Caesarian Section

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Caesarian Section Presented by Dr. Narayan M.
Patel M.D.,D.G.O. FICS Emeritus Professor
Muni. Medical college Postal address-- Mahalaxmi
Institute of medical teaching, 3, Shantiniketan
park, Naranpura, Nr. Sardar Patel Colony,
AHMEDABAD- 380 014 (Gujarat) INDIA T.N.(079)
27682572, Mobile- 98252 95530 E mail-
narayanpatel1932_at_yahoo.com

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Caesarian section Definition
Removal of a fetus from the uterus by abdominal
incision, after 28 weeks of pregnancy. It is
called hysterotomy, if removal is done before 28
weeks of pregnancy.
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Caesarian section

It is one of the oldest obstetric operation
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Caesarian section
Historical aspect-- As per Roman low called Lax
Ragia, it was forbidden to bury a pregnant dead
women, before her child has been cut out. Year
762 B.C.
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Caesarian section
Historical aspect-- In times of Julius Caesar,
the law was called Lax Caesesara. The term
Caesarian section was first used by James
Gullimeau, in his book of midwifery published in
1598.
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Caesarian section
Historical aspect-- Year 1500-Jacob Neufer, a
saw gleder asked permission of local mayer to cut
open abdomen of his wife, who was in prolonged
labor. First request was not granted. He went
second time and his request was granted. He
opened his wife abdomen. History says that, she
not only survived but later gave birth to 5 more
children. People think that this may be a case of
advances secondary abdominal pregnancy.
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Caesarian section

• Historical aspect--
• 1882 -- Sanger introduced technique of
  suturing of uterus.
• 1912 ---Lower segment caesarian segment
  section was first performed by Kronig and latter
  by Monro kerr.
• 1940 --- In my city at Ahmedabad (India)
  first L.S.C.S. was performed by my teacher,
  late Dr.(miss) S.C.Pandya

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Caesarian section
Historical aspect-- Year 1581- Francis Russet
first published article on caesarian
section. Maternal mortality was almost 100 at
that time. In Year 1876 Porro advocated
amputation of body of uterus and this cause fall
in maternal mortality to 50 in first half of
19th century.
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Caesarian section
Historical aspect-- Year 1876- Porro -an
Italian obstetrician advocated amputation of body
of uterus after C.S. to decrease the maternal
mortality. Amputation was done by cintracts
constrictor. Even to day Caesarian hysterectomy
is called Porros section.
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Caesarian section

• Once a caesarian section always a caesarian
  section.
• Dr.E.B.carngin 1916
• Modified to-
• Once a caesarian not always a caesarian.
• Now modified to-
• Once a caesarian, always a hospital delivery

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Caesarian section
Incidence of C.S. is rising-- Formally it was 10
to 15 but now it 25 to even as high as
50 Rising incidence is more because of fetal
indications. There is a trend to do repeat C.S.
without giving trial in Pt. with previous C.S.
Doctor do not want to take any risk with the
child, doctor has fear of medico legal
problems. C.S. has also become more safe due to
- Better anesthesia, more availability of blood
transfusion, better antibiotics, better suture
material etc. Hence C.S. is more frequently done,
even at a trivial indication.
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Caesarian section
Because of public mentality of a small family
norms, neither the obstetrician nor the patient
desires to take even slightest extra risk of
trial of labor. The pain tolerance power of
patient has gone down and obstetrician has become
too busy to fine time for a long trial of labor.
Fear of medico legal problems to the doctor leads
him of her, to a safe short cut of C.S.
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Caesarian section

• Most commen indications of C.S.-
• Severe degree contracted pelvis.
• Central placenta pravia
• Breech with extended limbs in elderly primi.
• Transverse presentation, or hand prolapse and
  cervix not fully dilated.
• Fetal distress and cervix not fully dilated.
• Brow presentation.
• Previous 2 L.S.C.S.

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Caesarian section

• Indications of C.S.-
• Non recurrent indications
• Fetal distress
• Breech presentation
• Placenta previa.
• Occipito posterior presentation.
• Recurrent Indication--
• Contracted pelvis

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Caesarian section

• Some old books has divides indications of
  Caesarian section in this manner.
• This author do no approve of this, however to
  complete the subject, I have included in this
  presentation.
• Fault with the passage.
• Fault with the passenger.
• Fault with the forces.

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Caesarian section Uterine Incision

• Transverse lower segment
• Curves incision Concavity towards funds of
  uterus
• Inverted T incision.
• Classical
• J shaped.
• Lower segment verticle
• Extraperitonial.( I have not seen any)

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Caesarian section

• Elective C.S.
• Emergency C.S.

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Elective caesarian section (Planned operation)

• Advantages are-
• Patient with empty stomach and surgeon usually
  with full breakfast
• Best anesthetist available at that time
• Best assistant and nursing staff.
• Disadvantages are -
• If wrong judgment, premature child may be
  born.
• Cervix may not be dilated and hence poor
  drainage of lochia
• Lower segment is not formed and hence uterine
  incision in lower part of upper segment.

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Emergency caesarian section (Unplanned)

• Working under adverse circumstances-
• Patient may be with full stomach and surgeon
  may be with empty belly
• Odd working hours either of day or night
• Anesthetist, assistant and nursing staff may
  not be of your choice.
• Advantage is -
• Mature child as patient is in labor
• Cervix is open, better drainage of lochia.
• Lower segment is well formed.

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Caesarian section

• Mortality and morbidity are
• significantly higher in,following
• emergency C.S. than a
• planned C.S.

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Caesarian section

• Types of anesthesia
• Spinal.
• General.
• Epidural.
• Local.

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Caesarian section

• Spinal anesthesia
• It is best and cheapest
• More popular now in European countries.
• Patient remain conscious.
• Less incidence of cardiac arrest.
• Drug used is 5 lignocain- hyperbaric 1.5 to 2 cc
• Some times difficult for anesthetist to find
  space due to lumber lordosis of pregnancy.
• Some times there is fall of blood pressure.
• Post operative spinal headache.
• Rarely meningitis, or total spinal may occur.
• Spinal anesthesia should not be given if Pt. has
  already low B.P. or baby has transverse
  presentation or deeply engaged head or failed
  forceps or failed vacuum delivery.

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Caesarian section

• General anesthesia
• Many times Pt. demand G.A.
• Drug used is I.V. Pentothal sodium with oxygen
  and Nitrous oxide and muscle relaxant.
• Intubations some times difficult, if anesthetist
  is not well experienced.
• Incidence of cardiac arrest is more than spinal.
• Post operative vomiting is common.
• If Pt. has taken food, regurgitation complication
  like aspiration pneumonia may occur.
• Deep anesthesia, only to be given after baby has
  been delivered.
• Pt. at sleep but anesthetist has to be alert in
  G.A.

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Caesarian section

• Epidral anesthesia
• These days patients are asking for painless
  delivery and for that, many times continuous
  epidural anesthesia is given. If the trial of
  labor fails, patient may be taken for caesarian
  section or forceps delivery. In that case
  caesarian may be performed in the same epidural
  anesthesia.
• It is a good anesthesia with less risk of fall of
  blood pressure.Due to lumber lordosis of
  pregnancy, some times epidural becomes
  technically difficult.

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Caesarian section

• Local anesthesia
• This is rarely requires except in conditions,
  like vary low patient as in central placenta
  pravia or in deeply sedated Pt. of eclampsia.
• If doctor is working in a place where
  anesthetist is not available and surgeon has to
  manage all alone, local anesthesia is used.
• Drug used is 0.5 Lignocain. Total quantity to be
  used is not more than 100 c.c.
• In this anesthesia, the surgeon may not be as
  comfortable as spinal or general anesthesia.

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Caesarian section

• Incision on abdominal wall
• Verticl midline- it is easy, more working place
  but incidence of incisional hernia is high.
• Paramedian-- Less chances of incisional hernia
  than midline incision.
• Phenestial transverse- it is most popular, less
  pain full, early mobility of patient, less
  chances for dehiscence. It has also a cosmetic
  value.
• Its disadvantages is, it takes more time to
  open abdomen, less exposure than vertical scar,
  and at repeat caesarian is more difficult.

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Caesarian section
Lower segment C.S Classical C.S.

• Upper segment edges are
• thick and hence difficult to
• approximate.
• Upper segment is active
• segment so contraction makes
• stitches loose.
• Upper segment is not covered
• with peritoneum, and remains
• in abdomen so more chances
• for adhesions formation.
• Chances for ruptures Ut. in next
• pregnancy 8 times more.

• Lower segment edges are
• thin, hence suturing is
• better.
• Lower segment is a passive
• segment so does not
• contract, so healing is better.
• Lower segment is covered
• with peritoneum, It remains
• in pelvis so less chances
• for adhesions formation.
• Chances for ruptures Ut. in
• next pregnancy much less.

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Caesarian section Maternal mortality after
C.S. is bet.5 to 30 per 1000 Perinatal mortality
is 5 to 10 -due to--

• Emergency operation.
• Fotal asphyxia-(RDS)
• Prematurely-
• Infection.
• Intracranial hemorrhage.
• Fracture dislocation of big bones.

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Caesarian section
Maternal complcations- Immediate- Haemorrage, Sh
ock, sepsis, Anesthetic hazards, Thrombosis and
wound complication. Paralitic ilius. Late-
Incisional hernia. Ruptured uterus in next
pregnancy
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Caesarian section Ecbolics

• Inj. Ergometrin 0.5 mg I.M. or I.V.
• Inj Oxytocin 20 to 20 units in 500
• ml. glocose saline or ringer Lactate
• Inj. Prostagandin i.m.

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Some technical minutes of Caesarian section.
Presented by Dr.Narayan M.Patel M.D.,D.G.O.
FICS Emeritus Professor Muni. Medical
college Postal address-- Mahalaxmi Institute of
medical teaching,3, Shantiniketan park,
Naranpura, Nr.Sardar Patel Colony, AHMEDABAD-
380 014 (Gujarat) INDIA T.N.[phone],
Mobile- 98252 95530 E mail- narayanpatel1932_at_yah
oo.com
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• Excision of previous scar
• Always at the beginning of operation by
• an elliptical incision. Excising previous
• scar at the end of operation is difficult.
• Multiple scars multiple surgeons name,
• multiple signatures on skin.

Name of the surgeon is always written on the
scar
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Caesarian section

• Initial Uterine incision should be small
• by knife and then
• Enlarging it by scissors
• Enlarging it by knife
• Enlarging it by tearing it with fingers.

Try to avoid rupturing of membranes at
incision. Catch uterine edges with Ellisis
forceps, Swab holder or Green Aarmitage forceps.
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Caesarian section
How to deliver of head?

• By putting hand to disengaged head and than
  bringing out of incision
• Application of short forceps.
• Pushing head from below by a strong persons
  wearing gloves, especially in case of failed
  forceps, deeply jammed head or occipito post.
  presentation or deep transverse arrest.
• Putwardhens Manuvary in deeply engaged head,
  is bringing out first trunk and than head.
• Using Babcocks forceps to rotate floating head
• to bring occiput anterior.

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Caesarian section

• Problem of floating head
• In elective cesarean section, floating head
• is more difficult to deliver than an
• engaged head.
• Use short forceps in floating head.
• In twins- for delivery of second child, if it
  is
• breech, it is easy. If it is cephalic, do
  internal
• podalic version, or try apply vacuum forceps.

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Caesarian section
Problem of deeply jammed head

• Always give general anesthesia with Halothain
• to relax uterus.
• Never- never attempt in spinal anesthesia. I
  have
• seen once my teacher struggling for 30 mit.
  to
• bring out head and got out a dead baby.
• Ask a strong person to pus head from below
• with gloved hand, to disengage head.
• Patwardhns method- is difficult and problem of
• extending of uterine incision is commen.

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Uterine incision suturing Suturing material---
Mostly Vicryl or catgut
Single layer Now a days many prefer single layer
continuous suture. In elective C.S. where low.
segment not formed and is thick, single layer
suturing may not be possible. Double layer 1st
layer ---continuous 40 mm heavy needle No-1
suture 2nd layer -- continuous 40mm needle 1/0
suture Peritoneum --continuous 40 mm needle 1/0
suture Some prefer suturing first both uterine
angles, to stop bleeding. Some prefer interrupted
stitches for the first layer.
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To suture or not to suture pelvic peritoneum and
parital peritoneum is a debatable point and of
individual choice and belief. Old generation
doctors still like to suture both peritonium.
Newer generation usually avoid
suturing. Literature reports no difference in
either technique. How ever it needs few more
years follow up for its further to evaluate it.
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Clearing air passages of child after birth

• Surgeon himself managing.
• Hanging the child- holding it by feet.
• Suction with rubber catheter.
• Using mucous catheter.
• Hand over to anesthetist.
• Hand over to a pediatrician.

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Delivery of placenta

• 3rd stage of labor- duration is 5 to7 minutes
• Let placenta separate by itself.
• Never pull out placenta before it separates.
• I.V.Methegine 10 to 20 units Syntocinon in
  drip.
• Practice spontaneous delivery of placenta.

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Problem of central placenta pravia

• Anterior placenta-
• Try to find out membrane up or down, rt. Or
  left.
• If you fail, cut placenta quickly and first
  remove child.
• Posterior placenta
• (Dangerous placenta of Stall-Worthy.)
• To stop bleeding or oozing from lower post
  segment,
• pack it systematically with multiple roller
  packs. Push first
• end in cervical canal. Remove pack after 24
  hours.
• Some time as a desperate measure you may need
• Internal iliac ligation, or subtotal
  hysterectomy, to save Pt.

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Cesarean section

• Misgav Ladch Hospital method of C.S.
• Skin incision phenestial.
• Peritonium opened transversely.
• Single layer non locking suturing of uterine
  incision.
• Pelvic and parital peritoneum not sutured.
• Reported as safe, simple ,fast and cost
  effective.
• Least post operative pain and early ambulation.

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Cesarean section

• Caesarian hysterectomy
• (Porros section)
• It refers to an operation
• when C.S. is followed
• by removal of uterus.

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Cesarean section
Indications of Porros section

• Atonic uterus and uncontrolled P.P.H.
• Morbid adherent placenta
• Extensive laceration of uterus in case of
• ruptured Ut. extensive tear in broad
• ligament.
• Couvalair uterus.
• Grossly infected uterus

Ato
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Cesarean section
Porros section

• Rarely necessary now a days.
• P.P.H. is now better treated with
  Prostaglandin,
• Synocinon, and Methergin
• Internal ilac ligation is practiced more often.
• For treatment of D.I.C. blood and
• blood components,are now easily available.
• Subtotal hysterectomy is more safer than
• total hysterectomy.
• Timely intervention and enrollment of
• experienced personal, gives good results.

ii
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Phenestial skin Incision

• More time to open and close abdomen.
• Less exposure than vertical incision.
• Repeat C.S. is more difficult, with previous
• phenestial incision.
• Not advisable in obstructed labor
• and with transverse presentation.
• Less pain and early ambulation to patient .
• Early discharge from hospital.
• Less chances for incisional hernia.
• It is a cosmetic scar- called Bikini incision.

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Indications of Classical Cesarean section

• Severe Kypho- scoliosis lower segment
• not approachable.
• Big varicose veins in lower segment.
• Cervical fibroid with pregnancy.
• Transverse presentation with big child.
• Constriction ring in uterus.
• Central placenta pravia. (some times)
• Previous difficult V.V.F. repair.
• Pregnancy with cancer cervix.
• Post mortem C.S.

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Cesarean section
Bringing uterus out at pelvis (uterine
exteriorization)
At suturing -- Rarely required unless
uncontrolled bleeding. It can can cause febrile
morbidity and venous air remobilization After
suturing -- To detect posterior wall rupture and
any congenital uterine anomaly.
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Caesarian section Prophylaxis against scar
rupture

• Ask patient to preserve operation card and all
  relevant case papers and reports.
• Put emphasis on follow up in next pregnancy,
  from vary beginning to end.
• Insist on hospital delivery with previous C.S.
• Now a days obstetricians are either to busy or
  are too much afraid to give trial of labor
  in case with previous C.S. and hence repeat
  elective C.S. is for them a safe short cut.

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Caesarian section

• Pregnancy and labor following C.S.
• Trial of labour is attempted when-
• Non recurrent indication of previous C.S.
• Well engaged head.
• Previous L.S.C.S. with uneventful recovery.
• Anterior cephaalic position of child.
• Average size child.
• Good trained staff to monitor the patient.
• Efficient emergency operative facility
  available at vary short notice.

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Caesarian section Delivery of trunk

• At the time of delivery of trunk
• bi-aromial diameter should always be in line of
  uterine incision and not perpendicular to it.

52
Cesarean section
The mobs put in abdominal Uterine cavity are
all removed counted doubly by surgeon himself.
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Caesarian section

• Araumatic abdominal delivery is always
  preferred to a traumatic difficult vaginal
  delivery.

54
Caesarian section

• Is Caesarian section ?
• An answer for all problems ?
• A universal obstetric remedy ?
• A short cut to all obstetric problems?

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Thank you