Caesarean section - indications and types

my ostetrics and gynecology presentation in final year.. 2012...

1. Caesarean Section Indications and types VISHNU AMBAREESH M S 2007 BATCH

2. According to legend, Julius Caesar was born by this operation and hence the origin of the term caesarean. ???? Used to be invariably fatal Most important modification was the lower segment transverse incision. First done by kehrer and popularized by Munro Kerr

3. DEFINITION CAESAREAN SECTION is the removal of a child through an incision in the abdominal wall of an intact uterus. Term not applied to removal of a child from the abdomen after rupture of the uterus with or without protrusion of the whole or part of the child into the peritoneal cavity, nor to an operation for abdominal pregnancy.

4. INCIDENCE It is the most commonest operation performed worldwide. Ideal CS rate is 10 to 15 % (WHO) Increased incidence worldwide during last 25 years.

5. Why has the incidence increased? Mainly due to 3 factors Repeat caesarean Dystocia Fetal distress Increased safety of the surgery Increased demand

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

7. MATERNAL INDICATORS PREVIOUS CS DYSTOCIA due to - CPD - tumours complicating pregnancy -non progressive labour -threatened rupture and obstructed labour -failed forceps or vacuum - deep transverse arrest

8. Antepartum hemorrhage - placenta praevia - abruptio placenta - vasa praevia -carcinoma cervix Medical disorders -pre- eclampsia and eclampsia - coarctation of aorta

9. Maternal obstetric problem -elderly nullipara -prolonged period of infertility or pregnancy following IVF -bad obstetric history -previous repair of nulliparous prolapse - stress incontinence or fistula -failed induction

10. 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

11. CAESARIAN SECTION - TYPES

12. CAESARAEAN SECTION -TYPES Lower Segment C aeserean Section(LSCS) Lower segment vertical incision Classical CS Extraperitoneal caeserean Caeserean hysterectomy

13. LSCS Most commonly employed type Involves lower segment transverse incision

14. LOWER SEGMENT VERTICAL INCISION Indications: Constriction ring Lower segment not formed as in transverse lie Disadvantages : Extension downwards may involve the cervix,vagina and even the bladder Extension into the upper segment increases the chance of rupture in next pregnancy

15. Classical C aesarean section Lower segment is not approachable Uterine incision –on the anterior uterine wall in the upper segment above the reflection of the UV fold of peritoneum Fetal foot grasped and baby delivered as breech

16. Classical CS - Indications Lower segment is unapproachable due to severe adhesions or myomas Ca cervix Some cases of anterior placenta praevia with a previous caeserean Some cases of transverse lie with ruptured membranes Conjoined twins

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

18. LSCS SCAR CLASSICAL SCAR Apposition Better Difficult Healing in puerperium Better as the Lower segment is quiscent Imperfect due to contraction and retraction of upper segment Placental implantation May be over the scar much more likely Rupture .5-2% 4-8% Timing of rupture In labour In pregnancy and labour Infection Less chance More chance

19. Extraperitoneal Caesarean section In severe infection Uterus opened through an extraperitoneal approach Through the space of Retzius beneath the bladder

20. Caesarean Hysterectomy Life saving measure for severe atonic PPH Indications Severe atonic PPH Placenta accreta , increta , percreta Severe sepsis Multiple large myomas Carcinoma in situ of the cervix

21. Cesarean section is safe, but it ’ s not as safe as a planned vaginal delivery Many pregnant women believe that undergoing a cesarean section is a no risk surgery They suffer more than three times the number of cardiac arrests, blood clots and major infections than those who deliver vaginally