Cesarean Section

Prepared by:

Dr. Gehanath Baral

MBBS,DGO,MD
Senior Consultant Gynecologist & Obstetrician: Government of Nepal
Visiting Professor: CTGU
10th April, 2007

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 Definition

1. Operative procedure whereby the fetus is

delivered through an incision on the abdomen
and anterior uterine wall after the age of
extrauterine viability or at and after 28 weeks
of gestation.

2. Surgical delivery of fetus via abdominal route

after 28 weeks of gestation.

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 Types by uterine incision

1. Lower segment CS (LSCS)

– Incision over the lower, thin and passive part of uterine wall
– Commonly used

2. Upper segment or Classical CS

– Incision over the upper ,thick and active part of uterine wall
– Obsolete now, only if:
1. No access to lower segment:
– Adhession
– Cx fibroid
2. Risky:
– Cx carcinoma
– VVF repair
3. Post mortem

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 Types by timing

Elective CS (Planned)

Emergency CS (Unplanned)

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 Indication: Absolute

1. Placenta previa grade 3 & 4

2. Contracted pelvis/CPD

3. Obstructing pelvic mass and vaginal narrowing

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 Indication: Relative

• Fetal distress • VVF repair

• Mild CPD • Cord prolapse
• Obstructed labor • Cx/Shoulder dystocia
• APH • Uterine scars
• Malpresentation • Failed induction/
progress of labor

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 Procedure

• Preparation of pt: • Anesthesia

– Theatre gown • Antiseptic cleaning
– I/V line + Crystalloid • Draping
– Ranitidine 50mg I/V
• Incision:
– Metoclopramide
10mg I/V – Abdominal
• Vertical (Median/
– Dorsal positioning Paramedian)
– Catheterization • Pfannenstiel/Transverse
– Uterine
• Lower segment
• Classical

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 LSCS

Abd.incision:
1. Median:
– Skin Subcutaneous tissue Linea alba Parietal
peritoneum Abd.cavity.
2. Paramedian:
– Skin Subcutaneous tissue Ant.rectus sheath  Rectus
muscle Post.rectus sheath Parietal peritoneum
Abd.cavity.
3. Pfannenstiel:
– Skin Subcutaneous tissue Ext.oblique aponeurosis 
Ext.oblique m. Int.oblique m. Transversus abdominis m.
Post.rectus sheath Parietal peritoneum Abd.cavity.
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 LSCS

Uterine incision:
1. Open vesico-uterine pouch (visceral
peritoneum) transversely
2. Push down urinary bladder downward from
lower segment of uterus
3. Transverse incision over the lower segment
4. Open up full thickness uterine wall
5. Extend incision laterally to accommodate fetal
head
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Incision: Classical vs Transverse

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Opening uterus

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 LSCS

Delivery of fetus:
• Puncture amniotic membrane
• Suction fluid
• Insinuate right hand beneath the fetal head
• Pull out head gently
• Mop nose,mouth & eyes
• Deliver trunk
• Oropharyngeal suction
• Clamp cord and cut in between clamps
• Transfer baby to resuscitation cot
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 LSCS

Delivery of placenta:
1. Observe contraction of uterus
– Ask to administer oxytocics: Oxytocin &/or Methyl-ergometrine
I/V
– Gentle uterine massage
2. Remove placenta
– Gentle traction of cord and placenta
– Manual removal: Stripe out placental attachment with fingers
3. Explore uterine cavity to see placental pieces &
membrane if any
4. Examine placental integrity

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Delivery of Head and Placenta

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 LSCS

Uterine closure:
• Apply clamps (Green Armytage)
– Clamp both ends (angles) of incised wound
– Clamp both flaps at the center
– Haemostatic clamp
• Suture in 3 layers
– 1st layer: Inner muscle layer, Continuous no.1Catgut, from one
end to another
– 2nd layer: Outer muscle layer,Continuous no.1or 1-0 Catgut,
from one end to another
– 3rd layer: Peritonealization, Continuous no.1-0or 2-0 Catgut,
from one end to another
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Uterine suture:1st layer

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Uterine closure:2nd layer & Peritoneum

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 LSCS

Abdominal wound closure:

1. Parietal peritoneum: Continuous no.2-0 Catgut

2. Anterior rectus sheath/ External oblique aponeurosis: Continuous

no.1 or 2 Vicryl or Prolene from one end to another

3. Skin: Interrupted no.2 Silk or Clips.

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 End of procedure

• Sterile gauze cover to the sutured wound

• Adhesive tape over the covered wound
• Vaginal cleansing:
– To remove blood clot and blood
– To see PPH if any
• Change pt’s gown and transfer to ward.

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 Post-operative care

1. Monitor vital signs q4-6hrs 1. Start breast feeding

2. Watch for: 2. Start oral feed from 2nd
– PPH
day
– Intake
– Output (urine & vomiting if 3. Start ambulation from
any) 2nd day
3. Medication: 4. Suture removal on 5-
– Antibiotics 7days
– Analgesics/Sedation
– Oxytocics
– Antiemetics
4. I/V fluid for 12-24hrs: N/S or
R/L + 5% Dextrose

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 Complication
1. PPH
2. Injury to:
– Uterine vessels
– Bladder
– Ureter
– Bowel
– Fetus
3. TTN (transient tachypnoea of neonate) or RDS
(respiratory distress syndrome)
4. Anesthetic hazard
5. Infection:
• Wound Infection & Dehiscence
• Genital tract
• UTI
• Pneumonia
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