CESAREAN SECTION

CESAREAN SECTION

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 OUT LINE
Definition
Incidence and prevalence
Indication
Types
Pre op care
Techniques
Post op care
complication

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 Definition
Cesarean delivery is defined as the birth of a fetus , placenta
& membranes through incisions in the abdominal wall
(laparotomy) and the uterine wall (hysterotomy) after 28
weeks of pregnancy.
Note: Surgical delivery of fetus prior to age of viability
(28wks) is called Hysterectomy./AFPT/test
This definition does not include removal of the fetus from

the abdominal cavity In the case of:

Rupture of the uterus
In the case of an abdominal pregnancy
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 Incidence
The incidence of cesarean sections in the United States
has continued to increase over the past 30 years.
Cesarean section is now the most common operative
procedure performed in many hospitals throughout the
country.
In the United States, approximately 29% of infants were
delivered by cesarean birth in 2004, compared to 21% in
1996, 15% in 1970, and 5% in 1960.

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 Incidence cont…
Since 1970- rate of c/s was increasing for the procedure
was safer than before because there was improvement
of:
 Antiseptic
 ABCs
 Suture
Transfusions
Anesthesia
IN 2004- the rate of C/s became very high .
As the number of primary cesarean sections increased,
previous cesarean section as an indication for a repeat
cesarean section increased.
Thirty-eight percent of cesarean sections performed in

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the United States were repeat cesarean sections in 2004.
 Incidence cont…
 Reasons why the cesarean rate increased are:/PwrE/
1. Women are having fewer children, thus, a greater
percentage of births are among nulliparas,
2. Average maternal age is rising, old-nullipara
3. The use of electronic fetal monitoring
4. Breech presentation
5. Incidence of midpelvic forceps and vacuum deliveries has
decreased

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 6. Rates of labor induction continue to rise
7. Obesity
8. Concern for malpractice litigation
9. Concern over pelvic floor injury associated with
vaginal birth
10. Socioeconomic and Demographic factors

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 PREVALENCE
C/S rate worldwide = 15 % of births
Mexico, Brazil, and Italy = over 35 %

Africa has the lowest = < 5%

China = 20 to 60 %, ( rural/urban)

Teaching hospitals in India = 25%

Here = 20 – 25%

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 Indications
Performed when the clinician and patient feel that abdominal
delivery is likely to provide a better maternal and/or fetal
outcome than vaginal delivery.
Compared with vaginal delivery, a properly performed cesarean
section carries no increased risk for the fetus; however, the risk
of maternal morbidity and mortality is higher.
Cesarean birth is preferred when the benefits for the mother,
fetus, or both outweigh the risk of the procedure for the mother.

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 Benefits of C/S/PwrE/
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

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 Risks of C/S
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

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 Indications For C/S
Indications can be:-
Absolute Or Relative; Or
Maternal Or Fetal; Or
Common
The commonnest indications are:-
Fetal distress
CPD
Repeat cesarean

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 Indications contd….
Maternal   
Repaired fistula, colporaphy for POP.
Specific cardiac disease ( unstable coronary artery
disease)   
Specific respiratory disease   
Conditions associated with increased intracranial pressure
(Cerebral aneurysm or arterio-venous malformations ) 
Mechanical obstruction of the lower uterine segment
(tumors, fibroids)   
Mechanical vulvar obstruction (condylomata)   
 Ca Cx
Pelvic fructure
Utrine surgery( myomoctomy, hysterotomy)
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 Indications contd….
Fetal   
Non-reassuring fetal status (intra or antepartum)  
Breech
EFW >3500gm
Extended neck
Footling   
PMTCT
Maternal genital herpes
Twin - first non cephalic
High order multiple pregnancy   
Congenital anomalies ( large hydrocephalus)
Cord prolapse,
Severe I U G R
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 Indications contd….
Maternal-fetal   
Previous Cesarean [ 30 % of all C S ].
Cephalopelvic disproportion   
Placental abruption   
Placenta previa   
Macrosomia (EFW>4.5kg)
Obstructed labor,
Transverse lie
Failed induction and augmentation
Cx Dystocia,

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 Contraindications
No absolute contraindications.
When no indications.
Benefits must outweigh risks.
In 1984, 20 countries with 62 participants, including the
US…Literature review and recommendations.
C/S 10% in a low risk population

C/S 15% in a high risk population

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 Types of Cesarean Section:
It may be Elective or Emergency according to its
indication and timing.
It may be Primary (first performed) or Repeat CS.
Cesarean operations are classified according to the
orientation (transverse or vertical) and the site of
placement (lower segment or upper segment) of the uterine
incision.
Cesarean  hysterectomy -consists of a Cesarean section
followed by the removal of the uterus.
Peritmortem cesarean delivery- on dead or going to die
mother and alive fetus.
The Hemostatic Cesarean Section- for RVI patient.
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Elective cesarean delivery
Elective caesarean section may be justified, but decisions
must take into account the risk to the infant associated with
delivery before 39 weeks' gestation
It is now clear that respiratory distress syndrome is indeed
seen in "term" infants and is a considerable source of
morbidity and mortality in this group
mechanical ventilation to treat presumed surfactant
deficiency is 120 times more likely to be needed after
elective delivery at 37-38 weeks than after delivery at 39-41
weeks
Emergency cesarean section
In cases of suspected or confirmed acute fetal compromise,
delivery should be accomplished as soon as possible.
The accepted standard is within 30 minutes

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Emergency caesarian section (Unplanned)
• 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 are :-
• Mature child as patient is in labor
• Cervix is open, better drainage of lochia.
• Lower segment is well formed

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 Elective caesarian section (Planned
operation)

 Advantages are:-
 Patient with empty stomach and surgeon usually with full
breakfast
 Best anesthetist available at that time
 Best assistant and nursing staff.
 Disadvantages are :-
 If wrong judgment, premature child may be born.
 Cervix may not be dilated and hence poor drainage of
lochia
 Lower segment is not well formed and hence uterine
incision in lower part of upper segment.
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 Cesarean Hysterectomy
 Hysterectomy is carried out after caesarean section in the
same sitting for one of the following reasons:
Uncontrollable postpartum haemorrhage.
Unrepairable rupture uterus.                   
Operable cancer cervix.
Couvelaire uterus.
Placenta accreta cannot be separated.      
Severe uterine infection.
Multiple uterine myomas in a woman not desiring future
pregnancy although it is preferred to do it 3 months later.

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Perimortem Cesarean Delivery( PMCD)
PMCD has evolved through 23 centuries from a means of
providing appropriate burial and/or ritual for both mother
and baby to a way of saving a child's life when maternal
death is inevitable to a method of optimizing resuscitation
for both mother and baby.

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The Hemostatic Cesarean Section.
Is a new surgical technique to manage pregnant women
infected with HIV-1
This is an elective cesarean section with technical
modification. It is used in all patients plus antiretroviral
treatment(ARV) and breast feeding period has been
inhibited.
The Hemostatic Cesarean Section (programmed at 38 weeks
from gestation in intact membranes and not in labour), and
consent of patients. It consist in the management of lower
uterine segment keeping integrity of membranes, avoiding
the massive contact between maternal blood and the fetus
This technique has shown to be useful, as it decreases
vertical transmission to less than 2%
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 Types...
Low transverse (Kerr) /common/
The low transverse uterine incision is the preferred incision
and the one most frequently used today.
The incision is made in the noncontractile portion of the uterus,
minimizing chances of rupture or separation in subsequent
pregnancies.
The incision requires creation of a bladder flap and lies behind the
peritoneal bladder reflection, allowing reperitonealization.
Uterine closure is accomplished more easily because of the thin
muscle wall of the lower segment, and the potential for blood loss
is lowest with this type of incision.
This incision may involve potential extension into the uterine
vessels laterally and into the cervix and vagina inferiorly.

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 The Lower uterine segment incision:
 It is the most commonly performed. It has the advantage
of:
Having less bleeding unless extended (as the lower
segment is less vascular and away from implantation),
2-the scar is stronger and less incidence of subsequent
rupture (0.2-0.4%).
3- less ileus, stomach dilatation ,
4-easier to repair

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 Type of c/s……..
The de Lee incision
A vertical incision, two-thirds of which are in the lower
segment, and one- third in the upper one.
A lateral tear is likely, as can happen if the lower
segment is very thin, or the baby is in an abnormal
position, as in a transverse lie.
Upper segment transverse incision
If there is a transverse lie, or a contraction ring (Bandl's
ring).
Extraperitoneal Caesarean section
If there is established or potential intrauterine infection.
It greatly reduces the incidence of peritonitis, especially
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if you do not have antibiotics, particularly metronidazole.
 Types...
 Classic incision/upper vertical incision/
 The classic incision is a longitudinal incision in
the anterior fundus.
Infrequently used
Significant risk of uterine rupture in
subsequent pregnancies,
Associated with excessive blood loss, infection
and poor healing.

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 Types…/classical
Indications are :
c/s Massive obesity ,
Difficulty exposing Preterm,
lower segment, Severe adhesion,
Myoma Postmortem,
Cervical CA Densely adherent
Transverse lie, back bladder.
down in transverse lie,
PP ant,
Breech in LUS not
well developed

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Prerequisites
− Appropriate indication
− Trained providers
− Appropriate facilities and equipments

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 Pre operative preparation
 ELECTIVE CESAREAN SECTION
Time: should preferably start at eight- nine in the morning
Lab investigations
o Hct. or Hgb bl group and Rh
o Urine analysis
o Cross match blood as necessary 2 or more units
Other investigation accordingly
 Get written informed consent
 Keep the mother NPO after mid night

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 Pre op preparation for elective cs
cont…
Start IV fluid in the morning
 Administer Prophylactic antibiotics
 Transfer the mother to the operation theater with
stretcher in lateral position
 Instruct the mother to void just before the
procedure or catheterize
Start the Cesarean section at 8:30am. In the morning

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 Preoperative preparation for emergency CS:
o Lab investigations
o Hct. or Hgb bl group and Rh
o Urine analysis
o Cross match blood as necessary 2 or more units
 Get written informed consent
 Administer a teaspoonful of antacid solution
 Open IV line with large bore 16 guage or >cannula
Catheterize
Administer Prophylactic antibiotics or start treatment as

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needed
At least 2 units of crossed matched blood
should be prepared for conditions that have
high possibility of transfusion need such as:
• Active bleeding
• Preeclampsia
• Anemia
• Coagulopathy
• Previous uterine scar
• Over distended uterus and other predisposing
factors for atonic PPH

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 Antibiotic prophylaxis
 a single IV & narrow spectrum antibiotic;
30min
(eg, ampicillin 2 g or cefazolin 1 to 2 g)
 significantly reduced the incidence of
postoperative fever,
endometritis,
wound infection,
urinary tract infection, and
serious infection
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Thromboembolism prophylaxis
Intermittent intra- and post-operative pneumatic
leg compression and
Early ambulation,
Prophylactic anticoagulation in high-risk
women( low-molecular weight heparin)

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To reduce the risk of aspiration pneumonitis:
Empty stomach, Pre-medication with Give an antacid
(sodium citrate 0.3% 30 mL or magnesium trisilicate 300
mg) + Cimetidine IV 1 hr before CS
All obstetric patients undergoing CS should be positioned
with left lateral tilt to avoid aorto-caval compression
By tilting the operating table to the left or place a pillow or
folded linen under her right lower back.
Addition procedures (e.g., Tubal ligation,
Salphingiopherectomy , myomoctomy, appendectomy……)
Tubal ligation (sterilization), may also be performed during
cesarean delivery
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 Caesarean myomectomy
There is no significant difference in intra-operative and
post-operative morbidity and blood loss in performing
caesarean section alone and caesarean section with
myomectomy when a tourniquet is applied.
Make sure that the anesthesia team, the necessary drugs and
equipments, neonatal resuscitation set and personnel are in
place
- Check fetal heart beat before proceeding to the CS
- Record maternal vital signs before anesthesia and during the
CS
- Use double gloving
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-

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 Anaesthesia
1 General anaesthetic.
2 Regional anaesthesia ( Epidural block. - Spinal block ).
3 Infiltration of local anaesthetic agents.
 Regional anaesthesia
Safer with respect to maternal mortality and fetus
morbidity like depression of the infant immediately after
delivery.
It allows the mother to remain awake, experience the
birth, and have immediate contact with her infant.
 It is usually safer than general anesthesia.
Many practitioners prefer spinal or epidural techniques
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because of more rapid onset and better blockage of pain.
 Local anesthesia

• This is rarely requires except in conditions, eg 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.
NB: Halothane should not be used uterine relaxation &
bleeding

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 Prepare The skin
Wash the area around the proposed incision site with soap
and water,
Do not shave the woman’s pubic hair as this increases the
risk of wound infection. The hair may be trimmed, if
necessary
Patients skin at the operation site is routinely cleaned
with antiseptic solutions before surgery.
 Antiseptic skin cleansing before surgery is thought to
reduce the risk of postoperative wound infections

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 Sterlize The Skin
Apply antiseptic solution three times to the incision site
using a high-level disinfected ring forceps and cotton or
gauze swab. If the swab is held with a gloved hand, do not
contaminate the glove by touching unprepared skin;
 Begin at the proposed incision site and work outward in a
circular motion away from the incision site;
 At the edge of the sterile field discard the swab.
Never go back to the middle of the prepared area with the
same swab.
Keep your arms and elbows high and surgical dress away
from the surgical field.

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 Drape The Skin
Drape the woman immediately after the area is prepared
to avoid contamination:
-If the drape has a window, place the window directly
over the incision site first.
-Unfold the drape away from the incision site to avoid
contamination

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Anterior abdominal wall: anatomy
o Boundaries:
 Superiorly: xiphoid process and costal margins
 Posteriorly: vertebral column
 Inferiorly: upper parts of the pelvic bones.
o Layers:
 Skin
 Superficial fascia (subcutaneous tissue)
 Muscles and their associated deep fascias
 Extraperitoneal fascia
 Parietal peritoneum.

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 Anterior abdominal wall: Layers

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Anterior abdominal wall: Innervation
 Intercostal nerves (T7 - T11)

 Subcostal nerve – T12

 Iliohypogastric nerve and ilio-inguinal nerve - branches of

L1
 Along their course, nerves T7 - L1 supply branches to the

anterolateral abdominal wall muscles.

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 Anterior abdominal wall: Innervation
o All terminate by supplying skin:
 Nerves T7 - T9 supply the skin from the xiphoid process to
just above the umbilicus.
 T10 supplies the skin around the umbilicus.
 T11, T12, and L1 supply the skin from just below the
umbilicus to, and including, the pubic region.
 Additionally, the ilio-inguinal nerve supplies the anterior
surface of the scrotum or labia majora, and sends a small
cutaneous branch to the thigh.

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 Anterior abdominal wall: Innervation

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 Arterial supply and venous drainage:
o Superficially:
 Superior part: branches from the musculophrenic artery,
a terminal branch of the internal thoracic artery.
 Inferior part: by the medially placed superficial
epigastric artery and the laterally placed superficial
circumflex iliac artery, both branches of the femoral
artery.

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 Blood vessels of the abdominal wall

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 Arterial supply and venous drainage:
o At a deeper level:
 Superior part: superior epigastric artery, a terminal
branch of the internal thoracic artery.
 Lateral part: branches of the 10th and 11th intercostal
arteries and the subcostal artery.
 Inferior part: by the medially placed inferior epigastric
artery and the laterally placed deep circumflex iliac
artery, both branches of the external iliac artery.
NB:- Veins of similar names follow the arteries and are
responsible for venous drainage.

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o 4 basic principles to guide selection of the incision
and closure of the wound:
 Accessibility: good exposure.
 Flexibility: amenable to extension if the complexity
of the procedure demands greater exposure than
originally anticipated.
 Security: closure of the wound must be strong and
reliable.
 Preservation of function.

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Additional considerations in selecting the
type of incision include:
 Need for rapid entry
 Certainty of the diagnosis
 Body habitus
 Location of previous scars
 Potential for significant bleeding
 Cosmetic outcome
 The preference and experience of the operating surgeon.

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 Techniques for c/s
 Abdominal incision
1.Vertical Incision
Infraumblical midline-quickest to make, good exposure ,less bleeding,dehiscence↑
Indicated in cases of urgency- APH massive bleeding, upper abdominal exposure,&
perimortem caesarean.
Paramedian- A vertical incision lateral to the umbilicus. It is rarely used.
2.Transeverse incision
pfannenstiel- pubic hair line, cosmetic, benefits of early ambulation, dehiscence is
less likely, exposure is optimal
Incision may cause illioinguinal & illiohypogastric nerves, blood loss.
Joel Cohen (jc)-

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Abdominal entry

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 Joel Cohen incision (JC)
The JC incision is performed by a superficial transverse cut
about 3 cm below an imaginary line connecting the anterior
supierior ileac spine.
A small transverse opening is made in the fascia, and then the
fascia is opened transversely underneath the fat tissue and
blood vessels by pushing the slightly open tip of a pair of
straight scissors, first in one direction, and then in the other.
 The fascia is stretched using the index fingers to make room
for the next step.
The surgeon and his assistant each insert their index and third
fingers under the muscles, and stretch the muscles, blood
vessels, and the fat tissue by manual bilateral traction.

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 Pfannenstiel's incision
The most popular transverse incision for pelvic surgery, is
placed 2 to 5 cm above the pubic symphysis and usually is
10 to 15 cm in length.
After the skin is entered, the incision is carried through the
subcutaneous tissue to the anterior rectus sheath, which is
incised transversely.
The upper and lower fascial edges are grasped with a heavy
toothed clamp, such as a Kocher, elevated, and dissected
bluntly and sharply off the underlying rectus muscle .

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(Pfannenstiel) vs (Joel Cohen)
--improvement in febrile morbidity with J-C.
There was little difference in wound infection.
No data available for endometritis.

The basic principles of the blunt Joel Cohen incision include a

shorter surgical time , minimisation of tissue damage, operating in
harmony with body's anatomy & physiology and minimal use of
instruments.less fever, less pain and less analgesic requirements;
less blood loss; and shorter hospital stay

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 Midline Incisions

 The fastest approach toward the peritoneal cavity and has a number of
advantages:
 It offers adequate exposure to almost every region of the abdominal
cavity, pelivic cavity and retroperitoneum.
 It is nearly bloodless and does not require division of muscle fibers or
sectioning of nerves.
 Is simple and can be performed rapidly, closed quickly and extended
easily.
 Indicated in cases of urgency- APH massive bleeding, upper abdominal
exposure,& perimortem caesarean

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 Paramedian Incisions
a vertical incision that is made 2.5–5 cm from the midline on
either the right or left side of the abdomen.
Like the midline incision, it avoids injury to nerves and limits
trauma to the rectus muscle.
It provides a secure, anatomic closure with good restoration of
function.
When necessary, it can also be extended from xiphisternum to
pubis, allowing excellent exposure of the abdomen.
It is, however, considerably more time-consuming than a midline
incision.

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 Excision of previous scar

• Always at the beginning of operation by an

elliptical incision.
 Excising previous scar at the end of
operation is difficult
 Or incise in the same incision with trimming
of the fibrosed edges of the wound to help
good healing
 Multiple scars –multiple surgeon’s name

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 SPECIAL CONSIDERATIONS
FOR OBESE PATIENTS
Incisions should not be placed within the overlapping fold of a
panniculus due to the anaerobic bacterial load.
The panniculus may be grasped with towel clamps and pulled
down.
An alternative approach is removal of the
panniculus(panniculectomy), the rate of wound infection was 2.6
percent.
A further advantage of this procedure is that the depth of the
surgical field is significantly reduced.
A protocol utilizing this technique has been shown to lower the
rate of wound infection from 42 to 3 percent.
While the topography of the abdomen is distorted, the fascial
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anatomy is not.
Incise the skin and subcutaneous tissue
 Make a small incision over the fascia with a scalpel
 Incise the whole length of the fascia with scissors
 Dissect the rectus and pyramidalis muscles by sharp instrument
and then with blunt dissection
 Elevate the peritoneum at the upper edge of the incision by
holding it with two artery forceps about 2 cms. apart
 Palpate the tent of peritoneum to check if omentum or bowel is
not grasped If grasped release the artery forces and grasp again

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o Incise between the two artery forceps with scalpel to open
the peritoneal cavity
 Check if there is adhesion of the peritoneum or dense
infiltration by inserting a finger and palpating up and down
the peritoneal opening
 Extend the peritoneal opening with scissors up wards up to
the upper border of the incision and downward up to the
reflection of the bladder checking for any adhesion.
 Correct the uterus if dextro-rotated
Insert moistened packs on each side of the uterus.

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Moistened laparatomy pack inserted in
each paracolic gutters : to absorb fluid &
blood, when thick meconium or infected
aminotic fluid
Cause –postoperative adhesion formation,
peritoneal surface abrasion, delay in
return of bowel activity, increased need of
analgesia

69Insert a bladder retractor

 Visceral Peritoneal Incision
 Place a bladder retractor over the
pubic bone.
 Use forceps to pick up the loose
peritoneum covering the anterior
surface of the lower uterine
segment and incise with scissors.
 Extend the incision by placing the
scissors between the uterus and the
loose serosa and cutting about 3 cm
on each side in a transverse fashion.
 Use two fingers to push the bladder
downwards off of the lower uterine
segment. Replace the bladder
retractor over the pubic bone and
bladder.
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 Uterine incision
The pregnant uterus is palpated and inspected for
rotation.
The type of uterine incision is selected depending
on development of the lower uterine segment,
presentation of the infant, and placental location.
Abladder flap is created to approach the lower uterine
segment.
The reflection of bladder peritoneum is incised and
dissected free from the anterior uterine wall, exposing
the myometrium.
This step is not necessary with a classical incision.
71 Incision of the myometrium is made as indicated.
 Intraperitoneal cesarean section
1,lower-segement transverse
Introduced by Munro Kerr.
2,Low segment vertical
Introduced by DeLee & Cornel.
3,upper segment vertical ( Classical )
4, In case of delivery of baby-
J-shaped, inverted T-incision, "U"- shaped or trap-door
incision.
 Extraperitoneal cesarean section( Latzko operation)
 Vaginal cesarean section

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Push the peritoneum downwards with gauze on a
holder or using your fingers
 Incise transversely over the exposed uterine
lower segment for about 2 cm with a scalpel
 NB your incision should be just enough to cut
through the myometrium and not reach the fetal
part neither too shallow to peel the myometrium
 Extend the incision bluntly with your index
fingers of the two hands laterlly and upwards
 Membranes are ruptured by toothed or
Kocher’s forceps if it is intact.
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 If uterine incision is narrow
Extension of the lower uterine segment incision may be done by:
1- "J" shaped or hockey-stick incision: i.e. extension of one end
of the transverse semilunar incision upwards.
2- "U"- shaped or trap-door incision: i.e. extension of both ends
upwards.
3- An inverted T incision: i.e. cutting upwards from the middle of
the transverse incision. This is the worst choice because of its
difficult repair and poor healing

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 DELIVERY OF THE BABY
 To deliver the baby, place one hand inside the
uterine cavity between the uterus and the
baby’s head. 
 With the fingers, grasp and flex the head. 
 Gently lift the baby’s head through the incision
taking care not to extend the incision down
towards the cervix.
 With the other hand, gently press on the
abdomen over the top of the uterus to help
deliver the head. 
 If the baby’s head is deep down in the pelvis or
vagina
 Ask an assistant (wearing high-level disinfected
gloves) to reach into the vagina and push the
baby’s head up through the vagina. Then lift and
deliver the head
 Pull the anterior shoulder in upward & forward
direction by left hand
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Safe delivery of the fetal head during
cesarean section
 With the goals of minimizing delay, head compression, and
strain on the uterine incision, a sequence of maneuvers the
elevate, rotate, and reduce (ERR) technique for expeditious
delivery of the head from a deep pelvic station To prevent
extension of the uterine incision and risk injury to the uterine
vessels and bladder
 Position yourself so your upper trunk, arm, and
hand move as a unit to elevate the head.
 Elevate. Lock the fingers into a quarter-circle around the
vertex. Apply traction out of the pelvis with the hand and
the entire extended arm
 Rotate. Grasp the fetal head between the thumb and
fingers and rotate it so the occiput faces the incision.
 Reduce. Push the lower edge of the uterine incision down
until it is posterior to the fetal head..

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Wipe the nares and mouth once the head is delivered
Deliver similarly if multiple fetuses
Administer oxytocics to manage the third stage actively
 Deliver the rest of the body
At the time of delivery of trunk
bi-acromial diameter should always be in line of uterine
incision and not perpendicular to it.
 Aspirate nose and mouth of newborn

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78
 Clamp the cord at two sites and cut in between
 Hand over the neonate to the midwife for immediate newborn
care
 Administer uterotonics
 Deliver the placenta by CCT or manual removal
 Clean the uterine cavity with pack to ensure completeness of the
placenta and membranes
 Clamp the edges of the uterine incision and any briskly bleeding
sites with green armitage or ring forceps
 Lift the uterus out of the abdominal cavity and cover the fundus
with moist pack

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 Presence of paediatrician at CS
An appropriately trained practitioner skilled in the
resuscitation of the newborn should be present at
CS performed under general anaesthesia or where
there is evidence of fetal compromise.
infants born by CS with general anaesthesia are at
an increased risk of having 1- and 5-minute Apgar
scores of less than 7 when compared with those
born by CS with regional anaesthesia (1-minute
Apgar less than 7).

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 Maternal contact (skin to skin)
Early skin-to-skin contact between the woman and
her baby should be encouraged and facilitated
Women who have had a CS should be offered
additional support to help them to start
breastfeeding as soon possible after the birth of
their baby.
This is because women who have had a CS are less
likely to start breastfeeding in the first few hours
after the birth, but, when breastfeeding is
established, they are as likely to continue as
women who have a vaginal birth.

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 Give Oxytocin
Give oxytocin 20 units in 1 L IV fluids (normal saline or
Ringer’s lactate) at 60 drops per minute for 2 hours.
To encourage contraction of the uterus and to decrease blood loss.
Exteriorisation associated with reduction in febrile
morbidity and diagnosis of uterine anomalies but no effect
on endometritis, wound complication, sepsis or blood
transfusion.
Exteriorization of uterus- ↓bl loss, facilitate suturing,
massage, examine tubes & ovaries ↑risk of venous
embolism

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 Uterine closure
Lower segment→ closed in double layers-absorbable chromic
no 1- atramutic needle
1st- running locked avoiding entry into uterine cavity
2nd- Continuous
Single layer - less tissue damage, less foreign materials, less
operative time
Except for haemostatic in immediate postoperative time uterine
sutures have little function
Classical incision –three layers

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Make sure hemostasis is secured and uterus is well
contracted
 Replace back the uterus into the abdominal cavity
 Dry the abdominal cavity with gauze pack
The laparotomy pads put in abdominal cavity are all
removed & counted doubly by surgeon himself and then by
nurse
Single vs double layer uterine closure
chromic catgut vs vicryl
locking vs non-locking suture
continuous vs interrupted sutures
 No studies found.
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 -

85
Closure of the Abdominal Incision
Closure of the Peritoneum: Controvercial.

 Closure of the peritoneum is based on the premise that:

 normal anatomy will be restored.
 the risks of infection and wound herniation will be
reduced.
 Closure of the peritoneum is associated with:
 a slightly longer operative time
 more postoperative pain
 there are some suggestions that it may cause increased
formation of adhesions, so unnecessary and not
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recommended.
Closure of the Abdominal Incision
Closure of the Fascia:
A continuous, running suture will result in more secure wound closure than a

series of sutures placed in an interrupted fashion.

Synthetic absorbable sutures with delayed degradation were introduced to

combine the advantages of absorbability with strength comparable to

nonabsorbable materials.
The resorbable sutures polyglycolic acid (dexon), polyglactic acid (vicryl),

polydioxanone (pds), and polyglyconate (maxon) have been shown to be

equally as effective with respect to wound dehiscence and incisional hernia.

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 Closure of the Abdominal Incision
Subcutaneous Tissue Closure:

 Poor vascular supply - rendering it susceptible to soft-tissue infection.

 Reduction in wound disruption in wounds with greater than 2 cm of tissue.

 We do not routinely close the subcutaneous layer of the wound.

 On some occasions, in obese patients, we will employ the use a series of simple,

interrupted, absorbable catgut or polyglactic acid (vicryl) sutures to

reapproximate the subcutaneous layer.

 These stitches are inverted to bury the knots within the wound.

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Closure of the Abdominal Incision
Skin Closure: Goals
 tissue approximation
 minimizing wound infection
 acceptable cosmesis
 minimizing postoperative pain.
 skin can be closed primarily by interrupted suture,
subcuticular suture, surgical staples, surgical tape, and
adhesive glues.
Close the skin with Continuous subcuticular vicril or interrupted
silk as needed .

89
 Do
􀀹Wear double gloves.
􀀹 Use a transverse lower abdominal incision (Joel Cohen
incision or Pfannenstiel incision)
􀀹 Use blunt extension of the uterine incision
􀀹 Give oxytocin (5iu) by slow intravenous injection
􀀹 Use controlled cord traction for removal of the placenta
􀀹 Close the uterine incision with two suture layers
􀀹 Check umbilical artery pH if CS performed for fetal
compromise
􀀹 Consider women’s preferences for birth (such as music
playing in theatre)
􀀹 Facilitate early skin-to-skin contact for mother and baby
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 Don’t
 Don’t Close subcutaneous space (unless > 2 cm fat)

 Don’t Use superficial wound drains

 Don’t Use separate surgical knives for skin and deeper
tissues
Don’t Use routinely use forceps to deliver babies head
Don’t Suture either the visceral or the parietal peritoneum
Don’t Manually remove the placenta

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 Post-operative care. immidiate
After surgery is completed, the woman will be monitored in a
recovery area
To ensure that the uterus remains contracted, that there is no
excessive vaginal bleeding or bleeding at the incision site, that
there is adequate urine output, and to monitor routine vital signs
Q 30 minute(blood pressure, temperature, breathing) For 4 hours.
Pain medication is also given, initially through the IV line, and
later with oral medications.
When the effects of anesthesia have worn off, about four to eight
hours after surgery, the woman is transferred to a postpartum
room

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 Late post op. care
check vital signs every 6 hours
Start sips followed by fluid after 12/24 hrs after ascertaining
that the bowel sounds are active
 Discontinue IV fluids when mother has started fluid diet if
no other IV medication is needed
Ambulate
 Look for evidences of PPH, pulmonary infection, UTI, and
wound infection
 Initiate breast-feeding as soon as the mother is awake

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If there were signs of infection or the woman currently has
fever, continue antibiotics until the woman is fever-free for
48 hours.
Removal of the urinary bladder catheter should be carried
out once a woman is mobile after a regional anaesthetic and
not sooner than 12 hours after the last epidural ‘top up’ dose.
A pediatrician will examine the baby within the first 24
hours of the delivery
If the surgical procedure was uncomplicated, give the
woman a liquid diet.
If there were signs of infection, or if the cesarean was for
obstructed labour or uterine rupture, wait until bowel sounds
are heard before giving liquids.
When the woman is passing gas, begin giving her solid
food.
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Oral fluids and food after caesarean section: early
versus delayed initiation
 If the woman is receiving IV fluids, they should be continued
until she is taking liquids well.
 If you anticipate that the woman will receive IV fluids for 48
hours or more, infuse a balanced electrolyte solution (e.g.
potassium chloride 1.5 g in 1 L IV fluid).
 If the woman receives IV fluids for more than 48 hours, monitor
electrolytes every 48 hours. Prolonged infusion of IV fluids can
alter electrolyte balance.
 Ensure the woman is eating a regular diet prior to discharge
from hospital.
 Women who are recovering well and who do not have
complications after CS can eat and drink when they feel hungry
or thirsty

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 Ambulation after cs
Ambulation started earlier in the simplified
technique group (6-8 hours post-op vs 10-12
hours post-op).
Ambulation enhances circulation, encourages
deep breathing and stimulates return of normal
gastrointestinal function. Encourage foot and
leg exercises and mobilize as soon as possible,
usually within 24 hours.

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 Dressing and wound care
 The dressing provides a protective barrier against infection while a
healing process known as “re-epithelialization” occurs. Keep the
dressing on the wound for the first day after surgery to protect against
infection while re-epithelialization occurs. Thereafter, a dressing is not
necessary.
 If blood or fluid is leaking through the initial dressing, do not change
the dressing:
Reinforce the dressing;
Monitor the amount of blood/fluid lost by outlining the blood stain on
the dressing with a pen;
 - If bleeding increases or the blood stain covers half the dressing or
more, remove the dressing and inspect the wound. Replace with
another sterile dressing.
 If the dressing comes loose, reinforce with more tape rather than
removing the dressing. This will help maintain the sterility of the
dressing and reduce the risk of wound infection.
 Change the dressing using sterile technique.
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 Length of hospital stay
Length of hospital stay is likely to be longer after a CS (an
average of 3–4 days) than after a vaginal birth (average 1–2
days). However, women who are recovering well, are apyrexial
and do not have complications following CS should be offered
earlydischarge (after 24 hours) from hospital and follow up at
home, because this is not associated with more infant or
maternal readmissions.
Open the wound site and remove stitches on the sixth day (can
be done at the OPD if the woman is discharged earlier)

98
Complications
Intra operative Complications
-Bleeding & The need for blood transfusion
-Hysterectomy
-Complications of anaesthesia
-Damage to the
-bladder
- ureter
- colon
- Retained placental tissue
-Fetal injury
-Uterine laceration.

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 POSTOPERATIVE
Gaseous distension
Paralytic ileus
Wound dehiscence
Infectins  UTI,Endomyometritis,RTI
DVT & pulmonary embolism
Vesico uterine fistula
Necrotizing fasctis
Septic pelvic thrombophlibites
Death
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 Consider CS complications
Endometritis if excessive vaginal
bleeding
Thromboembolism if cough or
swollen calf
Urinary tract infection if urinary
symptoms
Urinary tract trauma (fistula) if
leaking urine
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 Complications
Common postoperative complications include the following
conditions:
Endomyometritis
Postoperative infection is the most common complication after
cesarean section.
The average incidence of endomyometritis is 34% to 40%.
Risk factors include lower socioeconomic status, prolonged labor,
prolonged duration of ruptured membranes, and the number of
vaginal examinations.
Use of prophylactic antibiotics at the time of the procedure
decreases incidence.
With the use of modern, broad-spectrum antibiotics, the incidence
of serious complications, including sepsis, pelvic abscess, and septic
thrombophlebitis, is less than 2%.
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 Complications...
Urinary tract infection
Urinary tract infections are the second most common infectious
complication after endomyometritis.
Incidence varies from 2% to 16%.
Practices that decrease risk include preparing the patient properly
and minimizing duration of catheter.
Wound infection
The incidence of postcesarean wound infection rates ranges from
2.5% to 16%.
Risk factors include prolonged labor, ruptured membranes,
amnionitis, meconium staining, morbid obesity, anemia, and
diabetes mellitus.
Common isolates include Staphylococcus aureus, Escherichia coli,
Proteus mirabilis, Bacteroides sp., and group B streptococci.
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 Complications...
Thromboembolic disorders
The incidence is 0.24% of deliveries, and deep vein thromboses are three to

five times more common after cesarean delivery.
Diagnosis and treatment are the same as for nonpregnant women.
Prompt diagnosis and treatment decrease the risk of complicating pulmonary
embolus to 4.5% and that of death to 0.7%.

Cesarean hysterectomy
Hysterectomy after cesarean delivery is an emergency

procedure that occurs in less than 1% of cesarean
sections.
Indications include uterine atony (43%), placenta accreta
(30%), uterine rupture (13%), extension of a low
transverse incision (10%), leiomyoma preventing uterine
closure, and cervical cancer.
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 Complications...
Uterine rupture in future pregnancies
The risk of rupture of previous cesarean scar varies with the location of
the incision.
Low transverse scar (one): less than 1%
Low vertical scar: 0.5% to 6.5%
Classic scar: as high as 10%
Separation of the uterine scar can be categorized as dehiscence or rupture.
A dehiscence is a frequently asymptomatic separation and is
found incidentally at the time of repeat cesarean or on palpation
after a vaginal birth.
Uterine rupture is a catastrophic event with sudden separation of
the uterine scar and expulsion of the uterine contents into the
abdominal cavity.
Fetal distress is usually the first sign of rupture, followed by
105 severe abdominal pain and bleeding.
 LONG-TERM RISKS
Abnormal placentation
Placenta previa, Accreta,

Subfertility
Scar complications
Ectopic pregnancy in the scar = 1/1000
Numbness or pain (Ilioinguinal and Iliohypogastric nerve
injury)
Incisional endometriosis

Uterine rupture

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MODE OF DELIVERY IN NEXT PREGNANCY
CRITERIA FOR VBAC
Pt must agree to the procedure, CS facility exists
A low transverse uterine incision
No more than 1 prior low-transverse CS.
No malposition, multiple gestation, breech.
No macrosomia( <4000gm).

Contraindication
Previous classical CS, inverted T- incision scar
2 or more previous CS ,induction and augmentation.
Previous other uterine surgery (Eg: Myomectomy..
Hx of scar rupture, CPD
Placenta previa or transverse lie

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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
108 A CONTROVERSY
 THANK YOU

109
 References:
 Maingot’s Abdominal operations, 11th ed.

 UpToDate.

 Gray’s Anatomy for students.

 Telinde’s operative gynecology, 10th editon.

 Williamf obstetrics, 22th edition.

 Essential GYNOBS ,4th edition.

 Internet

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