CESAREAN SECTION DR. SALWA NEYAZI CONSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT GYNECOLOGIST

TYPES OF CS Lower segment CS Lower segment CS Classical CS Classical CS Indications for classical incision: Transverse lie with SROM Transverse lie with SROM Structural abnormality that makes lower segment approach difficult Structural abnormality that makes lower segment approach difficult Constriction ring with neglected labour Constriction ring with neglected labour Fibroids in the lower segment Fibroids in the lower segment Ant PP & abnormally vascular lower segment Ant PP & abnormally vascular lower segment Mother dead & rapid delivery is required Mother dead & rapid delivery is required Very preterm fetus in breech pres Very preterm fetus in breech pres

INDICATIONS FOR ELECTIVE CS Known CPD Known CPD Fetal macrosomia > 4500 gm Fetal macrosomia > 4500 gm Placenta previa Placenta previa VV fistula repair VV fistula repair HIV HIV Active herpes Active herpes Repeat CS Repeat CS 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 placntae Abruptio placntae 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 APH APH

TIMING OF ELECTIVE CS For maternal interest  no choice For maternal interest  no choice For fetal interest  consider maturity & fetal condition For fetal interest  consider maturity & fetal condition Usually at 38 wks Usually at 38 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 injuryPOSTOPERATIVE Gaseous distension Gaseous distension Paralytic ileus Paralytic ileus Wound dehiscence & infection Wound dehiscence & infection Infectins  UTI, pulmonary Infectins  UTI, pulmonary DVT & pulmonary embolism DVT & pulmonary embolism Death Death Vesico uterine fistula Vesico uterine fistula

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, breechContraindication 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 Similar to the conduct of normal labour Observe for Progress Progress Fetal wellbeing Fetal wellbeing Maternal well being Maternal well being Cx may be ripened Cx may be ripened Labour may be agumented Labour may be agumented Epidural & other analgesics may be used Epidural & other analgesics may be used 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

SCAR RUPTURE O.2-1.5% for LSCS O.2-1.5% for LSCS 4-9% for classical 4-9% for classical INDICATIONS 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