CESAREAN SECTION
Name-Vishnu Kumar Bairwa
Roll no.-132
DEFINITION
 It is an operative procedure whereby the
fetuses after the end of 28th weeks are
delivered through an incision on the
abdominal and uterine walls.
This excludes delivery through an abdominal
incision where the fetus, lying free in the
abdominal cavity following uterine rupture or
in secondary abdominal pregnancy.
INDICATION
Time of operation
Elective
Operation is done at a
prearranged time
during pregnancy.
Emergency
When the operation is
to be done due to an
acute obstetric
emergency (fetal
distress). A time interval
of 30 minutes between
the decision and
delivery is taken as
reasonable
Types of operation
Lower segment
cesarean section(LSCS)
In this operation, the
extraction of the baby is
done through an
incision made in the
lower segment through
a transperitoneal
approach.
Classical or upper
segment CS
In this operation, the
baby is extracted
through an incision
made in the upper
segment of the uterus.
Lower segment cesarean section(LSCS)
PREOPERATIVE PREPARATION
Informed written permission for the procedure,
anesthesia and blood transfusion is obtained. „
• Abdomen is scrubbed with soap and nonorganic
iodide lotion.
• Premedicative sedative must not be given. „
• Nonparticulate antacid (sodium citrate) is given orally
to neutralize the gastric acid. „
• Ranitidine (H2 blocker) 150 mg is given orally night
before (elective procedure) and it is repeated (50 mg
IM or IV) 1 hour before the surgery to raise the
gastric pH. „
• The stomach should be emptied. „
• Metoclopramide (10 mg IV) is given to increase the
tone of the lower esophageal sphincter as well as to
reduce the stomach contents.
• Bladder should be emptied by a Foley catheter.
• FHS should be checked once more at this stage.
• Cross matching of blood for transfusion.
• Prophylactic antibiotics should be given (IV) before
making the skin incision
• •IV cannula: Sited to administer fluids (Ringer’s
solution, 5% dextrose). •
• Position of the patient:The patient is placed in the
dorsal position. In susceptible cases, to minimize any
adverse effects of venacaval compression, a 15° tilt
to her left using a wedge till delivery of the baby
should be done. •
• Anesthesia—may be spinal, epidural or general.
• Antiseptic painting:The abdomen is painted with
7.5% povidone-iodine solution or savlon lotion and
to be properly draped with sterile towels.
I•ncision on the abdomen
1) Vertical incision may be infraumbilical midline or
paramedian.
2) Transverse incision, modified Pfannenstiel is made 3
cm above the symphysis pubis.
Packing:
• The doyen’s retractor is introuced. The
peritoneal cavity is now packed off using two
taped large swabs.
• The tape ends are attached to artery forceps.
This will minimize spilling of the uterine
contents into the general peritoneal cavity.
Uterine incision
(A) Lower segments transverse
(B) Lower segment vertical
(C) “J” incision
(D) Classical incision
(E) Inverted T incision
Steps of LSCS
(A) The loose peritoneum on the lower segment is cut
transversely
(B) A short incision is made in the midline down to the
membranes
(C) The incision of the lower segment is being enlarged using
index fnger of both hands
(D) Sagittal section showing insinuation of the fingers between
the lower uterine flap and the fetal head until the posterior
surface is reached
(E) Methods of delivery of the head
(F) Placenta is being delivered
(G) Inserting the continuous catgut (No. ‘0’) suture taking deeper
muscles excluding the decidua
(H) Similar method of continuous suture taking superficial muscles
and fascia down to the first layer of suture
(I) Continuous peritoneal catgut suture
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CLASSICAL CESAREAN SECTION
This is relatively easy to perform.
Abdominal incision is always longitudinal (paramedian)
and about 15 cm (6") in length, 1/3rd of which extends
above the umbilicus.
A longitudinal incision of about 12.5 cm (5") is made on
the midline of the anterior wall of the uterus starting
from below the fundus.
The incision is deepened along its entire length until
the membranes are exposed which are punctured.
The baby is delivered commonly as breech extraction.
Intravenous oxytocin 5 IU IV (slow) or methergine 0.2
mg is administered following delivery of the baby.
The uterus is eventrated.
The placenta is extracted by traction on the cord or
removed manually
Suture of the uterine incision
• The uterus is sutured in three layers. ‹
• A continuous suture is placed with chromic catgut No “0”
or vicryl taking deep muscles excluding the decidua. ‹
• A second layer of interrupted sutures (1 cm apart) using
chromic catgut No. “1” or vicryl taking the entire depth of
superficial muscles down to the first layer of suture. ‹
• The third layer of continuous suture taking the peritoneum
with the adjacent muscles using chromic catgut No “0” and
round-bodied needle.
 The uterus is returned back into the abdominal cavity.
 Packings are removed.
 peritoneal toileting is done and the abdomen is closed in
layers.
POSTOPERATIVE CARE
First 24 hours: (Day 0) „
 Observation for the frst 6–8 hours is important.
Monitor vitals,amount of vaginal bleeding and behavior of the
uterus.
 Fluid: Sodium chloride (0.9%) or Ringer’s lactate drip is continued
until at least 2.0–2.5 L of the solutions are infused. Blood
transfusion is helpful in anemic mothers.
 Oxytocics: Injection oxytocin 5 units IM or IV (slow) or methergine
0.2 mg IM is given and may be repeated. „
 Prophylactic antibiotics (cephalosporins, metronidazole) for all
cesarean delivery is given for 2–4 doses.
 Analgesics in the form of pethidine hydrochloride 75–100 mg is
administered and may have to be repeated. „
 Ambulation:She is encouraged to move her legs and ankles and to
breathe deeply to minimize leg vein thrombosis and pulmonary
embolism. „
 Baby is put to the breast for feeding after 3–4 hours when mother
is stable and relieved of pain
• Day1: Oral feeding in the form of plain or electrolyte
water or raw tea may be given. Active bowel sounds
are observed by the end of the day.
• Day2: Light solid diet of the patient’s choice is given.
Bowel care: 3–4 teaspoons of lactulose is given at
bed time, if the bowels do not move spontaneously.
Day 5 or day 6: The abdominal skin stitches are to be
removed on the D-5 (in transverse) or D-6 (in
longitudinal).
Discharge
• The patient is discharged on the day following
removal of the stitches, if otherwise fit.
• Usual advices like those following vaginal delivery are
given.
• Depending on postoperative recovery and availability
of care at home, patient may be discharged as early
as third to as late as seventh postoperative days.
COMPLICATIONS OF CESAREAN SECTION
 The complications are related either due to the „
operations (inherent hazards)‚ or due to „anesthesia.
 The complications are grouped into
o Maternal •
o Fetal
 The maternal complications may be
o Intraoperative „
o Postoperative
INTRAOPERATIVE COMPLICATIONS •
• Extension of uterine incision involve the uterine
vesssel to cause severe hemorrhage, may lead to broad
ligament hematoma formation. •
• Uterine lacerations at the lower uterine incision—may
extend laterally or inferiorly into the vagina. •
• Bladder injury
• Ureteral injury
• Gastrointestinal tract injury •
• Hemorrhage may be due to uterine atony or uterine
lacerations.•
• Morbid adherent placenta (placenta accreta):Total
hysterectomy is often needed for such a case to control
hemorrhage.
POSTOPERATIVE COMPLICATIONS MATERNAL
1) Immediate •
2) Remote
IMMEDIATE „
 Postpartum hemorrhage
 Shock
 Anesthetic hazards
 Infections
 Intestinal obstruction
 Deep vein thrombosis and thromboembolic disorder
 Wound complications: Abdominal wound sepsis is
quite common.
i. sanguineous or frank pus
ii. hematoma
iii. dehiscence (peritoneal coat intact)
iv. burst abdomen (involving the peritoneal coat)
REMOTE: •
 Gynecological: Menstrual excess or irregularities,
chronic pelvic pain or backache.
 General surgical: Incisional hernia, intestinal
obstruction due to adhesions and bands.
 Future pregnancy: There is risk of scar rupture
FETAL:
(1) asphyxia may be preexisting
(2) RDS
(3) prematurity
(4) infection and
(5) intracranial hemorrhage