CAESAREAN SECTION

DEFINITION
• Cesarean delivery defines the birth of a fetus via laparotomy and then
hysterotomy.
• Two general types —primary refers to a first-time hysterotomy and
secondary denotes a uterus with one or more prior hysterotomy
incisions.
HISTORY
• 715 BC : “lex Cesarea” – a Roman law promulgated.
• 1668: French obstetrician, Francois Mauriceau first reported cesarean
section.
• 1876: Porro performed subtotal hysterectomy.
• 1907: Frank described the extraperitoneal operation.
• 1912: Kronig introduced lower segment vertical incision, popularized by De
Lee (1922).
• Although Kehrer in 1881 did the transverse lower segment operation for the
first time,
• 1926 :Munro Kerr : reintroduced and popularized.
One of the earliest printed illustrations of Cesarean section.
Purportedly the birth of Julius Caesar. A live infant being surgically removed from a dead
woman.
From Suetonius' Lives of the Twelve Caesars, 1506 woodcut.
 INCIDENCE
• A total of 54 countries had C-section rates below 10%, whereas 69
showed rates above 15%.
• 14 countries had rates between 10 and 15%.
• Further estimated that in 2008, 3.18 million additional CS were needed
and 6.20 million unnecessary sections were performed.
• Although the international health community has long considered 10-
15 percent to be the ideal rate for CS at the population level, the World
Health Organization (WHO) emphasizes that medical indication should
be present for the procedure to be performed, and does not
recommend a target figure for countries to achieve.
REASONS FOR THE CONTINUED
INCREASE IN THE CESAREAN RATES
• Nulliparas • Maternal request
• Maternal age • Rising rates for IOL and failed IOL
• Electronic fetal monitoring • Decline for VBAC
• Decline in vaginal breech
deliveries
• Decline in operative vaginal
deliveries
• Malpractice litigations
INDICATIONS
• 4 principal indications:
o Prior cesarean delivery-26.1%,
o Dystocia-23%,
o Abnormal fetal presentation-11.7% or,
o Fetal jeopardy-10.7%.
INDICATIONS
MATERNAL
• Prior cesarean delivery
• Abnormal placentation
• Maternal request
• Prior classical hysterotomy
• Unknown uterine scar type
• Uterine incision dehiscence
• Prior full-thickness myomectomy
• Genital tract obstructive mass
• Invasive cervical cancer
• Prior trachelectomy
• Permanent cerclage
• Prior pelvic reconstructive surgery
• Pelvic deformity
• HSV or HIV infection
• Cardiac or pulmonary disease
• Cerebral aneurysm or arteriovenous
malformation
• Pathology requiring concurrent
intraabdominal surgery
• Perimortem cesarean delivery
MATERNAL-FETAL
• Cephalopelvic disproportion
• Failed operative vaginal delivery
• Placenta previa or placental abruption
FETAL
• Nonreassuring fetal status
• Malpresentation
• Macrosomia
• Congenital anomaly
• Abnormal umbilical cord Doppler study
• Thrombocytopenia
• Prior neonatal birth trauma
ABSOLUTE: • Monoamniotic monochorionic
• Central Placenta Previa twins
• Contracted Pelvis • Footling breech
• Adherent placenta • HIV with viral load > 1000
• Previous 2 or more LSCS • Macrosomia >4.5 kg
• Classical caesarean section
• Advanced carcinoma cervix
• Transverse lie/brow presentation
• Active genital herpes

CURRENT DIAGNOSIS AND TREATMENT IN OBSTETRICS AND GYNAECOLOGY

RELATIVE
• CPD
• Fetal distress
• Previous LSCS
• IUGR
• BOH
• Primi with breech
• Elderly primi
• Pre-eclampsia/eclampsia
TIME OF OPERATION (NICE
GUIDELINES)
ELECTIVE: When the operation is done at a prearranged time during
pregnancy to ensure the best quality of obstetrics, anesthesia, neonatal
resuscitation and nursing services.
• Time:
(a) Maturity is certain: The operation is done about 1 week prior to the
expected date of confinement.
(b) Maturity is uncertain: Ultrasound assessment in first or second
trimesters if available is corroborated.
• Otherwise spontaneous onset of labor is awaited and then CS is done.
EMERGENCY: Category of C.S (NICE): When the operation is to be done
due to an acute obstetric emergency (fetal distress). A time interval of 30
minutes between the decision and delivery is taken as reasonable.
• Category 1: When there is immediate threat to the life of the woman
or the fetus. Decision delivery interval should be 30 minutes.
• Category 2: When there is maternal or fetal compromise which is not
immediately life threatening. CS should be done within 75 minutes of
making decision.
• Category 3: There is no maternal or fetal compromise but needs early
delivery.
• Category 4: Delivery is planned to suit the woman, family members and
the hospital staff.
PATIENT PREPARATION
• Delivery Availability :The American Academy of Pediatrics and the American
College of Obstetricians and Gynecologists (2012) recommend that facilities
giving obstetrical care should have the ability to initiate cesarean delivery in
a time frame that best incorporates maternal and fetal risks and benefits.
• Informed Consent : enhance a woman’s awareness of her diagnosis and
contain a discussion of medical and surgical care alternatives, procedure
goals and limitations, and surgical risks. (American College of Obstetricians
and Gynecologists, 2012a)
-prior cesarean delivery: the option of a trial of labor should be included for
suitable candidates.
-Also, in those desiring permanent sterilization, consenting for tubal ligation.
• Timing of Scheduled Cesarean Delivery.
• Perioperative Care:
-A sedative may be given at bedtime the night before surgery.
-Oral intake is stopped at least 8 hours before the procedure.
-Recently performed hematocrit and availability of compatible blood
must be ensured.
-Regional analgesia.
-Antacid is given shortly before regional analgesia or induction with
general anesthesia.
-Once woman is supine, a wedge beneath the right hip creates a left
lateral tilt to aid venous return and avoid hypotension.
-Fetal heart sounds should be documented in the operating room prior to
surgery.
-If hair obscures the operative field it should be removed the day of surgery
by clipping.
-An indwelling bladder catheter.

• Infection Prevention
Most recommend a single intravenous dose of a β-lactam antimicrobial—
either a cephalosporin or extended-spectrum penicillin derivative.
A 1-g dose of cefazolin is an efficacious and cost-effective choice.
For obese women, a 2-g dose usually provides adequate coverage, although
Pevzner and associates (2011) showed this dose may be inadequate for
those with bodymass index > 40.
-The American College of Obstetricians and Gynecologists (2011b)
recommends that prophylaxis be administered within the 60 minutes prior
to the start of planned cesarean delivery.
-For emergent delivery, prophylaxis should be given as soon as feasible.
-Preoperative preparation of the abdominal wall skin is effective to prevent
wound infection.

• Surgical Safety
-An instrument, sponge, and needle count before and after surgery and
vaginal delivery is crucial to surgical safety.
-If counts are not reconciled following abdominal or vaginal examination,
then radiographic imaging for retained foreign objects is obtained
(American College of Obstetricians andGynecologists, 2012b).
TECHNIQUE FOR CESAREAN
DELIVERY
• Abdominal Incision: usually a midline vertical or a suprapubic
transverse incision is chosen for laparotomy.
 Transverse incision: either Pfannenstiel or Maylard incisions.
-Pfannenstiel incision: a low, transverse, slightly curvilinear incision.
-At the level of the pubic hairline, which is typically 3 cm above the
superior border of the symphysis pubis ; extended somewhat beyond
the lateral borders of the rectus abdominis muscles.
-Sharp dissection is continued through the subcutaneous layer to the
fascia.
• The fascia is then incised sharply at the midline.
• The inferior fascial edge is grasped with suitable clamps and elevated
by the assistant as the operator separates the fascial sheath from the
underlying rectus muscles either bluntly or sharply until the superior
border of the symphysis pubis is reached.
• Next, the superior fascial edge is grasped and again, separation of
fascia from the rectus muscles is completed. The fascial separation is
carried near enough to the umbilicus to permit an adequate midline
longitudinal incision of the peritoneum.
• The rectus abdominis and pyramidalis muscles are then separated in
the midline by sharp and blunt dissection to expose the transversalis
fascia and peritoneum.
• The transversalis fascia and preperitoneal fat are dissected carefully to
reach the underlying peritoneum.
• The peritoneum near the upper end of the incision is opened carefully,
either bluntly or by elevating it with two hemostats placed
approximately 2 cm apart.
• The incision is extended superiorly to the upper pole of the incision and
downward to just above the peritoneal reflection over the bladder.

- Maylard incision : the bellies of the rectus abdominis muscles are

transected horizontally to widen the operating space.
Vertical Incision:
-Infraumbilical midline vertical incision begins 2 to 3 cm above the superior
margin of the symphysis and should be of sufficient length to allow fetal
delivery without difficulty.
-Sharp or electrosurgical dissection is performed to the level of the
anterior rectus sheath.
-A small opening is made sharply with scalpel in the upper half of the linea
alba.
-Index and middle fingers are placed beneath the fascia, and the fascial
incision is extended superiorly and inferiorly with scissors or scalpel.
Joel-Cohen and Misgav-Ladach Techniques
Joel-Cohen technique creates a straight 10-cm transverse skin incision 3
cm below the level of the anterior superior iliac spines.
-The Misgav-Ladach technique: greater use of blunt dissection.
The myometrial incision closure is completed with a single layer locking
continuous suture (Hofmeyr, 2009; Holmgren, 1999).
These techniques have been associated with shorter operative times
and with lower rates of intraoperative blood loss and postoperative
pain.
PFANNENSTEIL INCISION VERTICAL INCISION

Superior cosmetic results Poorer

Decreased rates of postoperative pain Greater

Less fascial wound dehiscence Higher

Lesser rates of incisional hernia Higher

More time consuming Provide quick entry to shorten incision-to-delivery time

Inferior Superior access to the upper abdomen

Lesser Greater operating room and flexibility for easy wound

extendion
More chances of injury to neurovascular structures Less

High infection rates Less

Hysterotomy
• Low Transverse Cesarean Incision:
-The surgeon should palpate the fundus and adnexa to identify degrees of
uterine rotation.
-The reflection of peritoneum above the upper margin of the bladder and
overlying the anterior lower uterine segment—termed the bladder flap—is
grasped in the midline with forceps and incised transversely with scissors.
-Scissors are inserted between the vesicouterine serosa and myometrium
of the lower uterine segment, pushed laterally from the midline on
eachnside to further open the visceral peritoneum and expose the
myometrium.
-The lower edge of peritoneum is elevated, and the bladder is gently
separated from the underlying myometrium with blunt or sharp
dissection within this vesicouterine space.
-The uterus is entered through the lower uterine segment
approximately 1 cm below the upper margin of the peritoneal
reflection.
Uterine Incision: transversely incise the exposed lower uterine
segment for 1 to 2 cm in the midline.
-Careful blunt entry using hemostats or fingertip to split the muscle
may be helpful.
-Once the uterus is opened, the incision can be extended by simply
spreading the incision, using lateral and slightly upward pressure
applied with each index finger.
- Scissors : the index and midline fingers of the nondominant hand
should be insinuated beneath the myometrium and above fetal parts
to prevent fetal laceration.
- At instances, low-transverse hysterotomy provides inadequate room
for delivery , hence, one corner of the hysterotomy incision is
extended cephalad into the contractile portion of the myometrium—a
J incision.
- If this is completed bilaterally, a U incision is formed.
- Last, some prefer to extend in the midline—a T incision.
- As expected, these have been linked with higher intraoperative blood
loss (Boyle, 1996; Patterson, 2002).
Delivery of the Fetus
-In a cephalic presentation, a hand is slipped into the uterine cavity between
the symphysis and fetal head.
-The head is elevated gently with the fingers and palm through the
incision.
-Once the head enters the incision, delivery may be aided by modest
transabdominal fundalpressure.
-After head delivery, a finger should be passed across the fetal neck to
determine whether it is encircled by one or more umbilical cord loops.
-The head is rotated to an occiput transverse position, which aligns the fetal
bisacromial diameter vertically.
-The sides of the head are grasped with two hands, and gentle downward
traction is applied until the anterior shoulder enters the hysterotomy
incision.
-Next, by upward movement, the posterior shoulder is delivered.
-With steady outward traction, the rest of the body then readily follows.
Gentle fundal pressure may aid this.
-The umbilical cord is clamped, and the newborn is given to the team
member who will conduct resuscitative efforts as needed.
Difficulties with particular presentation
If labour is OBSTRUCTED WITH CEPHALIC PRESENTATION
Enter abdomen just below umbilicus to avoid bladder
injury.
An assistant is to push baby’s head up through vagina.
If delivering head is difficult, don’t panic. Find this
problem, especially when uterus is tight around baby.
Take time to push back its wall around head, by
inserting two finger all around, then applying forceps.
Method used for delivery in cesarean
• Reverse breech extraction –”Pull technique”

• Assist from a vaginal hand-”Push technique”

• If delivery becomes difficult through a transverse hysterotomy incision,

making a J or T incision can be considered
REVERSE BREECH EXTRACTION- “PULL TECHNIQUE”
 PUSH TECHNIQUE

While pushing the head, try to flex the head, if possible use three or four fingers or cupped
hand to apply force spread widely across the presenting part
Cont.
• If still have difficulty ,enlarge wound upward and laterally at its end.
Caution
• Don’t lever head out with your whole hand because it can cause
vertical downward tear in lower segment.
Placental Delivery
-The uterine incision is observed for any vigorously bleeding sites.
These should be promptly clamped with Pennington or ring forceps.
-The placenta is then delivered unless it has already done so
spontaneously.
-Immediately after delivery and gross inspection of the placenta, the
uterine cavity is suctioned and wiped out with a gauze sponge to
remove avulsed membranes, vernix, and clots.
• RCOG RECOMMENDATION
The placenta should be removed using controlled cord traction and not
manual removal as this reduces the risk of endometritis.
Uterine Repair
-The uterine incision is then closed with one or two layers of
continuous 0- or No. 1 absorbable suture.
-Chromic suture is used by many, but some prefer synthetic delayed-
absorbable sutures.
-Single-layer closure is typically faster and is not associated with higher
rates of infection or transfusion (CAESAR study collaborative group,
2010; Dodd, 2008; Hauth, 1992).
-Moreover, most studies observed that the type of uterine closure does
not significantly affect complications in the next pregnancy (Chapman,
1997; Durnwald, 2003; Roberge, 2011).
• The initial suture is placed just beyond one angle of the uterine
incision.
• A running-lock suture for hemostasis is then performed, with each
suture penetrating the full thickness of the myometrium.
• The running-lock suture is continued just beyond the opposite
incision angle.
RCOG RECOMMENDATIONS
-Intraperitoneal repair of the uterus at CS should be undertaken.
-Exteriorization of the uterus is not recommended because it is associated
with more pain and does not improve operative outcomes such as
hemorrhage and infection.
-The effectiveness and safety of single layer closure of the uterine incision
is uncertain.
-Except within a research context, the uterine incision should be sutured
with two layers.
Abdominal Closure
• Any laparotomy sponges are removed, and the paracolic gutters and
cul-de-sac are gently suctioned of blood and amniotic fluid.
• The abdominal incision is closed in layers.
• Many surgeons omit the parietal peritoneal closure.
• The rectus abdominis muscles are allowed to fall into place. With
significant diastasis, the rectus muscles may be approximated with
one or two figure-of-eight sutures of 0 or No.1 chromic gut suture.
• The overlying rectus fascia is closed by a continuous, nonlocking
technique with a delayed-absorbable suture.
• RCOG RECOMMENDATION
- Neither the visceral nor the parietal peritoneum should be sutured at
CS because this reduces operating time, the need for postoperative
analgesia and improves maternal satisfaction.
• The subcutaneous tissue usually need not be closed if it is less than 2
cm thick.
• With thicker layers, however, closure is recommended to minimize
seroma and hematoma formation, which can lead to wound infection
and/or disruption (Bohman, 1992; Chelmow, 2004).
• Skin is closed with a running subcuticular stitch using 4-0 delayed-
absorbable suture or with staples.
Classical Cesarean Incision
• Indications:
Maternal
-a densely adhered bladder from previous surgery is encountered;
-a leiomyoma occupies the lower uterine segment;
-cervix has been invaded by cancer;
-massive maternal obesity precludes safe access to the lower uterine
segment
-placenta previa with anterior implantation, especially those
complicated by placenta accrete syndromes.
• Fetal :
-Transverse lie of a large fetus
- Multifetal pregnancy (malpositioned or preterm)
- Breech
Uterine Incision and Repair
• A vertical uterine incision is initiated with a scalpel beginning as low
as possible and preferably within the lower uterine segment.
• Once the uterus is entered with a scalpel, the incision is extended
cephalad with bandage scissors until it is long enough to permit
delivery of the fetus.
• With scissor use, the fingers of the nondominant hand are insinuated
between the myometrium and fetus to prevent fetal laceration.
• As the incision is opened, numerous large vessels that bleed profusely
are commonly encountered within the myometrium.
• For incision closure, one method employs a layer of 0- or No. 1 chromic
catgut with a continuous stitch to approximate the deeper halves of
the incision.
• The outer depth of myometrium is then closed with similar suture and
with a running stitch or figure-of-eight sutures.
• To achieve good approximation and to prevent the suture from tearing
through the myometrium, it is helpful to have an assistant compress
the uterus on each side of the wound toward the midline as each stitch
is placed.
COMPARISON OF LOWER SEGMENT
& CLASSICAL CAESAREN
Lower Segment Classical
Incision Transverse incision in lower Vertical incision in upper
segment. segment.

Muscle damage less More

Hemorrhage less more
Suturing Easy Difficult
Technical Difficulty Size of incision may not be Size of incision is mostly
adequate and may adequate with adequate
extend in broad exposure.
ligament and open
major vessels.
Bladder injury more Less
Post-op recovery quick delayed
 Lower segment Classical

Adhesion Less More

Subsequent Pregnancy: Scar is under tension

Risk of scar rupture is during pregnancy and
0.5%. can rupture during
antenatal period as well
as in labor ( 2.2% ).
COMPLICATIONS
Intra-operative complications:
– Anesthetic complications: almost all are associated with general anesthesia. Due to
failure of endotracheal intubation or inhalation of gastric contents into the lungs
"Mendelson syndrome ", cardiac arrest, severe convulsions.
– Bleeding: more than the average (1000 ml)
• Uterine abnormalities:
– Atony.
– Uterine incision:
» Classical C.S. incision.
» Lateral extension to uterine vessels.
» Downward extension to cervix, vagina, or bladder
– Presence of uterine myoma.
– Placental abnormalities:
» Placenta previa.
» Abruptio placentae.
» Incomplete removal of the placenta: accreta, anomalies.
• Failure of blood coagulation mechanisms: DIC, HELLP syndrome
• Trauma:
– Urinary tract injury:
• Bladder injury: due to
– Difficult dissection off the lower uterine segment.
– Bladder trauma during uterine incision.
– Extension of uterine incision to the bladder.

• Ureteric injury: due to

– Extension of the uterine incision.
– Secondary to hemostatic sutures in the base of the broad ligament.
– Bowel injury:
• Causes:
– Blunt dissection of thick adhesions due to previous surgery, PID.
– Putting a clamp on the bowel.
– Needle or suture passing through it.
– Sharp dissection by a scalpel or scissors
• Early postoperative complications:
– Post anesthetic complications:
• Respiration difficulties.
• Paralytic ileus and intestinal obstruction.
• Deep venous thrombosis and pulmonary embolism
– Uterine bleeding: reactionary or secondary.
– Trauma: fistula.
– Infection: endometritis, peritonitis, cystitis, chest infection, wound
infection.
• Delayed " long-term" sequelae of C.S.:
1. Adhesions:
i. Tubo-peritonal leading to infertility.
ii. Bladder adhesions making subsequent surgeries difficult.
iii. Intrauterine adhesions if the anterior and posterior walls of the uterus
were sutured together leading to Asherman syndrome.
iv. Intestinal adhesions leading to intestinal obstruction.
v. Adhesions and pelvic pain may need an operation to treat them.
2. Weak uterus:
i. Perforation of the uterus is more common if D&C is done in the
presence of a weak scar.
ii. Rupture of the uterus at the site of the scar in future pregnancies.

3. Risk of incisional hernia.

4. Higher risk of placenta accreta.