APPROACH TO CAESAREAN

SECTION
PRESENTATION BY DR MAKOJOA K – INTERN DR FMMED
MOTEBANG HOSPITAL
OCTOBER 2022
APPROACH TO CAESAREAN
SECTION
1. Identify Indication for Caesarean Section
2. Prepare for Caesarean Section
3. Intra-operative Events
4. Post-Operative Management
5. Post – Operative Assessment
6. Discharge Criteria
7. Follow-up: Post - Partum
Why Approach to C-Section
Motebang Hospital, in September of 2022
1. Out of 170 deliveries, 50 were Caesarean Sections: average 2 C-sections everyday
2. Caesarean Sections contributed 68 % of all surgical procedures
3. Received a number of new Intern Drs, who needed guidance towards this approach
4. All doctors have to consolidate and update their approach based on recent literature

OK SO LET’S DO THIS…….
Indications of Caesarean Section
Classified into:
1. Very Urgent
2. Emergency
3. Planned (Elective) Caesarean Sections
Indications of C/S Classified
INDICATIONS OF VERY URGENT C/S
1. Umbilical Cord Prolapse
2. Abruptio placentae – if living child
3. Partial or Total Placenta Praevia
4. Pre-rupture syndrome
5. Uterine rupture
6. Eclamptic seizure
7. Acute Foetal Distress (FHR <80bpm for >10 mins or
late deceleration repeated for ½ hr)
INDICATIONS OF EMERGENCY C/S
1. Foetopelvic Disproportion (CPD): Failure to progress in
labour due to: dilatation stopped, obstructed labour, stagnation of the
presentation at midpelvis
2. Dynamic dystocia: cervical dilatation not responding to
treatment
3. Malpresentation and Malposition: brow, face, shoulder,
breech, transverse
4. Chorioamnionitis: T ≥ 39°C, foul-smelling pv discharge,
uterine tenderness without contractions
5.Severe PreEclampsia
6.Foetal Heart Rate Abnormalities: FHR > 180bpm for > 1hr,
regular or late deceleration of FHR < 90bpm for 1 hr
Indications of Elective C/S
1. Iterative Uterine Procedure:
◦ Previous C/S X1 or X2
◦ Previous uterine rupture

2. Maternal Causes:
◦ Cervical and mechanical dystocia; pelvic abnormality
◦ Active genital herpes (vesicles), condyloma acuminata
◦ HIV+ without ART
◦ Genital mutilation, vesico-vaginal fistula (repaired or not)
◦ Severe cardiac or neurologic disease

3. Foetal Causes:
◦ IUGR, Chronic Foetal Distress (CFD)
◦ Non-reducible transverse position
◦ Twin pregnancy ; 1 twin - transverse, breech-cephalic or breech – breech presentation,
◦ Foetal Macrosomia

4. Placental Causes:
◦ placenta praevia IV

5. Adnexal Causes:
◦ Praevia barrier; adnexal mass, uterine fibroma
Indications of C-Section
Preparation
1. Inform, Educate and Counsel (IEC) patient plus partner
2. Optimise patient with co-morbidities eg anaemia, DM, HTN and obesity
3. Sign consent
4. Inform Theatre
5. Draw blood for Hb and group & save (sometimes cross match, if low Hb)
6. Tubes: IV access (IVF & Pre-Op meds + Indwelling urinary catheter)
7. Obtain blood results

(common practice – Motebang Hospital, 2022)

 Pre-Operative Preparation
- prevent low gastric pH with: histamine H2 antagonist (oral ranitidine) and non-particulate antacid eg sodium
citrate
- Keep NPO for ≥ 6 hrs for solid feeds and on clear liquids ≥ 2 hrs
- Pre-operative gabapentin recommended for post – op analgesia
- Antibiotic Prophylaxis: cover G+ve & G-ve bacs plus anaerobes…recommended cephazolin doses as
follows: < 80 kg: 1g IV stat
> 80kg < 120kg: 2g IV stat
> 120kg : 3g IV stat
For cephazolin contraindications like allergic reactions, administer: clindamycin 900mg + aminoglycoside
5mg/kg
For patients with MRSA : add vancomycin
- Topical preparation with povidone or chlorhexidine or both
- Vaginal Preparation done with povidone/chlorhexidine mixture (reduces post-op wound infxn by 5%)
If membranes ruptured or after labour, administer azithromycin 500mg IV stat (reduces wound infxn by 1 %).
- Foley catheter size 14 or 16
(Sung, 2022)
Anaesthesia
Options:
1. Regional Anaethesia (Spinal)
◦ Use bupivacaine hyperbaric 0.5% (2nd choice – bupivacaine isobaric 0.5%) plus opioid (morphine,
fentanyl or sufentanil)

2. General Anaesthesia
◦ If Spinal anasthesia is contraindicated
Personnel
1. The Surgeon: obstetrician/gynaecologist, family physician, general surgeon,
2. Surgeon’s Assistant: practice practitioner, nurse, midwife
3. Anaesthesiologist/Anaesthetist: for general patient well-being, administration of meds
including IV fluids & blood products, blood loss, urine output. Can also draw blood if
necessary.
4. Scrub nurse/Technician: provides surgeon with instruments or sometimes assists
5. Circulating Nurse: non-sterile member for supplies plus swab and instrument count
6. Someone to care for the neonate: nurse, nurse practitioner or surgeon. Anaesthesiologist or
anaesthetist or paediatrician may have to be called. (Sung, 2022)
Equipment
- Patient be in supine position, table tilted to 15°, soles of feet together
Intra-Operative Events
- to achieve C/Section, the surgeon traverses all the layers that separate them from foetus:
◦ 1. Abdominal Wall
◦ 2. Uterine Wall
◦ 3. Membranes (if still intact)
- There are other important structures that need to be taken care of in order to minimize tempering
with normal anatomy
- Blood vessels
- Urinary bladder
- adnexa

(Sung, 2022)
Anatomical Considerations – Abd.
Wall

(Moore, 2014)
Anatomical Considerations - Uterus
2014)
(Moore,
Anatomical Considerations – Uterus
(Moore, 2014)
Technique

Technique (Sung2,022)

- complicated, major procedure

- needs appropriate tissue handling, adequate haemostasis, avoiding tissue ischaemia, infection
prevention to maximize wound healing and reduce adhesion formation
General Precautions:
- Pubic hair may not be removed or if done, use hair clipper and NOT RAZOR
- several surgical approaches:
◦ 1. Pfannenstiel – Kerr Method
◦ 2. Joel – Cohen Method
◦ 3. Misgav-Ladan Method
◦ 4. Modified Misgav – Ladan Method
 Surgical Approaches
PFANNENSTIEL – KERR METHOD
•slightly curved skin incision, 2 finger-breaths above
symphysis pubis
•sharp dissection of subcutaneous layer
• sharp extension of fascial opening
• sharp superficial then blunt entry into uterus
• manual removal of placenta
• single layer interrupted uterine closure
• closure of peritoneum
• interrupted closure of fascia
• continuous suture of skin
JOEL – COHEN METHOD
•Straight and slightly more cephalad than pfannenstiel, 3cm below
the line connecting ASIS
•Blunt dissection of subcutaneous layer
•Blunt dissection of fascial opening
•Blunt entry into peritoneum
•Sharp superficial, then blunt entry into uterus
•Spontaneous removal of placenta
•Single layer interrupted uterine closure
•Non-closure of peritoneum
•Interrupted closure of fascia
•Continuous skin closure
Abdominal Wall Incision (Pfannenstiel Incision)

Objective:
To access the lower segment of the uterus
Giving adequate exposure at the hysterotomy site
Causing minimal tissue damage

NB: Johel Cohen incision has fewer complications than other approaches
Incision ( Possible Detachment) of Peritoneum
Uterine Incision
It should be performed in the lower segment of the uterus and in the center of the dissected
space, not at the uterine body level (so LSCS)
The thickness of the lower segment wall is highly variable and should be carefully assessed
before fully opening the uterine wall.
Child Delivery
Identification of the presentation through the hysterotomy
and evaluation of its degree of engagement:
Cephalic presentation (also called head first or vertex pres)
Occiput : Left Occipito Anterior (LOA) presentation: the most
common position and lie (the child is delivered face down).
Right Occipito Anterior (ROA) presentation, Left Occipito
Posterior (LOP) presentation: Right occipitoposterior
(ROP)presentation or occipitoposterior presentation (OP).
The child is delivered face up (brow, eyebrows, face, chin)
Breech presentation : you can see a buttock or a foot
◦ Frank breech : buttocks
◦ Footling breech : one foot
◦ Complete breech : two feet
Shoulder presentation :
◦ Arm (neglected shoulder)
◦ Shoulder
Placenta : placenta previa, regardless of the type of
presentation
Amniotic fluid aspiration
Amniotic fluid [use large suction tube, no nozzle], whether
clear or meconial, is sucked up to avoid contamination,
which occurs when the fluid leaks onto the drapes
[usually tissue].
EXCEPTION :
- if it is haemorrhagic [to save time]
- in the event of acute foetal distress
NB: If the placenta appears in the hysterotomy incision,
remove it quickly and immediately deliver the child
depending on the type of presentation. Find the
membranes, break the pouch and quickly take the baby
out.
Child Delivery
Child Delivery in Cephalic
Presentation
Placental Delivery
•After foetal delivery, Oxytocin 5 I.U IM, then another Oxytocin 5 I.U. IM after placental delivery
•Check that there is no active bleeding from large vessels
•Ensure haemostasis of the uterine wound edges with abdominal compresses.
•Check the integrity of the placenta and membranes.
•Perform systematic uterine cleaning.
•Spontaneous delivery of the placenta must be the rule.
Uterine Closure
Attention should be given to exposure of the operating site
This point is too often neglected, the quality of the suture depends on it
Two continuous over-and-over stitch layers are recommended
The locking stitch is currently only used in thick uterine walls (outside labour) or in the case of a
severe myometrial hemorrhage
The bladder must be located so that it is not caught in the suture.

NB: Endometrium may have to be mopped clear of membranes before closure

 Abdominal Wall Closure
1. Cavity Inspection - Check annexes.
Check the uterine pedicles (anterior and posterior).
Check the suture of the uterine hysterotomy.
Express uterine clots by massage.
Aspiration of secretions and amniotic fluid, removal of clots with a compress, rinse if necessary.
2. Swab Count
3. Close the wall
Installation of a peritoneal drain in the Pouch of Douglas only if there is a risk of collection or infection. In the
event of major diastasis of the rectus muscles (> 8cm):
 Suture the two pyramidalis muscles at their upper end.
 If diastasis persists in the upper part of the wound, bring the two rectus abdominis muscles closer by suturing together the
edges of the posterior wall of the rectus sheath
 Post-Operative Care
Close monitoring of vital signs during the first 2 hours:
Pulse, blood pressure, temperature, pallor, uterine fundus
and blood loss urine colour & output and pain
•IV infusion : 12- 24 hours (for security reasons)
•Post-operative analgesia: First-line treatment: , -
Paracetamol 1g
po tds for 48 hours
Other possibilities:
- Diclofenac 50mg three times daily for 48 hours
- Paracetamol/Diclofenac alternately for 48 hours
[Recommended]
-Ibuprofen 400mg three times daily for 48 hours
Resume feeding:
◦[It must be conducted early, whether after general or
regional anaesthesia.]
Drinks allowed after six hours (even after 3 hours)
Light meal allowed after 12 hours
Dressing: Remove on Day 3 [change before if soiled] Then leave
the wound undressed
Remove the stiches, if not subcuticular, on Day 9
Prevention of thromboembolic risks. Early out of bed
mobilization, with help, the next day (or even earlier at the 12th
hour)
Elastic support stockings ideally for 7 days [often financially
unaffordable]
Low molecular weight heparins (LMWHs): for at-risk patients
(obese, history of thrombophlebitis, etc.)
Removal of the bladder catheter Before the 12th hour
or when the initially bloody urine becomes clear or after 7 days, if
there is any doubt concerning a bladder injury
Monitor the resumption of urination
Discharge from hospital : Possible after 1 or 2 days
Post-Discharge
- Prior to discharge , it must be ensured that the patient has access to a reliable means of
communication with the labour and delivery unit
- And patient should know who to contact in case of any concerns
- Patient should be contacted within 24 hrs post discharge
In Conclusion – Take Home
Be conversant with each step of the process………………………
“Begin with the end in mind”….Dr Stephen R Covey
 References
1. Clipple C et al. 2020. Caesarean Section – In Conditions of Limited Resources. Jean-Michel Pochet Louvain
Coopération au Dévelopment. Louvain-la-Neuve – Belgique
2. Dutta D.C. 2014. DC Dutta’s Textbook of Obstetrics. 7th Edition. Jaypee Bothers Medical Publishers (P) Ltd. New Dehli
3. Ituk U,Enhanced Recovery After Cesarean Delivery. 2018, (1)7:513
4. Moore K.L et al. 2014. Clinically Oriented Anatomy. 7th Edition. Walters Kluwer – LippincottWilliams & Wilkins.
Philadelphia
5. Patel K & Zakowski M. Enhanced Recovery After Cesarean: Current and Emerging Trends. Curr Anaesthesiol
Rep (2021), 11: 136 - 144
6. Ritter J.M et al, 2008. Textbook of Clinical Pharmacology and Therapeutics. 5th Edition. Hoddern Anorld.
London
7. Sung S & Mahdy H. Caesarean Section. 2022 .pubmed.ncbi.nlm.nih.govMoore K. L. et al, 2014.
Step by Step (Sung, 2022)

1. Anaesthesia – epidural/spinal/general
2. Patient Position - supine, bed tilted to 15° to left
3. Scrubbing – with povidone 7.5% plus savlon solutions
4. Draping - done with sterile drapes, hold with towel clips
- sterile screen
5. Abdominal Wall Incision - Vertical or transverse (Pfannenstiel/Joel-Cohen
- subcut layer: blunt/sharp dissection, may use cautery
- fascial incision with scalpel, then extension sharply/bluntly
- fascial dissection bluntly from underlying rectus muscle both
superiorly and inferiorly using Kocher Forceps
- separation of rectus muscle in midline
- sharp or blunt entry into peritoneum, take care of injury to underlying structures eg bowels and or urinary bladder
- blunt extension of peritoneal incision
- place bladder blade (Doyen’s Retractor), visualize lower uterine segment
6. Uterine Entry (hysterotomy): - transverse or classical (Inverted “T”, “J” or “U”), preferably
starting from midline
- incision made with scalpel in shallow strokes,
- blunt lateral extension with fingers or sharply with bandage scissors (not preferred
though), in a cephalad-caudad fashion
7. Amniotomy: preferably with amniotomy hook
NB: safe delivery of the foetus is the ultimate goal of Caesar, regardless of details of the technique
8. Delivery of Foetus: - insert hand into uterine cavity and elevate head into the hysterotomy.
- instruments may be used
- once head grasped, fundal pressure is applied by assistant surgeon
- If in breech: - identify foetal lie
- either grasp feet or hips to bring foetus into hysterotomy
- gentle traction to deliver shoulders
- bilateral ar ms are swept down and delivered
Or apply Mauriceau Smellie Veit Maneuver
9. Umbilical Cord Delivery: - No need to rush!!!!!!!!!!!!!!
- clamp cord 2 finger breaths away from foetal abdomen in 1-
3 mins for a live crying baby, more quicker for a floppy baby
- use cord clamps, 3-4 finger breaths apart, then cut cord with
cord scissor
10. Placenta Delivery: - spontaneous delivery more preferred
- then clear endometrium of membranes with moist/dry laparotomy
sponges
11. Uterine Closure: - Hold uterine incision corners with Allis Forceps or Green Armitage Forceps (at
least 4 needed)
- re-introduce Doyen’s Retractor to protect bladder
- Uterus may be sutured in situ or exteriorised
- in layers (either 2 or 3), ideally starting from the farthest end
- Layer 1: using suture material of No ‘0’ chromic catgut or vicryl and the
needle is round bodied. Continuous suturing technique, taking deeper myometrium, with attempt
to spare decidua
- Layer 2: another continuous suture, holding myometrium with perimetrium
- Ensure Haemostasis
12. Examine Cul-de-sac and paracolic gutters: Blood clots cleared abdominal sponges or suctioned
out and swab count done
13. Closure of Abdominal Wall: - peritoneum examined for bleeding and not necessarily sutured
- may or may not re-approximate rectus muscle
- Close fascia with a delayed-absorbable suture in continuous technique
- monofilament suture is a more preferred option (reduces risk of hernia)
- Irrigate subcutaneous tissue and ensure haemostasis
- Close subcutaneous tissue more especially if > 2cm thick.
NOTE: NO DRAIN PLACEMENT
- Close skin with monofilament suture or surgical staples
Other Intra-Op Care
Hypotension: preferably use phenylephrine 50mcg/min in 2L of crystalloid
Temperature: No best strategy yet but normothermia is encouraged
Neuraxial Anaesthesia + Opioids: bupivacaine & fentanyl/sufentanil, then hydrophilic opioid like
morphine added
IONV & PONV: IONV usu induced by Hypotension. Treat hypotension as above and
metoclopramide
PONV – Prophylactic ondasetron + dexamethasone or droperidol
Complications of C-Section (Sung, 2022 & Dutta, 2014)

INTRA-OPERATIVE POST-OPERATIVE
Immediate

- Excessive haemorrhage - PPH with/without shock

- Anaesthetic hazards: aspiration, hypotension, headache
- Extension of uterine incision
- Infections
- Gastrointestinal tract injury - intestinal obstruction

- Bladder injury: rare - Venous ThromboEmbolism (VTE)

- Wound complications: pus, haematoma, dehiscence, etc
- Ureteral injury: rare
Remote
- Gynaecological: menstrual disturbance, chronic pelvic pain
- General surgery: incisional hernia, bowel obstruction
- Future pregnancy: ? scar rupture
Post-Operative Care (Sung, 2022, Patel, 2021 & Dutta, 2014)

First 24 hours (Day 1):

◦ 6-8 hrs post-op regular vitals, PV bleeding and and behavior of uterus in LSCS
◦ IV Fluids; 2 – 2.5l of NS or RL, BT if blood loss > 1 000ml
◦ Oxytocic 5 I.U IM stat or IV slow, may have to repeat
◦ Prophylactic antibiotics (cephalosporins & metronidazole) for 2 – 3 days
◦ Analgesics eg pethidine 100mg IM with acetaminophen-NSAID or acetaminophen-opioid combination
◦ Early ambulation and deep breaths are encouraged
◦ Early Breastfeeding

Day 2:
◦ Oral Feeding (soft diet, warm tea)
◦ Confirm bowel sounds by end of the day
Day 3:
◦ Light solid diet
◦ Lactulose 3-4 teaspoons norcte if still no bowel movements
◦ May discharge

Day 4-7:
◦ Removal of abdominal stitches (Day 5 for transverse, Day 6 for longitudinal)
◦ Discharge home