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Latin Verb caedere which means to cut. French Obstetrician, Francois Mauriceau first reported caesarean section in 1668. Kronig in 1912,introduced lower segment vertical incision. Kehrer in 1881 did the transverse lower segment operation for the first time. Munro Kerr in 1926 not only reintroduced the present technique of lower segment operation but also popularized.
Definition
It is an operative procedure whereby the fetuses after the end of 28th week are delivered through an incision on the abdominal and uterine walls.
Incidence
Factors for increasing caesarean section Identification of at risk fetuses before term Identification of at risk mothers. Wider use of repeat C.S. in cases with previous caesarean delivery. Rising incidence of elderly pimigravidae. Decline in difficult operative or manipulative vaginal deliveries.
Decline in vaginal breech delivery Increased diagnosis of fetal distress and fear of litigation. Adoption of small family norm
Indications
1.Absolute Indications Vaginal delivery is not possible, CS is needed even with a dead fetus. 1. Central placenta praevia 2. Contracted pelvis or CPD 3. pelvic mass causing obstruction 4. Advanced carcinoma cervix 5. Vaginal obstruction (atresia, stenosis)
2.Relative Indications
Vaginal delivery may be possible with or without aids. But risks to the mother and /or to the baby are high. 1. CPD 2. Previous caesarean delivery(CPD, previous two CS, scar dehiscence, previous classical C.S) 3. Non reassuring FHR 4. Dystocia 5. Antepartum Haemorrhage
6. Malpresentations 7. Failed surgical induction 8. Bad obstetric history 9. Hypertensive disorders 10.Medical and gynaecological disorders
3. Common Indications
Primigravidae CPD Fetal distress dystocia
Maternal Indications
CPD and contracted pelvis Inadequate uterine force Previous classical cesarean section Previous LSCS Placenta praevia Eclampsia or pre-eclampsia Dystocia Carcinoma cervix
Fetal indications
Fetal distress Prolapse of umbilical cord Mal presentation Bad obstetrical history and habitual intrauterine death of fetus Abruption placenta Multiple pregnancy Maternal HIV infection
Time of operation
Elective Emergency Elective When the operation is done at a pre arranged time during pregnancy to ensure the best quality of obstetrics, anaesthesia, neonatal resuscitation and nursing services.
Time
Maturity is certain the operation is done about one week prior to the expected date of confinement. Maturity is uncertain Ultrasound assessment in first or second trimesters. Amniocentesis to ensure fetal maturity. Spontaneous onset of labour is awaited and then CS is done.
Type of operation
Lower segment Classical or Upper segment
Classical
The baby is extracted through an incision made in the upper segment of the uterus. Indications A. Lower segment approach is difficult 1. Dense adhesions due to previous abdominal operation 2. Severe contracted pelvis with pendulous abdomen
B. Lower segment approach is risky 1. Big fibroid on the lower segment 2. Carcinoma of cervix 3. Repair of difficult and high VVF 4. Severe degree of placenta praevia with engorged vessels in the lower segment
Premedication Ranitidine or Metaclopramide NG tube if needed Emptying the bladder, Keep catheter in place Checking of FHS Presence of Neonatologist
Anaesthesia
Spinal Epidural General
Position
Supine 15 tilt
Incision
Vertical Infraumbilical or paramedian Transverse 3cm above the symphisis pubis
Disadvantages
Takes a little longer time and as such unsuitable in acute emergency operation. Blood loss is little more Requires competency during repeat section Unsuitable for classical operation.
Packing
The Doyens retractor is introduced. The peritoneal cavity is now packed of using two taped large swabs. The tape ends are attached to artery forceps. This will minimize spilling of the uterine contents in to the general peritoneal cavity.
Uterine incision
Peritoneal incision The loose peritoneum of the utero-vesical pouch is cut transversely across the lower segment with convexity downwards at about 1.25cm below its firm attachments to the uterus. The lower flap of the peritoneum is pushed down a little.
Muscle incision The most commonly used incision is low transverse Advantages 1. Ease of operation. 2. less bladder dissection 3. less blood loss 4. easy to repair 5. complete reperitonisation 6. less adhesion formation 7. less risk of scar rupture
The method 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 10cm in length, the concavity directed upwards.
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 up the head by sterile gloved fingers introduced in to the vagina. The head can be also delivered using either wrigleys forceps
The rest of the body is delivered slowly and the baby is placed in a tray placed in between the mothers thigh and with the head tilted down for gravitational drainage. The cord is cut in between two clamps and the baby is handed over to the nurse. The Doyens retractor is reintroduced.
First layer the first stitch is placed on the far side in the lateral angle of the uterine incision and is tied with 0 chromic catgut or vicryl. A continuous running suture taking deeper muscles excluding the decidua ensures effective apposition.
Second layer -the superficial muscles and fascia by continuous suture. Third layer-the peritoneal flap by continuous inverting suture. Concluding part The mops placed inside are removed and the number verified. Peritoneal toileting is done and the 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 of blood clots and a sterile vulval pad is placed.
Prophylactic antibiotics Analgesics Breast feeding Ambulation and exercises- leg, ankles, deep breathing ,sitting or walking-prevent deep vein thrombosis and pulmonary embolism
Day 1 Observe for bowel sound Oral feeding-clear liquid, coffee tea. Day 2 Light solid diet Laxatives Day 5-6 Stitches are removed
Transverse D-5 Longitudinal D-6 Discharge Patient is discharged on the day following removal of the stiches. Health education
The incision is deepened along its entire length until the membranes are exposed which are punctured. The baby is delivered as breech extraction Methergin Placental removal Suture of the uterine incision Uterus is returned back into the abdominal cavity
Packings are removed Peritoneal toileting is done The abdomen is closed in layers
Classical
Technically easy Blood loss is more The wall is thick and apposition of the margins is not perfect Not possible Comparatively safer in such circumstances.
Post operative
Haemorrhage and shock-less Peritonitis is less Peritoneal adhesion and intestinal obstruction are less
More
Convalescence is better Relatively poor Morbidity and mortality are lower Morbidity and mortality are higher
Wound healing
The scar is better healed The scar is weak because because of : of:
Perfect muscle apposition due to thin margins Imperfect muscle apposition because of thick margins
Complications
Due to operation or anaesthesia Intra operative complications Extension of uterine incision to one or both the edgesinvolve uterine vessels broad ligament haematoma Uterine lacerations-laterally or inferiorly to vagina Bladder injury two layer closure with 2-0 chromic catgut, continuous bladder drainage for 7-10 days
Urethral injury Gastrointestinal tract injury Uterine atony and primary post partum haemorrhage Morbid adherent placenta
Wound complications Wound sepsis, sanguineous or frank puss, haematoma, dehiscence, burst abdomen.
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