Difficult lscs

LSCS is the most common obstetric procedure but it can be very difficult to manage in cases of previous LSCS, low lying placenta, and PPH. please check out the youtube links to the videos embedded in this PPT.
ADHESIOLYSIS DURING LSCS https://youtu.be/2Hv80v3yu20
BLADDER DISSECTION https://youtu.be/6qsaTJ1yRUY
RECTUS SHEATH ADHESIOLYSIS https://youtu.be/SryJHjuGsME
VECTIS IN FLOATING HEAD DURING LSCS https://youtu.be/3PECperU8Cw
BREECH DELIVERY https://youtu.be/i-LcmTNNVvU
TRANSVERSE LIE WITH IUFD https://youtu.be/hG28uqpkdpU
CONJOINT TWINS https://youtu.be/KLR7D6wkf38
LSCS IN PLACENTA PREVIA https://youtu.be/dNKQwt4KhVY
SYSTEMATIC PELVIC DEVASCULARISATION https://youtu.be/UwSH6V6GBVw

1. A TO Z OF DIFFICULT LSCS

2. Dr. Niranjan Chavan MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H Chairperson, FOGSI Oncology and TT Committee (2012-2014) Treasurer, MOGS (2017- 2018) Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016) Chief Editor, AFG Times (2015-2017) Editorial Board, European Journal of Gynecologic Oncology Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters Member, Managing Committee, IAGE (2013-2017) Member , Oncology Committee, AOFOG (2013 -2015) Recipient of 6 National & International Awards Author of 15 Research Papers and 19 Scientific Chapters Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

3. INTRODUCTION Caesarean section is the MOST COMMON obstetrics operative procedure performed However, a obstetrician can face many difficulties throughout the procedure.

4. TYPES OF LSCS Traditional Caesarean section: The classic Caesarean section involves a long, vertical incision being made in the midline of the abdomen. Lower Uterine Segment Caesarean section (LUCS): The risk of bleeding and other complications such as hernia are minimal and the surgical wound repairs more easily than the wound that is left after a traditional C-section.

5. INDICATIONS for planned lscs Indication for Planned LSCS : Breech presentation and Transverse Lie At 38wks In twin pregnancies where the first twin is not cephalic Placenta Praevia Morbidly Adherent Placenta HIV who: are not receiving any anti-retroviral therapy or are receiving any anti-retroviral therapy and have a viral load of 400 copies per ml or more Previous Classical Caesarean

6. Indications for emergency lscs Absolute Indication Contracted Pelvis or cephalopelvic disproportion Pelvic mass causing obstruction for E.g. cervical or broad ligament fibroid Advanced Carcinoma Cervix Vaginal obstruction Relative Indication Non-Assuring foetal heart rate Cord prolapse Relative Cephalopelvic Disproportion Ante partum haemorrhage Previous 2 CS Previous Classical CS Features of Scar dehiscence Dystocia leading to Non-progress of labour Failed instrumental delivery Failed induction

7. Difficult Abdominal Access

8. TYPES OF INCISIONS Compared with Pfannenstiel caesarean section, the Joel-Cohen-based methods were associated with less blood loss, shorter operating time, less fever and shorter time from skin incision to birth of the baby. Vertical incision : emergent access. Maylard incision can be used if the access is restricted due to dense adhesions, however surgeons should be extremely cautious with the integrity of inferior epigastric artery.

9. Previous scar should be excised with an elliptical incision. If the sides of this incision is difficult to join up accurately, make some scratch marks across it and align them later. Special care must be taken while entering the peritoneum to prevent bladder or bowel injury so peritoneum should be opened as high as possible. Adhesions could have been prevented by if omentum had been placed between uterus and abdominal wall, at the last operation.

10. ADHESIOLYSIS BETWEEN RECTUS SHEATH

11. Difficult Uterine Incision

12. A . CLASSICAL INCISION B . LOWER SEGMENT TRANSVERSE INCISION C . LOWER SEGMENT VERTICAL INCISION Difficulties in taking a uterine incision can be attributed to following factors: Dense intraperitoneal adhesions Bladde r adhered to the lower uterine segment Previous classical caesarean section scar Uterine anomaly Fibroid in lower segment or cervical cancer INTRODUCTION

13. Dense intraperitoneal adhesions Adhesions are formed if the patient has a history of previous laparotomy. Parietal peritoneum should be opened high up. Adhesions should always be divided with the points of scissors directed towards uterus. Important pointers while tackling adhesions are: to stay close to uterus to avoid bladder and open uterus between stay sutures.

14. ADHESIOLYSIS

15. Bladder adhered to the lower uterine segment The incidence of bladder injury during caesarean section ranges from 0.08 to 0.94%. Most commonly bladder injury occurs in cases of previous LSCS. A very common problem encountered in cases of previous operation is that the bladder gets adhered to lower segment. If such is the case, peritoneum should be incised on uterus about 2 cm above the bladder so that UV fold could be mobilize with a finger or a swab.

16. Bladder adhered to the lower uterine segment Lifting the lower edge of the UV fold in forceps to stretches the adhesions between bladder and uterus. If bladder adhesiolysis is difficult, an incision should be made about 3 cm above where bladder and uterus have stuck together. Bladder separated from lower uterine segment

17. BLADDER ADHESIOLYSIS

18. Previous classical caesarean section scar In cases of previous classical caesarean section, it is wiser to do a lower segment operation.

19. uterine anomaly In cases of bicornuate uterus or didelphys uterus, it is important to recognize both the horns. Lateral extensions of the uterine incision should be watched for. A mop curettage of the uterine cavity should be done, especially in cases of septate uterus, so that any adhered membranes and placental bits are not left behind.

20. Leiomyoma in lower segment or cervical cancer The incidence of uterine leiomyomas varies from 0.3 to 7.2% during pregnancy. A classical caesarean section might be required if a large leiomyoma in lower segment , prevents adequate exposure. Caesarean myomectomy can be done if the fibroid is subserous, at the incision site and can easily be removed. Classical section is also advised in cases of cervical cancer.   Anterior wall leiomyoma size 5x5 cms at the level of uterine incision

21.   Difficult Baby Deliveries

22. FLOATING HEAD Head might not be engaged during caesarean section with a poorly formed and highly vascular lower uterine segment. A pre-assessment and placental localisation is necessary as complete placenta praevia might be the cause of the floating head. After amniotomy, the liquor should be allowed to drain completely as this facilitates the descent of head especially in cases of polyhydramnios.

23. FLOATING HEAD Delivery of floating, non-engaged head can be facilitated by: Vacuum, Vectis or forceps extraction Internal Podalic version

24. VECTIS IN DELIVERY OF FLOATING HEAD

25. DEEPLY ENGAGED HEAD Deeply engaged foetal heads that are difficult to deliver complicate about 1.5 percent of caesarean deliveries. These cases often follow a prolonged second stage and failed attempts at operative vaginal delivery. The impacted head places the infant at increased risk of intracranial haemorrhage, skull fractures, neck fractures, and asphyxia injuries , while simultaneously increasing the risk of maternal complications, such as severe uterine lacerations, damage to the uterine vessels, and injury to the lower urinary tract.

26. DEEPLY ENGAGED HEAD The best methods to dislodging the deeply engaged foetal head include: Abdominovaginal delivery Patwardhan’s shoulders first technique Modified Patwardhan’s technique Use of a head elevators Reverse breech extraction technique Forceps delivery Reverse breech extraction

27. Patwardhan’s manoeuvre 1. BOTH SHOULDERS 2. BACK & TRUNK 3. BUTTOCKS 4. LOWER LIMBS

28. Extremely low birth weight baby Extremely low birth weight infants (premature or growth restricted) present many challenges at caesarean delivery. The lower uterine segment is less well-developed . Uterine incision is deeper and bloodier. As the uterus is significantly smaller, the mother's intestines , frequently descend into the operative field and need to be displaced with either retractors or packing.

29. BREECH PRESENTATION Breech may present as Frank Breech Complete Breech Footling presentation

30. BREECH DELIVERY IN LSCS

31. Transverse lie The dorsosuperior (back up) transverse lie may be delivered as a footling breech through a low transverse incision in a well-developed lower uterine segment. At the Ankle you hold the lower limb like anCigarette held between the Index and middle finger. Dorsoinferior (or back down) may requires a vertical incision on the uterus. If the foetal membranes are intact at the time the caesarean delivery is performed, intra-abdominal version of the foetus can convert the transverse lie to a cephalic or breech presentation allowing delivery through a low-segment transverse incision.

32. TRANSVERSE LIE

33. CONJOINT TWINS

34. Placenta praevia Placenta praevia carries a risk of massive obstetric haemorrhage and hysterectomy. The six elements considered to be reflective of good care were: ● Consultant obstetrician planned and directly supervising delivery. ● Consultant anaesthetist planned and directly supervising anaesthetic at delivery. ● Blood and blood products available. ● Multidisciplinary involvement in pre-op planning. ● Discussion and consent includes possible interventions (such as hysterectomy, leaving the placenta in place, cell salvage and intervention radiology). ● Local availability of a level 2 critical care bed.  

35. Placenta praevia De Lee incision is preferred (lower vertical incision) if Poorly developed lower segment, which would not allow a transverse incision of adequate length. A very vascular lower segment with large veins on it. The presenting part is high , and baby is lying transversely, indicating that the placenta praevia is probably central.

36. BABY DELIVERY IN PLACENTA PREVIA

37. Placenta praevia If the placenta fails to separate with the usual measures, closing the uterus and proceeding to a hysterectomy are both associated with less blood loss. If the placenta separates, sutures can be taken on the placental bed.

38. PLACENTAL BED HAEMOSTASIS IN PLACENTA PREVIA

39. Difficult Haemostasis

40. Strategies to control intraoperative bleeding Incise loose UV fold not the serosa over the incision. Avoid wide lateral dissection of the bladder. Plan uterine incision properly as per the presenting part and the placental localisation. Careful delivery of foetal head to avoid extension of uterine incision. Prefer spontaneous expulsion of placenta. Prophylactic use of oxytocic drugs. Clamping the cut edge of uterine incision with haemostatic forceps.

41. Colporrhexis Colporrhexis is a laceration causing separation of the cervix from the vaginal fornix. It can be primary or secondary. Primary colporrhexis is a vaginal vault tear which is not associated with cervical or uterine extension Secondary colporrhexis cannot be differentiated from a rupture originating in the uterus and then extending to involve the vagina.

42. Uterine incision extension leading to uterine artery avulsion After a prolonged labour or in case of deeply impacted, standard uterine incision frequently get extended laterally, leading avulsion of uterine artery. Extension might be in to the broad ligament or to the vagina and bladder. uterine artery ligation in uterine lacerations

43. Compression sutures A woman meets the criteria of compression sutures if bimanual compression of uterus controls bleeding by abdominal and vaginal inspection.

44. Systematic devascularisation of uterus Step wise devascularisation was 1 st reported from Egypt. It is effective in controlling PPH in 80% of cases. Bilateral uterine artery ligation, initially in upper part of the lower uterine segment. It is followed by ligation of lower uterine vessels and ovarian vessels.

45. Internal iliac ligation Experiments in the 1960’s by Burchell , ascertained that ligating the hypogastric artery turned the pelvic circulation like a venous system, thereby aiding clotting and controlling PPH. It is effective in Uterine atony, Midline perforation, Large broad ligament or lateral pelvic wall haematoma, Multiple cervical tears and Lower segment bleeding.

46. SYSTEMATIC PELVIC DEVASCULARISATION

47. Obstetric hysterectomy Most common indications are: Placenta accrete Uterine atony Severe Couvelaire uterus Uterine rupture Cornual or cervical pregnancy Refractory uterine scar infection Chronic recurrent uterine inversion

48. Bladder Injury The incidence of bladder injury during caesarean section ranges from 0.08 to 0.94%. Most commonly bladder injury occurs in cases of previous LSCS. Ninety-five (95) % of bladder injuries during caesarean section occur at the dome of the bladder with the remaining occurring at the trigone.

49. Bladder injury The average length of bladder injury is 4.2 cm (1–10 cm). The most likely time bladder injury occurs is during the 1. Creation of a bladder flap (43%) 2. Time of entry into the peritoneal cavity (33%). 3. During uterine incision or delivery.

50. BLADDER INJURY A simple rent is normally repaired in two layers , with the first layer consisting of a simple running closure of the mucosa with a 3–0 absorbable suture. The second layer may be closed continuous interlocking stitch using either 2–0 or 3–0 absorbable suture to include the submucosa and muscularis. Foley catheter for at least 7–10 days postoperatively.

51. CONCLUSION With the increasing rate of caesarean sections , there are higher chances to encounter adhesions during LSCS. Difficulties can be encountered during opening the abdomen, uterine incision, baby delivery and haemostasis. So every obstetricians should be equipped with these surgical techniques to overcome these difficulties and reduce maternal and foetal morbidity.

52. REFERENCES Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY, editors. 23rd ed. New York:: McGraw Hill; 2014. Williams Obstetrics. Silver RM, Landon MB, Rouse DJetal . Maternal morbidity associated with multiple repeat cesarean deliveries.  Obstet Gynecol. 2006;107:1226–32 Phipps MG, Watabe B, Clemons JL, Weitzen S, Myers DL. Risk factors for bladder injury during cesarean delivery.  Obstet Gynecol. 2005;105:156–60 Prendiville W J, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database Syst Rev. 2000;(3):CD000007 11. B-Lynch C Coker A Lawal A H Abu J Cowen M J; C BL. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported Br J Obstet Gynaecol  1997104372–375.375 Dodd JM, Crowther CA. Elective repeat caesarean section versus induction of labour for women with a previous caesarean birth. Cochrane Database Syst Rev. 2012;16:5.  American College of Obstetricians and Gynecologists , Task Force on Cesarean Delivery Rates: Evaluation of cesarean delivery. Washington, DC: ACOG; 2000.