CAESAREAN SECTION-1.pptxvyfyytytioytilt7tp98

jbo;ug;iohpi

1. CESAREAN SECTION PRESENTERS YUSUF ABDI FARAH MOMOHAMED ABDULLAHI

2. OBJECTIVES Definition History incidence Classifications General indications and contraindications Procedure Complications Subsequent birth following caesarean section Post operative care

3. definition It is a surgical procedure where incisions are made through a woman’s abdomen( laparatomy ) and uterus( hysteretomy ) to deliver one or more babies after 28 weeks ofamenorrhea . The first operation performed on a patient is reffered to as a primary c section and when the operation is performed in subsequent pregnancies it is called repeat c section .

4. history The operation derives its name from the notification “ lex Cesarea ” – a Roman law promulgated in 715 BC which was continued even during Caesar’s reign. The law provided either an abdominal delivery in a dying woman with a hope to get a live baby or to perform postmortem abdominal delivery for separate burial. The other explanation is that the word cesarean is derived from the Latin Verb “ Cedere ” which means “to cut”. French obstetrician, Francois Mauriceau first reported cesarean section in 1668. In 1876, Porro performed subtotal hysterectomy. It was Max Sanger in 1882, who first sutured the uterine walls. In 1907, Frank described the extraperitoneal operation. Kronig in 1912, introduced lower segment vertical incision and it was popularized by De Lee (1922). Although Kehrer in 1881 did the transverse lower segment operation for the first time, Munro Kerr in 1926 not only reintroduced the present technique of lower segment operation but also popularized it.

5. Incidence : The incidence of cesarean section is steadily rising. During the last decade there has been two-to-threefold rise in the incidence from the initial rate of about 10%. Currently the use of this method is estimated between 20-25% for both primary and repeated c section.

6. Reasons for the increased incidence Identification of at risk fetuses before term(FGR) Decline in vaginal breech delivery Decline in operative vaginal (mid forceps, vaccum ) delivery and manipulative vaginal delivery(rotational forceps) Fear of litigation in obtsetric practice Wider use of electronic fetal monitoring and increased diagnosis of fetal distress Increased number of women with age>30 and associated medical complications. Most are nulliparous Caesarean delivery on maternal request Wider use of repeat c section Attempt to decrease perinatal mortality Identification of high risk pregnancy Rising rate of induction of labour and failure of induction

7. classification /TYPES OF CESAREAN SECTION

8. Elective c section This is when the operation is done at a prearranged time during pregnancy to ensure the best quality of obstetrics, anesthesia, neonatal resuscitation and nursing services. (a) Maturity is certain : The operation is done about 1 week prior to the expected date of confinement. (b) Maturity is uncertain : Ultrasound assessment in first or second trimesters is used to ensure fetal maturity. Otherwise spontaneous onset of labor is awaited and then CS is done. Benefits of elective operation : Reduction in perinatal morbidity and mortality as there is no hazard from labor and delivery process. Maternal benefits : no pelvic floor dysfunction. Maternal risks are : Longer recovery time and hospital stay. Risks of placenta previa and hysterectomy are more in subsequent delivery

9. Emergency c section This is when the operation is to be done due to an acute obstetric emergency for example fetal distress. A time interval of 30 minutes between the decision and delivery is taken as reasonable. It can be classified according to the following categories; Category 1 : this is when there is immediate threat to the life of the woman or the fetus. Decision delivery interval should be 30 minutes. Category 2 : this is when there is maternal or fetal compromise which is not immediately life threatening. CS should be done within 75 minutes of making decision. Category 3 : There is no maternal or fetal compromise but needs early delivery. Category 4 : Delivery is planned to suit the woman, family members and the hospital staff.

10. General indications of c section maternal fetal Contracted pelvis Non reassiuring FHR(fetal distress) APH (severe abruptio placenta, central placenta previa Malposition and malpresentation (breech and transverse lie) Severe oligohydromnious Fetal abnormalities Previous c section>=2 Big baby Failure to progress in labor Macrosomia and extreme prematurity Pelvis fracture Multiple pregnancy Extensive Genital herpes Prolapse of the umblical chord Obstructed labor Precious baby ( early PG, bad obsetric history, long period of infertility) Hypertensive disorders eg severe pre eclampsia and eclampsia Medical gynaecological disorders eg uncontrolled diabetes, heart diseases, vvf

11. contraindications There are no absolute contraindicatios which have been documented. It is best avoided in cases of fetal demise, major anomalies incompatible with life such as anencephaly and some maternal diseases like coagulopathies , severe pulmonary disease In presence of absolute indications, cs should be performed

12. procedure Pre operative procedure - Patient informed consent -Ensure fetal hearts are still audible -Ensure indication is still valid -Do routine ultrasound scan site of placenta-presenting part -Do preoperative testing ( cbc , coagulation profile, grouping and cross matching) -Ensure availability of blood -Be sure that neonatal resuscitation team is available - C annulate and give iv fluids(preload) -Give required medications ie ; antacids, prophylactic antibiotics, anti inflammatory, analgesics, anti emetics -Fix a foleys catheter in the bladder and ensure the stomach is empty

13. procedure Position- supine, 15 degrees left-lateral tilt of theatre table to minimize caval obstruction Anaesthesia - general, spinal, epidural, combined spinal and epidural Surgical draping- apply antiseptic solution 3 times to the incision site using a high level disinfected ring forceps and cotton or gauze swab then draping that allows good exposure Abdominal wall incision Uterine wall incision ( Hysterotomy ) Delivery of the fetus Delivery of the placenta and cord Repair of uterine wall Repair of abdominal wall incision

14. Abdominal wall incision( laparatomy ) transverse abdominal incision( pfannenstiel incision) vertical midline incision( infraumbilical incision)

15. Types of abdominal wall incisions pfannenstiel incision infraumbilical incision A transverse incision through s kin and subcutaneous tissue using curvilinear incision 2 fingerbreadths from the symphysis pubis. Advantages Improved cosmetic results Reduced analgesic requirements Superior wound strength-Risk of scar rupture is low Early movement of the patient Less incidence of incisional hernia „ Fundus of the uterus can be better palpated during immediate postoperative period Disadvantages More bleeding Limited exposure of adnexae a vertical midline skin incision is made 2 finger breadths below the umblicus to the symphysis pubis. Advantages Greater ease of access to pelvic and intra-abdominal organs. It is enlarged more easily. Less bleeding. Disadvantages Rate of wound dehiscence is high. Poor cosmetic result Higher incidence of hernia

16. Laparatomy continued Subcutaneous tissue – blunt dissection offers less operation time i.e ; Faster, and less chance of injury to vessels. Fascia- small transverse incision made and extended laterally (scissors) or cephalo -caudally (fingers) Rectus sheath- separate by blunt dissection. Peritoneum- blunt dissection with fingers to minimize injury to bowel and other organs. *In case of adhesions, an alternative route with most accessible location should be used. Supravesical approach can be used but it requires experienced hands. For adequate exposure the abdominal incision should be adequate to allow delivery of the fetus, the surgeon and the assistant can manually stretch apart the opening and can use retractors.

17. Uterine incision(hysterectomy) Lower segment c section Upper (classical) segment c section

18. Upper segment Lower Segment Peritoneal covering -Firmly attached -Loosely attached Muscle layer -Thick, arranged in 3 layers; outer longitudinal, inner circular and middle interlacing -Thin, arranged in 2 layers outer lateral and inner circular Decidua -Well developed - Poorly developed Fetal membranes - Firmly attached - Loosely attached Role in Labour - Active; contraction retraction - Passive; stretched

19. Other types of uterine incision Lower segment vertical; which may be extended upwards when needed. It is also made when the lower segment is poorly developed or when there is complete anterior placenta previa or any myoma occupying the lower segment classical incision (upper segment). “J” incision; upward vertical extension of the initial transverse incision. inverted “T” incision; upward extension from the mid-transverse incision. Lower segment transverse; most commonly used. This is due to : Ease of operation; less bladder dissection, less blood loss, easy to repair, complete reperitonization , less adhesion formation, less risk of scar rupture when trial (VBAC) of labor is given for subsequent delivery

20. Delivery of the fetus Cephalic presentation: Insert hand into uterine cavity, flex fetal head and bring to level of uterine incision then extract. Assistant should apply transabdominal fundal pressure. Incase of difficulty, use vacuum device or forceps Deeply impacted fetal head Push method : Insert hand into vagina and push Pull or reverse breech method : Pull fetal legs in UUS. ( Risk extending the incision, but associated with lower maternal and neonatal morbidity The duration from incision to delivery shouldn’t be long otherwise its associated with low fetal blood gas Ph, and APGAR score

21. Delivery of the placenta and membranes Cord should be clamped. Delayed (more than one minute clamping is preferred, as it is associated with higher hemoglobin levels in fetus Allow placenta to drain and give oxytocin (5 IU syntocinon ), apply gentle cord traction (spontaneous extraction). CCT leads to less blood loss and reduces the risk of endometritis than manual extraction. Check for remaining tissues with your hand. Incase of hemorrhage, give; IV oxytocin Massage uterus

22. Closure of incision Ideally, avoid exterorising the uterus Use absorbable sutures. Suture single or double layers with continuous or interrupted sutures. Don’t close peritoneum Don’t suture rectus Fascial suture provides most tensile strength of wound *Avoid suturing with unnecessary tension Subcutaneous tissue- interrupted absorbable suture. Skin- non absorbable interrupted suture

23. Post operative care First 24 hours: (Day 0) Observation for the first 6–8 hours is important. Periodic checkup of pulse, BP, amount of vaginal bleeding and behavior of the uterus (in low transverse incision) is done and recorded. Fluid: Ringer’s lactate drip is continued until at least 2.0–2.5 L of the solutions are infused. Blood transfusion is helpful in anemic mothers for a speedy post-operative recovery. Blood transfusion is required if the blood loss is more than average during the operation (average blood loss in cesarean section is approximately 0.5–1.0 L). .

24. Post operative care continued Oxytocics : Injection oxytocin 5 units IM or IV (slow) or methergine 0.2 mg IM is given and may be repeated. Prophylactic antibiotics metronidazole for all cesarean delivery is given for 2–4 doses. Therapeutic antibiotic is given when indicated. Analgesics in the form of pethidine hydrochloride 75–100 mg is administered and may have to be repeated. Ambulation : The patient can sit on the bed or even get out of bed to evacuate the bladder, provided the general condition permits. She is encouraged to move her legs and ankles and to breathe deeply to minimize leg vein thrombosis and pulmonary embolism. Baby is put to the breast for feeding after 3–4 hours when mother is stable and relieved of pain

25. Day1 : Oral feeding in the form of plain or electrolyte water or raw tea may be given. Active bowel sounds are observed by the end of the day. Day2 : Light solid diet of the patient’s choice is given. Bowel care: 3–4 teaspoons of lactulose is given at bed time, if the bowels do not move spontaneously. Day 5 or day 6 : The abdominal skin stitches are to be removed on the D-5 (in transverse) or D-6 (in longitudinal). Discharge : The patient is discharged on the day following removal of the stitches, if otherwise fit. Usual advices like those following vaginal delivery are given. Depending on postoperative recovery and availability of care at home, patient may be discharged as early as third to as late as seventh postoperative day

26. Complications Intraoperative complications Post operative complications Haemorrhage Infection Caesarean hysterectomy Venous thromboembolism Placenta praevia Psychological Organ damage

27. vaginal birth after cesarean (VBAC) It is the trial of vaginal birth after C.S in previous pregnancy Previously, once CS,always cecarean Now, once CS always hospital delivery Selection criteria : -1 previous scar, LSCS (transverse) with a pregnancy interval of 2years -Pelvis must be adequate -Continued labor monitoring -Availability of resources eg ; blood and anaesthesia -Competent HW

28. Contraindications: - Previous classical uterine incision -2 or more previous LSCS -Contracted pelvis -Presence of complications eg ; PET (Positron Emission Tomography) , malpresentation , placenta praevia -Limited resources NB: Pt should be allowed to go into spontaneous labor as induction may cause rapture of the scar