CESAREAN SECTION

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CESAREAN SECTION
Dr.R.alyamani
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Definition Abdominal delivery, commonly known
as cesarean section (cesarean birth), is a
surgical procedure that permits delivery of the
infant through incisions in the abdominal and
uterine wall. Cesarean hysterectomy is a
hysterectomy performed at the time of cesarean
delivery. The technique was not widely used
until the 1920s.The adjective cesarean describing
this procedure did not emanate from Julius
Caesar's reign but rather from Pompilius II, who
in 730 BC decreed that no pregnant woman who died
would be buried until the baby was removed from
the abdomen. The term may arise from a
combination of the latin verbs (caedere) and
(Seco) both meaning to cut.
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Incidence and Trends For many years, the
incidence of the procedure was stable (3-5) yet
since 1960s, the rate of CS was rising steadily
reaching (20-25) in late 1980s. Causes for
increase CS rates include Dystocia (30
increase). Breech presentation. Fetal distress
(10-15 increase). repeat CS (gt50
increase). Malpractice suites.
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Maternal Indications 1-Antepartum hemorrhage
(placenta praevia, severe abruptio-placentae),
Contracted pelvis. 2-Pelvic tumors obstructing
labor. 3-Pelvic fracture. 4-Previous successful
vaginal surgery for stress incontinence or
urinary fistula. 5-Invasive carcinoma of the
cervix. 6-Previous Cesarean Sections or other
uterine scar threatening uterine rupture.
7-Severe maternal hypertension. 8-Cerebral
aneurysm or arterio-venous malformations.
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Fetal Indications 1-Fetal distress (with or
without dystocia). 2-Certain cases of
Malpresentations (face, brow, compound
presentation, persistent OP or DTA, transverse
lie as no place for internal version with living
single fetus and CS for breech presentation is
increasing). 3-Multiple pregnancies. 4-Fetal
anomalies (with associated dystocia or due to
worsening conditions in utero). 5-Macrosomia and
extreme prematurity are examples of fetal
indications for CS. Maternal genital Herpes
infection and thrombocytopenia are also fetal
indication for CS due to risk of fetal infection
and hemorrhage.
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Contraindications of Cesarean Section There are
no absolute contraindications, yet CS is better
avoided in cases of fetal demise, major anomalies
incompatible with life and in some maternal
diseases as cardiac diseases and coagulopathy.
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Types of Cesarean Section It may be Elective or
Non-Elective procedure i.e (failed labor
induction, trial or forceps) according to its
indication and timing. It may be Primary (first
performed) or Repeat CS. The uterine incision
either in the lower segment (LSCS) or upper
segment (USCS) usually through a transperitoneal
route rarely through extraperitoneal route. 1 -
The classical uterine incision is a vertical
incision that involves the upper uterine segment.
Although this incision allows rapid uterine
entry. Complications encountered include A -
increased blood loss. B - risk of uterine rupture
prior to or during labor in a subsequent
pregnancy. Indication of classic uterine incision
include Maternal condition whereby lower segment
is not accessible or not developed, cancer
cervix, previous successful repair of
vaginouterine fistula, or when the procedure is
to be followed by hysterectomy or done
postmortem. It may be also performed for
transverse lie, fetal major malformation
(sacrococcygeal tumor, severe hydrocephalus), or
to fetal distress (due to rapidity of the
procedure).
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• 2 -The Lower uterine segment incision
• It is the most commonly performed. It has the
  advantage of
• 1-having less bleeding unless extended (as the
  lower segment is less vascular and away from
  implantation),
• 2-the scar is stronger and less incidence of
  subsequent rupture (0.2-0.4).
• 3- less ileus, stomach dilatation ,
• 4-infection and adhesions is anticipated with
  lower segment incisions compared to upper segment
  incisions.
• Low cervical incision may be a low cervical
  transverse (LCT) incision (Monroe/Kerr) or a low
  cervical vertical (LCV) incision (Kronig/Selheim)
  . In general, the LCV incision tends to have
  increased blood loss because it extends into the
  upper uterine segment and has been thought to
  have a greater incidence of rupture during
  subsequent pregnancies when compared with the LCT
  incision, although this has not been
  substantiated. Its main disadvantage is possible
  downward extension with bladder injury. On the
  other hand, the LCT uterine incision has a
  greater tendency to extend laterally into the
  uterine vessels at the time of operation.

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• Preoperative Preparation
• Preoperative visit by the anesthesiologist is
  important to assess the patient's anesthesia
  status and risk for untoward events during and
  after surgery.
• Patients scheduled for elective procedure should
  be kept fasting for at least 8 hours. Plans to
  decrease potential morbidity associated with
  aspiration of gastric contents should be carried
  out in non-elective procedure including
  administration of oral antacid (Magnesium Citrate
  within 1h of start of anesthesia).
• A large intravenous line is begun prior to the
  anesthetic administration and an infusion of
  crystalloid solution started.
• A recent Hb and Hct is checked and blood type
  and screen is done.
• Blood should be available in high risk
  parturient.
• Urinary bladder should be empty, either by a
  catheter or allowing the woman to empty her
  bladder immediately before operation.
• Preparation of the abdominal and perineal area
  include shaving just prior to surgery, 5-min
  scrubbing with a suitable detergent
  (hexachlorophene, povidone-iodine, and
  chlorhexidine) and covered with a sterile
  draping.
• The operating team should comply with all phases
  of universal precautions to avoid exposure to
  infectious agents.
• Anesthesia for cesarean birth is usually divided
  into two categories general endotracheal
  technique and regional anesthesia. Local
  anesthesia is rarely performed is critically ill
  patients only with the midline incision. Regional
  techniques usually entail either spinal or
  epidural blocks.

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Postoperative care Regardless of the type of
abdominal wound 1 - The incision should be
covered with a compression dressing and should be
checked when the vital signs are measured for
signs of hemorrhage through the bandage. In
general, the morning of the first postoperative
day, bandages are removed whether skin clips,
subcuticular closure, or mattress silk sutures
have been used. 2 - Care is taken to assess for
the development of hematomas, seromas, or wound
infections. Areas of redness and palpable masses
or extraordinary tenderness or induration are
carefully assessed twice daily. Signs of
cellulitis require cultures and antibiotic
therapy. 3 - The notation of a watery discharge
from the wound may herald impending wound
dehiscence and should be treated as an
emergency. 4 -With primary transverse CS, the
skin clips and mattress sutures are removed on
the fourth or fifth postoperative day or
according to wound condition. 5 - As after any
major surgical procedure, the potential for
severe maternal postoperative complications is
present. Because of the hypercoagulable state of
pregnancy, the hazard of postoperative
embolization is increased Patients are
encouraged to ambulate on the first postoperative
day and are made to turn, cough, and deep-breathe
immediately after surgery. The diet is
progressed from clear liquids on the evening of
the operative day if surgery was in the morning,
usually beginning about 8 to 12 hours after
surgery. Adequate pain medication is an
essential component of postoperative management.
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Complications of Cesarean Section A - Maternal
Mortality Improved surgical and anesthesia
skills, antibiotics, aseptic techniques, and
blood product availability have decreased the
risks of this procedure. However, cesarean birth
still holds a much greater risk for the mother,
with a maternal mortality rate of 20 per 100,000
births in the United States compared with a
maternal mortality rate from vaginal delivery of
2.5 per 100,000 births. Anaesthetic accidents,
including aspiration pneumonia, severe sepsis and
thromboembolic and hemorrhagic complication are
the main cause of maternal death.
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B - Maternal Morbidity Although maternal
morbidity has decreased significantly with
cesarean section, it is still between eight and
12 times higher than for a vaginal birth. It may
result from similar postpartum etiological
factors , anesthetic complications, or those that
arise in the intraopertative period as injury
(bladder, ureter, bowel), bleeding with
consequent anemia, infectious or thromboembolic
complications. Remote morbidity include adhesive
intestinal obstruction, ruptured uterine scar in
next pregnancy, placenta accerta to previous scar
and incisionnal hernia more common with midline
subumbilical vertical incision. Postoperative
febrile morbidity (10-50), depending on whether
the cesarean birth is performed electively or
during labor with ruptured membranes, is markedly
decreased with vaginal delivery (1-3).
Endometritis, urinary tract infection, and wound
infections are the major causes of postoperative
morbidity following cesarean births.
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C - Fetal/Neonatal Mortality and Morbidity. The
safety of cesarean birth for the neonate has
increased dramatically over the past 2 decades.
Elective cesarean sections are the major cause of
iatrogenic preterm delivery (1 to 20 of hyaline
membrane disease (HMD) cases are products of
elective cesarean delivery). When abdominal
delivery must be performed prior to fetal
maturity, it is imperative to document, confirm
or be assured of pulmonary maturity. Elective
cesarean delivery no earlier than 39 weeks is
advised by the American College of Obstetricians
and Gynecologists. If the patient has
insulin-requiring diabetes mellitus during
pregnancy, or dating cannot be firmly
established, an amniocentesis is recommended to
confirm lung maturity via a series of lung
phospholipid studies if delivery is to be
undertaken prior to 39 weeks' gestation.
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D - Family, Maternal-Infant attachment attitudes
toward cesarean births among women. This is not
surprising, since maternal anxiety and
disappointment at not having a "normal birth," as
well as a sense of failure and loss of autonomy,
are associated with the operations. E -
Obstetrician and Medico-Legal aspects Legally,
obstetricians and hospitals are at risk if the
outcome of any birth is less than perfect,
particularly if a cesarean birth was not
performed.
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Vaginal Delivery after Cesarean Section Because
more than 25 of cesarean sections are repeat
procedures, vaginal births after cesarean
section (VBAC) have become increasingly supported
by the medical community. The success rate for
VBAC has been reported to be from about 60 for
patients who were previously delivered for pelvic
dystocia to more than 70 for patients who were
delivered by cesarean birth for nonrecurring
conditions such as breech presentation or fetal
distress. The advantages of vaginal birth include
decreased maternal and neonatal morbidity as
well as decreased hospital time for both mother
and baby. The use of oxytocin or epidural
anesthesia is not contraindicated in VBAC. A
trial of labor should be offered for all with a
nonclassical uterine incision. The risk of
uterine rupture for which the dictum "once a
cesarean section, always a cesarean section" was
once used has been noted to be approximately 0.5
as compared with 10 in patients with prior
classical incisions.
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