C-section

C-section is considered as one of the most remarkable and

important subject . It’s long and doubtful history takes place
from the ancient times . In 272 BC , the mother of the Indian
emperor second Chandragupta Maurya accidentally consumed
poison and died when she was close to delivering him.
Chandragupta's teacher and adviser, made up his mind that the
baby should survive. He cut open the belly of the queen and
took out the baby, thus saving the baby's life. At the same
period according to the ancient Chinese
Records of the Grand Historian, a sixth-generation descendant
of the Yellow Emperor, had six sons, all born by "cutting open
the body".
 This procedure had a high mortality rate.
However, it was considered an extreme measure,
performed only when the mother was already dead
or considered to be beyond help. The origin of the
term “cesarean section“ is obscure . Three
principal explanations have been suggested .
1. According to legend Julius Caesar was born in this manner ,
with the result that the procedure became known as the
“Cesarean operation”, however it is doubtful subject.
2. It has been widely believed that the name of the operation
is derived from a Roman law, supposedly created by Numa
Pompillus 8th century BC, ordering that the procedure be
performed upon women dying in the last few weeks of
pregnancy in the hope of saving the child.
3. The word “caesarean” was derived sometime in the middle
Ages from the Latin verb “caedere “, “to cut”. However it is
not known when it was first applied to the operation is
uncertain .
 C-section is defined as delivery of the fetus through
incisions in the abdominal wall (laparotomy) and the
uterine wall (hysterotomy). This definition does not
include removal of the fetus from the abdominal cavity
in case of rupture of the uterus or abdominal pregnancy.
Indications:
The four most frequent indications for c-section are: 1)
repeat procedures; 2) dystocia or failure to progress in labor,
3) breech presentation , 4) fetal distress .
Frequency:
The rate for delivery by c-section has increased in the US and
other developed countries. Reasons for quadrupling of the
section rate over about the past two decades are not
completely understood, but some explanations include the
following:
• 1. There is reduced parity, and almost half of pregnant
women are nulliparas. Therefore an increased number of c-
section might be expected for conditions that are more common
in nulliparous women
• 2. Older women are having children - the frequency of c-
secion increases with advancing age
• 3. Electronic fetal monitoring is used extensively and there is
little question that it is associated with an increased c-section
rate compared with intermittent fetal heart rate auscultation
• 4. Breeches - by 1989 almost 85% of all breeches were
delivered abdominally
• 5. The incidence of midpelvic vaginal deliveries has
decreased . Between 1972 -1980, forceps deliveries declined
from 37 to 18 %, while the c-section rate increase from 7 to 17
%
• 6. It is widely held belief that increase cesarean delivery
rated will result in decreased perinatal mortality
• 8. Socioeconomic factors have a significant role in the c-
section rate. Gould and associates reported that the primary
section rate in Los Angeles Country was 23 % for women
from areas with a median family income of more than $
30.000 compared with 13% for women with a median income
less than $11.000 .
 Because failure to progress in labor or dystocia and repeat
operations account for approximately two thirds of all
cesarean deliveries, it seems logical to address these two
areas if the cesarean section rate is to be reduced.
• Maternal mortality : Certainly maternal and prenatal
mortality and morbidity typically are higher with cesarean
section than with vaginal delivery, if for no other reason than
because of the complication that led to the cesarean section ,
as well as because of increased risks inherent in abdominal
delivery .
Maternal morbidity: Even when morbidity and mortality
associated with the complication that led to cesarean section
are excluded, maternal morbidity is more frequent and likely
to be more severe following c-section that following vaginal
delivery . The common causes of morbidity from cesarean
delivery are infection, hemorrhage and injury to the urinary
tract,tromboembolism.
• Perinatal Mortality - The frequency of stillbirth and neonatal
mortality will depend on the underlying reason for the c-
section and the gestational age of the fetus. Although the
decreasing perinatal mortality rate observed since the mid
1980s in many instances has been associated with, and has
even been attributed to, the marked increase in c-section rates
in the US.
• Perinatal Morbidity : It must be emphasized that c-section is
not a guarantee against fetal injury. For example, the head of a
preterm breech can be entrapped in a small transverse uterine
incision that was judged incorrectly to be large enough for
delivery. This may result in injury to the fetal spinal cord or
brain, and may lead to extension of the uterine incision into the
uterine vessels. The fetus may also be wounded during the
incision into the uterus.
• Timing of repeat C-Sestion: - There are advantages to a
predetermined time for carrying out repeat cesarean sections. For
example, the family can better arrange for assistance in caring
for other children and for the care of the mother and infant after
leaving the hospital. Importantly an alert team can be assembled
more easily to provide optimal care, including anesthesia, infant
resuscitation if needed and subsequent newborn care.
• Iartogenoc Preterm Delivery. Elective termination of pregnancy
with the delivery of a preterm infant has been a major problem.
This unfortunate circumstance has led some to routinely practice
amniocentesis for pulmonary maturity studies before any elective
delivery. It is now well established that amnionic fluid studies
to assure fetal maturity are unnecessary in women with good
gestational dating criteria.
• Vaginal Delivery Subsequent to Cesarean Section: There is
no doubt that vaginal delivery will most often prove to be
safe following a previous c-section . Moreover, the rate of
vaginal births after c-section has increase in the US from
approximately 7% to 18.5% last time. Numerous reports
have been published in the past decade that attest to the
safety and efficacy of vaginal delivery in these women.
Even with the numerous reports of successful outcomes,
several areas of management remain controversial:
• 1. How many c-sections can be done before it is unsafe to allow a trial
of labor?
• 2. What is the incidence of uterine rupture or scar dehiscence?
• 3. Following vaginal delivery , should uterine exploration be performed
routinely ? If so, what should be done if a uterine defect is discovered?
• 4. If the woman had a c-section for a recurrent problem such as
cephalopelvic disproportions, should a trial of labor be allowed?
• 5. Can epidural analgesia be used safely for a trial of labor?
• 6. Can oxytocin be used safely to induce or augment labor?
• 7. Should women with multifetal gestation be allowed a trial of labor?
• 8. Should women with a breech presentation be allowed a trial of labor?
• 9. What standards should be established for obstetrical services before a
trial of labor is justified ?
Uterine Exploration: After vaginal delivery in a woman with
a previous c-section , many recommended exploration of the
uterine cavity. The issues to be assessed at the uterine
exploration are whether there is a defect and if so whether it
is connected with the peritoneal cavity and the woman
manifests signs of hemodynamic instability, or if there is
obvious excessive bleeding, laparotomy and either repair of
the defect discovered in the uterine wall that does not open
into the peritoneal cavity and it is small and not bleeding,
repair probably is unnecessary. Under these circumstances, the
woman is observed closely with frequent vital signs and
serial hematocrit determinations. Most such patients do well
without uterine repair. In case of a subsequent pregnancy
the decision to allow a trial of labor must be made on an
individual basis.
• Guidelines for a Trial of labor: The question is not, whether a
woman can deliver vaginally following a previous c-section ,
but rather the criteria that should be applied and rigidly
enforced in order to allow her to labor safely.
• Unlike prior recommendations, it is now felt that women
with one prior transverse cesarean section should be
counseled to undergo a trial of labor.
 Technique of Cesarean Section
Type of Uterine incision:
A vertical incision into the body of the uterus above the lower uterine segment
and reaching the uterine fundus, is seldom used today.
Most always the incision is made in the lower uterine segment transversely or
less often vertically.
The lower segment transverse incision has the advantage of requiring only modest
dissection of the bladder from the underlying myometrium. If the incision
extends laterally , the laceration may involve one or both of the uterine vessels.
The low vertical incision may be extended upward so that in those circumstances
where more room is needed, the incision can be carried into the body of the
uterus; otherwise, it is a less desirable incision. More extensive dissection of the
bladder is necessary to keep the vertical incision within the lower uterine
segment. Moreover, if the vertical incision extends downward, it may tear
through the cervix into the vagina and possibly involve the bladder.
During the next pregnancy the vertical incision is much more likely than is the
transverse incision to rupture , especially during labor.
Lower Segment Transverse Incision. For a cephalic presentation
a transverse incision through the lower uterine segment is
most often the operation of choice. Generally, the transverse
incisions
1) results in less blood loss;
2) is easier to repair;
3) is located at a site least likely to rupture with extrusion of
the fetus into the abdominal cavity during a subsequent
pregnancy
4) does not promote adherence of bowel or omentum to the
incision line.
Choice of Abdominal Incisions.
An infra-umbilical midline vertical incision is quickest to
make. The incision should be of sufficient length to allow
delivery of the infant without difficulty. Therefore its length
should correspond with the estimated fetal size. Sharp
dissection is performed to the level of the anterior rectus
sheath, which is freed of subcutaneous fat to expose a strip of
fascia in the midline about 2 cm. wide. Some surgeons prefer
to incise the rectus sheath with the scalpel throughout the
length of the fascial incision.
• The transversalis fascia and preperitoneal fat are dissected
carefully to reach the underlying peritoneum.
The peritoneum near the upper end of the incision is opened
carefully. Some elevate the peritoneum with two hemostats
places about 2 cm apart.
The tented fold of peritoneum between the clamps is then
visualized and palpated to be sure that omentum, bowel or
bladder are not adjacent.
In women who have had previous intra-abdominal surgery,
including c-section, omentum or even bowel may be adherent to
the under-surface of the peritoneum.
With the modified Pfannenstiel incision the skin and
subcutaneous tissue are incised a lower transverse, slightly
curvilinear incision. The incision is made at the level of the
pubic hairline and is extended somewhat beyond the lateral
borders of the rectus muscles. After the subcutaneous tissue
has been separated from the underlying fascia for 1 cm or so
on each side, the fascia is incised transversely the full length
of the incision.
Uterine incision. The uterus is opened through the lower
uterine segment about 2 cm above the detached bladder. The
uterine incision can be made by a variety of techniques.
Each is initiated by incising with a scalpel the exposed lower
uterine segment transversely for 2cm or so halfway between
the lateral margins.
It is very important to make the uterine incision large
enough to allow delivery of the head and trunk of the
fetus without either tearing into or having to cut into the
uterine arteries and veins that course through the lateral
margins of the uterus.
• Delivery of the infant: If the vertex is presenting a hand is
slipped into the uterine cavity between the symphysis and
fetal head and the head is elevated gently with the fingers
and palm through the incision aided by modest trans-
abdominal fundal pressure. To minimize aspiration by the
fetus of amnionic fluid and its contents , the exposed nares
and mouth are aspirated with a bulb syringe before the thorax
is delivered. The shoulder then are delivered using gentle
traction plus fundal pressure. The rest of the body readily
follows. After a long labor with cephalopelvic disproportion ,
the fetal head may be rather tightly wedged in the birth
canal. Upward pressure exerted through the vagina by an
assistant will help to dislodge the head and allow its delivery
above the symphysis.
• As soon as the shoulders are delivered , an intravenous
infusion containing oxytocin is allowed to flow at a brisk
rate of 10 mL per minute until the uterus contracts
satisfactorily , after which the rate of oxytocin can be
reduced. If the fetus is not presenting as a vertex, or if there
are multiple fetuses or a very immature fetus of a woman
who has had no labor, a vertical incision through the lower
segment may, at times, prove to be advantageous. The fetal
legs must be carefully distinguished from the arms to avoid
premature extraction of an arm and a difficult delivery of the
rest of the fetus. The placenta should be removed promptly
manually , unless it is separating spontaneously. Fundal
massage, begun as soon as the fetus is delivered , reduces
bleeding and fastens delivery of the placenta.
Repair of the Uterus. After delivery of the placenta, the
uterus may be lifted through the incision onto the draped
abdominal wall and the fudus covered with a moistened
laparotomy pack. Although some clinicians prefer to avoid
this latter step, uterine exteriorization often has advantages
that outweigh any disadvantages. The relaxing uterus can be
recognized quickly and massage applied. The incision and
bleeding points are visualized more easily and repaired ,
especially if there have been extensions laterally.
• Immediately after delivery and inspection of the placenta,
the uterine cavity is inspected and is wiped out with a gauze
pack to remove avulsed membranes, vernix, clots or other
debris. The upper and lower cut edges and each angle of the
uterine incision are examined carefully for bleeding vessels.
The lower margin of segment may be so thin as to be
inadvertently ignored. Especially when the lower segment is
thin. satisfactory approximation for the cut edges usually can
be obtained with one layer of suture.
• Immediately after delivery and inspection of the placenta,
the uterine cavity is inspected and is wiped out with a gauze
pack to remove avulsed membranes, vernix, clots or other
debris. The upper and lower cut edges and each angle of the
uterine incision are examined carefully for bleeding vessels.
The lower margin of segment may be so thin as to be
inadvertently ignored. Especially when the lower segment is
thin. satisfactory approximation for the cut edges usually can
be obtained with one layer of suture.
• Cesarean Hysterectomy.
• Indications: Indications for cesarean hysterectomy are discussed in
connection with the various conditions for which the operation is indicated.
A few of these include
• intrauterine infection;
• a grossly defective scar;
• a markedly hypotonic uterus that does not respond to oxytocin,
prostaglandins and massage ;
• laceration of major uterine vessels;
• large myomas; and severe cervical dysplasia or carcinoma in situ.
• Placenta accrete or increate often may best be treated by immediate
hysterectomy if cesarean section is performed.
Major derrents to cesarean hysterectomy are concern for increase blood loss
and the frequency of urinary tract damage. A major factor in the complication
rate appears to be whether the operation is performed as an elective procedure
or as an emergency. There are ; Supracervical Hysterectomy and Total
Hysterectomy.
• Recovery Suite: In the recovery suite, the amount of
bleeding from the vagina must be monitored closely, and the
uterine fundus must be indentified frequently by palpation to
assure that the uterus is remaining firmly contracted.
Unfortunately, as the woman awakens from general
anesthesia or the conduction analgesia fades, palpation of the
abdomen is likely to produce considerable discomfort. This
can be made much more tolerable by giving an effective
analgesic intramuscularly or intravenously such as morphine
10 mg. Once the mother is fully awake , bleeding is minimal,
the blood pressure is satisfactory and urine flow is at least 30
mL per hour, she may be returned to her room.
• Subsequent Care
• Analgesia. For the woman of average size , meperidine 75 mg
is given intramuscularly as often as every 3 to 4 hours as
needed for discomfort , or morphine 10 mg is similarly
administered. If she is small 50 mg, or if large 100 mg of
meperidine is more appropriate. An antiemetic, such as
promethazine 25 mg, is usually given along with the
narcotic.
• Vital Signs. The patient is not evaluated at least hourly for 4
hours ate the minimum, and blood pressure , pulse, urine flow,
amount of bleeding and status of the uterine fundus are
checked at these times. Thereafter , for the first 24 hours,
these are checked at intervals of 4 hours along with the
temperature.
• Fluid Therapy end Diet: Unless there has been pathological
constriction of the extracellular fluid compartment from
diuretics , sodium restriction, vomiting , fever or prolonged
labor without adequate fluid intake, the puerperium is
characterized by excretion of fluid that was retained during
pregnancy. Moreover , with the typical cesarean section or
uncomplicated cesarean hysterectomy , significant
extracellular fluid sequestration in bowel wall and bowel
lumen does not occur, unless it was necessary to pack the
bowel away from the operative field or peritonitis develops.
• Therefore, large volumes of intravenous fluids during and
subsequent to surgery are not needed to replace sequestered
extracellular fluid . As a generalization , 3 L of fluid should
prove adequate during the first 24 hours after surgery. If
urine output falls below 30 mL per hour, however , the
woman should be reevaluated promptly. The cause of the
oliguria may range from unrecognized blood loss to an
antidiuretic effect from infused oxytocin.
• In the absence of extensive intra-abdominal manipulation or
sepsis , the woman nearly always should be able to tolerate
oral fluids or even a regular diet the day after surgery. By the
second day after surgery, the great majority of women
tolerate a general diet.
• Bladder and Bowels. The bladder catheter most often can be
removed by 12 hours after operation or , more conveniently,
the morning after surgery.
• Ambulation. In most instances , by the day after surgery the
patient, with assistance , should get out of bed briefly at least
twice. Ambulation can be timed so that a recently administer
analgesic will minimize the discomfort.
• Wound care. The incision is inspected each day, and the skin
sutures (or clips) are removed on the 7-8 th day after surgery .
By the third postpartum day, bathing by shower is not harmful
to the incision.
• Laboratory. The hematocirt is routinely measured the day after
surgery. It is checked sooner when there was unusual blood
loss or when there is oliguria or other evidence to suggest
hypovolemia. If the hematocrit is decreased significantly
from the preoperative level, it is repeated and a search is
instituted to identify the cause of the decrease. If the lower
hematocrit is stable , the mother can ambulate without any
difficulty and if there is little likelihood of further blood
loss, hematological repair is response to iron therapy is
preferred to transfusion.
• Breast Care. Breast feeding can be initiated by the day after
surgery. If the mother elects not to breast feed, a breast binder
that supports the breasts without marked compression will
usually minimize discomfort.
• Discharge from the hospital; Unless there are complications
during the puerperium , the mother may be safely discharged
from the hospital on the third or fourth postpartum day. Her
activities during the following week should be restricted to
self-care and care of her baby with assistance. It is
advantageous to perform the initial postpartum evaluation
during the third week after delivery rather than at the more
traditional time of 6 weeks.
• Prophylactic Antimicrobial Therapy .Febrile morbidity is
rather frequent after cesarean section and appears to be more
common among indigent than affluent women. The literature
is replete with reports of reduced febrile morbidity with
antibiotics administered prophpylactically. Without
prophylactic antimicrobials 85% of women in labor with
membranes ruptured for longer than 6 hours who underwent
CD may developed serious infections . The incidence was
much less in women who underwent C-section after laboring
with membranes intact.
• Moreover associated complications such as wound abscesses
and pelvic phlegmons were encountered in less than 1% of
women with intact membranes, compared with 30 % of
women whose membranes ruptured more than 6 hours
before cesarean section.
• Finally , bacteremia was four times more common in those
women whose membranes ruptured longer than 6 hours before
surgery and who subsequently demonstrated infection.
Subsequently therapeutic intervention was evaluated for this
high-risk group of nulliparous women who underwent CD
because of cephalopelvic disproportion. The administration of
an antibiotic as soon as the cored was clamped , followed by
two more doses of the same medications give at intervals of 6
hours , resulted in a reduction in postoperative metritis from 85
to 20 %
 Associated compilations , such as pelvic phlegmons,
incisional abscesses and pelvic thrombophlebitis also
decrease dramatically.
It is emphasized that the woman with clinically diagnosed
chorioamnionitis should be given continuous antimicrobial
therapy postoperatively until she is a febrile .
• Cesarean delivery (CD)
• The birth of a fetus through incisions in the abdominal wall
(laparotomy) and the uterine wall (hysterotomy)
• There are 2 types:
• 1. Low -transverse cesarean section (LTCS)
• -Horizontal incision made in lower uterine segment
• -Most common type performed
• 2. Classical
• -Vertical incision made in the contractile portion of uterine
corpus
• -Performed when :
• a) Lower uterine segment is not developed (ie, prematurity )
• b) Fetus is transverse lie with back down
• c) Placenta previa
 Indications
• Prior cesarean (elective repeat, previous classical )
• Dystocia or failure to progress in labor
• Breech presentation
• Transverse lie
• Concern for fetal well-being (ie, no reassuring fetal
heart tones)
• Uterine malformation / scars
• Trial of labor after cesarean (TOLAC) - is associated with a
small but significant risk of uterine rupture with poor outcome
for mother and infant:
• Classical uterine incision : 10% risk
• Low-transverse incision : 1% risk
• Maternal and infant complications are higher with a failed
trial of labor followed by cesarean delivery
• Candidates for TOLAC
• One LTCS
• Clinically adequate pelvis
• No other uterine scars or previous rupture
• Physician immediately available throughout active labor
capable of monitoring labor and performing and emergency CD
• Availability of anesthesia and personnel for emergency CD
THE END.