placenta previa
Severe PE or Eclampsia, failed induction
Threatened Uterine Rupture, transverse lie

9. Combined indications Placenta previa Abruptio placenta, alive fetus
Severe Preeclampsia /Eclampsia
FPD/CPD
Threatened Uterine Rupture (Over stimulation)

10. Contraindications Severe chorioamnionitis
Very poor fetal prognosis, exp: extremely premature, severe congenital anomaly.
Fetal death, except in case of placenta previa
No adequate facilities for surgical procedure

11. Types of Cesarean Section
Based on incision
1. Classical or corporal (vertical incision)
2. Low segment (horizontal incision)
Based on time
1. Emergency CS
2. Elective CS
Other
1. Extraperitoneal CS
2. Cesarean hysterectomy

12. Clasic CS, Indications (1)
1. Difficult to reach the LUS
2. Transverse lie
3. Fetal distress
4. Placenta previa, anterior implantation
5. Followed by sterilization

13. Classic CS, Advantages
1. Faster
2. Easier

14. Classic CS, Disadvantages
1. Bleeding may be more profuse
2. Difficult to luxate fetal head
3. Reperitonisation is incomplete
4. Risk of rupture during future pregnancy

15. Low segment CS, Indications
Longitudinal lie
No problem with the LUS
Future pregnancy is expected

16. Low segment CS (Advantages)
Less bleeding
Incision to placenta is avoided
Easy to luxate fetal head
Easy to close (suture)
Good reperitonization
Risk of rupture in the next pregnancy is minimal

17. Low segment CS (Disadvantages)
Takes more time
Bleeding may be more severe, if the incision runs too laterally
Injury to the bladder may happen, if the incision is too low
During repeated CS, post laparotomy, or post infection, LUS may be too difficult to identify

18. Cesarean histerectomy (1)
Definition: Cesarean section followed by hysterectomy
Indications:
Uncontrolled bleeding
Placenta acreta, increta dan percreta
Multiple mioma
Cervical or ovarial ca
Unrepairable uterine rupture
Infection

19. Cesarean histerectomy(2)
Complications
Morbidity and mortality is higher:
Takes more time
Trauma to gut and bladder is higher
More bleeding
Psychological effects
No menstruation
Becomes steril

20. Complication of CS Bleeding (Atonia, Too large incision)
Infection (Incision site, peritonitis)
Trombophlebitis
Trauma (Gut, Bladder, Baby)
Ileus
Complications due to anesthesia and surgical action

21. Delivery after CS Once cesarean always cesarean
Trial of vaginal delivery
Labor will progress easily
No significant complication to mother and baby

22. Contraindications to vaginal delivery:
Repeated cesarean section
Vertical incision
Absolut indication for CS
Malposition and mal presentation
Maternal diseases (DM, Toxaemia)
Fetal distress, expenssive child etc.

23. Maternal Death due to CS
10-30 cases per
Causes
Bleeding
Infection
Anesthesia
Pulmonary emboli
Heart and renal failure due to prolonged hipotension

24. Maternal Death due to CS (Risk Factor)
Elderly women
Grandemulti gravida
Obesity
PROM
Maternal diseases
Complicated pregnancy
Low social economic condition

25. Infant Mortality Theoretically it is not higher
Practically it is higher, because:
Complication of pregnancy
Misdetermination of age
Fetal distress

26. Preparation for CS Hemoglobin min. 10 g/dL
Heart, lung, electrolyte, liver and kidney, are normal
Fast 6-8 hours
Match Blood, ml
Antacid (30 ml) 1 hour before
Ampicillin 1 gram iv, minutes before operation

27. Monitoring post operation
Stop oral feeding until peristaltics is good
Ivfd: Dextrose 5% and Na Cl 3:1
Closed monitoring of vital sign and fluids balance
Antibiotics: Ampicillin 3 X 1000 mg and Gentamycin 2 X 80 mg for 3 days
Vitamin
Mobilisation on day 2
Removal of suture on day 7
Discharge on day 8.