2DefinitionCS 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 uterusRemoval of a fetus outside the uterus (abdominal pregnancy) or through a ruptured uterus or before 28 weeks is then not a CS.
3Objective 1. To reduce infant and maternal morbidity 2. To reduce infant and maternal mortality
4Indications A. Based on urgency Absolute or Relative Emergency or ElectiveB. Based on prognosisMaternal indicationFetal indicationCombinedC. General indications, based on certain clinical situation or diagnosis
5General indications based on diagnosis Fetopelvic or cephalo pelvic disproportionObstruction of birth canalUterine disfunctionMalposition or malpresentationMaternal diseasesScarred uterus or anomaly of the uterusCancer of the cervix
6Fetal indications (I) Fetal distress Malpresentation or malposition Failed vacuum or forcepsExpensive childCord prolapsedPlacental insufficiency (IUGR)
7Fetal indications (II) Incompatibility of rhesusPost term pregnancyGenital herpesDiabetes mellitusElderly primigravida (>35 th)Poor obstetric historyGiant fetus (> 4000 grams)
8Maternal indication (Fetus already died) Total placenta previaSevere PE or Eclampsia, failed inductionThreatened Uterine Rupture, transverse lie
10Contraindications Severe chorioamnionitis Very poor fetal prognosis, exp: extremely premature, severe congenital anomaly.Fetal death, except in case of placenta previaNo adequate facilities for surgical procedure
11Types of Cesarean Section Based on incision1. Classical or corporal (vertical incision)2. Low segment (horizontal incision)Based on time1. Emergency CS2. Elective CSOther1. Extraperitoneal CS2. Cesarean hysterectomy
12Clasic CS, Indications (1) 1. Difficult to reach the LUS2. Transverse lie3. Fetal distress4. Placenta previa, anterior implantation5. Followed by sterilization
14Classic CS, Disadvantages 1. Bleeding may be more profuse2. Difficult to luxate fetal head3. Reperitonisation is incomplete4. Risk of rupture during future pregnancy
15Low segment CS, Indications Longitudinal lieNo problem with the LUSFuture pregnancy is expected
16Low segment CS (Advantages) Less bleedingIncision to placenta is avoidedEasy to luxate fetal headEasy to close (suture)Good reperitonizationRisk of rupture in the next pregnancy is minimal
17Low segment CS (Disadvantages) Takes more timeBleeding may be more severe, if the incision runs too laterallyInjury to the bladder may happen, if the incision is too lowDuring repeated CS, post laparotomy, or post infection, LUS may be too difficult to identify
18Cesarean histerectomy (1) Definition: Cesarean section followed by hysterectomyIndications:Uncontrolled bleedingPlacenta acreta, increta dan percretaMultiple miomaCervical or ovarial caUnrepairable uterine ruptureInfection
19Cesarean histerectomy(2) ComplicationsMorbidity and mortality is higher:Takes more timeTrauma to gut and bladder is higherMore bleedingPsychological effectsNo menstruationBecomes steril
20Complication of CS Bleeding (Atonia, Too large incision) Infection (Incision site, peritonitis)TrombophlebitisTrauma (Gut, Bladder, Baby)IleusComplications due to anesthesia and surgical action
21Delivery after CS Once cesarean always cesarean Trial of vaginal deliveryLabor will progress easilyNo significant complication to mother and baby
22Contraindications to vaginal delivery: Repeated cesarean sectionVertical incisionAbsolut indication for CSMalposition and mal presentationMaternal diseases (DM, Toxaemia)Fetal distress, expenssive child etc.
23Maternal Death due to CS 10-30 cases perCausesBleedingInfectionAnesthesiaPulmonary emboliHeart and renal failure due to prolonged hipotension
24Maternal Death due to CS (Risk Factor) Elderly womenGrandemulti gravidaObesityPROMMaternal diseasesComplicated pregnancyLow social economic condition
25Infant Mortality Theoretically it is not higher Practically it is higher, because:Complication of pregnancyMisdetermination of ageFetal distress
26Preparation for CS Hemoglobin min. 10 g/dL Heart, lung, electrolyte, liver and kidney, are normalFast 6-8 hoursMatch Blood, mlAntacid (30 ml) 1 hour beforeAmpicillin 1 gram iv, minutes before operation
27Monitoring post operation Stop oral feeding until peristaltics is goodIvfd: Dextrose 5% and Na Cl 3:1Closed monitoring of vital sign and fluids balanceAntibiotics: Ampicillin 3 X 1000 mg and Gentamycin 2 X 80 mg for 3 daysVitaminMobilisation on day 2Removal of suture on day 7Discharge on day 8.