CAESAREAN

SECTION

PRESENTED BY:
MS LAXMI G TAWALAGI
REG NO : 19NUG036
BSC(N) IV YEAR
SDMINS
INTRODUCTION

 Caesarean section, also known as C-section or caesarean delivery, is

the surgical procedure by which one or more babies
are delivery through an incision in the mother's abdomen, often
performed because vaginal delivery would put the baby or mother at
risk.
 DEFINITION
• Caesarean section is an operative procedure
where by the foetuses after the end of 28 th
week is delivered through an incision on the
abdominal and uterine wall.
• The first operation performed on woman is
referred to as a primary caesarean section.
• when the operation is performed in
subsequent pregnancies. It is called repeat
caesarean section
 INCIDENCE
 The incidence of caesarean section is steadily rising. During
the last decade there has been two-three fold rise in the
incidence from the initial rate about 10%.

 Apart from increased safety of the operation due to improved

anaesthesia, availability of blood transfusion and antibiotics
 FACTORS FOR INCREASING CS RATE

 Identification of risk foetuses before term.

 Identification of at risk mothers.

 Wide use of repeat caesarean section in cases with previous caesarean section
delivery.

 Rising incidence of elderly Primigravida.

• Decline in difficult operative or manipulative vaginal deliveries.

• Decline in vaginal breech delivery.

• Increased diagnosis of fetal distress.

• Adoption of small family norms.

 INDICATIONS

Caesarean delivery is done when labour is contraindicated or

vaginal delivery is found unsafe for foetus and mother

 The indications are broadly divided into :

1. Absolute indications
2. Relative indications
3. Common indications
 1. ABSOLUTE INDICATIONS

 When the Vaginal delivery is not possible , caesarean section is needed even
with a dead foetus

1. Central placenta previa.

2. Contracted pelvis or cephalo pelvic disproportion .
3. Pelvic mass causing obstruction (cervical or broad ligament fibroid)
4. Advanced carcinoma of cervix
5. Vaginal obstruction (atresia, stenosis)
2. RELATIVE INDICATIONS
 Vaginal delivery may be possible with or without aids but risks
to the mother and to the baby are high.

 More often multiple factors may be responsible .

 Indications are more common than absolute ones.

1. Cephalo-pelvic disproportions.
2. Previous caesarean delivery.
a) When primary CS was due recurrent indications.

b) Previous two CS.

c) Features of scar dehiscence.

d) Previous classical CS.

3. Non reassuring FHR (Fetal distress)

4. Dystocia may be due to (3P’S) relatively large fetus

(passenger), small pelvic (passage) or insufficient uterine
contractions (power)

5. Ante partum hemorrhage

a) placenta preview

b) b) Abruptio placenta
6. Mal presentation

a) Breech

b) Shoulder

c) Brow

7. Failed surgical induction of labor, Failure to progress in labor

8 Bad obstetric history- with recurrent Fetal wastage

9. Hypertensive disorders

10. Medical-Gynecological disorders

3.COMMON INDICATIONS

 PRIMIGRAVIDA

1. Cephalo pelvic disproportion (CPD)

2. Fetal distress

3. Dystocia
 MULTI GRAVIDA

1. Previous caesarean delivery.

2. Ante partum hemorrhage.

3. Mal presentations (Breech)

CONTRAINDICATIONS

 Dead fetus

 Disseminated intravascular coagulation

 Extensive scar or pyogenic infections in the abdominal wall

E.g. in burns
 INSTRUMENTS
 1 SPONGE HOLDING FPRCEP.
 4 GREEN ARMYTAGE
FORCEPS.
 6 CURVED ARTERY FORCEPS.
 6 STRAIGHT ARTERY
FORCEPS.
 4 ALLIS FORCEPS.
 2 BABCOCK FORCEPS.
 2 TOOTHED FORCEPS.
 2 NON TOOTHED FORCEPS.
 1 NEEDLE HOLDER.
 UMBLICAL CORD CUTTING
SCISSORS.
 4 KLIK CLAMP.
 SUCTION TIP.
 TISSUE CUTTING SCISSOR.
 DOYEN RETRACTOR
 MORRIES RETRACTOR
 DEAVERS RETRACTOR
 Elective

TIME OF
OPERATION

Emergency
ELECTIVE CAESAREAN SECTION

 When the operation is done at a prearranged time during

pregnancy to ensure the best quality of obstetrics.
 Anesthesia. Neonatal resuscitation and Nursing Services.

a) Maturity is certain

b) Maturity is uncertain
EMERGENCY CAESAREAN SECTION

 When the operation is performed due to unforeseen or acute

obstetric emergencies. An arbitrary time limit of 30 minutes is

throughout to be reasonable from the time of decision to the

start of the procedure.

 TYPES OF OPERATIONS

1. LOWER SEGMENT CAESAREAN SECTION.

2. CLASSICAL OR UPPER SEGMENT CAESAREAN SECTION
LOWER SEGMENT CAESAREAN SECTION

 In the LSCS the extraction of the baby is done through an

incision made in the lower segment through a trans peritoneal
approach.
 CLASSICAL CAESAREAN SECTION
 Definition: In this operation, the baby is extracted
through an incision made in the upper segment of the
uterus.
 Its indication in the present day in the obstetrics are

very much limited and the operation is only done under

forced circumstances.
i. Lower segment approach is difficult.
ii. Lower segment approach is risky.
iii. Post Mortem section.
 ADVANTAGES OF LSCS OVER
CLASSICAL CS
LSCS CCS
1. LESS INCISIONAL BLEEDING 1. INCISIONAL BLEEDING MORE
2. MUSCLE APPOSITION IS 2. IMPERFECT MUSCLE APPOSITION
PERFECT 3. MORE WOUND DIHISCENCE
3. LESS WOUND DIHISCENCE 4. HEALING IS LESS
4. HEALS BETTER 5. SCAR RUPTURE IS MORE
5. SCAR RUPTURE IS LESS 6. POST OP DISCOMFORT IS MORE.
6. POST OP COMFORT IS MORE. 7. MORE CHANCE OF INCISIONAL
7. COSMETIC VALUE HERNIA
8. LESS CHANCE OF INCISIONAL HERNIA

.
PREOPERATIVE PREPARATION

 NIL PER MOUTH

 INFORMED WRITTEN CONSENT
 PREOPERATIVE MEDICATIONS
 BLADDER EMPTIED BY A
FOLEYS CATHETER
 KEEP IV LINE PATENT
• PART PREPARATION

• ANTI-SEPTIC PAINTING
• POSITION OF THE PATIENT

• BLOOD TEST

• FHS MONITORING

• INFORM NEONATALOGIST

• ANESTHESIA

• INSTRUMENTS
STRUCTURES ARE BEING CUT

1. SKIN

2. SUBCUTANEOUS TISSUE

3. ANTERIOR RECTUS SHEATH

4. RECTUS ABDOMINUS MUSCLE

5. TRANSEVERSE FASCIA AND PERITONEUM

 UTERINE INCISION

A. Peritoneal Incision
B. Muscle Incision

 Other types of Incisions

A. Lower transverse Incision
B. Lower vertical Incision
PROCEDURE
 Delivery of the Head
 Delivery of the Trunk

 Removal of the Placenta and membranes.

DELIVERY OF THE HEAD
 The membranes are ruptured if still intact. The blood mixed
amniotic fluid is sucked out by continuous suction.
 The Doyen's retractor is removed.
 The head is delivered by hooking the head with the Fingers which
are carefully insulated between the Lower uterine flap and the head
until the palm is placed below the head.
 As the head is drawn to the incision line. The assistant is to apply
Pressure on the fundus. If the head is Jammed, an assistant may
push pop up the head by sterile gloved Fingers introduced into the
vagina. The head is delivered using either Wrigley's or Barton's
Forceps
DELIVERY OF TRUNK
 As soon as the head is delivered, the mucus from the mouth. Pharynx, and
nostrils sucked out using Rubber catheter attached to a electric sucker.
 After the delivery of the shoulder, intravenous Oxytocin 20 units of
methergin 02.md is to be administered.
 The rest of the body is delivered slowly and the baby placed in a tray placed
in between the mother's thighs with the head tilted down for gravitational
Drainage. The cord is cut in between two clamps & the baby is handed over
to the nurse. The Doyen's Reactor is Reintroduced.
REMOVAL OF THE PLACENTA & MEMBRANES
 By this time. The placenta is likely to be separated.
 The Placenta is extracted by traction On the cord with simultaneous pushing
the uterus towards the umbilicus abdomen using the left hand.
 Routine manual removal should not be done. The membranes are to be
carefully removed preferably intact and even a small piece.
 it attached to the decidua should be removed using a dry gauze dilatation of
internal os is not required, exploration of the uterine cavity is desirable.
THE SUTURE OF THE UTERINE WOUND
 It is done with the uterus Keeping in the abdomen. Some however.
prefer to eventrate the uterus prior to suture. The Margins of the
wound are Picked up by Allis tissue forceps of green Armytage
haemostatic clamps. The Uterine incision is sutured in three layer.

1. FIRST LAYER
2. SECOND LAYER
3. THIRD LAYER

•Concluding part
FIRST LAYER

 The First stitch is placed on the far side ins the lateral angle of the
Uterine incision and is tied. The suture material is No ' O 'chromic
catgut or vicryl and the Needle 15 round bodied. A continuous
running suture taking deeper tied after the suture includes The near
end of the angle
SECOND LAYER

 A similar continuous suture is placed take the superficial muscles and

adjacent fascia overlapping the 1st layer of suture. Uterine muscles
may be closed using a continuous Single layer stitch. This does not
increase the risk of uterine scar rapture.
THIRD LAYER (Peritoneal)
 The Peritoneal flaps are apposed by continuous inverting suture.
 Post-operative recovery & outcomes are no different if the visceral &
parietal peritoneal Layers are left unapposed

CONCLUDING PART:
The Mops placed inside are removed and the number verified. Peritoneal
toileting is done and for blood clots are removed meticulously. The tubes and
ovaries are examined. Doyen's retractor is removed. After being satisfied that
the uterus is well contracted. The abdomen is closed in Layers. The Vagina is
cleansed et blood clots and a sterile vulva pad is placed .
COMPLICATIONS OF CLASSICAL CS
 The complications may be

I. INTRA OPERATIVE
II. POST OPERATIVE
INTRA OPERATIVE COMPLICATIONS
 Extension of uterine incision
 Uterine lacerations

 Ureteral injury

 Bladder injury

 Gastro intestinal tract injury

 Uterine atony and primary PPH

 Morbid adherent placenta

POST OPRATIVE COMPLICATIONS
 IMMEDIATE

• POST PARTUM HEMORRHAGE

• SHOCK
• ANAESTHETIC HAZARDS
• INFECTIONS
• INTESTINAL OBSTRUCTION
 REMOTE

• GYNECOLOGICAL
 Menstrual disorders
 Chronic pelvic pain
 Infertility

• GENERAL SURGICAL
 Incisional hernia
 Intestinal obstruction

• FUTURE PREGNACNY
 There is risk of scar rupture.
 POST OPERATIVE CARE
1.First 24 hours (DAY O)
 Observation 2. DAY 1
 Fluid management
3. DAY 2
 inj. Methergin
4. DAY 5-6
 Prophylactic antibiotics

 Analgesics

 Ambulation
DISCHARGE

 The patient is discharged on the day following

removal of the stitches. If otherwise fit.
 Usually advices like those following vaginal
delivery given.
NURSES RESPONSIBILITY
 THANK YOU