Cesarean Section

Dr. Fekadu R.
November , 2019
 Definition
2
 Caesarian section is delivery of fetus or fetuses along with
the placenta and membranes by an incision made through the
abdominal and uterine wall after the fetus has reached
viability
 The correct terminology for the surgical delivery of a
previable fetus is hysterotomy

 According to tradition, Roman statesman Julius Caesar was

born by this method, hence its name.

 The first documented case of a cesarean section on a living

woman occurred in 1610. The patient died 25 days later

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Types of Cesarean Section
3

 According to timing:
 Elective CS
 Emergency CS

 Elective CS - caesarian section that is performed before

the onset of labor or before the appearance of any
complication that mandates an urgent delivery

 Emergency CS - caesarian section that is performed

after the onset of labor or appearance of a complication that
mandates urgent delivery

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Elective Cesarean Section
4

Advantages
Patient with empty stomach and surgeon usually with full
breakfast
Best anesthetist available at that time
Best assistant and nursing staff.
The risk of puerperal sepsis is minimized
Disadvantages
If wrong judgment, premature child may be born
Cervix may not be dilated and hence poor drainage of
lochia
Lower segment is not formed and hence uterine incision in
lower part of upper segment

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Emergency Cesarean Section ( unplanned)
5

 Working under adverse circumstances:-

 Patient may be with full stomach and surgeon may be
with empty belly
 Odd working hours either of day or night
 Anesthetist, assistant and nursing staff may not be of
your choice

 Advantage
Mature child as patient is in labor
Cervix is open, better drainage of lochia.
Lower segment is well formed

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Types….
6

 According to number of the operation:

 Primary CS
 Repeated CS

 Primary CS
caesarian section is one that is done for the first time
 Repeat CS
caesarian section is the one that is done for more than
one time

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Types…
7

 According to opening the peritoneal cavity

Transperitoneal
 The ordinary operation where the peritoneal cavity is
opened before incising the uterus.

Extraperitoneal
 The peritoneal cavity is not entered & the LUS is
reached either laterally or inferiorly by reflecting the
peritoneum of vesico-uterine pouch.

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Types…
8
 According to the site of uterine incision:
Classical CS (USCS)
 The incision is done in the upper uterine segment & it is
always vertical.
LSCS
 The incision is done in the lower uterine segment & may
be transverse (the usual) or vertical.

 Less common types of CS According to the site of uterine

incision:
 Lower segment vertical (Selheim)
 Inverted T- shaped incision
 Delee incision (J shaped)

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Types ….

n
io
c is
inl
ca
ti
r
Low

ve
w
transverse

Lo
incision

Classical
incision
n
i sio
c
in
ped
J-shaped incision ha
s
T-
Cesarean Section & VBAC - WKU Sunday, July 18, 2021
 Classical Cesarean Section (USCS)
10

Indications for classical incision:

Transverse lie with impacted shoulder presentation
Structural abnormality that makes lower segment
approach difficult
Constriction ring with neglected labor
Fibroids (myoma) in the lower segment
Anterior Placenta Previa & abnormally vascular lower
segment
Mother dead & rapid delivery is required
Very preterm fetus in breech presentation

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Advantages of the lower segment over the upper
segment operation
11

 Less blood loss

 Easier to repair
 The resultant uterine scar is stronger
 Less subsequent adhesions to the bowel and omentum

 The major disadvantages of LUCS are:

Lateral extension with damage to uterine vessels and

ureters
Bladder injury especially in repeat cases.

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Benefits of C/S
12

Reduction in perinatal morbidity and mortality   

Elimination of intrapartum events associated with
perinatal asphyxia (if elective)   
Reduction in traumatic birth injuries   
Reduction in stillbirth beyond 30 weeks'
gestation   
Possible protective effect against pelvic floor
dysfunction   
PMTCT

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Risks of C/S
13

Increased short-term morbidity   

Increased endometritis , transfusion, venous
thrombosis rates   
Increased length of hospital stay and longer
recovery time   
Increased long term morbidity   
Increased risk for placenta accreta &
hysterectomy with subsequent cesarean
deliveries

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Pre Operative Considerations
14

Decision Making & Recording

Informed Consent
Blood Hct, Hb, ABO & Rh, U/A if not done.
U/S to rule out Congenital Anomaly,
Prematurity, EFW and Fetal Wellbeing
Catheterization
Prophylactic antibiotics e.g. ampicillin 2gm IV
stat
Check FHB on table

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Post Op Care Of C/S
15

Monitor vital signs

I V fluids for 24hrs (at least 3 liters)
In uncomplicated cases, solid food may be offered
within 8 hours of surgery
Anti pain
The catheter most often can be removed by 12
hours postoperatively
Early ambulation
Proper wound care
Hematocrit after 8hours of surgery

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Complications
16
Intraoperative
Bleeding & the need for
blood transfusion
Hysterectomy
Complications of
anaesthesia
Damage to the bladder,
ureter, colon , retained
placental tissue
Fetal injury
Cesarean Section & VBAC - WKU
Postoperative
Gaseous distension
Paralytic ileus
Wound dehiscence &
infection
Infections  UTI,
pulmonary
DVT & pulmonary embolism
Death
Vesico uterine fistula
Sunday, July 18, 2021
 VAGINAL BIRTH AFTER CESAREAN
DELIVERY (VBAC) /TRIAL OF LABOR
(TOL)

Cesarean Section & VBAC - 17

Sunday, July 18, 2021 WKU
 Introduction
18

“ONCE A CESAREAN, ALWAYS A CESAREAN “

has been changed to

“ONCE A CESAREAN ALWAYS A

HOSPITALISATION”
also has been changed to

“ONCE A CESAREAN ALWAYS A CONTROVERSY “

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Candidates for trial of labor (VBAC)
19
a) One previous lower segment transverse cesarean delivery
b) Clinically adequate pelvis
c) No other uterine scars or previous rupture
d) Singleton and estimated fetal weight < 4000 gm
e) No malpresentations
f) Physician immediately available throughout active labor
capable of monitoring labor and performing an emergency
cesarean delivery
g) Availability of anesthesia and personnel for emergency
cesarean delivery
h) Consented for VBAC/TOL

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Contraindication
20
When criteria for VBAC not met
Previous uterine rupture repair
Previous classical or T-shaped incision or J-shaped incision
extensive trans-fundal uterine surgery
More than one prior uterine scars
Medical or obstetric complications that preclude vaginal
delivery
Declined consent for VBAC
Contracted pelvis
Malpresentations & malposition
Recurring cause e.g. contracted pelvis

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Management
21

 Interdelivery intervals of 18 months or less were

associated with a threefold increased risk of
symptomatic uterine rupture compared with that of
those over 18 months.

 Antenatal
 Routine visits
 Emphasis on
 Screening for the previous C/S situation
 Pelvic assessment at term
 Fetal weight estimation
 Decide eligibility for VBAC – birth planning
 Counseling

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Mx …
22

 Intrapartum
Admit all presenting in labor
FHB every 15 minutes
Uterine contraction every 30 minutes
Closely follow for evidence of scar dehiscence

 Delivery and post partum

 Delivery like others
 Watch for bleeding immediately after delivery

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Success Rates for Trial of Labor
23
 Depends to some extent on the indication for the previous
cesarean delivery
 The overall success rate for VBAC appears to be in the 70–
80 percent

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Benefits of VBAC
24

Decreased anesthesia risk

No surgical complication
Less PPH
Comparable perinatal morbidity and mortality
Shorter hospital stay
Lower cost
Early and smooth mother-infant interaction
(favorable mother and child bonding).

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

 Risks of VBAC
25

uterine rupture
Failure

Cesarean Section & VBAC - WKU Sunday, July 18, 2021

26

u !! !
k y o
ha n
T