Caesarean Section

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 week of gestation. NOTE: Non- surgical means of expulsion of the fetus/ embryo from the uterine cavity as in uterine rupture or ropture of an ectopic pregnancy is not included. The operation for such condition is known as LAPAROTOMY.

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HISTORICAL PERSPEDTIVE  Origin controversial.  Hypothesised to be named after the manner of birth of Julius     

Caesar in 100 BC. Originally used to deliver the baby of a mother who had died in ancient Egypt, Asia AND Europe. First caesarean section on a live woman was that on the wife of Jacob Nufer in the 16th century. Earliest report of a child that survive C/S was the birth of Gorgias of Sicily in 508 BC. The procedure was associated then with high mortality due to sepsis ( lack of antibiotics) and there was no anaesthesia. Great improvement and survival from the 19th century especially with the advent of the lower segment C/S BY Munro – Kerr.

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incidence  Inwest Africa 15 – 21 %.  In UPTH average about 30%.

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Preoperative preperation. A full history and physical examination. Past medical and surgical history. Current medications. Hx of drug allergies. Indication for the C/S. Consent for the surgery. Laboratory investigations – PCV, Urinalysis, EU/Cr. More extensive investigations in complicated cases like hypertension, cardiac diseases etc. patients are individualised in such cases.  Pass indwelling Folley urethral catheter into the bladder and retain.  During transfer to the theatre, and during anaesthasia, patient should lie on her left lateral side with a wedge on her right buttocks to prevent to prevent supine hypotension.       

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Preoperative preparation contd.  Pre – medication with antacid is

standard.  Prophylatic antibiotics before the surgery.

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Indication For C/S,  MATERNAL INDICATIONS   

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Severe pre- eclampsia with unfavourable cervix for vaginal delivery. (absolute) Previous classical caesarean delivery. (absolute) . Previous extensive uterine surgery with entry into the uterine cavity eg myomectomy. Obstructive pelvic tumours eg friboids, ovarian cysts. 6

Maternal indications for C/S contd.  Previous 30 perineal tears.  Previous successful V V F repair

( absolute).  Vulva herpes simplex.

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FETAL INDICATIONS FOR C/S.  Fetal distres.  Abnormal presentations – breech, brow

(absolute), persistent occipito – posterior in labour, face with mento – posterior.  Abnormal lies – transverse, oblique,  Multiple gestations – triplets and higher order gestations.  Fetal macrosomia – weight greater than 4500g. 8

Fetal indications for C/S contd.  Footling breech,  . Very low birth weight – ( less than

1500g).  Fetal abnormality –hydrocephalus, conjoint twins, spina bafida.

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MATERNAL – FETAL INDICATIONS FOR C/S.  Cephalopelvic disproportion.  Dystocia –arrest of cervical dilatation or

failure of descent of presenting part.  Major degree placenta praevia.  Placental abruption with a live fetus.  Absolute pelvic disproportion.

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SKIN INCISIONS FOR C/S  Skin incicions could be vertical or

transverse. Both have advantages and disadvatages.  Vertical incisions – 

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Midline sub – umbilical incision (most commonly used skin incision in (UPTH). Midline incisionextending above the umbilicus. Paramedian. 11

Vertical incisions contd. ADVANTAGES:  Less vascular, less haemorrhage.  Gives good exposure of both pelvic and abdominal organs.  Very useful in emergencies due to speed and ease of the procedure. DISADVANTAGES – prone to hernia formation and evisceration risk.

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Transverse skin incisions.  Pfannenstiel (most popular).  Advantages:

Excellent cosmetic appearance.  Less risk of wound dehiscence.  Early ambulation.  Less risk of hernia formation. Disadvantages.  Takes longer time to perform. 

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Transverse skin incisions contd.   

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May result in injury to ileo – inguinal and ileo – hypogastric nerves. Increased blood loss. Cohen incision – It is a straight transverse incision – anterior rectus sheath incised in the midline followed by blunt dissection. Maylard incision – (UNCOMMON) – transverse incision like the Pfannenstiel but the rectus is cut through at any level between the pubis and the umbilicus. Cherney incision – like Pfannenstiel but unlike the latter, the two recti muscles are pulled away from their insertion into the pubis. 14

UTERINE INCISIONS.  Lower segment transverse incision – 90

% of C/S.  Low vertical (De Lee) incision- made parallel to the longitudinal axis of the uterus in the midline but keeping mainly to the lower segment.  Classical incision – is made by incising the uterus parallel to the longitudinal axis of the uterus in the midline. 15

Classical incision  Indications.      

Preterm delivery with poorly formed lower segment. Placenta praevia with large vessels in lower segment. Premature rupture of membranes, poor lower segment and transverse lie. Transverse lie with back inferior. Large cervical fibroid. Postmortem C/S. 16

Advantages of transverse lower uterine incisions over classical incision  Less risk of entry into upper uterine segment.  Great ease of entry.  Less risk of adhesion formation to bowel or    

omentum. Less likelihood of uterine rupture in subsequent pregnancies. VBAC is possible. Less intra- operative bleeding. NOTE THAT CLASSICAL C/S ARE NOT ROUTINELY DONE. 17

Advantages of classical incision over lower segment incision.  Rapid entry into the uterus.  No lateral extensions into the uterine

vessels and broad ligament.  If lower segment is poorly developed, delivery by classical C/S is advantageous without lateral extension.  Easy entry into the uterus when there is fibroid in the lower segment. 18

Anaesthesia For C/S.  General anaesthesia.  Regional anaesthesia.

Spinal.  Epidural AVOID FULL STOMACH ESPECIALLY INLABOUR DURING ANY FORM OF ANAESTHESIA. 

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COMPLICATIONS OF C/S.  Haemorrhage which may lead to anaemia.  Injury to maternal organs – bladder, blood      

vessels, uterus, bowel. Injury to neonate. Wound infection. Deep vein thrombosis. Endometritis. Maternal mortality. Anaesthetic complications. 20