Caesarian Section

Presented by

Dr. Narayan M. Patel

M.D.,D.G.O. FICS Emeritus Professor Muni. Medical college Postal address--

Mahalaxmi Institute of medical teaching, 3, Shantiniketan park, Naranpura, Nr. Sardar Patel Colony, AHMEDABAD- 380 014 (Gujarat) INDIA
T.N.(079) 27682572, Mobile;- 98252 95530 E mail:- narayanpatel1932@yahoo.com

Caesarian section

Definition
Removal of a fetus from the uterus by abdominal incision, after 28 weeks of pregnancy. It is called hysterotomy, if removal is done before 28 weeks of pregnancy.

Caesarian section

It is one of the oldest obstetric operation

Caesarian section

Historical aspect:-As per Roman low called Lax Ragia, it was forbidden to bury a pregnant dead women, before her child has been cut out. Year 762 B.C.

Caesarian section

Historical aspect:-In times of Julius Caesar, the law was called Lax Caesesara. The term Caesarian section was first used by James Gullimeau, in his book of midwifery published in 1598.

Caesarian section
Historical aspect:-Year 1500:-Jacob Neufer, a saw gleder asked permission of local mayer to cut open abdomen of his wife, who was in prolonged labor. First request was not granted. He went second time and his request was granted. He opened his wife abdomen. History says that, she not only survived but later gave birth to 5 more children. People think that this may be a case of advances secondary abdominal pregnancy.

Caesarian section
Historical aspect:--

1882 -- Sanger introduced technique of suturing of uterus. 1912 ---Lower segment caesarian segment section was first performed by Kronig and latter by Monro kerr. 1940 --- In my city at Ahmedabad (India) first L.S.C.S. was performed by my teacher, late Dr.(miss) S.C.Pandya

Caesarian section
Historical aspect:--

Year 1581:- Francis Russet first published article on caesarian section. Maternal mortality was almost 100% at that time. In Year 1876 Porro advocated amputation of body of uterus and this cause fall in maternal mortality to 50% in first half of 19th century.

Caesarian section
Historical aspect:--

Year 1876:Porro -an Italian obstetrician advocated amputation of body of uterus after C.S. to decrease the maternal mortality. Amputation was done by cintracts constrictor. Even to day Caesarian hysterectomy is called Porros section.

Caesarian section

Once a caesarian section always a caesarian section.

Dr.E.B.carngin 1916 Modified to:-

Once a caesarian not always a caesarian.

Now modified to:-

Once a caesarian, always a hospital delivery

Caesarian section

Incidence of C.S. is rising:-Formally it was 10 to 15 % but now it 25 to even as high as 50% Rising incidence is more because of fetal indications. There is a trend to do repeat C.S. without giving trial in Pt. with previous C.S. Doctor do not want to take any risk with the child, & doctor has fear of medico legal problems.
C.S. has also become more safe due to :Better anesthesia, more availability of blood transfusion, better antibiotics, better suture material etc. Hence C.S. is more frequently done, even at a trivial indication.

Caesarian section
Because of public mentality of a small family norms, neither the obstetrician nor the patient desires to take even slightest extra risk of trial of labor. The pain tolerance power of patient has gone down and obstetrician has become too busy to fine time for a long trial of labor. Fear of medico legal problems to the doctor leads him of her, to a safe short cut of C.S.

Caesarian section
Most commen indications of C.S.:1) 2) 3) 4) Severe degree contracted pelvis. Central placenta pravia Breech with extended limbs in elderly primi. Transverse presentation, or hand prolapse and cervix not fully dilated. 5) Fetal distress and cervix not fully dilated. 6) Brow presentation. 7) Previous 2 L.S.C.S.

Caesarian section
Indications of C.S.:Non recurrent indications 1) Fetal distress 2) Breech presentation 3) Placenta previa. 4) Occipito posterior presentation. Recurrent Indication:-Contracted pelvis

Caesarian section
Some old books has divides indications of Caesarian section in this manner. This author do no approve of this, however to complete the subject, I have included in this presentation.

Fault with the passage.

Fault with the passenger. Fault with the forces.

Caesarian section

Uterine Incision
Transverse lower segment Curves incision Concavity towards funds of uterus Inverted T incision. Classical J shaped. Lower segment verticle
Extraperitonial.( I have not seen any)

Caesarian section

Elective C.S.
Emergency C.S.

Elective caesarian section (Planned operation)

Advantages are:1)Patient with empty stomach and surgeon usually with full breakfast 2)Best anesthetist available at that time 3)Best assistant and nursing staff. Disadvantages are :4) If wrong judgment, premature child may be born. 5) Cervix may not be dilated and hence poor drainage of lochia 6) Lower segment is not formed and hence uterine incision in lower part of upper segment.

Emergency caesarian section (Unplanned)

Working under adverse circumstances:-

1) Patient may be with full stomach and surgeon may be with empty belly 2) Odd working hours either of day or night 3) Anesthetist, assistant and nursing staff may not be of your choice. Advantage is :4) Mature child as patient is in labor 5) Cervix is open, better drainage of lochia. 6) Lower segment is well formed.

Caesarian section

Mortality and morbidity are

significantly higher in,following emergency C.S. than a planned C.S.

Caesarian section

Types of anesthesia Spinal. General. Epidural. Local.

Caesarian section

Spinal anesthesia
It is best and cheapest More popular now in European countries. Patient remain conscious. Less incidence of cardiac arrest. Drug used is 5% lignocain- hyperbaric 1.5 to 2 cc Some times difficult for anesthetist to find space due to lumber lordosis of pregnancy. Some times there is fall of blood pressure. Post operative spinal headache. Rarely meningitis, or total spinal may occur. Spinal anesthesia should not be given if Pt. has already low B.P. or baby has transverse presentation or deeply engaged head or failed forceps or failed vacuum delivery.

Caesarian section

General anesthesia Many times Pt. demand G.A. Drug used is I.V. Pentothal sodium with oxygen and Nitrous oxide and muscle relaxant. Intubations some times difficult, if anesthetist is not well experienced. Incidence of cardiac arrest is more than spinal. Post operative vomiting is common. If Pt. has taken food, regurgitation complication like aspiration pneumonia may occur. Deep anesthesia, only to be given after baby has been delivered. Pt. at sleep but anesthetist has to be alert in G.A.

Caesarian section

Epidral anesthesia
These days patients are asking for painless delivery and for that, many times continuous epidural anesthesia is given. If the trial of labor fails, patient may be taken for caesarian section or forceps delivery. In that case caesarian may be performed in the same epidural anesthesia. It is a good anesthesia with less risk of fall of blood pressure.Due to lumber lordosis of pregnancy, some times epidural becomes technically difficult.

Caesarian section

Local anesthesia This is rarely requires except in conditions, like vary low patient as in central placenta pravia or in deeply sedated Pt. of eclampsia. If doctor is working in a place where anesthetist is not available and surgeon has to manage all alone, local anesthesia is used. Drug used is 0.5% Lignocain. Total quantity to be used is not more than 100 c.c. In this anesthesia, the surgeon may not be as comfortable as spinal or general anesthesia.

Caesarian section

Incision on abdominal wall Verticl midline- it is easy, more working place but incidence of incisional hernia is high. Paramedian:-- Less chances of incisional hernia than midline incision. Phenestial transverse:- it is most popular, less pain full, early mobility of patient, & less chances for dehiscence. It has also a cosmetic value. Its disadvantages is, it takes more time to open abdomen, less exposure than vertical scar, and at repeat caesarian is more difficult.

Caesarian section

Lower segment C.S

Lower segment edges are thin, hence suturing is

Classical C.S.

Upper segment edges are thick and hence difficult to approximate. better. Lower segment is a passive Upper segment is active segment so contraction makes segment so does not stitches loose. contract, so healing is better. Lower segment is covered Upper segment is not covered with peritoneum, and remains with peritoneum, It remains in abdomen so more chances in pelvis so less chances for adhesions formation. for adhesions formation. Chances for ruptures Ut. in Chances for ruptures Ut. in next pregnancy 8 times more. next pregnancy much less.

Caesarian section

Maternal mortality after C.S. is bet.5 to 30 per 1000 Perinatal mortality is 5 to 10% -due to:--

Emergency operation. Fotal asphyxia-(RDS) PrematurelyInfection. Intracranial hemorrhage. Fracture dislocation of big bones.

Caesarian section

Maternal complcations:-

Immediate:Haemorrage, Shock, sepsis, Anesthetic hazards, Thrombosis and wound complication. Paralitic ilius.

Late:Incisional hernia. Ruptured uterus in next pregnancy

Caesarian section

Ecbolics

Inj. Ergometrin 0.5 mg I.M. or I.V. Inj Oxytocin 20 to 20 units in 500 ml. glocose saline or ringer Lactate Inj. Prostagandin i.m.

Some technical minutes of Caesarian section.

Presented by

Dr.Narayan M.Patel
M.D.,D.G.O. FICS

Emeritus Professor Muni. Medical college Postal address-Mahalaxmi Institute of medical teaching,3, Shantiniketan park, Naranpura, Nr.Sardar Patel Colony, AHMEDABAD- 380 014 (Gujarat) INDIA T.N.(079) 27682572, Mobile;- 98252 95530 E mail:- narayanpatel1932@yahoo.com

Excision of previous scar

Always at the beginning of operation by

an elliptical incision. Excising previous scar at the end of operation is difficult. Multiple scars multiple surgeons name, multiple signatures on skin. Name of the surgeon is always written on the scar

Caesarian section

Initial Uterine incision should be small by knife and then Enlarging it by scissors Enlarging it by knife Enlarging it by tearing it with fingers.
Try to avoid rupturing of membranes at incision. Catch uterine edges with Ellisis forceps, Swab holder or Green Aarmitage forceps.

Caesarian section

How to deliver of head?

By putting hand to disengaged head and than bringing out of incision Application of short forceps. Pushing head from below by a strong persons wearing gloves, especially in case of failed forceps, deeply jammed head or occipito post. presentation or deep transverse arrest. Putwardhens Manuvary in deeply engaged head, is bringing out first trunk and than head. Using Babcocks forceps to rotate floating head to bring occiput anterior.

Caesarian section

Problem of floating head

In elective cesarean section, floating head is more difficult to deliver than an engaged head. Use short forceps in floating head. In twins- for delivery of second child, if it is breech, it is easy. If it is cephalic, do internal podalic version, or try apply vacuum forceps.

Caesarian section

Problem of deeply jammed head

Always give general anesthesia with Halothain to relax uterus. Never- never attempt in spinal anesthesia. I have seen once my teacher struggling for 30 mit. to bring out head and got out a dead baby. Ask a strong person to pus head from below with gloved hand, to disengage head. Patwardhns method- is difficult and problem of extending of uterine incision is commen.

Uterine incision suturing

Suturing material--- Mostly Vicryl or catgut Single layer
Now a days many prefer single layer continuous suture. In elective C.S. where low. segment not formed and is thick, single layer suturing may not be possible.

Double layer
1st layer ---continuous 40 mm heavy needle No-1 suture 2nd layer -- continuous 40mm needle 1/0 suture Peritoneum --continuous 40 mm needle 1/0 suture Some prefer suturing first both uterine angles, to stop bleeding. Some prefer interrupted stitches for the first layer.

To suture or not to suture pelvic peritoneum and parital peritoneum is a debatable point and of individual choice and belief. Old generation doctors still like to suture both peritonium. Newer generation usually avoid suturing. Literature reports no difference in either technique. How ever it needs few more years follow up for its further to evaluate it.

Clearing air passages of child after birth

Surgeon himself managing.

Hanging the child- holding it by feet.

Suction with rubber catheter. Using mucous catheter.

Hand over to anesthetist.

Hand over to a pediatrician.

Delivery of placenta

3rd stage of labor- duration is 5 to7 minutes

Let placenta separate by itself.

Never pull out placenta before it separates. I.V.Methegine &10 to 20 units Syntocinon in drip. Practice spontaneous delivery of placenta.

Problem of central placenta pravia

Anterior placentaTry to find out membrane up or down, Posterior placenta

rt. Or left. If you fail, cut placenta quickly and first remove child.

(Dangerous placenta of Stall-Worthy.) To stop bleeding or oozing from lower post segment, pack it systematically with multiple roller packs. Push first end in cervical canal. Remove pack after 24 hours.
Some time as a desperate measure you may need Internal iliac ligation, or subtotal hysterectomy, to save Pt.

Cesarean section

Misgav Ladch Hospital method of C.S.

Skin incision phenestial. Peritonium opened transversely. Single layer non locking suturing of uterine
incision. Pelvic and parital peritoneum not sutured. Reported as safe, simple ,fast and cost effective. Least post operative pain and early ambulation.

Cesarean section

Caesarian hysterectomy (Porros section)

It refers to an operation when C.S. is followed by removal of uterus.

Cesarean section

Indications of Porros section

Atonic uterus and uncontrolled P.P.H. Morbid adherent placenta Extensive laceration of uterus in case of A ruptured Ut. & extensive tear in broad t ligament. o

Couvalair uterus. Grossly infected uterus

Cesarean section

Porros section

Rarely necessary now a days. P.P.H. is now better treated with Prostaglandin, Synocinon, and Methergin i Internal ilac ligation is practiced more often. i For treatment of D.I.C. blood and blood components,are now easily available. Subtotal hysterectomy is more safer than total hysterectomy. Timely intervention and enrollment of experienced personal, gives good results.

Phenestial skin Incision

More time to open and close abdomen. Less exposure than vertical incision. Repeat C.S. is more difficult, with previous phenestial incision. Not advisable in obstructed labor and with transverse presentation. Less pain and early ambulation to patient . Early discharge from hospital. Less chances for incisional hernia. It is a cosmetic scar- called Bikini incision.

Indications of Classical Cesarean section

Severe Kypho- scoliosis & lower segment not approachable. Big varicose veins in lower segment. Cervical fibroid with pregnancy. Transverse presentation with big child. Constriction ring in uterus. Central placenta pravia. (some times) Previous difficult V.V.F. repair. Pregnancy with cancer cervix. Post mortem C.S.

Cesarean section

Bringing uterus out at pelvis

(uterine exteriorization)

At suturing :-Rarely required unless uncontrolled bleeding. It can can cause febrile morbidity and venous air remobilization After suturing :-To detect posterior wall rupture and any congenital uterine anomaly.

Caesarian section

Prophylaxis against scar rupture

Ask patient to preserve operation card and all relevant case papers and reports. Put emphasis on follow up in next pregnancy, from vary beginning to end. Insist on hospital delivery with previous C.S. Now a days obstetricians are either to busy or are too much afraid to give trial of labor in case with previous C.S. and hence repeat elective C.S. is for them a safe short cut.

Caesarian section

Pregnancy and labor following C.S.

Trial of labour is attempted when:-

Non recurrent indication of previous C.S. Well engaged head. Previous L.S.C.S. with uneventful recovery. Anterior cephaalic position of child. Average size child. Good trained staff to monitor the patient. Efficient emergency operative facility available at vary short notice.

Caesarian section

Delivery of trunk

At the time of delivery of trunk bi-aromial diameter should always be in line of uterine incision and not perpendicular to it.

Cesarean section

The mobs put in abdominal & Uterine cavity are all removed & counted doubly by surgeon himself.

Caesarian section

Araumatic abdominal delivery is always preferred to a traumatic difficult vaginal delivery.

Caesarian section

Is Caesarian section ?
An answer for all problems ? A universal obstetric remedy ?

A short cut to all obstetric problems?

Thank you