Transcript Slide 1

CESAREAN SECTION
Dr.R.alyamani
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.
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 (>50% increase).
Malpractice suites.
Maternal Indications:
1-Antepartum hemorrhage (placenta praevia, severe abruptioplacentae), 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.
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.
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.
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).
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.
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, povidoneiodine, 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.
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.
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.
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.
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.
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.
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.