CESAREAN

SECTION
(CS)
CONTENT
● Definition
● Nomenclature & History
● Factors for rising CS rate
● Indications
● Type of Operations
● LSCS
● Classical CS
● Complications
● Measures to reduce Cesarean Births
● Cesarean Hysterectomy
● Perimortem Cesarean Delivery
 DEFINITION
It is an operative procedure whereby the fetuses after the
end of 28th weeks are delivered through an incision on
the abdominal and uterine walls.
This excludes :
● delivery through an abdominal incision where the fetus,
lying free in the abdominal cavity following uterine rupture
or
● in secondary abdominal pregnancy.
The first operation performed on a patient is referred to as a
primary cesarean section.
When the operation is performed in subsequent pregnancies,
it is called repeat cesarean section.
 NOMENCLATURE & HISTORY
The operation derives its name from “lex Cesarea” – a
Roman law regulated in 715 BC, which was continued
even during Caesar’s reign. The law provided either an
abdominal delivery in a dying woman with a hope to get a
live baby or to perform postmortem abdominal delivery
for separate burial of baby. The operation does not derive
its name from the birth of Caesar, as his mother lived
long time after his birth. The other explanation is that the
word cesarean is derived from the Latin Verb “Cedere”
which means “to cut”.
Francois Mauriceau first reported cesarean section in
1668.
Kronig in 1912, introduced lower segment vertical
incision.
FACTORS FOR RISING CS RATE
INDICATIONS
Indications for cesarean delivery: Cesarean delivery is done when labor is
contraindicated (central placenta previa) and/or vaginal delivery is found unsafe
for the fetus and/or mother.

The indications are broadly divided into two categories:

● Absolute
● Relative (common)
INDICATION BASED ON TIMING OF CS
● Elective
● Emergency (Category 1, 2 and 3)
ELECTIVE CS
When the operation is done at a prearranged time during pregnancy to ensure the best quality of obstetrics, anesthesia, neonatal resuscitation and
nursing services.

INDICATIONS

● Placenta previa with no active bleeding

● Malpresentation
● History of previous hysterotomy
● Past history of repair of vesico-vaginal or recto-vaginal fistulae

Time:

(a) Maturity is certain: The operation is done about 1 week prior to the expected date of confinement.

(b) Maturity is uncertain: confirmed by USG in 1st and 2nd trimesters and also Amniocentesis for L:S ratio is used to ensure fetal maturity

Benefits:

● Reduction in perinatal morbidity and mortality as there is no hazard from labor and delivery process.
● Maternal benefits: no pelvic floor dysfunction.

Maternal risks are:

● Longer recovery time and hospital stay.

● Risks of placenta previa and hysterectomy are more in subsequent delivery
 EMERGENCY CS
Category of C.S (according to NICE):

Emergency: 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.
TYPES OF OPERATIONS

● Lower segment
● Classical or Upper segment
LOWER SEGMENT CESAREAN SECTION (LSCS)
In this operation, the extraction of
the baby is done through an
incision made in the lower
segment through a
transperitoneal approach. Unless
specified, this is the only method
practiced in obstetrics.
PREOPERATIVE PREPARATION
● Informed written permission for the procedure, anesthesia and blood transfusion is
obtained.
● Abdomen is scrubbed with soap and nonorganic iodide lotion. Hair may be clipped.
● Premedicative sedative must not be given.
● The stomach should be emptied, if necessary by a stomach tube (emergency procedure).
● Bladder should be emptied by a Foley catheter which is kept in place in the perioperative
period.
● FHS should be checked once more at this stage.
● Neonatologist should be made available.
● Cross match blood when above average blood loss (placenta previa, prior multiple
cesarean delivery) is anticipated.
● Prophylactic antibiotics should be given (IV) before making the skin incision.
IV cannula: Sited to administer fluids (Ringer’s solution,
5% dextrose).

Position of the patient:The patient is placed in the dorsal

position. In susceptible cases, to minimize any adverse
effects of venacaval compression, a 15° tilt to her left using
a wedge till delivery of the baby should be done.

Anesthesia—may be spinal, epidural or general.

UTERINE INCISIONS FOR CS
Incision on the abdomen: either a vertical or a transverse skin incision can be made.
● Vertical incision may be infraumbilical midline or paramedian.
● Transverse incision, modified Pfannenstiel is made 3 cm above the symphysis pubis.
The most commonly used incision (90%) is low transverse.

Advantages
● ease of operation;
● less bladder dissection,
● less blood loss,
● easy to repair,
● complete reperitonization,
● less adhesion formation,
● less risk of scar rupture when trial (VBAC) of labor is given
for subsequent delivery.
PACKING
The Doyen’s retractor (as shown) is
introduced. The peritoneal cavity is now
packed off using two taped large swabs.
The tape ends are attached to artery
forceps. This will minimize spilling of the
uterine contents into the general
peritoneal cavity.
STEPS OF
LSCS
 SUTURE OF THE UTERINE WOUND
The uterine incision is
sutured in three
layers.
 POSTOPERATIVE CARE
First 24 hours: (Day 0)

Observation for the first 6–8 hours is important. Periodic checkup of pulse, BP, amount of vaginal bleeding and behavior
of the uterus (in low transverse incision) is done and recorded.

Fluid: Sodium chloride (0.9%) or Ringer’s lactate drip is continued until at least 2.0–2.5 L of the solutions are infused.
Blood transfusion is helpful in anemic mothers for a speedy post-operative recovery. Blood transfusion is required if the
blood loss is more than average during the operation (average blood loss in cesarean section is approximately 0.5–1.0L).

Oxytocics: Injection oxytocin 5 units IM or IV (slow) or methergine 0.2 mg IM is given and may be repeated.

Prophylactic antibiotics (cephalosporins, metronidazole) for all cesarean delivery is given for 2–4 doses. Therapeutic
antibiotic is given when indicated.

Analgesics in the form of pethidine hydrochloride 75–100 mg is administered and may have to be repeated.

Ambulation: The patient can sit on the bed or even get out of bed to evacuate the bladder, provided the general
condition permits. She is encouraged to move her legs and ankles and to breathe deeply to minimize leg vein thrombosis
and pulmonary embolism.

Baby is put to the breast for feeding after 3–4 hours when mother is stable and relieved of pain.
Day1: Oral feeding in the form of plain or electrolyte water or raw tea may be
given.Active bowel sounds are observed by the end of the day.

Day2: Light solid diet of the patient’s choice is given.

Bowel care: 3–4 teaspoons of lactulose is given at bed time, if the bowels do not
move spontaneously.

Day 5 or day 6: The abdominal skin stitches are to be removed on the D-5 (in
transverse) or D-6 (in longitudinal).

Discharge: The patient is discharged on the day following removal of the

stitches, if otherwise fit.
CLASSICAL CS
In this operation, the baby is extracted through an incision made in the upper segment of the uterus. done
under forced circumstances such as:

Lower segment approach is difficult:

(1) Dense adhesions due to previous abdominal operation

(2) severe contracted pelvis (osteomalacic or rachitic) with pendulous abdomen.

Lower segment approach is risky:

(1) Big fibroid on the lower segment—blood loss is more and contemplating myomectomy may end in
hysterectomy

(2) carcinoma cervix—to prevent dissemination of the growth and postoperative sepsis

(3) repair of high VVF

(4) complete anterior placenta previa with engorged vessels in the lower segment—risk of hemorrhage.

Perimortem cesarean section: It is done to have a live baby (rare).

LOWER
SEGMENT CS
VS
CLASSICAL
CS
COMPLICATIONS OF CESAREAN SECTION
The complications are related either due to the operations (inherent hazards)‚ or
due to anesthesia.

The complications are grouped into:

● Maternal
● Fetal

The maternal complications may be:

● Intraoperative
● Postoperative
INTRAOPERATIVE COMPLICATIONS
Extension of uterine incision
Uterine lacerations
Bladder injury
Ureteral injury (rare)
Gastrointestinal tract injury
Hemorrhage may be due to uterine atony or uterine laceration
Morbid adherent placenta (placenta accreta)
 POSTOPERATIVE COMPLICATIONS
MATERNAL

● Postpartum hemorrhage
● Shock
● Anesthetic hazards
● Infections
● Intestinal obstruction
● Deep vein thrombosis and thromboembolic disorders
● Wound complications: Abdominal wound sepsis is quite common
● Secondary postpartum hemorrhage.

FETAL

Iatrogenic prematurity and development of RDS

MEASURES TO REDUCE CESAREAN BIRTHS
Cesarean Hysterectomy

Cesarean hysterectomy refers to an operation where cesarean section is followed

by removal of the uterus. The common conditions are:

(1) morbid adherent placenta

(2) atonic uterus and uncontrolled postpartum hemorrhage

(3) big fibroid (parous women)

(4) extensive lacerations due to extension of tears with broad ligament hematoma

(5) grossly infected uterus and

(6) rupture uterus.

Perimortem Cesarean Delivery
It is the caesarean delivery of a woman who is expected to
die within next few moments or has just died. It is done within
4–5 minutes of start of cardiopulmonary resuscitation (CPR)
when the fetus is alive.