CAESAREAN SECTION. BY DR. ADDAH A. O.

DEFINITION: Caesarean section is the delivery of a fetus

through an abdominal and uterine incision after the 28th ee! of gestation" NOTE: Non# surgical means of e$%ulsion of the fetus& embryo from the uterine cavity as in uterine ru%ture or ro%ture of an ecto%ic %regnancy is not included" The o%eration for such condition is !no n as '()(*OTO+,"

HISTORICAL PERSPEDTIVE
Origin controversial. H !ot"esise# to $e na%e# a&ter t"e %anner o& $irt" o& '(li(s

Caesar in )** BC. Originall (se# to #eliver t"e $a$ o& a %ot"er +"o "a# #ie# in ancient Eg !t, Asia AND E(ro!e. -irst caesarean section on a live +o%an +as t"at on t"e +i&e o& 'aco$ N(&er in t"e ).t" cent(r . Earliest re!ort o& a c"il# t"at s(rvive C/S +as t"e $irt" o& 0orgias o& Sicil in 1*2 BC. T"e !roce#(re +as associate# t"en +it" "ig" %ortalit #(e to se!sis 3 lac4 o& anti$iotics5 an# t"ere +as no anaest"esia. 0reat i%!rove%ent an# s(rvival &ro% t"e )6t" cent(r es!eciall +it" t"e a#vent o& t"e lo+er seg%ent C/S BY 7(nro 8 9err.

inci#ence
In+est A&rica )1 8 2) ;. In <PTH average a$o(t :*;.

Preo!erative !re!eration.
A &(ll "istor an# !" sical e>a%ination. Past %e#ical an# s(rgical "istor . C(rrent %e#ications. H> o& #r(g allergies. In#ication &or t"e C/S. Consent &or t"e s(rger . La$orator investigations 8 PCV, <rinal sis, E</Cr. 7ore e>tensive investigations in co%!licate# cases li4e " !ertension, car#iac #iseases etc. !atients are in#ivi#(alise# in s(c" cases. Pass in#+elling -olle (ret"ral cat"eter into t"e $la##er an# retain. D(ring trans&er to t"e t"eatre, an# #(ring anaest"asia, !atient s"o(l# lie on "er le&t lateral si#e +it" a +e#ge on "er rig"t $(ttoc4s to !revent to !revent s(!ine " !otension.

Preo!erative !re!aration cont#.

Pre 8 %e#ication +it" antaci# is

stan#ar#. Pro!" latic anti$iotics $e&ore t"e s(rger .

In#ication -or C/S,

7ATERNAL INDICATIONS

Severe !re? ecla%!sia +it" (n&avo(ra$le cervi> &or vaginal #eliver . 3a$sol(te5 Previo(s classical caesarean #eliver . 3a$sol(te5 . Previo(s e>tensive (terine s(rger +it" entr into t"e (terine cavit eg % o%ecto% . O$str(ctive !elvic t(%o(rs eg &ri$oi#s, ovarian c sts.
.

7aternal in#ications &or C/S cont#.

Previo(s :* !erineal tears. Previo(s s(ccess&(l V V - re!air

3 a$sol(te5. V(lva "er!es si%!le>.

-ETAL INDICATIONS -OR C/S.

-etal #istres. A$nor%al !resentations 8 $reec", $ro+

3a$sol(te5, !ersistent occi!ito 8 !osterior in la$o(r, &ace +it" %ento 8 !osterior. A$nor%al lies 8 transverse, o$liA(e, 7(lti!le gestations 8 tri!lets an# "ig"er or#er gestations. -etal %acroso%ia 8 +eig"t greater t"an =1**g.
2

-etal in#ications &or C/S cont#.

-ootling $reec", . Ver lo+ $irt" +eig"t 8 3 less t"an

)1**g5. -etal a$nor%alit 8" #roce!"al(s, conBoint t+ins, s!ina $a&i#a.

7ATERNAL 8 -ETAL INDICATIONS -OR C/S.

Ce!"alo!elvic #is!ro!ortion. D stocia 8arrest o& cervical #ilatation or

&ail(re o& #escent o& !resenting !art. 7aBor #egree !lacenta !raevia. Placental a$r(!tion +it" a live &et(s. A$sol(te !elvic #is!ro!ortion.

)*

S9IN INCISIONS -OR C/S

S4in incicions co(l# $e vertical or

transverse. Bot" "ave a#vantages an# #isa#vatages. Vertical incisions 8

7i#line s($ 8 (%$ilical incision 3%ost co%%onl (se# s4in incision in 3<PTH5. 7i#line incisione>ten#ing a$ove t"e (%$ilic(s. Para%e#ian.
))

Vertical incisions cont#.

ADVANTA0ESC Less vasc(lar, less "ae%orr"age. 0ives goo# e>!os(re o& $ot" !elvic an# a$#o%inal organs. Ver (se&(l in e%ergencies #(e to s!ee# an# ease o& t"e !roce#(re. DISADVANTA0ES 8 !rone to "ernia &or%ation an# evisceration ris4.

)2

Transverse s4in incisions.

P&annenstiel 3%ost !o!(lar5. A#vantagesC

E>cellent cos%etic a!!earance. Less ris4 o& +o(n# #e"iscence. Earl a%$(lation. Less ris4 o& "ernia &or%ation. Disa#vantages. Ta4es longer ti%e to !er&or%.

):

Transverse s4in incisions cont#.

7a res(lt in inB(r to ileo 8 ing(inal an# ileo 8 " !ogastric nerves. Increase# $loo# loss. Cohen incision 8 It is a straig"t transverse incision 8 anterior rect(s s"eat" incise# in t"e %i#line &ollo+e# $ $l(nt #issection. +aylard incision 8 3<NCO77ON5 8 transverse incision li4e t"e P&annenstiel $(t t"e rect(s is c(t t"ro(g" at an level $et+een t"e !($is an# t"e (%$ilic(s. Cherney incision - li4e P&annenstiel $(t (nli4e t"e latter, t"e t+o recti %(scles are !(lle# a+a &ro% t"eir insertion into t"e !($is.
)=

<TERINE INCISIONS.
Lo+er seg%ent transverse incision 8 6*

; o& C/S. Lo+ vertical 3De Lee5 incision? %a#e !arallel to t"e longit(#inal a>is o& t"e (ter(s in t"e %i#line $(t 4ee!ing %ainl to t"e lo+er seg%ent. Classical incision 8 is %a#e $ incising t"e (ter(s !arallel to t"e longit(#inal a>is o& t"e (ter(s in t"e %i#line.
)1

Classical incision
In#ications.

Preter% #eliver +it" !oorl &or%e# lo+er seg%ent. Placenta !raevia +it" large vessels in lo+er seg%ent. Pre%at(re r(!t(re o& %e%$ranes, !oor lo+er seg%ent an# transverse lie. Transverse lie +it" $ac4 in&erior. Large cervical &i$roi#. Post%orte% C/S.
).

A#vantages o& transverse lo+er (terine incisions over classical incision

Less ris4 o& entr into (!!er (terine seg%ent. 0reat ease o& entr . Less ris4 o& a#"esion &or%ation to $o+el or

o%ent(%. Less li4eli"oo# o& (terine r(!t(re in s($seA(ent !regnancies. VBAC is !ossi$le. Less intra? o!erative $lee#ing. NOTE THAT CLASSICAL C/S ARE NOT RO<TINELY DONE.
)@

A#vantages o& classical incision over lo+er seg%ent incision.

Ra!i# entr into t"e (ter(s. No lateral e>tensions into t"e (terine

vessels an# $roa# liga%ent. I& lo+er seg%ent is !oorl #evelo!e#, #eliver $ classical C/S is a#vantageo(s +it"o(t lateral e>tension. Eas entr into t"e (ter(s +"en t"ere is &i$roi# in t"e lo+er seg%ent.
)2

Anaest"esia -or C/S.

0eneral anaest"esia. Regional anaest"esia.

S!inal. E!i#(ral AVOID -<LL STO7ACH ESPECIALLY INLABO<R D<RIN0 ANY -OR7 OANAESTHESIA.

)6

CO7PLICATIONS O- C/S.
Hae%orr"age +"ic" %a lea# to anae%ia. InB(r to %aternal organs 8 $la##er, $loo#

vessels, (ter(s, $o+el. InB(r to neonate. Do(n# in&ection. Dee! vein t"ro%$osis. En#o%etritis. 7aternal %ortalit . Anaest"etic co%!lications.
2*