CESAREAN SECTION CS CESAREAN SECTION CS

CESAREAN SECTION Cs CESAREAN SECTION Cs Ghadeer Al-Shaikh, MD, FRCSC Assistant Professor & Consultant Obstetrics & Gynecology Urogynecology & Pelvic Reconstructive Surgery

TYPES OF CS Lower segment CS Lower segment CS Classical CS Classical CS

Indications for classical CS Transverse lie back down (with SROM) Transverse lie back down (with SROM) Structural abnormality that makes lower segment approach difficult (Fibroids) Structural abnormality that makes lower segment approach difficult (Fibroids) Anterior Placenta Previa & abnormally vascular lower segment Anterior Placenta Previa & abnormally vascular lower segment Poorly developed lower segment in Very preterm fetus in breech presentation Poorly developed lower segment in Very preterm fetus in breech presentation Cervical cancer Cervical cancer

INDICATIONS FOR ELECTIVE CS Repeat CS Repeat CS Placenta previa Placenta previa VV fistula repair VV fistula repair HIV (poor controlled) HIV (poor controlled) Active herpes Active herpes Fetal macrosomia > 4500 gm Fetal macrosomia > 4500 gm Uterine surgery eg. Hystrotomy, myomectomy Uterine surgery eg. Hystrotomy, myomectomy Severe IUGR Severe IUGR Breech Breech Multiple pregnancy Multiple pregnancy Transverse lie Transverse lie Ca of the Cx/ TR obstructing the birth canal Ca of the Cx/ TR obstructing the birth canal

INDICATIONS FOR EMERGRENCY CS Severe PET Severe PET Abruptio placenta (APH) Abruptio placenta (APH) Fetal distress Fetal distress Failure to progress in the first stage of labour Failure to progress in the first stage of labour Cord prolapse Cord prolapse Obstructed labour Obstructed labour Failed induction Failed induction Malpresentation  brow, chin post, shoulder & compound presentations, breech Malpresentation  brow, chin post, shoulder & compound presentations, breech Compromised fetus 2ry to DM, HPT, isoimmunization Compromised fetus 2ry to DM, HPT, isoimmunization

TIMING OF ELECTIVE CS Usually at wks Usually at wks

Before Emergency CS Explain to the Pt & husband & obtain consent Explain to the Pt & husband & obtain consent Inform anesthetist, OR staff, ped Inform anesthetist, OR staff, ped 100% oxygen mask in case of fetal distress 100% oxygen mask in case of fetal distress Sodium citrate 20 ml, metoclopramide 10 mg IV Sodium citrate 20 ml, metoclopramide 10 mg IV Transfer to the theatre, IV, take blood for Hb, x- match 2 U of blood Transfer to the theatre, IV, take blood for Hb, x- match 2 U of blood Preferable to use spinal or epidural anaethesia Preferable to use spinal or epidural anaethesia

Catheterize the bladder Catheterize the bladder Tilt the mother 15 º by using wedge Tilt the mother 15 º by using wedge Pneumatic inflatable boots or Ted stockings Pneumatic inflatable boots or Ted stockings Prophylactic Ab ↓↓ incidence of infection Prophylactic Ab ↓↓ incidence of infection Inform ped if the mother had opiates in the last 4 hrs Inform ped if the mother had opiates in the last 4 hrs Halothane should not be used  uterine relaxation & bleeding Halothane should not be used  uterine relaxation & bleeding

COMPLICATIONS INTRAOPERATIVE Bleeding & the need for bl transfusion Bleeding & the need for bl transfusion Hysterectomy Hysterectomy Complications of anaesthesia Complications of anaesthesia Damage to the bladder, ureter, colon, retained placental tissue Damage to the bladder, ureter, colon, retained placental tissue Fetal injury Fetal injury

COMPLICATIONS POSTOPERATIVE Paralytic ileus Paralytic ileus Wound dehiscence & infection Wound dehiscence & infection Infectins  UTI, pnemonea Infectins  UTI, pnemonea DVT & pulmonary embolism DVT & pulmonary embolism Fistula Fistula Death Death

POSTNATAL CARE V/S & blood loss must be monitered V/S & blood loss must be monitered Uterine fundus palpated Uterine fundus palpated Effective parentral analgesics Effective parentral analgesics Deep breathing & coughing encouraged Deep breathing & coughing encouraged Early mobilization Early mobilization Fluid therapy &diet Fluid therapy &diet Bladder & bowel function Bladder & bowel function Wound care Wound care Lab Lab Breast care Breast care Prophylaxis for thrombembolism Prophylaxis for thrombembolism

MODE OF DELIVERY IN NEXT PREGNANCY CRITERIA FOR VBAC Pt must agree to the procedure Pt must agree to the procedure A low transverse uterine incision A low transverse uterine incision Non recurrent cause of the previous CS Non recurrent cause of the previous CS No macrosomia, malposition, multiple gestation, breech No macrosomia, malposition, multiple gestation, breech

MODE OF DELIVERY IN NEXT PREGNANCY Contraindication Previous classical CS Previous classical CS 2 or more previous CS 2 or more previous CS Previous other uterine surgery Previous other uterine surgery Hx of scar rupture Hx of scar rupture Placentaprevia or transverse lie Placentaprevia or transverse lie

CONDUCT OF LABOUR Observe for Progress Progress Fetal wellbeing Fetal wellbeing Maternal well being Maternal well being Epidural Epidural HOSPITAL SHOULD PROVIDE BLOOD, OPERATING ROOM 24 HRS, NEONATAL RESUSCITATION, NURSING ANAESTHESIA &SURGICAL PERSONNEL CAN START CS WITHIN 30 MIN HOSPITAL SHOULD PROVIDE BLOOD, OPERATING ROOM 24 HRS, NEONATAL RESUSCITATION, NURSING ANAESTHESIA &SURGICAL PERSONNEL CAN START CS WITHIN 30 MIN

Risk of SCAR RUPTURE Risk of SCAR RUPTURE O.5% for LSCS O.5% for LSCS 4-9% for classical 4-9% for classical

SCAR RUPTURE Signs OF SCAR RUPTURE Fetal distress Fetal distress Ease of fetal palpation Ease of fetal palpation Cessation of contractions Cessation of contractions Elevation of presenting part Elevation of presenting part Scar pain Scar pain Bleeding / shock Bleeding / shock

ABNORMAL LABOUR/DYSTOCIA/FAILURE TO PROGRESS IN LABOUR CAUSES 1-Abnormalities of the pasage Alteration in the shape of the pelvis Alteration in the shape of the pelvis Mass occupying the birth canal Mass occupying the birth canal

ABNORMAL LABOUR/DYSTOCIA/FAILURE TO PROGRESS IN LABOUR 2-Abnormalities in the passenger Abnormal lie Abnormal lie Abnormal presentation Abnormal presentation  occiput-postrior, occiput-transverse  occiput-postrior, occiput-transverse  brow  brow  face  face  breech  breech Macrosomia, perinatal mortality 5* higher than N Wt Macrosomia, perinatal mortality 5* higher than N Wt Congenital malformation Congenital malformation Multiple gestation Multiple gestation

ABNORMAL LABOUR/DYSTOCIA/FAILURE TO PROGRESS IN LABOUR 3-Abnormalities in the powers Ineffective uterine activity Ineffective uterine activity Lack of voluntary expulsive efforts in the 2 nd stage Lack of voluntary expulsive efforts in the 2 nd stage DYSTOCIA IS THE MOST COMMON INDICATION FOR CS