Caesarean section & others

Caesarean section & others

1. Caesarean Section Mrs. U SREEVIDYA Msc . NURSING, Associate Professor, Apollo college of nursing, CHITTOOR

2. Caesarean Section Definition: It is an operative procedure whereby the fetus or foetuses after the end of 28 th week are delivered through an incision on the abdominal and uterine walls.

3. Incidence It is steadily raising about 10% Increased from 5% in 1970 to 25% in 1990 due to: Procedures as high forceps and difficult mid forceps are abandoned in favour of Caesarean Section (C.S.) Increased C.S delivery in breech presentation. Destructive operations are abandoned in favour of C.S. Decreased morbidity and mortality due to C.S encourages its use.

4. Incidence Increased safety of the operation Improved anaesthesia Availability of blood transfusion and antibiotics Early identification of at risk mothers Wider use of c/s in post c/s pregnancies and Mal -presentations.

5. INDICATIONS Divided into Maternal indicators Fetal indicators Fetomaternal indicators- coexist

6. Indi ca tions Maternal indications: Severe degree of Contracted pelvis and cephalopelvic disproportion Pelvic tumours especially if impacted in the pelvis or cancer cervix. Vaginal atresia The above are considered as absolute indications of c/s, whereby the vaginal delivery is impossible. The relative indications are as follows - Minor degree of contracted pelvis and CPD Antepartum hemorrhage 4.Hypertensive disorders with pregnancy Abnormal uterine action Previous uterine scar as previous c/s, hysterotomy or metroplasty. Previous successful repair of vesico-vaginal fistula.

7. Indi ca tions cont.. 7 .Previous caesarean section if, the cause of the previous section is permanent e.g. contracted pelvis. previous section was upper segment. c.suspected weak scar as evidenced by: History of puerperal infection after the previous section. Hysterosalpingography or hysteroscopy done after the previous section reveals a defect in the scar. Vaginal bleeding during current labour. Marked tenderness over the scar during current labour. >Associated conditions as antepartumhaemorrhage or malpresentations.

8. FETAL INDICATION Fetal distress and cord prolapse Breech presentation –[footling, knee presentation, complicated breech] Malpresentation [ brow, transverse lie persistent mentoposterior ] Sever IUGR Macrosomia Multiple pregnancy[first twin non -vertex and monoamniotic twin] HIV complicating

9. Indi ca tions cont.. Foetal indications: 1. Malpresentations and malposition 2.Prolapsed pulsating cord or foetal distress before full cervical dilatation. Diabetes mellitus Bad obstetric history as recurrent intrauterine foetal death in last weeks of pregnancy or repeated intranatal foetal death. Post-mortem C.S. done within 10 minutes of maternal death to save a living baby.

10. C o n t r aindi c a tions 1.Dead foetus: except in; a. Extreme degree of pelvic contraction. b. Neglected shoulder presentation c. Severe accidental haemorrhage. 2. Disseminated intravascular coagulation (blood coagulation disorder) : to minimise blood loss. 3. Extensive scar or pyogenic infection in the abdominal wall e.g. in burns. 4. Too premature baby.

11. Time of operation 1. Elective 2. Emergency Elective: when the operation is done at a pre-planned time during pregnancy. Conditions to be fulfilled – Maturity of the foetus and lungs maturity should be complete. The operation is done at a pre-selected time before onset of labour , usually at completed 39 weeks Emergency: when the operation is performed due to sudden complication arising either during pregnancy or during labour.

12. Types of Caesarean Section According to the site of uterine incision a. Upper segment caesarean section (classical C.S.): The incision is done in the upper uterine segment and it is always vertical. b. Lower segment caesarean section (LSCS): It is the common type. The incision is done in the lower uterine segment and may be transverse (the usual) or vertical in the following conditions: Presence of lateral varicosities. Constriction ring to cut through it. Deeply engaged head.

13. Classical CS - Disadvantages Chance of scar rupture more General peritonitis ,if infection occurs

14. Abdominal Incisions 1. Vertical Incision Vertical incisions are very rare. quickest to make greater chance of dehiscence 2. The horizontal or Pfannenstiel Incision It i s placed at the top of to pubic hair or just over the hair line as the c-section is started. cosmetically better & stronger less chance of dehiscence

15. Types of Caesarean Section According to number of the operation Primary caesarean section: for the first time. Repeated caesarean section: with previous caesarean section(s).

16. Types of Caesarean Section According to opening the peritoneal cavity a. Transperitoneal: The ordinary operation where the peritoneal cavity is opened before incising the uterus. b. Extraperitoneal: The peritoneal cavity is not opened and the lower uterine segment is reached either laterally or inferiorly by reflecting the peritoneum of the vesico-uterine pouch . It is indicated in case of infected uterine contents as chorioamnionitis.

17. Advantages of elective C.S. Pre - operative good preparation as regard sterilisation and antiseptic measures, fasting and bowel preparation. The risk of puerperal sepsis is minimised. The operation is scheduled and working is in ease.

18. Disadvantages of elective C.S. * The risk of immaturity of the foetus or its lung is present. Higher incidence of respiratory distress syndrome. The lower segment may be not well formed. Postpartum haemorrhage is more liable to occur. Imperfect drainage of lochia as the cervix is closed so it should be dilated by the index finger introduced abdominally through the uterine incision.

19. Pre operative preparation Skin preparation Antacid: Rantidine (H2 blocker)- 150mg is given orally before night and repeated 50mg, IM/IV Injection one hour before surgery. Administer Metoclopramide – 10mg, IV Bowel and bladder should be emptied. FHS should be recorded. Anaesthesia : General inhalation anaesthesia with nitrous oxide + oxygen (the most commonly used), epidural, spinal or rarely local infiltration anaesthesia. * Position: Tilting the patient 15 degree to the left in the dorsal position to minimise the aorto-caval compression.

20. Procedure of Lower Segment Caesarean Section Skin incision : Pfannenstiel (transverse suprapubic) incision is the most commonly used, but midline or paramedian , vertical suprapubic incisions may be used. If the patient had a previous C.S , incise in the same incision with trimming of the fibrosed edges of the wound to help good healing. Pfannenstiel incision has a better cosmetic appearance, better healing and less incidence of incisional hernia but it is more time consuming associated with more blood loss and gives less exposure.

21. Procedure of Lower Segment Caesarean Section * The subcutaneous fat is incised. * The anterior rectus sheath is incised transversely in case of Pfannenstiel incision and longitudinally in case of vertical incisions * The rectus muscles: are separated in the midline in Pfannenstiel incision or retracted laterally in case of vertical incisions * The parietal peritoneum: is opened vertically.

22. *The uterus is centralised, the bowel and omentum are packed off with moist laparotomy pads, however this is usually unnecessary. *The loose peritoneum over the lower uterine segment is held and incised transversely, for about 10 cm in a semilunar fashion with its edges directed upwards. * The bladder is compressed downward and is retained behind a Doyne retractor placed over the symphysis.

23. * The uterus is incised: in the same semilunar fashion by one of the following methods: A semilunar mark is made by the scalpel cutting partially through the myometrium for 10 cm. A short (3cm) cut is made in the middle of this incision mark reaching up to but not through the membranes. The incision is completed by the 2 index fingers along the incision mark. If the lower uterine segment is very thin, injury of the foetus can be avoided by using the handle of the scalpel or a haemostat (an artery forceps) to open the uterus. The short (3cm) middle incision may be enlarged by a bandage scissors over 2 fingers introduced into the uterus to protect the foetus.

24. *Membranes are ruptured by toothed or Kocher’s forceps. * The head is delivered by: introducing the right hand gently below it and lifting it up helped by fundal pressure done by the assistant, using one blade of the forceps or, using Wrigley’s forceps. >If the head is deep in the pelvis it can be pushed up vaginally by an assistant. The Doyen’s retractor is removed after the hand or forceps blade is applied and before head extraction.

25. * Suction for the foetus is carried out before delivery of the head. * In breech or transverse lie the foetus is extracted as breech. * The placenta is removed.

26. * Closure of the uterine incision is done in 3 layers . >The first is a continuous locking suture taking most of the myometrium but not passing through the decidua to guard against endometriosis and weakness of the scar. >The second is a continuous or interrupted one inverting the first layer. >The third is a continuous or interrupted layer to close the visceral peritoneum of the uterus. Closure of visceral and/or parietal peritoneum is omitted by some surgeons. * The abdomen is then closed in layers . Clean the vagina and place the sterile pad.

27. Upper Segment Caesarean Section Indications: Dense adhesions, extensive varicosity or myoma in the lower uterine segment making its exposure or incising through it difficult. Impacted shoulder presentation. Anterior placenta praevia. Defective scar in the lower segment. Cancer cervix. Rapid delivery is indicated. If a n associated tubal sterilisation will be done. Previous successful repair of high vesico-vaginal or cervico-vaginal fistula. Post-mortem hysterectomy.

28. Procedure: Abdominal incision: is vertical. Uterine incision: 10 cm vertical incision is made in the midline of upper uterine segment without incising the peritoneal coat separately as it is adherent in the upper segment. Extraction of the foetus: as a breech in cephalic presentation. The last layer of the uterine incision closure includes the superficial part of the myometrium with the peritoneal covering. The remainder of the procedure is as lower segment C.S.

29. Post operative care Patient is observed for at least 6-8 hours Vital signs should be recorded. I.V fluids should be administered Blood transfusion if necessary Inj. Methergin – 0.2mg, IM, should be given. Repeat if necessary. Prophylactic antibiotics for 48 hours. Analgesics – Pethidine-75 to 100 mg Ambulation: sit on the bed with in 24 hrs Breast feeding Diet: second day- liquid diet like electrolyte water or tea, third day – light solid diet Mild laxative – milk of magnesia – 4-6 spoons Removal of stiches – 6 th or 7 th day. Discharge: on the day following removal of the stiches.

30. Advantages of the lower segment over the upper segment operation Less blood loss: due to less vascularity and the placental bed is away from the incision. Easier to repair. *The resultant uterine scar is stronger *Less subsequent adhesions to the bowel and omentum. *Less liability to acute gastric dilatation and paralytic ileus. Less liability to peritonitis due to better peritonization and healing.

31. Caesarean Hysterectomy Hysterectomy is carried out after caesarean section in the same sitting for one of the following reasons: Uncontrollable postpartum haemorrhage. Unrepairable rupture uterus. Operable cancer cervix. Couvelaire uterus. Placenta accreta cannot be separated. Severe uterine infection particularly that caused by Cl. welchii. *Multiple uterine myomas in a woman not desiring future pregnancy .

32. Caesarean Sterilisation Tubal sterilisation is usually advised during the third c aesarean section.

33. Complications of Caesarean Section 1. Operative: Primary maternal mortality is 4 times that of vaginal delivery which may be due to: shock . Anaesthetic complications particularly Mendelson’s syndrome Haemorrhage usually due to extension of the uterine incision to the uterine vessels, atony of the uterus or DIC. Injuries to the bladder or ureter. Fetal injuries , RDS- Respiratory distress syndrome to foetus.

34. Complications of Caesarean Section 2. Post-operative: b. Early: Thrombosis and pulmonary embolism. Acute dilatation of the stomach and paralytic ileus. Wound infection, puerperal sepsis and burst abdomen. >Chest infection. c. Late: Rupture of the uterine scar. Incisional hernia. Chronic pelvic pain or backache Menstrual irregularities.

35. DESTRUCTIVE OPERATIONS

36. DESTRUCTIVE OPERATIONS DEFINITION: The destructive operations are designed to diminish the bulk of the fetus so as to facilitate easy delivery through the birth canal. These procedures are difficult and may be dangerous too unless the operator is sufficiently skilled.

37. Types of destructive operations Some commonly performed operations are Craniotomy Evisceration Decapitation Cleidotomy

38. CRANIOTOMY Definition It is an operation to make a perforation on the fetal head , to evacuate the contents followed by extraction of the fetus.

39. Indications Cephalic presentation producing obstructed labour with dead fetus Hydrocephalus even in a living fetus Interlocking head of twins

40. Contraindications  The operation should not be done when the pelvis is severly contracted. So as to shortened the true conjugate to less than 7.5cm (3``).  Rupture of the uterus Condition to be full filled  The cervix must be fully dilated  Baby must be dead

41. Procedure Step1: Two fingers are introduced into the vagina and the fingertips are to be planned on proposed site of perforation. However when the suture line cannot be defined because of big caput , the perforation should be done through the dependent part. Step 2: The Oldham’s perforator , with the blades closed , is introduced protecting the anterior vaginal wall and the adjacent bladder until the tip reaches the proposed site of perforation. Step 3 :- By rotating movements the skull is perforated . After the skull is perforated , the instrument is thrust up to the shoulder and the handles approximated ,so as to allow separation of the sharp blades for about 2.5 cm . Step 4 :- With the fingers brain matter is evacuated. The idea is to make the skull collapsed as much as possible. Step 5 :-when the skull is found sufficiently compressed, the extraction of the fetus is achieved either by using cranioclast or by two Gaint Vulsella are used to hold the incised skull and scalp margins. Step 6 :- the traction is now excreted in the same direction is like that mentioned in forceps operations. Step 7 :- after the delivery of the placenta, the uterovaginal canal must be explored as a routine for evidence of rupture uterus or any tear. Inj. Methergin 0.2mg is to be given intravenously with the delivery of the anterior shoulder. The rest of the delivery is completed as in normal delivery.

42. EVISCERATION The operation consists in removal of thoracic and abdominal contents piecemeal through an opening on the thoracic or abdominal cavity at the most accessible site. The objective is to diminish the bulk of the fetus which facilitates its extraction. If difficulty arises , the spine may have to be divided ( spondylotomy ) with embryotomy scissors. Indications Neglected shoulder presentation with dead fetus , the neck is not easily assessable. Fetal malformation such as fetal ascites or hugely distended bladder or monsters.

43. DECAPITATION Definition It is a destructive operation whereby the fetal head is severed from the trunk and the delivery is completed with the extraction of the trunk and that of the decapitated head per vaginam . Indications Neglected shoulder presentation with dead fetus where neck is easily assessable Interlocking head of the twins

44. Procedure The operation should be done at general anesthesia Step 1 :- if the fetal hand is not prolapsed bring down the hand. A roller gauze is tied on the fetal wrist and assistant is asked to give the traction towards the side away from the fetal head to make the neck more assessable and fixed Step 2 :- two fingers of the left hand are introduced with the palmar surface downwards and the fingertips are to be placed on the superior surface of the neck –the prolapsed site of decapitation. Step 3 :- the decapitation hook with knife is to be introduced flushed under the guidance of the fingers placed into the vagina, with knob pointing toward the fetal head. The hook is pushed above the neck and rotated to 90 ̊ , to placed the knife firmly against the neck. Step 4 :- by upward and downward movement of the hook with knife the vertebral column is severed. Step 5 :- delivery of the decapitation head – the methods are By hooking the index fingers into the mouth By holding the severed head with Giant Vulsellum and delivery of he head as that of aftercoming head in breech. Using forceps Step 6 :- routine exploration of the utero vaginal canal to exclude rupture of the uterus or any other injury.

45. CLEIDOTOMY The operation consists of reduction in the bulk of the shoulder girdle by division of one or both the clavicles. The operation is done only in dead fetus ( anencephaly excluded ) with shoulder dystocia. The clavicles are divided by the embryotomy scissors or long straight scissors introduced under the guidance of left two fingers placed inside the vagina.

46. Post operative care following destructive operation  Exploration of the utero-vaginal canal must be done to exclude rupture of the uterus or lacerations on the vagina or any genital injury.  A self retaining catheter is put inside specially following craniotomy for a period of 3-5 days or until the bladder tone is regained.  Dextrose saline drip is to be continued till dehydration is corrected.  Blood transfusion may be given if required .  Ceftriaxone 1gm IV infusion is given twice daily.

47. Complications Injury to the utero-vaginal canal Rupture of the uterus Post partum haemorrhage -atonic or traumatic Shock due to blood loss and or dehydration Puerperal sepsis Subinvolution Injury to the adjacent viscera Prolonged ill health

48. Nursing diagnosis Alteration in comfort due to pain related to delivery process  Assess the types of pain ,types , duration and intensity  Provide comfortable left lateral position to the mother  Provide psychological reassurance to the mother Potential for complication related to destructive operation  Assess for any types of laceration  Maintain aseptic technique  Handle the case carefully  Case should handle by experts  Clean the perineal area with betadine

49. Nursing diagnosis 3. Potential for infection related to destructive operation Assess for any scar Maintain strict aseptic technique  Clean the surrounding  Avoid many visitors 4. Fear and anxiety of parents related to delivery process  Provide proper explanation about baby’s condition  Give information about progress of delivery frequently  Provide psychological reassurance to the mother  Clarify the mother doubts.

50. VE R SION

51. DEFINITION Version is the turning out of fetus from one presentation to another and may be done either externally or internally by the physician. If the aim is to make the head the presenting part is called cephalic version and if the breech will be the presenting part it is called podalic version.

52. TYPES OF VERSION According to the methods employed. External cephalic version Internal podalic version Bipolar version

53. External cephalic version It is a procedure used to turn a fetus from a breech position or transverse position into a cephalic pole of the uterus.

54. INDIC A TION Breech presentation Transverse lie/ oblique lie

55. PRELIMINARIES The patient is asked to empty bladder. She is to lie on her back with the sholders slightly raised and the thighs slightly flexed. abdomen is fully exposed and FHR is auscultated. The most commonly used tocolytic medication (terbutaline-0.25mg sc ) to relax the uterus.

56. FLOW CHART OF ECV :- Confirm breech presentation at >36 completed weeks of gestation  Review contra indication , obtain inform ed con sent  Consider tocolytic for nulliparous patient  Assess NST .  cephalic version att em pt Successful unsuccessful

57. PROCEDURE (a) (a) Step-1. The breech mobilised using both hands On the surface of the abdomen at first. Then one by the fetus'head and the other by the buttocks the fetus is turned and rolled to the vertex position. (b) (b) Step-2. Gen e rally podalic pole is grasped by right hand and head is grasped by left hand till the lie becomes transverse.

58. CONTINUE : Step-3. The hand is now changed one after the other hold the fetal poles to prevent crossing of the hand. (c) ( (d)

59. INSTRUCTIONS The patient is advised for follow up to check the corrected position. To report to the physician if there is vaginal bleeding or liquor amnii. Rh-negative non immunised women must be protected by intramuscular administration of 100.mug anti-D gamma globulin.

60. CONTRAINDICATION Fetal distress. The amniotic sac has ruptured. A mother has a condition(such a heart problem). A ca esarean delivery is needed,such as when there is placenta praevia or abruptio placentae.

61. Advantages of ECV Reduces the number of caesarean delivery. Reduces maternal morbidity due to caesarean or vaginal breech delivery . Reduces the fetal hazards of vaginal breech delivery.

62. EX TERNAL PODALIC VERSION The external podalic version may be done in cases when the external cephalic version fails in transverse lie in case of the second baby of twins.

63. INTERNAL PODALIC VERSION Internal version is always a podalic version and is almost always completed with the extraction of the fetus.

64. INDICATION S Its only indication being the transverse lie in case of the second baby of twins. However, it may be employed in singleton pregnancy to expedite delivery in adverse condition where the caesarean section facilities are lacking. Such condition are: Transverse lie with cervix fully dilated. Cord prolapse with cervix fully dilated with transverse lie or head high up and the baby is alive.

65. PRELIMINARIES Lithotomy position. Empty bladder. Give general anesthesia. Antiseptic cleaning , draping and catheterisation are done. Wearing gloves.

66. PROCEDURE Step-1: If the podalic pole of the fetus is on left side of the mother, the right hand is to be introduced and vice versa. Step-2: The identification of the foot is done by palpation of the heel. Step-3: While the leg is brought down by a steady traction the cephalic pole is pushed up using the external hand. Step-4: After one leg is brought down,there is no difficulty to deliver the other leg.

67. CONTINUE Step-5: Routine exploration of the utero-vaginal canal to exclude rupture of the uterus or any other injury. (a) ( (b)

68. CONTRAINDICATION Obstructed labour. Tonically contracted uterus. Restricted fetal mobility.

69. COMPLICATIONS Maternal risk include - Placental abruption. Rupture of the uterus. Fetal risk include - Asphyxia. Cord prolapse. Intra cranial hemorrhage.

70. BIPOLAR VERSION It also known as braxton -hicks. The version is done introducing one or two finger through the cervix and the other hand on the abdomen.

71. INDICATION Correction of a transverse lie in a dead or Premature foetus.

72. PROCEDURE Under the general anethesia. At least two finger are passed through the partially dialated cervix, the foot is grasped as in internal podalic version pulled through the cervix while the other hand is assisting the version externally .

73. BIBLIOGRAPHY BOOK REFER E NCE Annama Jocab, text book of comprehensive text book of ‘MIDWIFY and GYNECOLOGY nursing ‘ JAYPEE publication 3 rd edition page no.285-287. D.C. DUTTA text book of obsterical including perinatary and contraception central publication 7 th edition page no. 58 2- 585. NETREFER E NCE ww w .wiki p edia. c o m www.pubm e d.com

74. THANK YOU