operative delivery

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Operative Deliverycaesarian section

• Dr.Makanda,MD Mmed
• HKMU
• OBGY Department

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Definition

• The birth of a fetus through incisions in the
  abdominal wall (laparotomy) and the uterine wall
  (hysterotomy).
• It does not include removal of the fetus from the
  abdominal cavity in the case of rupture of the
  uterus or in the case of an abdominal pregnancy.

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Definition

• When done due to emergent complications such as
  intractable hemorrhage, abdominal hysterectomy is
  indicated following delivery.
• If it is performed at the time of cesarean
  delivery, the operation is termed cesarean
  hysterectomy.
• If done within a short time after vaginal
  delivery, it is termed postpartum hysterectomy

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Historical background

• Julius Caesar was born through this procedure ,
  the result of the procedure to be called
  Caesarean operation.
• But Several circumstances weaken this
  explanation
• First, the mother of Julius Caesar lived for many
  years after his birth in 100 BC, and as late as
  the 17th century, the operation was almost
  invariably fatal.

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Historical background ..

• Second, the operation, whether performed on the
  living or the dead, is not mentioned by any
  medical writer before the Middle Ages.
• Historical details of the origin of the family
  name Caesar are found in the monograph by
  Pickrell (1935).
• The second explanation is that the name of the
  operation is derived from a Roman law, supposedly
  created in the 8th century BC by Numa
  Pompilius,involved operation upon women dying in
  the last few weeks of pregnancy to save the
  child.

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Historical background ..

• This lex regiaking's rule or lawlater became
  the lex caesarea under the emperors, and the
  operation itself became known as the caesarean
  operation.
• The German term KaiserschnittKaiser cutreflects
  this derivation
• Birth in this extraordinary manner, as described
  in ancient mythology and legend, was believed to
  confer supernatural powers and elevated the
  heroes so born above ordinary mortals

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Historical background ..

• Cesarean deliveries in the living were first
  recommended, and the current name of the
  operation used, in the celebrated work of
  Francois Rousset (1581) entitled Traité Nouveau
  de l'Hystérotomotokie ou l'Enfantement Césaerien

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INCIDENCE

• There has been a steady rising of the incidence
  of cesarean section .
• During the last decade there has been 2 to 3 fold
  rise in the incidence from the initial rate of
  about 10.
• The increased safety of the operation has been
  due to
• Improved anesthesia,
• Availability of BT and,
• Antibiotics

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Factor for rising of the rate of C/S

• Early identification of at risk fetuses before
  term (IUGR)
• Identification of at risk mothers
• Wider use of repeat CS in cases with previous
  cesarean delivery
• Rising rates of induction of labor and failure of
  induction
• Decline in operative vaginal (mid forceps,
  vacuum) delivery and manipulative vaginal
  delivery (rotational forceps

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Factor for rising of the rate of C/S..

• Decline in vaginal breech delivery
• ? number of women with age gt 30 and associated
  medical complications
• Adoption of small family norm- neither the
  obstetricians, nor the patients are ready to
  accept any risk of abnormal labor
• Wider use of electronic fetal monitoring and
  ?diagnosis of fetal distress
• Fear of litigation in obstetric practice
• Cesarean delivery on demand (controversial)

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Factor for increasing rate of C/S..

• Dramatic ? prevalence of obesity , obesity
  increases the risk of cesarean delivery
• Some elective cesarean deliveries are now
  performed due to concern over pelvic floor injury
  associated with vaginal birth

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INDICATIONS

• The procedure is done when labor is
  contraindicated (central placenta previa) and/or
  vaginal delivery is found unsafe for the fetus
  and/or mother

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Absolute indications

• Vaginal delivery is impossible. Cesarean is
  needed even with a dead fetus
• Indications are few
• 1. Central placenta previa
• 2. Contracted pelvis or CPD
• 3. Pelvic mass causing obstruction(cervical or
  broad ligament fibroid)
• 4. Advanced carcinoma cervix
• 5. Vaginal obstruction (atresia, stenosis)

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COMMON INDICATIONS

• Primigravidae
• Failed indication
• Fetal distress (nonreassuring fetal FHR)
• Cephalo pelvic disproportion(CPD)
• Dystocia (dysfuctional labour nonprogress of
  labour )
• Malposition and malpresentation
  (occipitoposterior, breech)

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COMMON INDICATIONS.

• Multigravidae
• Previous Caesarean delivery
• APH (placenta praevia, placental abruption)
• Malpresentation (breech, transverse lie).

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Absolute indications

• Vaginal delivery is impossible. Cesarean is
  needed even with a dead fetus Indications are
  few
• 1. Central placenta previa
• 2. Contracted pelvis or cephalopelvic
  disproportion (absolute)
• 3. Pelvic mass causing obstruction (cervical or
  broad ligament fibroid)
• 4. Advanced carcinoma cervix
• 5. Vaginal obstruction (atresia, stenosis)

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COMMON INDICATIONS

• Primigravidae
• (1) Failed indication
• (2) Fetal distress (nonreassuring fetal FHR)
• (3) Cephalo pelvic disproportion (CPD)
• (4) Dystocia (dysfuctional) nonprogress of labour
  (5) Malposition and malpresentation
  (occipitoposterior, breech).

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COMMON INDICATIONS

• Mutigravidae
• (1) Previous Caesarean delivery
• (2) Antepartum haemorrhage (placenta praevia,
  placental abruption)
• (3) Malpresentation (breech, transverse lie).

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Relative indications

• Vaginal delivery may be possible but risks to the
  mother and/ or to the baby are high More often
  multiple factors may be responsible
• 1. Previous cesarean delivery
• (a) when primary CS was due to recurrent
  indication (contracted pelvis).
• (b) Previous two CS
• (c) Features of scar dehiscence.
• (d) Previous classical CS
• 2. Non-reassuring FHR (fetal distress)

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Relative indications.

• 4. Dystocia may be due to (three Ps)
• Relatively large fetus (passenger),
• Small pelvis (passage) or
• Inefficient uterine contractions (Power)

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Relative indications.

• 5. Antepartum hemorrhage
• Placenta previa and
• Abruptio placenta
• 6. Malpresentation
• Breech, shoulder (transverse lie),
• brow
• 7. Failed surgical induction of labor, Failure to
  progress in labor
• 8. Bad obstetric historywith recurrent fetal
  wastage .

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Relative indications.

• 9. Hypertensive disorders of pregnancy
• Pre-eclampsia with Severe features ,
• Eclampsiauncontrolled fits even with antiseizure
  therapy
• 10. Medical-gynecological disorders
• Diabetes (uncontrolled),
• Heart disease (coarctation of aorta,
• Marfans syndrome.
• Mechanical obstruction (due to benign or
  malignant pelvic tumors (carcinoma cervix), or
  following repair of VVF

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ANTERIOR ABDOMINAL WALL

• The anterior abdominal wall
• Boundaries
• Superior Xiphoid process and costal cartilages
  of the 7th - 10th ribs.
• Inferior Iliac crest, inguinal ligament,
  anterior superior iliac spine, pubic tubercle,
  pubic crest and pubic symphysis.

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Layers of anterior abdominal wall

• Skin
• Subcutaneous (Superficial fascia) Fatty and
  membranous
• Deep fascia
• Muscles and their aponeurosis
• Extra peritoneal tissue
• Peritoneum

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TIME OF OPERATION

• Elective - When the operation is done at a
  prearranged time during pregnancy
• EmergencyWhen the operation is performed due to
  unforeseen or acute obstetric emergencies.
• Should arbitary be done within 30 minutes from
  the time of decision to the start of the
  procedure.

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TYPES OF OPERATIONS

• Two types
• Lower segment caesarian section
• Upper segment or Classical

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TYPES OF OPERATIONS

• LSCS The baby is extracted through an incision
  made in the lower uterine segment through a
  transperitoneal approach
• Presently, this is the most common method
• Classical The baby is extracted through an
  incision made in the upper uterine segment

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Indications for upper segment c/s

• Difficulty in lower segment approach due to
• Dense adhesions due to previous abdominal
  operation
• Severe contracted pelvis (osteomalacic ) with
  pendulous abdomen.
• There is a risk in LS approach
• Big fibroid on the lower segmentsevere blood
  loss if myomectomy is attempted
• Carcinoma cervixTo prevent dissemination of the
  growth and postoperative sepsis
• Repair of high VVF
• Complete anterior placenta previa with engorged
  vessels in the lower segmentrisk of hemorrhage.

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Indications for upper segment c/s

• Perimortem cesarean sectionis done to have a
  live baby (rare).
• Perimortem section is an extreme emergency
  procedure. Classical section is done in a woman
  who has suffered a cardiac arrest.
• The infant may survive if delivery is done within
  10 minutes of maternal death.

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LOWER SEGMENT CESAREAN SECTION (LSCS)
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Preoperative preparation

• Written informed consent for the procedure,
  anaesthesia and possible BT
• Lab
• Haemoglobin level
• Bleeding clotting time
• - Blood grouping x-match
• Premedication
• IV Metronidazole 500mg stat
• IV Ceftriaxone 1 gm stat or Ampicilin 1 gm stat
• IV Fluids either RL or NS 1.5L-2L
• Catheterization

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Preoperative preparation

• Anesthesia
• Either spinal, GA or epidural
• Choice of the patient and urgency of delivery are
  also considered.
• Position of the patient
• Supine position with a little 15 tilt to the
  left using a wedge to minimize any adverse
  effects of venacaval compression, till delivery
  of the baby is beneficial.

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Preoperative preparation

• Put on boots
• Put on mask and cap
• Scrub
• Put on sterile gowns
• Put on sterile gloves

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Preoperative preparation

• Antiseptic painting
• The abdomen is painted with Povidone (iodine)
  solution or Savlon lotion followed by methylated
  spirit
• Then properly draped with sterile towels.

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Abdominal Incisions

• Either
• A vertical SUMI or paramedian or
• A transverse skin incision.
• Transverse incision, modified Pfannenstiel is
  made 3 cm above the symphysis pubis.

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Types of C-section (abdominal )incisions
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Lower abdominal incisions

• Advantages

• Disadvantages

• Postoperative comfort is more
• Fundus of the uterus can be better palpated
  during immediate postoperative period
• Less chance of wound dehiscence
• Less chance of incisional hernia
• Cosmetic value

• Takes a little longer time and as such unsuitable
  in acute emergency situation
• Blood loss is slightly more
• Requires competency during repeat section
• Unsuitable for classical operation

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Lower abdominal incisions

• Packing
• Introduce the Doyens retractor .
• Pack off the peritoneal cavity using two taped
  large swabs whose tape ends are attached to
  artery forceps.
• AIM - Minimize spilling of the uterine contents
  into the general peritoneal cavity.

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Uterine incisions

• Cut transversely the loose peritoneum of the
  uterovesical pouch across the lower segment with
  convexity downwards at about 1.25 cm (0.5) below
  its firm attachment to the uterus.
• Push the lower flap of the peritoneum a little
  downward
• Muscle incision
• The most commonly used incision (90) is low
  transverse.

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Uterine incisions

• Advantages are
• 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.

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Other types of uterine incisions

• (a) Lower verticalmay be extended upwards when
  needed.
• (b) Classical incision (upper segment).
• (c) J incisionupward vertical extension of the
  initial transverse incision.
• (d) Inverted T incisionupward extension from
  the mid transverse incision.
• Vertical uterine incision is made when the lower
  segment is poorly developed or there is complete
  anterior placentae praevia

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Other types of lower uterine incisions
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• Low transverse incision
• Make a small transverse incision in the midline
  by a scalpel at a level slightly below the
  peritoneal incision until the membranes of the
  gestation sac are exposed.
• Insert two index fingers through the small
  incision down to the membranes and the spliting
  transversely muscles of the lower segment across
  the fibers.
• Advantage
• Minimizes the blood loss but
• Requires experience.
• Alternatively, the incision may be extended on
  either sides using a pair of a curved scissors to
  make it a curved one of about 10 cm (4) in
  length, the concavity directed upwards.

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Delivery of the head

• Rupture the membranes if still intact.
• Continously suck the blood mixed amniotic fluid .
  
• Remove the Doyens retractor.
• Deliver the head by hooking the head with the
  fingers which are carefully insinuated 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 fundal pressure .
• In case of a jammed head , an assistant may push
  up the head by sterile gloved fingers introduced
  into the vagina.
• The head can also be delivered using either
  Wrigleys or Bartons forceps.

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Delivery of the trunk

• As soon as the head is delivered,
• Clean out the mucus from the mouth, pharynx and
  nostrils
• Give IV Oxytocin 10 IU after delivery of the
  shoulders.
• Deliver the rest of the body slowly
• Tilt the head down for gravitational drainage.
• Clamp the cord with two kockers then cut the cord
  in between the two clamps and handle the baby
  over to the nurse
• Then reintroduce Doyens retractor

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Delivery of the trunk

• Between uterine incision and delivery the optimum
  interval should be lt 90 seconds.
• Interval gt 90 seconds are associated with poor
  Apgar Scores.
• There is reflex uterine vasoconstriction
  following uterine incision and manipulation.

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Delivery of the placenta and membranes

• The placenta is extracted by traction on the cord
  with simultaneous pushing of the uterus towards
  the umbilicus per abdomen using the left hand
• (controlled cord traction).
• Routine manual removal should not be done.
• Deliver the membranes carefully not leaving any
  small piece.
• Can use a small sterile gauze to effect this
• Dilatation of the internal os is not required.
  Exploration of the uterine cavity is desirable.

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Closure of the uterine wound

• The margins of the wound should be picked up by
  Green Armytage hemostatic clamps (4 are required,
  one each for the angle and one for each margin).
• Uterine incision should be closed in three layers
  continuous or interrupted absorbable sutures

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Closure of the uterine wound ..

• First layer placed at the angle laterally then
  ending on the opposite angle using chromic catgut
  no. 0 or vicryl and the needle is round bodied.
• Second layer- commonly used
• To improve haemostasis and improve the integrity
  of the scar.
• Once repaired, the incision is assessed for
  haemostasis and additional figure-of-eight
  sutures can be employed to control any bleeding
  points
• Third layer- The peritoneal flaps may be apposed
  by continuous inverting suture (to prevent any
  raw surface).

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End of uterine closure

• Remove the mops
• Toilet the peritoneum and remove all the blood
  clots
• Examine the tubes and ovaries.
• Remove the Doyens retractor .
• When you are satisfied that the uterus is well
  contracted, close the abdomen in layers.
• Cleanse the vagina of blood clots and place a
  sterile vulval pad .

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Post operative

• First 24 hours (Day 0)
• Observation for the first 68 hours is important.
  
• Monitor pulse, BP, amount of vaginal bleeding and
  behavior of the uterus (in low transverse
  incision) and record.
• FluidN/S (0.9) or Ringers lactate drip is
  continued until at least 2 2.5 liter/24hrs .
• BT is helpful in anemic mothers for a speedy
  post-operative recovery.
• Oxytocics Injection oxytocin 10 units IM or IV
  and may be repeated if there is a need

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Post operative

• Prophylactic antibiotic (cephalosporins,
  metronidazole) for 23 days). Therapeutic
  antibiotic is given when indicated.
• Analgesics in the form of pethidine hydrochloride
  75100 mg is administered and may have to be
  repeated.
• AmbulationThe 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 34
  hours when mother is stable and relieved of pain.

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Post operative

• Day 1 observe the bowel sounds
• Oral feeding start with black tea
• Day 2 Light solid diet of the patients choice
  is given.
• Bowel care 34 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).if non absorbable sutures were
  used

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CLASSICAL CESAREAN SECTION

• Abdominal incision is always longitudinal
  (paramedian) and about 15 cm (6) in length,
  1/3rd of which extends above the umbilicus
• A longitudinal incision of about 12.5 cm (5) is
  made on the midline of the anterior wall of the
  uterus starting from below the fundus
• It is deepened along its entire length until the
  membranes are exposed and then punctured.
• Placenta is encountered in 40 of cases
• The baby is delivered commonly as breech
  extraction

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CLASSICAL CESAREAN SECTION

• Oxytocin 10 IU IV stat
• The placenta is extracted by traction or manually
  
• The uterus is sutured in three layers.
• A continuous suture is placed with chromic catgut
  No 0 or vicryl taking deep muscles excluding
  the decidua.
• A second layer of interrupted sutures (1 cm
  apart) using chromic catgut No. 1 or vicryl
  taking the entire depth of superficial muscles
  down to the first layer of suture.
• The third layer of continuous suture taking the
  peritoneum with the adjacent muscles using
  chromic catgut No 0 and round bodied needle

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Complications of caesarian section

• Intraoperative
• Postoperative

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Intraoperative complications

• Organ injury
• Extension of uterine incision to one or both the
  sides
• Uterine lacerations at the lower uterine incision
• Bladder injuryis rare in a primary CS but may
  occur in a repeat procedure
• Gastrointestinal tract injury
• Ureteral injury is rare
• Hemorrhage
• Morbid adherent placenta (placenta accreta)

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POSTOPERATIVE COMPLICATIONS

• MATERNAL
• Immediate
• Remote

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POSTOPERATIVE COMPLICATIONS

• IMMEDIATE
• PPH
• Shock
• Anesthetic hazards eg.high spine
• Infections
• Intestinal obstruction eg.paralytic ileus
• Deep vein thrombosis and thromboembolic disorders
• Wound complications
• Secondary postpartum hemorrhage.

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POSTOPERATIVE COMPLICATIONS

• REMOTE
• Gynecological
• General surgical
• Future pregnancy

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POSTOPERATIVE COMPLICATIONS

• Gynecological
• Menstrual excess or irregularities,
• Chronic pelvic pain or backache
• General surgical
• Incisional hernia,
• Intestinal obstruction due to adhesions and
  bands.
• Future pregnancy There is risk of scar rupture
• FETAL Iatrogenic prematurity and development of
  RDS is common following cesarean delivery.
• This is seen when fetal maturity is uncertain

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MATERNAL AND PERINATAL MORTALITY
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Maternal

• Overall maternal mortality - 6 /100,000 and
  22/100,000 procedures.
• The causes of death are
• Hemorrhage and shock
• Anesthetic hazards
• Infection
• Thromboembolic disorders

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Fetal

• The perinatal mortality ranges from 510
• Deaths are mostly related to emergency operations
  and the complicating factors for which the
  operations are done.
• The causes of death are
• Asphyxia may be pre-existing
• RDS
• Prematurity
• Infection and ,
• Intracranial hemorrhageattempting breech
  delivery through a small incision

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Cesarean Hysterectomy

• Definition removal of the uterus following
  cesarean section
• Factors
• Morbid adherent placenta
• Atonic uterus and uncontrolled PPH
• Big fibroid (parous)
• Extensive lacerations due to extension of tears
  with broad ligament hematoma
• Grossly infected uterus
• Rupture of uterus.

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