Lower segment cesarean section powe point presention

Lscs

1. CAESAREAN SECTION PRESENTED BY: MS LAXMI G TAWALAGI REG NO : 19NUG036 BSC(N) IV YEAR SDMINS

2. INTRODUCTION Caesarean section , also known as  C-section  or  caesarean delivery , is the  surgical procedure  by which one or more babies are  delivery  through an incision in the mother's abdomen, often performed because  vaginal delivery  would put the baby or mother at risk.

3. DEFINITION Caesarean section is an operative procedure where by the foetuses after the end of 28 th week is delivered through an incision on the abdominal and uterine wall . The first operation performed on woman is referred to as a primary caesarean section. when the operation is performed in subsequent pregnancies. It is called repeat caesarean section

4. INCIDENCE The incidence of caesarean section is steadily rising. During the last decade there has been two-three fold rise in the incidence from the initial rate about 10%. Apart from increased safety of the operation due to improved anaesthesia, availability of blood transfusion and antibiotics

5. FACTORS FOR INCREASING CS RATE Identification of risk foetuses before term. Identification of at risk mothers. Wide use of repeat caesarean section in cases with previous caesarean section delivery. Rising incidence of elderly Primigravida.

6. Decline in difficult operative or manipulative vaginal deliveries. Decline in vaginal breech delivery. Increased diagnosis of fetal distress. Adoption of small family norms.

7. INDICATIONS Caesarean delivery is done when labour is contraindicated or vaginal delivery is found unsafe for foetus and mother The indications are broadly divided into : Absolute indications Relative indications Common indications

8. 1. ABSOLUTE INDICATIONS When the Vaginal delivery is not possible , caesarean section is needed even with a dead foetus Central placenta previa. Contracted pelvis or cephalo pelvic disproportion . Pelvic mass causing obstruction (cervical or broad ligament fibroid) Advanced carcinoma of cervix Vaginal obstruction (atresia, stenosis)

9. 2. RELATIVE INDICATIONS Vaginal delivery may be possible with or without aids but risks to the mother and to the baby are high. More often multiple factors may be responsible . Indications are more common than absolute ones.

10. Cephalo-pelvic disproportions. 2. Previous caesarean delivery. When primary CS was due recurrent indications. Previous two CS. Features of scar dehiscence. Previous classical CS.

11. 3 . Non reassuring FHR (Fetal distress) 4. Dystocia may be due to (3P’S) relatively large fetus (passenger), small pelvic (passage) or insufficient uterine contractions (power) 5. Ante partum hemorrhage placenta preview b) Abruptio placenta

12. 6 . Mal presentation Breech Shoulder Brow 7. Failed surgical induction of labor, Failure to progress in labor 8 Bad obstetric history- with recurrent Fetal wastage 9. Hypertensive disorders 10. Medical-Gynecological disorders

13. 3.COMMON INDICATIONS PRIMIGRAVIDA Cephalo pelvic disproportion (CPD) Fetal distress Dystocia

14. MULTI GRAVIDA Previous caesarean delivery. Ante partum hemorrhage. Mal presentations (Breech)

15. CONTRAINDICATIONS Dead fetus Disseminated intravascular coagulation Extensive scar or pyogenic infections in the abdominal wall E.g. in burns

16. INSTRUMENTS 1 SPONGE HOLDING FPRCEP. 4 GREEN ARMYTAGE FORCEPS. 6 CURVED ARTERY FORCEPS. 6 STRAIGHT ARTERY FORCEPS. 4 ALLIS FORCEPS. 2 BABCOCK FORCEPS. 2 TOOTHED FORCEPS.

17. 2 NON TOOTHED FORCEPS. 1 NEEDLE HOLDER. UMBLICAL CORD CUTTING SCISSORS. 4 KLIK CLAMP. SUCTION TIP. TISSUE CUTTING SCISSOR. DOYEN RETRACTOR MORRIES RETRACTOR DEAVERS RETRACTOR

18. TIME OF OPERATION

19. ELECTIVE CAESAREAN SECTION When the operation is done at a prearranged time during pregnancy to ensure the best quality of obstetrics. Anesthesia. Neonatal resuscitation and Nursing Services. Maturity is certain Maturity is uncertain

20. EMERGENCY CAESAREAN SECTION When the operation is performed due to unforeseen or acute obstetric emergencies. An arbitrary time limit of 30 minutes is throughout to be reasonable from the time of decision to the start of the procedure.

21. TYPES OF OPERATIONS 1. LOWER SEGMENT CAESAREAN SECTION. 2. CLASSICAL OR UPPER SEGMENT CAESAREAN SECTION

22. LOWER SEGMENT CAESAREAN SECTION In the LSCS the extraction of the baby is done through an incision made in the lower segment through a trans peritoneal approach .

23. CLASSICAL CAESAREAN SECTION Definition: In this operation, the baby is extracted through an incision made in the upper segment of the uterus. Its indication in the present day in the obstetrics are very much limited and the operation is only done under forced circumstances. Lower segment approach is difficult. Lower segment approach is risky. Post Mortem section.

24. LSCS CCS LESS INCISIONAL BLEEDING MUSCLE APPOSITION IS PERFECT LESS WOUND DIHISCENCE HEALS BETTER SCAR RUPTURE IS LESS POST OP COMFORT IS MORE. COSMETIC VALUE LESS CHANCE OF INCISIONAL HERNIA . INCISIONAL BLEEDING MORE IMPERFECT MUSCLE APPOSITION MORE WOUND DIHISCENCE HEALING IS LESS SCAR RUPTURE IS MORE POST OP DISCOMFORT IS MORE. MORE CHANCE OF INCISIONAL HERNIA ADVANTAGES OF LSCS OVER CLASSICAL CS

25. PREOPERATIVE PREPARATION NIL PER MOUTH INFORMED WRITTEN CONSENT PREOPERATIVE MEDICATIONS BLADDER EMPTIED BY A FOLEYS CATHETER KEEP IV LINE PATENT

26. PART PREPARATION ANTI-SEPTIC PAINTING POSITION OF THE PATIENT BLOOD TEST FHS MONITORING INFORM NEONATALOGIST ANESTHESIA INSTRUMENTS

27. STRUCTURES ARE BEING CUT SKIN SUBCUTANEOUS TISSUE ANTERIOR RECTUS SHEATH RECTUS ABDOMINUS MUSCLE TRANSEVERSE FASCIA AND PERITONEUM

28. UTERINE INCISION Peritoneal Incision Muscle Incision Other types of Incisions Lower transverse Incision Lower vertical Incision

29. PROCEDURE Delivery of the Head Delivery of the Trunk Removal of the Placenta and membranes.

30. DELIVERY OF THE HEAD The membranes are ruptured if still intact. The blood mixed amniotic fluid is sucked out by continuous suction . The Doyen's retractor is removed . The head is delivered by hooking the head with the Fingers which are carefully insulated between the Lower uterine flap and the head until the palm is placed below the head . As the head is drawn to the incision line. The assistant is to apply Pressure on the fundus. If the head is Jammed, an assistant may push pop up the head by sterile gloved Fingers introduced into the vagina. The head is delivered using either Wrigley's or Barton's Forceps

31. DELIVERY OF TRUNK As soon as the head is delivered, the mucus from the mouth. Pharynx, and nostrils sucked out using Rubber catheter attached to a electric sucker. After the delivery of the shoulder, intravenous Oxytocin 20 units of methergin 02.md is to be administered. The rest of the body is delivered slowly and the baby placed in a tray placed in between the mother's thighs with the head tilted down for gravitational Drainage. The cord is cut in between two clamps & the baby is handed over to the nur se . The Doyen's Reactor is Reintroduced.

32. REMOVAL OF THE PLACENTA & MEMBRANES By this time. The placenta is likely to be separated . The Placenta is extracted by traction On the cord with simultaneous pushing the uterus towards the umbilicus abdomen using the left hand . Routine manual removal should not be done. The membranes are to be carefully removed preferably intact and even a small piece . it attached to the decidua should be removed using a dry gauze dilatation of internal os is not required, exploration of the uterine cavity is desirable.

33. THE SUTURE OF THE UTERINE WOUND It is done with the uterus Keeping in the abdomen. Some however. prefer to eventrate the uterus prior to suture. The Margins of the wound are Picked up by Allis tissue forceps of green Armytage haemostatic clamps. The Uterine incision is sutured in three layer. FIRST LAYER SECOND LAYER THIRD LAYER Concluding part

34. FIRST LAYER The First stitch is placed on the far side ins the lateral angle of the Uterine incision and is tied. The suture material is No ' O 'chromic catgut or vicryl and the Needle 15 round bodied. A continuous running suture taking deeper tied after the suture includes The near end of the angle

35. SECOND LAYER A similar continuous suture is placed take the superficial muscles and adjacent fascia overlapping the 1st layer of suture. Uterine muscles may be closed using a continuous Single layer stitch. This does not increase the risk of uterine scar rapture.

36. THIRD LAYER (Peritoneal) The Peritoneal flaps are apposed by continuous inverting suture. Post-operative recovery & outcomes are no different if the visceral & parietal peritoneal Layers are left unapposed CONCLUDING PART : The Mops placed inside are removed and the number verified. Peritoneal toileting is done and for blood clots are removed meticulously. The tubes and ovaries are examined. Doyen's retractor is removed. After being satisfied that the uterus is well contracted. The abdomen is closed in Layers. The Vagina is cleansed et blood clots and a sterile vulva pad is placed .

37. COMPLICATIONS OF CLASSICAL CS The complications may be INTRA OPERATIVE POST OPERATIVE

38. INTRA OPERATIVE COMPLICATIONS Extension of uterine incision Uterine lacerations Ureteral injury Bladder injury Gastro intestinal tract injury Uterine atony and primary PPH Morbid adherent placenta

39. POST OPRATIVE COMPLICATIONS IMMEDIATE POST PARTUM HEMORRHAGE SHOCK ANAESTHETIC HAZARDS INFECTIONS INTESTINAL OBSTRUCTION

40. REMOTE GYNECOLOGICAL Menstrual disorders Chronic pelvic pain Infertility GENERAL SURGICAL Incisional hernia Intestinal obstruction FUTURE PREGNACNY There is risk of scar rupture.

41. POST OPERATIVE CARE 1.First 24 hours (DAY O) Observation Fluid management inj. Methergin Prophylactic antibiotics Analgesics Ambulation 2. DAY 1 3. DAY 2 4. DAY 5-6

42. DISCHARGE The patient is discharged on the day following removal of the stitches. If otherwise fit. Usually advices like those following vaginal delivery given.

43. NURSES RESPONSIBILITY

44. THANK YOU