Caesarean section (C.

S)

02/18/2022 By: Fentahun T. (MSc) 1

 Session objectives
At the end of this session students will be able to:
 Know what caesarean section (C.S) is.
 Know indications and contraindications for C.S.
 Know types of C.S.
 Describe steps of C.S.
 Describe maternal and neonatal complications of C.S.

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 Caesarean section
An operative procedure to deliver a viable foetus after 28 weeks through
abdominal and uterine incisions.

The incidence increases time to time due to:

 High forceps and difficult mid forceps are abandoned in favor of C.S.
 Increased C.S delivery in breech presentation.
 Destructive operations are abandoned in favor of C.S.
 Decreased morbidity and mortality due to C.S encourages its use.
 Increased repeated C.S due to increased primary C.S.
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Indications:
Maternal indications:
 Cephalo-pelvic disproportion
 Pelvic tumors especially if impacted in the pelvis or cancer cervix
 Antepartum hemorrhage (uncontrolled)
 Placenta previa
 Hypertensive disorders with pregnancy (unable to deliver vaginally)
 Abnormal uterine action

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 Previous uterine scar as hysterotomy or metroplasty.

 Previous successful repair of vesico-vaginal fistula.

 Previous caesarean section if:

• The cause of the previous section is permanent (contracted pelvis).
• Previous C.S was upper segment (classical type).

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 • Suspected weak scar as evidenced by:
• History of puerperal infection after the previous section.
• Vaginal bleeding during current labor.
• Marked tenderness over the scar during current labor.

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Foetal indications:
 Malpresentations and malposition
 Prolapsed pulsating cord or foetal distress before full cervical dilatation.
 Diabetes mellitus (with CPD due to big baby)
 Bad obstetric history as recurrent IUFD in last weeks of pregnancy
 Post-mortem C.S. within 10 minutes of maternal death to save a living baby.

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 Contraindications:

 Dead foetus (relative): except in;

• Extreme degree of pelvic contraction.
• Severe accidental hemorrhage.

 Disseminated intravascular coagulation: to minimize blood loss.

 Extensive scar or pyogenic infection in the abdominal wall e.g. in burns.

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Types of Caesarean Section
1. According to timing:
 Elective caesarean section: is done at a pre-selected time before onset
of labor, usually at 39 completed weeks.
 Selective caesarean section (emergency c.s): is done after onset of
labor.

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2. According to the site of uterine incision:
 Upper segment caesarean section (classical C.S.):
• Incision is done in the upper uterine segment and it is always
vertical.
 Lower segment caesarean section (LSCS) :
• It is the commoner type. T
• Incision is done in the lower uterine segment and may be transverse
or vertical in the following conditions:
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 • Presence of lateral varicosities.
• Deeply engaged head.

3. According to number of the operation:

 Primary caesarean section: for the first time.
 Repeated caesarean section : with previous caesarean section

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4. According to opening the peritoneal cavity:

 Trans-peritoneal: the ordinary operation where the peritoneal cavity is

opened before incising the uterus.

 Extra-peritoneal: the peritoneal cavity is not opened and the lower

uterine segment is reached either laterally or inferiorly by reflecting the
peritoneum of the vesico-uterine pouch .

• It is indicated in case of infected uterine contents as chorioamnionitis.

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Advantages of elective C.S:
 Pre-operative good preparation as regard sterilization and antiseptic
measures, fasting and bowel preparation.
 The risk of puerperal sepsis is minimized.
 The operation is scheduled and working is in ease.

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Disadvantages of elective C.S:
 The risk of immaturity of the foetus or its lung.
• Higher incidence of respiratory distress syndrome.

 The lower segment may be not well formed.

 Postpartum hemorrhage is more liable to occur.
 Imperfect drainage of lochia as the cervix is closed
• So it should be dilated by the index finger introduced abdominally through the
uterine incision.
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Procedure
Abdominal incision:
 Incise the skin and subcutaneous tissue.
 Skin incision types include
• Lower transverse incision
• P-fannensteil incision
• Sub-umbilical midline incision
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 Make a small incision over the fascia with a scalpel and extend it to 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 cm apart.

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 Palpate the tent of peritoneum to check if omentum or bowel is not grasped.

 If grasped release the artery forces and grasp again.

 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.

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 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
• Insert a bladder retractor

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Lower segment transverse cesarean section:
Grasp the peritoneal flap at the site of the reflection with forceps and incise
with scissors.

Dissect the peritoneal flap at the reflection site be inserting the scissors
between the serosa and myometrium.

Open up your instrument to dissect the peritoneum and then cut moving to
the left and right side of the uterus (The assistant moves the bladder retractor
to the side you are moving your scissors).
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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.

The 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
laterally and upwards.
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Rupture the amniotic membrane if encountered.

Remove the bladder retractor.

Then insert your right hand between the symphysis pubis and the
presenting part and elevate the vertex gently through the incision assisted
by gentle abdominal pressure.

Wipe the nares and mouth once the head is delivered.

Deliver the rest of the body.

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The anesthetist administers uterotonics

Clamp the cord at two sites and cut in between.

Hand over the neonate to the midwife for immediate newborn care.

Give prophylactic antibiotics

One dose of a broad spectrum antibiotic (ampicilline or a first-

generation cephalosporin) IV is given immediately after the cord is

clamped.
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Deliver the placenta by CCT.

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 ring forceps.

Lift the uterus out of the abdominal cavity and cover the fundus with moist

pack
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Close the uterine incision with two layers of continuous starting from the
edge the first bite just behind the edge with Chromic 1- or 0-catgut or
polyglycolic (Vicryl).

Replace back the uterus into the abdominal cavity.

Make sure hemostasis is secured and uterus is well contracted

Dry the abdominal cavity with gauze pack if there is grossly contaminated
amniotic fluid or meconium.

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Close the Fascia with continuous Vicryl no 2

Approximate the subcutaneous layer with chromic 2-0 catgut

Close the skin with continuous subcuticular stitch or interrupted silk as

needed.

Check uterine contraction and clean any clot in the vagina.

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Major complications
Immediate complications
 Intraoperative damage to organs such as the bladder or ureters
 Anesthetic complications including aspiration pneumonia
 Hemorrhage
 Infection

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 Thromboembolism

 Transient tachypnea of the newborn is more common after caesarean

section.

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Long-term risks include an increased risk of
 Uterine rupture in subsequent pregnancies
 Limitation of number of children
 Placenta Previa
 Placental abruption
 Placenta accrete

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.

Thank you

02/18/2022 By: Fentahun T. (MSc) 29