Cesarean Section

Definition 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 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 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) Fetal distress Malpresentation or malposition Failed vacuum or forceps Expensive child Cord prolapsed Placental insufficiency (IUGR)

Fetal indications (II) 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) Total placenta previa Severe PE or Eclampsia, failed induction Threatened Uterine Rupture, transverse lie

Combined indications Placenta previa Abruptio placenta, alive fetus Severe Preeclampsia /Eclampsia FPD/CPD Threatened Uterine Rupture (Over stimulation)

Contraindications 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 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) 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) Definition: Cesarean section followed by hysterectomy Indications: Uncontrolled bleeding Placenta acreta, increta dan percreta Multiple mioma Cervical or ovarial ca Unrepairable uterine rupture Infection

Cesarean histerectomy(2) Complications Morbidity and mortality is higher: Takes more time Trauma to gut and bladder is higher More bleeding Psychological effects No menstruation Becomes steril

Complication of CS 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 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 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 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 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.