Lscs

Lscs made easy for final MBBS students

1. LOWER SEGMENT CESAREAN SECTION (LSCS) - S.R Kannan S. Karnan

2. Primary Cesarean Section. Repeat Cesarean Section First operation performed on a patient Performed in subsequent pregnancies I NTRODUCTION Operative procedure : fetuses after the end of 28th weeks are delivered through an incision on the abdominal and uterine walls. Incidence: steadily rising . - Initially 10%. 2-3 fold rise Increased safety of the operation Availability of blood transfusion Avaibility of antibiotics ,

3. >> FACTOR RISING CESAREAN SECTION RATE

4. INDICATION MATERNAL: Previous LSCS CPD Dystocia Inadequate uterine forces Preeclampsia, diabetes, CVS causes BOH Ca cervix Aortic aneurysm Following VVF Placenta: Placenta previa, Abruptio placenta FETAL: Fetal distress Malpresentation Multiple pregnancy Maternal HIV CORD : Cord prolapse Cord presentation INDIC A TION A B SOLUTE Vaginal delivery is not possible

5. Can be classified as absolute or relative too

6. TIMING TIM I NG E L E C TIVE Done at a prearrang e d time EME R GEN C Y Done due to an acute obstetric emergency . (A time interval of 30 minutes)

7. a. Elective Benefits No hazard from labor and delivery process. No pelvic floor dysfunction.  Ri s k s Placenta previa and Hysterectomy Longer recovery time /hospital stay. TIMING OF ELECTIVE SECTION Maturity is certain Maturity is uncertain Done about 1 week prior to the expected date of confinement (EDD) 1. Ultrasound assessment in first or second trimesters Amniocentesis for L:S ratio used to ensure fetal maturity. Otherwise spontaneous onset of labor is awaited and then CS is done.

8. b. Emergency - categories 1, 2 & 3 Category 1 -When there is immediate threat to the life of the woman or the fetus. -Decision delivery interval should be 17 minutes Category 2 -When there is maternal or fetal compromise which is not immediately life threatening . -CS should be done within 30 minutes of making decision C a tegory 3 There is no maternal or fetal compromise 75 mins C a t e go ry 4 Elective section

9. SECTION (type) LOWER SEGMENT CESAREAN SECTION Extraction through an incision made in the lower segment Through a transperitoneal approach. Only method practiced in present day obstetrics Cesarean section means lower segment operation . CLASSICAL Extracted through an incision made in the upper segment of the uterus. Its indications very much limited (done under forced circumstances)

10. Forced Circumstances For Classical Section Lower Segment Approach Is Difficult: Dense adh e sio ns Severe c o ntra c ted pelvis Lower Segment Approach Is Risky Big fibroid on the lower Ca r c inoma Repair of high VVF Complete anterior placenta previa with engorged vessels in the lower segment

11. LSCS SURGERY STEPS Perioperative preparation Incision Delivery of Head Trunk Placenta and membrane Suturing Concluding part

12. a. Perioperative Premedicative sedative must not be given. Hair may be clipped. Informed written permission for the procedure, anesthesia and blood transfusion is obtained. Abdomen is scrubbed with soap and nonorganic iodide lotion.

13. Metoclopramide (10 mg IV) to i n crease the tone o f the l o w e r es o p h a g e a l sphincter as well as to reduce the stomach contents.. R a niti dine (H2 b l ock e r) 150 mg is g i ven ora l ly n i g h t b e fore (elective procedure) and it is repeated (50 mg IM or IV) 1 hour before the surgery The stomach should be emptied, - stomach tube (emergency procedure). Nonparticulate antacid (0.3 molar sodium citrate, 30 ml) is given orally.

14. IV cannula : sited to administer fluids (ringer’s solution, 5% dextrose). FHS should be checked once more at this stage. Neonatologist should be made available. Cross match blood Prophylactic antibiotics should be given (IV) before making the skin incision. Bladder should be emptied by a foley catheter which is kept in place in the perioperative period.

15. ANESTHESIA -Spinal, epidural or general ANTISEPTIC PAINTING POSITION OF THE PATIENT IN C ISION P A C K ING -Painted with 7.5% povidone-iodine solution/ savlon lotion and properly draped with sterile towels -Dorsal position. In susceptible cases, -A 15° tilt to her left using a wedge till delivery of the baby should be done. -Vertical or a transverse skin incision. -Modified pfannenstiel is made 3 cm above the symphysis pubis. -The doyen’s retractor is introduced. -The peritoneal cavity is now packed off using two taped large swabs. -The tape ends are attached to artery forceps. -This will minimize spilling of the uterine contents into the general peritoneal cavity

16. A transverse incision also cutting the rectus muscles

17. b. incision U T E R INE INCISION Peritoneal Incision The loose peritoneum of the uterovesical pouch is cut transversely across the lower segment The lower flap of the peritoneum is pushed down a little. Musc l e Incision The most commonly used incision (90%) is low transverse.

18. Other types of uterine incisions Lower vertical — may be extended upwards when needed. - Kronig's incision Classical incision ( upper segment ). “J” incision — upward vertical extension of the initial transverse incision . Inverted “T” incision — upward extension from the mid-transverse incision . Vertical uterine incision - made when the lower segment is poorly developed or there is complete anterior placenta previa or any myo m a occupying the lower segment.

19. LOW TRANSVERSE INCISION Made at a level slightly below the peritoneal incision until the membranes of the gestation sac are exposed. Two index fingers are then inserted and the muscles of the lower segment are split transversely across the fibers. This method minimizes the blood loss but requires experience. This is called Munro-Kerr incision

20. c . Deliver y Of Th e Head The membranes are ruptured The blood mixed amniotic fluid is sucked The doyen’s retractor is removed. The head is delivered by hooking the head with the fingers The head is delivered by elevation and flexion using the palm to act as a fulcrum. As the head is drawn to the incision line, the assistant is to apply pressure on the fundus. Push up the head by sterile gloved fingers introduced into the vagina. Delivered using wrigley’s /Baton's forceps.

21. d. Delivery Of The Trunk Mucus from the mouth, pharynx and nostrils is sucked out After the delivery of the shoulders, intravenous Oxytocin 1 0 units is to be administered. (AMSTL- after delicery of body) The rest of the body is delivered slowly Baby is 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 and the baby is handed over to the pediatrician. The doyen’s retractor is reintroduced. The optimum interval between uterine incision and delivery should be less than 90 seconds.  Interval > 90 seconds are associated with poor apgar scores.

22. e. Removal Of The Placenta And Membranes placenta is separated spontaneously. The placenta is extracted by traction on the cord (controlled cord traction). The membranes are carefully removed preferably intact and even a small piece, if attached to the decidua should be removed using a dry gauze. Exploration of the uterine cavity is desirable

23. f. Suture Of The Uterine Wound The suture of the uterine wound 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 or Green Armytage hemostatic clamps (four are required, one each for angle and one for each margin). The uterine incision is sutured in 2 layers. (Three - controversial)

24.  FIRST LAYER: The first stitch is placed on the far side in the lateral angle of the uterine incision and is tied. The suture material is no “ 1 ” chromic catgut or vicryl and the needle is round bodied. A continuous running suture taking deeper muscles excluding or including the decidua (very difficult to exclude) ensures effective apposition of the tissues; the stitch is ultimately tied after the suture includes the near end of the angle. SECOND LAYER: A similar continuous suture is placed taking the superficial muscles and Adjacent fascia overlapping the first layer of suture. Uterine muscles may be closed using a continuous single layer stitch taking full thickness muscle and decidua. There is controversy as regard the place of single layer or double layer closure in relation to The risk of subsequent scar rupture. The peritoneal flaps may be apposed by continuous inverting suture (to prevent any raw surface). Nonclosure of visceral and parietal peritoneum is preferred.

25. g. Concluding Part The mops placed inside are removed and the number verified. Peritoneal toileting is done and the 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 of blood clots and a sterile vulval pad is placed

26. POSTOPERATIVE CARE First 24 hrs Day 1 Day 2 Day 5 and 6 Discharge

27. a. First 24 hours Day Observation for the first 6–8 hours is important. (Vitals, hemorrhage) Fluid: Sodium chloride (0.9%) or Ringer’s lactate drip is continued until at least 2.0–2.5 L of the solutions are infused. Blood transfusion is helpful in anemic mothers and if the blood loss is more than average during the operation Oxytocics: Injection oxytocin 5 units IM - only in case of hemorrhage .

28. Cont. Prophylactic antibiotics (cephalosporins, metronidazole) for all cesarean delivery is given for 2–4 doses. (Cefotaxime) Analgesics in the form of Tramadol is administered and may have to be repeated. Ambulation: She is encouraged to move her legs and ankles and to breathe deeply to minimize leg vein thrombosis and pulmonary embolism. The patient can sit on the bed or even get out of bed to evacuate the bladder. Baby is Put to the breast for feeding after 3–4 hours when mother is stable and relieved of pain.

29. b. Day 1 Oral feeding Clear fluids may be given. (after 6 to 8 hrs) Active bowel sounds are observed by the end of the day.

30. c. Day 2 Light solid diet of the patient’s choice is given. Bowel care:  3–4 teaspoons of lactulose is given at bed time.

31. c. Day 5 or day 6  The abdominal skin stitches are to be removed on the D- 7 (in transverse) or D- 10 (in longitudinal)

32. d. Discharge The patient is discharged on the day following removal of the stitches, if otherwise fit. Patient may be discharged as early as third to as late as seventh postoperative days

33. DIFFICULTIES IN CS 1.Floating head: Gentle fundal pressure helps to bring the fetal head at the site of incision which is then levered out 2. Deeply engaged head: Trendelenburg position helps Patwardhan's technique Anterior shoulder Posterior shoulder Body ( by hooking both axillae assissted by fundal pressure) Head 3. Impacted shoulders - Inverted T incision

34. CLASSIC CESAREAN SECTION Easy to perform Abdominal incision is always longitudinal (paramedian) and about 15 cm (6") in length, 1/3rd of which extends above the umbilicus. A longitudinal incision of about 12.5 cm (5") is made on the midline of the anterior wall of the uterus starting from below the fundus. The incision is deepened along its entire length until the membranes are exposed which are punctured. In about 40% cases, the placenta is encountered. In such cases, fingers are slipped between the placenta and the uterine wall until the membranes are reached. The baby is delivered commonly as breech extraction. Intravenous oxytocin 10 u nits im is administered following delivery of the baby. The uterus is eventrated. The placenta is extracted by traction on the cord or removed manually.

35. F orced Circumstances For Classical Section Lower Segment Approach Is Difficult: Dense adhesions Severe contracted pelvis Lower Segment Approach Is Risky Big fibroid on the lower Carcinoma Repair of high VVF Complete anterior placenta previa with engorged vessels in the lower segment

36. SUTURE OF THE UTERINE INCISION  The uterus is sutured in three layers.  The uterus is returned back into the abdominal cavity.  The abdomen is closed in layers. A CONTINUOUS SUTURE Chromic catgut no “0” or vicryl taking deep muscles excluding the decidua A SECOND LAYER OF CONTINUOUS SUTURES (1 cm apart) using chromic catgut no. “1” or vicryl taking the entire depth of superficial muscles down to the first layer of suture. THE THIRD LAYER OF CONTINUOUS SUTURE Taking the peritoneum with the adjacent muscles using chromic catgut no “0” and round-bodied needle

37. COMPLICATIONS OF CESAREAN SECTION Operations (inherent hazards) Anesthesia The Complications Are Grouped Into Intraop e rative Po s top e rati v e

38. a. Intraoperative Complications Extension of uterine incision to one or both the sides. Uterine lacerations at the lower uterine incision Bladder injury— may occur in a repeat procedure. Ureteral injury Gastrointestinal tract injury Haemorrhage Morbid adherent placenta

39. b. Postoperative Complications POS T OPER A T I VE COMPL I C A T I ONS Maternal Immediate Re m ote Fetal

40. MATERNAL (Immediate) Postpartum hemorrhage Shock Anaesthetic hazard Infection Intestinal obstruction DVT / TED Wound complication Secondary PPH

41. MATERNAL (remote) RE M OTE Gynecological Menstrual excess or irregularities, chronic pelvic pain or backache General surgical Incisional hernia, intestinal obstruction due to adhesions and bands. Future pregnancy There is risk of scar rupture

42. MATERNAL AND PERINATAL MORTALITY:  Maternal hemorrhage and shock anesthetic hazards infection and thromboembolic disorders.  Fetal Asphyxia RDS prematurity infection and intracranial hemorrhage— attempting breech delivery through a small incision.

43. SPECIAL CESAREAN Cesarean hysterectomy Peripartum hysterectomy Perimortem cesarean delivery Subtotal hysterectomy Extraperitoneal cesarean section

44. REFERENCES Mudaliar and Menon’s Clinical Obstetrics, 11 th edition, Sarala Gopalan and Vanita Jain, Cesarean Delivery DC Dutta’s Textbook of Obstetrics, 9 th edition, Hiralal Konar, Cesarean Delivery Essential Of Obstrectric, Lakshmi Seshadri, Gita Arjun, Cesarean Delivery