CESAREAN

SECTION
INDICATION FOR CAESERIAN
SECTION
DYSTOCIA(37%):
Secondary arrest of dilatation
Arrest of descent
Cephalopelvic disproportion
Failure to progress
NONREASSURING FHR(25%)
repetitive late deceleration
absent base line variability
prolonged bradycardia
sinusoidal pattern with no acceleration



Breech presentation: singleton breech at term is an
indication for cesarean section.

Multiple pregnancy:If first twin is non cephalic offer
an elective cesarean.
Cesarean section is usually required monoamniotic
twin


Preterm fetus: do not offer an elective LSCS.
vaginal delivery may be attempted.
cesarean section may be offered in case
of fetal heart rate abnormality and abnormal doppler
studies

Hepatitis C virus
1.Women who are infected with hepatitis C should not
be offered a planned CS
because this does not reduce mother-to-child
transmission of the virus. [2004]
2.Pregnant women who are co-infected with hepatitis
C virus and HIV should be
offered planned CS because it reduces mother-to-child
transmission of both
hepatitis C virus and HIV. [2004]
Hepatitis B virus
Pregnant women with hepatitis B should not be
offered a planned CS because there is insufficient
evidence that this reduces mother-to-child
transmission of hepatitis B virus

Antepartum hemorrhage:
Abruption:
Severe degree with alive fetus-CS
Mild to moderate-abnormal FHR CS
Placenta previa:
cesarean delivery (williams)
Vasa previa:Elective LSCS at 37-38WK.
PIH:
Eclampsia-if delivery is not anticipated with
in 6-8 hr of a seizure CS should be
performed.
DIABETES:
Estimated fetal weight>4kg with
clinical suspicion of CPD
Proliferative retinopathy
CS is preferred for delay in late first and second
stage of labour.
Difficult instrumental delivery should be avoided.



Herpes simplex virus
with primary genital herpes simplex virus (HSV)
infection occurring in the third trimester of pregnancy
should be offered planned CS because it decreases
the risk of neonatal HSV infection. [2004]

Pregnant women with a recurrence of HSV at birth
should be informed that there is uncertainty about the
effect of planned CS in reducing the risk of neonatal
HSV infection. Therefore, CS should not routinely be
offered
.
ACOG(2007a)CS is indicated for women with active
genital lesion or prodromal symptom.H/O HSV or
active lesion in non genital area is not an indication for
CS.



IUGR:
decision regarding cesarean section should
be decided by-
1.Doppler waveform analysis
2.Oligohydraamnios
3.CTG monitoring
PROLONGED PREGNANCY:
AFI<3
Doppler-absent or reverse flow
BPS<6




HIV:
Planned cesarean section
Who are not on ART
On ART with viral load>400copy/ml
Cesarean section should not be offered-
HIV with viral load<400copy/ml +HAART
HIV with viral load<50 copy /ml+ART
CARDIAC DISEASE:
Cesarean section indicated for obstetric
indication.
Aortic coarctation
MACROSOMIA:
Planned LSCS may be reasonable for
diabetic women with EFW>4.25kg(williams)
In general population planned LSCS on the
basis of macrosomia is not advised
It is defined as the birth of fetus(alive
/dead) through an incision
In the abdominal and the uterine
Wall after the period of viability
TRENDS IN CESAREAN
DELIVERY(4.5%-31.8%)
Identification of at risk fetuses
before term(IUGR)
Identification of at risk mothers
Wider use of repeat caesarean
section in cases with previous
caesarean delivery
Rising trend of induction of labour
and failure of induction
Decline in operative vaginal
delivery
Decline in vaginal breech delivery
Increased number of women with
age >30 and associated medical
complication
Adoption of small family norm
Wider use of electronic fetal
monitoring and increased
diagnosis of fetal distress
Fear of litigation in obstetric
practice
Caesarean delivery on demand
INDICATION
ABSOLUTE RELATIVE
1.Severe cephalopelvic disproportion 1.Cephalo-pelvic
disproportion(relative)
2.Central placenta previa 2.Previous caesarean delivery
3.Pelvic mass causing
obstruction(cerrvical or broad ligament
fibroid)
3.Nonreassuring FHR
4. Advanced carcinoma cervix 4.Dystocia
5.Vaginal obstruction(atresia or
stenosis
5.Antepartum haemorrhage(placenta
praevia,abruptio placenta)
6.Malpresentation(breech,transverse
lie)
7.Failed induction/failure to progress
8.Bad obstetric history
9.Medical
10.IUGR
11.Genital HPV
12.Fetal congenital anomaly
ELECTIVE INDICATION
MATERNAL FETAL PLACENTAL
Major pelvic
contraction
Malpresentation Major degree of
placenta praevia
Pelvic soft tissue
tumour
Conjoined twin/large
sacrococcygeal
tumour
Vasa praevia
Cervical atresia Fetal macrosomia
H/O repair of
VVF,stress
incontinence
Bony deformity
EMERGENCY INDICATION
Dystocia
Fetal distress
Failed trial of labour
Failed induction of labour
Failed trial of forceps
Abruptio placenta
Fulminant pre-eclampsia or eclampsia with
unfavourable cervix
Cord prolapse
DO NOT routinely offer planned CS to women with:

An uncomplicated twin pregnancy at term where the
first twin is cephalic
Preterm birth
A small for gestational age baby
Hepatitis B virus / Hepatitis C virus
Recurrent genital herpes at term
A BMI of over 50
NICE guidelines 2011
Offer planned CS to women with:

A singleton breech presentation at term
A twin pregnancy where the first twin is not cephalic

A placenta that partly or completely covers the
internal cervical os (placenta praevia)

HIV--- Not receiving any retroviral therapy
HIV --- viral load equal to or greater than 400
copies per ml regardless of anti-retroviral therapy
HIV with hepatitis C virus

Primary genital herpes simplex virus (HSV) infection
occurring in the third trimester of pregnancy







Decision-to-delivery interval for unplanned CS

30 minutes for category 1 CS
30 - 75 minutes for category 2 &3 CS.
Classification of CS based on urgency
1
immediate threat to the life of the
woman or fetus
2
maternal or fetal compromise which
is not immediately life-threatening
3
no maternal or fetal compromise but
needs early delivery
4
delivery timed to suit woman or staff
INDICATION FOR CLASSICAL C-
SECTION

Inaccessibility of lower uterine
segment
Fibroid
Dense adhesion
Placenta percreta
Advanced cervical cancer

SURGICAL TECHNIQUE
Preoperative assesment:
Plan a caeserian delivery,even an
emergency one.
Elicit proper history
Make a note of necessary
investigation
Appropiate preoperative
examination
anticipate complication and
ways to deal with them
Skin incision:

1. Transverse-
Pfannensteil
Joel cohen
Modified joel cohen
Maylard
Advantages:
Less painful,early postoperative ambulation,lower
risk of herniation


2. Vertical-
1.Low midline vertical
2.Paramedian incision

Advantages:
Less vascular rapid entry
Adequate exposure

Used:
Sense of extreme urgency
Massive haemorrhage,bleeding tendencies
Subcutaneous tissue:
campers fascia
Scarpas fascia
Anterior rectus sheath
Rectus muscle
Parietal peritoneum
Correct the dextrorotation
Vesico-uterine fold
Uterine incision
VESICO-UTERINE FOLD
Placental delivery
Spontaneous placental delivery
less blood loss
decreased incidence of post op
infection.
Manual delivery of placenta
Uterine closure
Peritoneal closure
Abdominal closure
Muscle bellies of the recti
Closure of the rectus sheath
Subcutaneous tissue
Closure of skin
MISGAV LADACH METHOD
1. Joel cohen skin incision.
2. UV fold opened and bladder pushed down by blunt
dissection.
3. Uterus opened by making a small incision and then by
stretching it mannually.
4. Uterus is exteriorized after delivery of fetus.
5. Single layer uterine closure.
6. Parietal and visceral peritoneum are left unsutured.
7. Rectus sheath and skin is closed.
8. It has shorter operative time, less wound infection, post
operative pain and febrile morbidity.
POSTOPERATIVE CARE
Adequate analgesia
Monitoring of vitals,uterine contraction and vaginal
bleeding-every hrly for first 4 hr then every 4hrly for 24hr.
Fluid therapy
Early ambulation
Thromboprophylaxis
Haemoglobin-mornin g after the surgery
Breast feeding
Bladder and bowel function
Wound care
Hospital discharge-3
rd
or 4
th
postoperative day


DIFFICULTIES IN CESAREAN DELIVERY
Difficult abdominal access:
Vertical midline skin incision remains the choice
where rapid delivery and maximum exposure is
required.
Pfannenteil incision may be converted to
maylard incision.
Difficulties with uterine incision:
Transverse lower segment incision when
inadequate for fetal delivery,inverted T shaped
incision can be made.
Classical midline vertical incision in upper
segment is indicated in densely adherent bladder
,ant placenta praevia ,fibroid in lower
segment,cervical carcinoma.
Classical and inverted T shaped incision requires
meticulous closure usually in three layer.
Difficulty in Delivery of head:
Floating head
Deflexed head
Deeply engaged head:
Abdomino-vaginal method
Patwardhans maneuver
Modified Patwardhan
Breech presentation
FORCEPS DELIVERY OF HEAD
COMPLICATIONS
RISK FACTOR:
Excessive speed
Lack of experience
Gestational age below<32 wk
Low station of vertex
Ruptured membrane preoperatively


Maternal mortality- 6/100,000 to22/100,000
5 fold increase in maternal
mortality

Complication of anaesthesia-
1. General anesthesia
Mendelsons syndrome
Displacement of G-O junction
Slow gastric motility-progesterone
Prophylactic measure-
H-2 receptor antagonist
metoclopromide
Prefer regional anaesthesia
Avoid head low position

FETAL PROBLEMS:
longer GA, I-D time adversely affect the neonate
Measures to avoid fetal depression:
Maintainence of uterine perfusion
Uterine displacement
Increase inspire maternal oxygen

2.Regional anaesthesia:
Hypotension
High spinal block
Postoperative headache/spinal headache

INTRAOPERATIVE COMPLICATION:
1. Hemorrhage:
factors associated with >1.5 lit blood loss at CS include
Placenta praevia
Prolonged second stage
General anaesthesia
Amninitis ,preterm CS
Preeclampsia
Extension of uterine incision-

2.Urinary tract injury:
Bladder injury(0.3%)
Ureter injury(0.1%)
3. Bowel injury
4. Injury to newborn
5. Unanticipated gynecological/surgical pathology





EARLY POSTOPERATIVE COMPLICATION:
Reactionary hemorrhage
Retention of urine
Paralytic ileus
Pulmonary embolism
Infection Endometritis,URTI,UTI,
Septic pelvic thrombophlebitis
Wound infection, pelvic abscess
Abdominal wound problem
stitch hematoma
stitch abscess
cellulitis
wound dehiscence
burst abdomen
LATE COMPLICATION:
Adhesion
Need for repeat section
Increase risk of placenta praevia
Scar endometriosis
Chronic pelvic pain

VAGINAL DELIVERY AFTER CESAREAN
(VBAC)
FACTORS FOR CONSIDERATION IN
SELECTION OF CANDIDATE FOR (VBAC)
One previous prior low transverse cesarean delivery
Previous section done for non recurrent indication
Clinically adequate pelvis
No other uterine scar(myomectomy) or previous
rupture
Physician immediately available capable of monitoring
labour and performing an emergency cesarean
delivery.
Availability of anaesthesia and personnel for
emergency cesarean delivery.
RECOMMENDED COUNSELLING POINTS
FOR WOMEN SELECTED FOR VBAC
Advantage ofsuccesseful vaginal delivery
(shorter hospital stay,less painful,rapid
recovery)
Contraindication to trial of labour
(prior classical CS,H/O uterine rupture,lack of
resources to perform emergency CS)
Relative contraindication H/O two previous
LSCS with no previous vaginal delivery)
Risk of uterine rupture-<1%
Uterine rupture is associated with fetal death
and neurological injury.

CANDIDATE FOR TRIAL OF LABOUR AFTER
CAESERIAN SECTION
1. Type of incision-
Classical 4-9%
T shaped 4-9%
low vertical 1-7%
low transverse 0.2-1.5%
prior uterine rupture
lower segment 6%
upper uterus 32%
2. Interdelivery interval
<18 month interval
3 fold increase risk of rupture
3. No of prior C-section
one-0.9%
two-1.8%
4. Prior vaginal delivery


5. Indication-
breech-91%
fetal distress-84%
dystocia(second stage)-75%
6. Obesity
7. Fetal weight
8. Induction or augmentation-
increases risk


SIGNS OF UTERINE RUPTURE WHILE
MONITORING A CASE OF VBAC
Most common sign of uterine rupture-nonreassuring
FHR with variable heart rate deceleration------late
deceleration,bradycardia and death.
Cessation of uterine contraction.
Hemoperitoneum-diaphragmatic irritation
which causes chest pain.
Pain which persist in between the contraction.
Hypovolemia.
Loss of station-per vaginal examination