CESAREAN SECTION Cesarean section is delivery after 28 weeks of the fetus, placenta and membranes through an abdominal and uterine incisions TYPES OF CESAREAN SECTION I. According to the operative methods: 1 .Extra peritoneal :was used in the past to avoid severe peritonitis 2 .Intraperitoneal : Upper segment C.S. (U.S.C.S). If the incision is done in the upper uterine segment. Lower segment C.S. (L.S.C.S) with transverse incision in the lower segment. Munro Kerr’s. L.S.C.S. with vertical incision in the lower segment = Kroning operation. II. Types according to the time of performing it: Elective: if the operation is performed before the onset of labour. Selective: if C.S. is done after the onset of labour. After failed trial of labour. III. Types according to the number of C.S:. Primary C.S.: is the first C.S. Repeat C.S. is the second, third, fourth, etc. INDICATIONS OF C.S. I. Faults in the passages . Hard passages as (= contracted pelvis and C.P.D.) if ® Gross outlet contraction. ® Inlet contraction ® Mid-pelvic contraction. . Soft passages Uterus ® previous C.S.: Repeat section is the commonest indication, previous scars in the uterus (myomectomy and uteroplasty) Cervix ® cervical stenosis and rigidity: if the cervix remains tough and does not dilate more than I inch. Vagina ® vaginal stenosis ® successfully repaired vesico vaginal fistula or recto vaginal fistula . Tumors such as: . cancer cervix . cervical fibroids . ovarian tumour. impacted in pelvis H.P.V. infections of the vagina or vulva to avoid fetal infection. • II. Faults in the passengers: Malpresentations ® persistent Brow. ® transverse lie . ® Deep Transverse arrest of the occiput (D.T.A( ® Persistent occipito-posterior ® Breech (in 10-15%) Placental site hemorrhage ® Placenta praevia. ® Accidental Hemorrhage Placental insufficiency . Prolapsed pulsating cord with undilated cervix. III. Faults in the powers: • Uterine over activity in malpresentations and cephalopelvic disproportion (C.P.D.). • Uterine under activity (secondary inertia due to C.P.D.) IV. Diseases of the mother: Hypertensive disorders such as: • Severe P.I.H not responding to treatment. • Eclampsia: • After control of fits, if the patient is not in labour. • If the patient has not improved immediately by treatment. • If uncontrolled in 38 weeks Diabetes Mellitus. V. Fetal conditions: • Fetal distress during the first stage of labour. • Postmaturity • Rh-isoimmunization. • Oversized fetus ® cephalopelvic disproportion • Vasa-praevia: to avoid severe fetal hemorrhage resulting in death. • Recurrent intrauterine fetal deaths near full term. LOWER SEGMENT CESAREAN SECTION Abdominal incision: Transverse suprapubic incision "pfannenstiel incision" in the skin. Incision of the rectus sheath followed by the peritoneum then put, towel packs in the lower abdomen at both sides of the uterus to prevent soiling of the peritoneum by blood or liquor. • Centralise the uterus at first to correct dextrorotation to bring the uterine vessels laterally. • Put a Doyen's retractor in the lower abdominal incision to retract the urinary bladder and protect it. • Transverse incision in the peritoneum of the Lower uterine segment (for about 10 cm). Dissect the lower flap together with the urinary bladder, from the underlying lower segment. • Then insert the Doyens retractor to protect and separate the urinary bladder and lower peritoneal flap from the lower uterine segment. Uterine incision "Munro Kerr incision:" • Perform transverse incision in the lower uterine segment and the incision is enlarged by either: • 2 index fingers in the angles and retract them outwards. This decreases the bleeding by retracting the blood vessels laterally. • By the scissor: it is more clean but more bloody. • Rupture the amniotic membrane. • If the incision in the lower segment is insufficient for delivery of the head, it is enlarged by cutting it up at both ends "U shaped incision" to avoid injury of the uterine vessels. • Extraction of the fetus If the head is not engaged in vertex presentation it will protrude through the incision. Apply fundal pressure to expel the head. :• • If the head is deeply engaged it is delivered by either: • Lifting it up by the hand below the head, the head will glide over the hand. • Apply Wrigly's forceps. • Ventouse extraction. • Vaginal disimpaction by an assistant. • Clamp and divide the cord. • Delivery of the placenta and membranes. • Exploration of the uterine cavity for remnants and for congenital anomalies. • Digital or instrumental dilatation of the cervix if the cervix is not dilated. 01 • • Control of bleeding from the uterine incision by: suturing the uterine incision in 3 layers: • Continuous (dexon or vicryl No-0) layer in the muscle layer (but not including the decidua). • Interrupted or continuous inverted suture: to cover the first layer. • Peritoneum is closed by No-2/0 dexon or vicryl. • Abdominal toilet and remove the packs. • Abdominal wall is closed in layers. 04 • 05 • UPPER SEGMENT CESAREAN SECTION (USCS) • Abdominal incision: Median incision. • Uterine incision: Anterior central vertical incision in the upper segment • Uterine closure: 2 or 3 layered closure. Indications of U.S.C.S:. • If the time factor is important as in fetal distress and accidental haemorrhage. • If the Lower uterine segment is not accessible due to large fibroids, excessive varices, excess adhesions. • High vesicovaginal fistula (successfully repaired) • Impacted shoulder presentation. • If C.S. hysterectomy is indicated. 06 • Advantages of the L.S.C.S: Strong scar: (it ruptures in 0.2%) due to: • Better healing as the lower segment is passive in puerperium • Better coaptation of the edges (as they are thin). • No haematoma in the suture line. • The site of the incision is away from the placental insertion in subsequent pregnancy so, there is no erosion of the incision site by the chorionic villi. Less Haemorrhage: because • The placental site is away from the operation area. • Lower segment is thin and less vascular. . Less abdominal distension and ileus :because the intestines are away and not manipulated during the operation. Less infection due to: • Better peritonization. • Firmer healing. Less adhesions and intestinal obstruction .Because the wound is low in the utero vesical pouch and is covered by peritoneum. The mortality rate are low. The vertical L.S.C.S. "Kronig's operation:" The incision in the L.ut.seg. is vertical and a stay suture is inserted at its lower angle to avoid downwards extension of the incision & injury of the bladder. The incision can be extended up. Indications: • Constriction ring : to cut the ring. • Varicose veins in the broad ligaments (to avoid their injury resulting in bleeding). • Head deeply engaged in the pelvis, to facilitate it's extraction & to avoid lateral extension in the transverse incisions. • Hydrocephalus or foetal tumours. Post-mortem or perimortem C.S. To save the life of a living foetus; it is done within 10 minutes of maternal death . Caesarean hysterectomy: "Perform C.S. and then remove the uterus" Indications . : • Uterine atony associated with: • Severe P.P. Hge that cannot be controlled. • Couvelaire uterus (severe concealed accidental haemorrhage) • .Tumours associated with pregnancy as: • Malignant: operable cancer cervix. • .Placenta increta and percreta Complications of C.S.: these may be: I. Immediate: • Shock: Neurogenic or Heamorrhagic. • Haemorrhage: due to injury of uterine vessels, uterine atony or D.I.C. in concealed accidental haemorrhage. • Injury to the bladder and ureters. • Pulmonary anaesthetic complications as aspiration of vomitus and Mendelson's syndrome. II. Remote: as: • G.I.T : Paralytic ileus, acute gastric dilatation, and intestinal obstruction. • C.V.S : Phlebothrombosis. • Genital: Rupture scar in subsequent pregnancy. • Abdominal adhesions and intestinal obstruction. • Abdominal wound: Sepsis – burst – incisional hernia. • Pulmonary: Bronchitis and Bronchopneomonia. • Infection : generalized peritonitis - localized parametritis. RUPTURE OF C.S. SCAR IN SUBSEQUENT PREGNANCY: Incidence: in U.S.C.S.: 2-4% Causes: Weak C.S. Scar, is due to • Operative faults: as • Incomplete haemostasis resulting in hematomas in the wound edges that heal by fibrosis • Inaccurate coaptation of the wound edges. • Inversion of the decidua in the wound. • Post operative infection. • Placental insertion over the scar with erosion of the scar by chorionic villi. • In the upper segment C.S. the upper segment is not at rest (i.e contractions and retractions) delaying healing of C.S. wound. • Repeated pregnancies. • Overdistension of the uterus by polyhydramnios or twins. Management of pregnancy with previous C.S:. • Trial of vaginal delivery. • Repeat C.S. Indications of trial vaginal delivery: • Non-persistent cause of C.S as cephalopelvic disproportion. • Only one previous C.S. • Previous Lower segment C.S. • Previous normal vaginal deliveries • Previous normal puerperium • No tenderness over the C.S. scar • Vertex presentation • Head deeply engaged N.B. • C.S. with sterilization is done during C.S. when indicated • Anesthesia for C.S is done by general, epidural or spinal anesthesia.
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