Cesarean Section
Definition
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CS is an attempt to deliver a fetus,
placenta and membrane after 28
weeks of gestation, through an
incision on the abdominal wall and
the intact uterus
Removal of a fetus outside the
uterus (abdominal pregnancy) or
through a ruptured uterus or before
28 weeks is then not a CS.
Objective
1. To reduce infant and maternal
morbidity
2. To reduce infant and maternal
mortality
Indications
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A. Based on urgency
Absolute or Relative
Emergency or Elective
B. Based on prognosis
– Maternal indication
– Fetal indication
– Combined
C. General indications, based on
certain clinical situation or diagnosis
General indications based on
diagnosis
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Fetopelvic or cephalo pelvic
disproportion
Obstruction of birth canal
Uterine disfunction
Malposition or malpresentation
Maternal diseases
Scarred uterus or anomaly of the uterus
Cancer of the cervix
Fetal indications (I)
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Fetal distress
Malpresentation or malposition
Failed vacuum or forceps
Expensive child
Cord prolapsed
Placental insufficiency (IUGR)
Fetal indications (II)
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Incompatibility of rhesus
Post term pregnancy
Genital herpes
Diabetes mellitus
Elderly primigravida (>35 th)
Poor obstetric history
Giant fetus (> 4000 grams)
Maternal indication
(Fetus already died)
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Total placenta previa
Severe PE or Eclampsia, failed
induction
Threatened Uterine Rupture,
transverse lie
Combined indications
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Placenta previa
Abruptio placenta, alive fetus
Severe Preeclampsia /Eclampsia
FPD/CPD
Threatened Uterine Rupture (Over
stimulation)
Contraindications
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Severe chorioamnionitis
Very poor fetal prognosis, exp:
extremely premature, severe
congenital anomaly.
Fetal death, except in case of
placenta previa
No adequate facilities for surgical
procedure
Types of Cesarean Section
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Based on incision
– 1. Classical or corporal (vertical incision)
– 2. Low segment (horizontal incision)
Based on time
– 1. Emergency CS
– 2. Elective CS
Other
– 1. Extraperitoneal CS
– 2. Cesarean hysterectomy
Clasic CS, Indications (1)
1. Difficult to reach the LUS
2. Transverse lie
3. Fetal distress
4. Placenta previa, anterior
implantation
5. Followed by sterilization
Classic CS, Advantages
1. Faster
2. Easier
Classic CS, Disadvantages
1. Bleeding may be more profuse
2. Difficult to luxate fetal head
3. Reperitonisation is incomplete
4. Risk of rupture during future
pregnancy
Low segment CS, Indications
–Longitudinal lie
–No problem with the LUS
–Future pregnancy is expected
Low segment CS (Advantages)
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Less bleeding
Incision to placenta is avoided
Easy to luxate fetal head
Easy to close (suture)
Good reperitonization
Risk of rupture in the next pregnancy
is minimal
Low segment CS
(Disadvantages)
– Takes more time
– Bleeding may be more severe, if the
incision runs too laterally
– Injury to the bladder may happen, if the
incision is too low
– During repeated CS, post laparotomy,
or post infection, LUS may be too
difficult to identify
Cesarean histerectomy (1)
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Definition: Cesarean section followed by
hysterectomy
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Indications:
– Uncontrolled bleeding
– Placenta acreta, increta dan percreta
– Multiple mioma
– Cervical or ovarial ca
– Unrepairable uterine rupture
– Infection
Cesarean histerectomy(2)
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Complications
– Morbidity and mortality is higher:
 Takes
more time
 Trauma to gut and bladder is higher
 More bleeding
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Psychological effects
– No menstruation
– Becomes steril
Complication of CS
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Bleeding (Atonia, Too large incision)
Infection (Incision site, peritonitis)
Trombophlebitis
Trauma (Gut, Bladder, Baby)
Ileus
Complications due to anesthesia and
surgical action
Delivery after CS
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Once cesarean always cesarean
Trial of vaginal delivery
– Labor will progress easily
– No significant complication to mother
and baby
Contraindications to vaginal
delivery:
– Repeated cesarean section
– Vertical incision
– Absolut indication for CS
– Malposition and mal presentation
– Maternal diseases (DM, Toxaemia)
– Fetal distress, expenssive child etc.
Maternal Death due to CS
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10-30 cases per 100.000
Causes
– Bleeding
– Infection
– Anesthesia
– Pulmonary emboli
– Heart and renal failure due to prolonged
hipotension
Maternal Death due to CS
(Risk Factor)
– Elderly women
– Grandemulti gravida
– Obesity
– PROM
– Maternal diseases
– Complicated pregnancy
– Low social economic condition
Infant Mortality
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Theoretically it is not higher
Practically it is higher, because:
– Complication of pregnancy
– Misdetermination of age
– Fetal distress
Preparation for CS
– Hemoglobin min. 10 g/dL
– Heart, lung, electrolyte, liver and kidney, are
normal
– Fast 6-8 hours
– Match Blood, 250-500 ml
– Antacid (30 ml) 1 hour before
– Ampicillin 1 gram iv, 15-30 minutes before
operation
Monitoring post operation
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Stop oral feeding until peristaltics is good
Ivfd: Dextrose 5% and Na Cl 3:1
Closed monitoring of vital sign and fluids
balance
Antibiotics: Ampicillin 3 X 1000 mg and
Gentamycin 2 X 80 mg for 3 days
Vitamin
Mobilisation on day 2
Removal of suture on day 7
Discharge on day 8.