CAESARIAN SECTION

BY BUGINGO JULITA AND ABDULLAHI MUHIBBA

TUTOR; DR WANYAMA JOHN
OBJECTIVES
• Definition
• Brief background
• Epidemiology
• Indications & Contraindications
• Types of C.s
• Pre and Post operative preparations
• Technique
• Complications
• Vaginal Birth After Cesarean Section (VBAC)
Definition
• A Caesarean section, also known as C-section or Caesar, is a surgical
procedure in which incisions are made through a mother’s abdomen
(laparotomy) and uterus (hysterotomy) to deliver one or more babies.
OR
• A cesarean section refers to the delivery of a fetus, placenta, and
membranes through an abdominal and uterine incision.
Introduction
• The first documented caesarean section on a living person was
performed in 1610. The patient died 25 days later. Since that time,
numerous advances have made caesarean section a safe procedure.
In the past 35 years, the rate of caesarean section has steadily
increased from 5% to approximately 30%.
• In Uganda, the rates of cesarean deliveries are approximately 27.7%
at a large regional referral hospital ( OBGYN department, Mbarara
RRH, 2010).
 Brief background
• There are three theories about the origin of the name;
In the first, according to legend, Julius Caesar was born in this manner, with the
result that the procedure became known as the Caesarean operation.

The second explanation is that the name of the operation is derived from a
Roman law, supposedly created in the 8th century BC by Numa Pompilius,
ordering that the procedure be performed upon women dying in the last few
weeks of pregnancy in the hope of saving the child.

The third explanation is that the word caesarean was derived sometime in the
Middle Age from the Latin verb caedere, to cut.
Factors that may contribute to an increase in
the rates of Caesarean section
• Inaccurate dating of the pregnancy
• Fetal monitoring
• Macrosomia(big baby)
• Maternal request.
• Fetal malpresentations
• Obesity in mothers
• Rising maternal age older nulliparous women are at risk
• Vaginal birth after cesarean—VBAC
 Indications
Fetal indications include;
a) *Nonreassuring fetal heart tracing
b) *Nonvertex or breech presentation
c) Conjoined twins
d) Fetal anomalies, such as hydrocephalus, that would make successful vaginal
delivery unlikely
e) Prior neotal birth trauma

*(common indications)
Maternal indications include;
a) Obstruction of the lower genital tract (e.g., large condyloma)
b) Abdominal cerclage (closing of cervix to prevent premature birth)
c) Active maternal herpes simplex virus infection
d) *Previous cesarean section (if not an appropriate candidate for
VBAC or VBAC is declined by the patient).
e) Previous uterine surgery involving the contractile portion of the
uterus (classical cesarean, myomectomy)
f) Preeclampsia
Maternal and fetal indications include;
a) Placenta previa or known vasa previa
b) Abruptio placentae
c) *Labor dystocia or cephalopelvic disproportion
Contraindications
Types of C.section
• Elective cesarean section; Elective delivery time to suit woman or staff
• Emergency cesarean section

Category Description
1 Immediate threat to the life of the woman or fetus
2 Maternal or fetal compromise that is not immediately life
threatening
3 No maternal or fetal compromise but needs early delivery
Types of C.s
• Classical Cesarean Section; simplest to perform. However, it is
associated with the greatest loss of blood and may result in uterine
rupture with subsequent pregnancies. It involves a longitudinal
midline incision allowing a larger space to deliver baby
Indications for classical cesarean section
• placenta previa
• transverse lie (especially back down)
• preterm delivery in which the lower uterine segment is poorly
developed.
• A classical cesarean section may be preferred if extremely rapid
delivery is needed, because this type of incision offers the quickest
means of delivering the baby.
• Low-Transverse Cesarean Section; this type of cesarean delivery is performed more
frequently. After the peritoneal cavity is opened and the uterus identified, the
bladder fold of peritoneum is picked up with tissue forceps and incised transversely.
• The bladder is bluntly separated from the anterior aspect of the uterus inferiorly for
a distance of 3–4 cm. The bladder is held away from this area by a specially
designed bladder retractor.
• A transverse incision is made through the anterior uterine wall with the scalpel.
Using either bandage scissors or fingers, the transverse incision is extended in a
semilunar fashion and extended superiorly at the lateral edges in order to avoid the
uterine vessels.
• It is associated with less blood loss and the risk of subsequent uterine rupture is
less than with a classic cesarean section.
 Preoperative preparations
• The patient is made aware of the indications for the cesarean section, the
alternatives, and the potential risks and complications. Patient should sign
informed consent.
• An intravenous 18-gauge needle should be in place with an appropriate
intravenous IV solution running before the operation begins.
• The patient is given a clear antacid to minimize the likelihood of aspiration
during anesthesia.
• A Foley catheter is placed to allow for continuous bladder drainage before,
during, and after surgery. Also monitor urine output.
• Prophylactic broad spectrum antibiotics should be given e.g. ceftriaxone
• Do blood CBC , blood grouping and cross matching and book blood
Contn
• Bowel preparation; Intake of water and other clear fluids up to (2)
hours before induction of anesthesia. For solid foods including milk
(6) hours is recommended and for Fried or fatty meal (8) hours is
recommended before induction of anesthesia.
• Anesthesia is administered, and the abdomen is prepped and shaved.
• The patient is covered with sterile drapes. Tilting the patient slightly
to the left moves the uterus to the left of the midline and minimizes
pressure on the inferior vena cava.
Technique/Operative Procedure for C.s
1. Abdominal incision
Abdominal incision; should be of sufficient length to allow for delivery
and may be vertical or transverse.
• a)Vertical incision; these are faster and can be extended above the
umbilicus if more room is needed. The resulting wound is weaker
than that from a transverse incision.
• It is indicated in cases of extreme maternal obesity, suspicion of other
intra-abdominal pathology necessitating surgical intervention, or
where access to the uterine fundus may be required (classical
Caesarean section).
• b) Transverse (Pfannenstiel) incision; is widely used with or without
transection of the rectus muscles because wound dehiscence and
postoperative incisional hernia are rare, and because the cosmetic
result usually is better.
2. Bladder Flap;
The vesicouterine serosa is grasped, elevated, and sharply incised
above the upper border of the bladder in the midline. Metzenbaum
scissors are used to extend the serosal incision transversely in a
curvilinear fashion, then opened in each direction to undermine the
serosa before sharply incising it. The bladder and lower portion of the
peritoneum are then bluntly dissected off the lower uterine segment,
and a bladder blade may be replaced between the bladder and lower
uterine segment.
 3) Uterine Incision;
a)Low Transverse incision; is used most commonly. A curvilinear
incision is made transversely in the lower uterine segment at least 1
to 2 cm above the upper margin of the bladder.
• Advantages ; less blood loss, fewer extensions into the bladder,
decreased time of repair, and lower risk of rupture with subsequent
pregnancies.
• Disadvantages are the limitation in length, particularly in preterm
pregnancies and greater risk of extension into the uterine vessels
b) Low Vertical incision; the advantage is that it can be extended cephalad if more
room is needed; in so doing, however, the active segment of the uterus may be entered.
Such an occurrence should be recorded in the operative notes, and the patient should
be informed and counseled that vaginal birth trial is contraindicated thenceforth.

c) Classical incision; extends from 1 to 2 cm above the bladder vertically up to the

fundus of the uterus. Classical incisions are associated with more bleeding, longer repair
time, greater risk of uterine rupture with subsequent pregnancy (4% to 9%), and greater
incidence of adhesion of bowel or omentum. In cases of fetal prematurity, lower uterine
segment fibroids, malpresentations, fetal anomalies, or placenta previa, however, it may
be necessary to make this type of incision.
d) T and J Extensions; If a low transverse incision is made, it may
extend, or need to be extended, in an inverted T or J fashion. If the
active segment of the uterus is entered, the event should be recorded
in the operative notes, and the patient should be informed and
counseled that vaginal birth trial is contraindicated thenceforth. The J
extension results in a stronger wound than the inverted T extension,
but neither type of extension is compatible with a subsequent trial of
labor
 4.Delivery of the Fetus
a) Term, Cephalic Presentation; Retractors are removed and a hand is inserted
around the fetal head. The head is elevated through the incision. The
remainder of the fetus is delivered using gentle traction on the head as well as
fundal pressure.. If the head is deeply wedged in the pelvis, it may be
necessary for an assistant to insert a sterile gloved hand into the vagina to
elevate and disengage the head. The infant is resuscitated.
b) Breech Presentation or Transverse Lie ; The fetal position should be
confirmed before surgery. If the fetal lie is transverse, back down, or
the fetus is preterm and the maternal lower uterine segment is poorly
developed, a classical cesarean section should be considered..
c) Preterm Delivery. If the lower uterine segment is inadequately
developed, a low vertical or classical uterine incision should be made.
Making a transverse incision under such circumstances may result in an
incision too small to accomplish delivery and risk injury to the uterine
vessels, bladder, cervix, and vagina resulting from extension of the
incision.
d) Vacuum Extraction or Forceps Use in Cesarean Delivery. If the fetus
is difficult to bring down to the low transverse incision and is in the
vertex presentation, a vacuum extractor or forceps may be applied to
assist in delivery without altering the uterine incision. Use of vacuum
should be avoided in fetuses less than 36 weeks' estimated gestational
age or with a known thrombocytopenia.
5. Uterine Repair.
• After delivery of the placenta, oxytocin is administered. The uterus
may be removed through the abdominal incision or left in its
anatomic position.
• Inspect for retained membranes. A running or running locking stitch is
placed. The incision is inspected, and further areas of bleeding may
be controlled
• In classical cesarean sections, two or three layers of sutures may be
required to close the myometrium.
6. Abdominal Closure
• The tubes and ovaries are inspected. The posterior cul-de-sac and
gutters are cleaned of blood and debris.
• The uterus is returned to the anatomic position in the abdominal
cavity and the incision reinspected to ensure hemostasis.
• The fascia is then closed with running delayed-absorption sutures.
• The subcutaneous tissue is inspected for hemostasis, and dead space
may be closed with interrupted absorbable sutures. The skin is closed
with subcuticular sutures or staples.
Complications
Intraoperative complications
1. Bowel damage
2. Caesarean hysterectomy; common indication for Caesarean
hysterectomy is uncontrollable maternal haemorrhage. Other
indications for hysterectomy are atony, uterine rupture, extension of a
transverse uterine incision and fibroids preventing uterine closure and
haemostasis. The most important risk factor for emergency postpartum
hysterectomy is a previous Caesarean section – especially when the
placenta overlies the old scar, increasing the risks of placenta accreta.
3. Haemorrhage ; due to damage of the uterine vessels, or may be
incidental as a consequence of uterine atony or placenta praevia.
4. Placenta praevia
5. Urinary tract damage
6. Anesthetic ; Aspiration , Respiratory Arrest
 Post-operative complications
1. Infection and endometritis
2. Pulmonary emboli and deep vein thrombosis
3. Psychological
4. Adhesions
5. Uterine rapture
 Vaginal Birth After Cesarean Section
(VBAC)
• Provided that no contraindications exist, a patient may be offered VBAC. Success
rates are higher for patients with nonrecurring conditions, such as
malpresentation or fetal intolerance of labor (60% to 85%), than for those with
a previous diagnosis of dystocia (13% to 70%).
A. Contraindications
 previous classical inverted T- or J-shaped incision
other transfundal uterine surgery,
 contracted pelvis,
medical or obstetric contraindications to vaginal delivery
inability to perform emergency cesarean delivery.
B. Management.
epidural anesthesia
 oxytocin
Appropriate staffing
fetal monitoring
Grouping , cross matching and blood products,
Prepare for emergency C-section
N.B; The most common sign of uterine rupture is a nonreassuring fetal heart rate
pattern with variable decelerations evolving into late decelerations, bradycardia,
and undetectable fetal heart rate. Other findings include uterine or abdominal
pain, loss of station of the presenting part, vaginal bleeding, and hypovolemia.
Thank you for listening