2022

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 presenter:

Dr Sebastian Chinkoyo
Obstetrician-Gynaecologist
Ndola Teaching Hospital
Ndola

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 Laparotomy

Definition:
A surgical procedure to gain entry
into the abdominal cavity for varied
reasons.

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 Laparotomy
 Most gynaecological and obstetrical
procedures are best performed through
one of two incisions:
 The subumbilical midline
or
 The low transverse.

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 Subumbilical midline incision.
Incising the skin.

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 Vertical Midline Incision
Advantages:
 Faster abdominal entry.
 Less blood loss and risk of
haematoma.
 Less nerve injury.
 It can be extended cephalad if more
space is required for access.
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Low Transverse Incision
 Generally skin incision is 2-4 cm
above the symphysis pubis.

 Rectus fascia is incised transversely

and sharply dissected from rectus
muscles superiorly and inferiorly.

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 The Pfannenstiel incision.
The Joel-Cohen incision is now preferred. The
incision is a straight horizontal incision, being
performed slightly higher than the Pfannenstiel.
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 Caesarean Section
Definition:
Delivery of the baby by an abdominal
and uterine incision.

Or simply

The surgical removal of the baby from

the uterus.
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 Background info
 It was not until 1793 that the first CS,
with subsequent survival of the
mother, was performed by James
Barlow in a Lancashire town,
England.

 CS is now increasingly used for safe

delivery for fetal or maternal
reasons.
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 Background info
 What has made CS a safe
procedure:
 Advent of blood transfusion.
 Improved anaesthesia.

 Aseptic and antiseptic techniques.

 The invention of antibiotics.

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 Background info
 CS can be performed:
 Electively, or as an emergency.
 A small proportion by maternal request for non-
medical reasons.
 Another smaller proportion by monetary
incentives.
 Incidence:
 In many developed countries CS rate is 20-25%,
but it varies from 3.5% in Africa to 29.2% in
Latin America.
 In China, Chile and Brazil the CS rate is 50%.
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 Types of CS
 CS is described based on the type of
incision on the uterus.
 Uterine incision does not correspond to
skin incision.

 Generally there are 2 types:

 Lower Segment CS (LSCS).
 Classical (upper segment) CS.
 Caesarean hysterectomy (very occasionally
might be necessary).
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 The lower segment of the uterus is
that lower part of the anterior
uterine wall which is covered by the
loose peritoneum of the utero-
vesical pouch.

 The lower uterine segment incision

is now the standard approach. It has
distinct advantages over the
classical incision.
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 Indications

 Most common indications:

 Failure to progress: 30%
 Previous CS or myomectomy: 30%

 Fetal malpresentation: 11%

 Non-reassuring fetal status: 10%

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 Indications

 Additional indications:
 Abnormal placenta: placenta praevia,
placental abruption.
 Multiple gestation.

 Maternal infection (1° genital herpes in

3rd trimester, high HIV viral load ≥400
copies/ml).
 Maternal request.

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 Indications
 Situations in which women with
previous CS are not eligible for a
trial of VBAC:
 Previous classical or T-shaped uterine
incision.
 Previous uterine rupture.

 Medical or obstetric complication

precluding vaginal delivery.
 2 or more caesarean births.

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 Classification of indications
Based on the timing of CS at the time of
decision making, the indications for CSs
are grouped under 1of 4 categories:

 Category 1 or emergency CS.

 Category 2 or urgent CS.
 Category 3 or scheduled CS.
 Category 4 or elective CS.

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 Emergency CS

 There is an immediate threat to the life

of mother or foetus.
 Ideally the CS should be done within
the next 30 min.
 e.g. placental abruption with fetal
distress, cord prolapse, scar rupture,
uterine rupture, acute fetal distress
(prolonged bradycardia).

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 Urgent CS

 There is maternal or fetal compromise

but is not immediately life threatening.
 The delivery should be completed
within 60-75 min.
 e.g. cases with FHR abnormalities.

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 Scheduled CS

 The mother needs early delivery but

there is no maternal or fetal
compromise.
 There may be concern that
continuation of pregnancy is likely to
affect the mother or foetus in hours or
days to come.

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 Scheduled CS

 The timing of the CS varies but some

plan should be in place to deliver
before further deterioration occurs.
 e.g. failure to progress, failed
induction, IUGR with poor BPP, severe
pre-eclampsia.

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 Elective CS
 The delivery is timed to suit the mother
and staff.
 These are cases where there is an
indication for CS but there is no
urgency.
 e.g. malpresentation, placenta praevia
with no active bleeding, 2 or more
previous CS, HIV+ women not on cART
or have a viral load ≥400 copies/ml.

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 Patient Preparation
 Informed consent.
 FBC, G & S or X-match if indicated.
 IV access, give IV fluids for preload.
 Prophylactic antibiotics (cefotaxime 1g IV
stat).
 Placement of urinary catheter.
 Measures to reduce risk of inhalation of
acid gastric content if patient is to have
G/A. Also give an antiemetic (ondansetron).

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 Anaesthesia
 The choice is between general, epidural or
spinal anaesthesia.
 Cochrane review shows no evidence that
regional anaesthetic is superior to general
regarding maternal or neonatal outcomes.
 The anaesthesia for the mother and foetus
should be light and for as short a period as
possible.
 To this end, the abdomen should be swabbed
and draped prior to induction of G/A.
 G/A is preferred if there is a need for extreme
speed, such as in acute fetal distress.

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 The operation: LSCS

Opening the abdomen:

 Skin incision:
 Low transverse incision.
 Subumbilical midline incision.

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 The operation: LSCS

Incising the lower segment:

 A 2-3cm transverse incision is made
on the lower uterine segment.

 The incision is extended laterally

using index fingers.

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 Extending the lower segment
incision.

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 Extending the lower segment
incision.

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 The operation: LSCS
Delivery of the presenting part:
 Surgeon inserts the hand below the
head to disimpact it from the pelvis.

 The assistant applies fundal

pressure when the head is brought
into the incision and the fetal head is
delivered.

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 Operator’s hand below the baby’s
head.

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 Baby’s head at uterine incision.

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 The operation: LSCS

Delivery of the presenting part:

 If head is deeply impacted in the
pelvis, assistant pushes head up
through the vagina.

 Occasionally may require obstetric

forceps to deliver fetal head.
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 Extracting baby’s head with forceps.

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 The operation: LSCS
Delivery of the presenting part:
 The baby’s respiratory passages are
cleared of mucous, blood and liquor (by
wiping and suction).

 At this stage the anaesthetist gives the

patient 5 IU oxytocin IV.
 For women at higher risk for PPH,
tranexamic acid (TXA), should be given
(RCOG, 2016).
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 The operation: LSCS
Delivery of the placenta:
 Spontaneous delivery by cord
traction together with fundal
pressure should be encouraged.

 The uterine cavity should be cleaned

not to leave any retained tissue.

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 Delivery of placenta.

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 Delivery of placenta and
membranes.

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 Suturing the lower segment in two
layers.

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 Suturing the lower segment in two
layers.

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 Closing visceral peritoneum
This is optional.

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 Classical CS
A subumbilical midline incision is
made on the abdomen.
 A 10cm vertical midline incision is
made in the anterior surface of the
uterus, which may extend into the
lower segment.
 The incision should be made quickly
as considerable haemorrhage may
occur from the uterine muscle.
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 Uterus opened in the midline.

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 Baby delivered as breech.

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 Classical CS
 The classical incision has the
following disadvantages:
 Difficult to make.
 Increased blood loss.

 Inadequate approximation at closure.

 Increased postoperative morbidity.

 Higher risk of scar rupture in next

pregnancy.

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 Classical CS
 Because of the disadvantages, the
classical incision is reserved for
specific indications:
 Where LSCS is difficult due to fibroids
or placenta praevia with large vessels
in the lower segment.
 Impacted transverse lie with ruptured
membranes.
 A perimortem CS (to assist in the
resuscitation of a woman with cardiac arrest).
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 Complications
 Morbidity and mortality associated with
CS cannot be totally avoided.
 The most common complications are:
 Haemorrhage that could lead to shock and
hysterectomy.
 Infection (SSI, endometritis, UTI).
 Injury to bowel, bladder, ureters or the foetus.
 Thromboembolism (DVT → PE).
 Future pregnancy risk (placenta praevia, uterine
rupture, repeat CS).
 Neonatal morbidity.
 Anaesthesia-related complications.
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 Complications
 Anaesthetic complications are
extremely rare due to availability of
experienced anaesthetists and most
CS being performed under regional
anaesthesia:
 Awareness resulting from light
anaesthesia.
 Aspiration of acid gastric contents on
intubation leads to Mendelson’s
Syndrome.
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 Post-operative care
 monitor vital signs and check for
bleeding.
 monitor fluid balance: IV fluids and urine
output (≥30ml/hr).
 give analgesia as prescribed.
 early ambulation.
 eating and drinking:
 can be resumed as the woman feels hungry
and thirsty if she is recovering well with no
complications (NICE, 2011a).

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 the end

thank you
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