Caesarean section

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1. CAESAREAN SECTION “yet another way to get OUT!”

2. Why called so?? According to legend , julius caesar was born by this operation It was a fatal operation until beginning of 20 th century. Now the most common operation performed worldwide

3. Definition The delivery of a viable fetus through an incision in the abdominal wall and uterus. Definition does not include removal of fetus from abdominal cavity in case of rupture uterus. WHO recommends an ideal caesarean rate of 15-20%. But in most countries it is 15-20%

4. Why rates increased? Increase in repeat caesareans. Difficult instrumental delivery and vaginal breech deliveries Increased diagnosis of intrapartum fetal distress Caesarian on demand Identification of risk of mothers and fetuses Increase in pregnancies by invitro fertilization

5. Indications Previous caesarian section Dystocia or dysfunctional labour Fetal distress Breech presentation Antepartum haemorrhage Maternal problems Caesarian section on demand

6. LSCS

7. Cross matched blood Catheter introduced Antibiotic prophylaxis Heparin as thromboprophylaxis Parts cleansed with antiseptic solution Left lateral position- reduce aortocaval compression. reduce risk of supine hypotension

8. ANAESTHESIA GA or REGIONAL REGIONAL - Spinal or Epidural Mendelson’s syndrome - GA given as emergency- risk of aspiration- chemical pneumonitis . To counteract- antacids given during labour , oral fluids withheld 30 ml 0.3 molar sodium citrate orally -1/2 hr before surgery. Sellick’s manoeuvre - endotracheal intubation accompained by pressure on cricoid cartilage

9. ABDOMINAL INCISIONS Pfannensteil incision -MC used. Transverse curvilinear incision above pubic hairline Deepened through s/c tissue upto rectus sheath Rectus sheath divided transversely Two recti muscles seperated in midline

10. Maylard incision Option when more exposure is needed in transverse incision Recti muscles are divided Midline vertical incision

11. Transverse incision Vertical incision Cosmetic appeal More Less Postoperative pain Less More Wound dehiscence Less More Incisional hernia Less More Technical skill More Less Time taken More Less Access to upper abdomen Less Good, can be extended

12. PROCEDURE Once abdomen opened- dextrorotation of uterus corrected Doyen retractor - visualize lower segment Peritoneum over lower segment identified-divided transversely- seperated from bladder by blunt dissection Small incision in lower segment-extended laterally Inadequate space- J shaped or inverted T incision Do not injure uterine vessels lying laterally

13. DELIVERY OF BABY Cephalic presentation Hand slipped into uterine cavity Head is levered out gently Floating head- use forceps to deliver the baby. Breech presentation feet hooked out first rest delivered as vaginal breech delivery

14. Transverse or oblique lie corrected to longitudinal lie before making uterine incision. Transverse lie with ruptured membranes & undeveloped lower segment extension of uterine incision required

15. CLOSURE OF UTERINE INCISION OXYTOCIN infusion started as soon as baby is delivered Uterine fundus contracts-placenta and membranes extrudes spontaneously- removed Wipe with moist pad- ensure uterine cavity is empty and cervical canal is open Uterine edges- held with ALLIS forceps or GREEN ARMYTAGE forceps- incision closed in 2 layers- continuous sutures

16. Chromic catgut or polyglactin used Any bleeding points- controlled with figure-of-eight sutures

17. CLOSURE OF ABDOMEN PERITONEUM- closed or not closed RECTUS SHEATH-non absorbable sutures- proline - to reduce wound dehiscence & incisional hernia Subcutaneous tissue- closed SKIN- mattress sutures of silk, subcuticcular suture or clips

18. POST OPERATIVE CARE

19. Close monitoring for 1 st 6-8 hrs Parenteral fluids Blood transfusion if needed Analgesics and sedatives Oral fluids Early ambulation and deep breathing exercises Light solid diet n laxatives Discharged –day following suture removal/if transverse or subcuticular-5 th /6 th day

20. Advantages of LSCS Healing better Scar rupture minimal

21. Other types of CS 1. Low segment vertical incision 2.Classical CS 3.Extra peritoneal CS 4.Caesarean hysterectomy

22. Lower segment vertical incision Indications :Constriction ring,lower segment not formed Disadv : injury to cervix, vagina,bladder increased chance of rupture in next pregnancy

23. Classical caesarean Indications lower segment unapproachable CA cervix Anterior placenta praevia with prev caesarian Transverse lie with ruptured membranes Conjoint twins Disadvantages Difficult healing Scar rupture General peritonitis

24. Extraperitonial caesarean Severe infection Extraperitoneal approach Space of Retzius

25. Caesarean hysterectomy Indications Severe atonic PPH Placenta accreta,increta,percreta Sepsis Multiple large myomas CA cervix

26. COMPLICATIONS OF CAESAREAN SECTION

27. Intraoperative complications Primary haemorrhage Injury to internal organs Injury to the baby Difficulty in delivery of the head Anaesthetic complications

28. Primary haemorrhage Atonic - oxytocin 20units in 500ml ergometrine0.25mg im or iv prostaglandin F2 alpha 250micgram im and intramurally PGE1 200micgram rectally Traumatic -ligation of concerned vessels Placenta accreta

29. Postoperative complications Paralytic ileus Respiratory complications Infections Peritonitis Pelvic abscess Pelvic thrombophlebitis Deep vein thrombosis and pulmonary embolism Wound dehiscence

30. Late sequelae Secondary PPH Incisional hernia Scar endometriosis Vesico -vaginal fistula Scar rupture in the next pregnancy Placenta praevia and placenta accreta Bladder injury