1. CAESAREAN SECTION Technique revisited “yet another way to get OUT!”
Prof. Hemantha Dodampahala. MD, FRCS, FRCOG
Obstetrician & Gynecologist

2. HISTORY
Goes back to 715 B.C when Numa Pompillus the king of Rome brought in a law which forbade the burial of pregnant women unless her child had been removed from abdomen and buried separately.
First recorded successful caesarean section done by Jacob Nufer on his wife for pronged obstructed labour in 1588.

3. Definition
The delivery of a viable fetus through an incision in the abdominal wall and uterus after fetal viability. Before viability its called hysterotomy.
Definition does not include removal of fetus from abdominal cavity in case of rupture uterus.
Since 1985, the international healthcare community has considered the ideal rate for caesarean sections to be between 10-15%.
Since then, caesarean sections have become increasingly common in both developed and developing countries.
WHO proposes the Robson classification system as a global standard for assessing, monitoring and comparing caesarean section rates within healthcare facilities over time, and between facilities

4. Indications Previous caesarian section
Dystocia or dysfunctional labour
Fetal distress
Breech presentation
Antepartum haemorrhage
Maternal problems
Caesarian section on demand

5. LSCS Evidence based practice
1.At population level, caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates.
2. Caesarean sections can cause significant and sometimes permanent complications, disability or death particularly in settings that lack the facilities and/or capacity to properly conduct safe surgery and treat surgical complications. Caesarean sections should ideally only be undertaken when medically necessary.

6. Also Note
Every effort should be made to provide caesarean sections to women in need, rather than striving to achieve a specific rate.
(WHO Statement on Caesarean Section Rates )

7. Preparation Cross matched blood Catheter introduced
Antibiotic prophylaxis
Heparin as thromboprophylaxis if indicated
Parts cleansed with antiseptic solution
Left lateral position- reduce aorto-caval compression.
reduce risk of supine hypotension

8. ANAESTHESIA GA or REGIONAL REGIONAL - Spinal or Epidural
Mendelson’s syndrome- GA given as emergency- risk of aspiration- chemical pneumonitis.
To counteract- antacids given during labour, oral fluids withheld
30 ml 0.3 molar sodium citrate orally -1/2 hr before surgery.
Sellick’s manoeuvre- endotracheal intubation accompained by pressure on cricoid cartilage

9. ABDOMINAL INCISIONS Pfannenstiel incision. Joel-Cohen incision.
Midline incision.
Maylard incision

10. Pfannensteil incision
Transverse curvilinear incision above pubic hairline
Deepened through s/c tissue upto rectus sheath
Rectus sheath divided transversely
Two recti muscles seperated in midline

11. Joel Cohen Incision
A modified transverse incision placed about 3cm below the line joining the anterior superior ileac spines.
Higher than the Pfannenstiel incision and not curved.

12. Maylard incision Option when more exposure is needed in transverse incision Recti muscles are divided Midline vertical incision Performed in the midline extending from just below the umbilicus to a point approximately 2cm above the symphysis.

13. Evidence NICe Guidelines
The transverse incision of choice should be the Joel Cohen incision because it is associated with shorter operating times and reduced postoperative febrile morbidity. [2004]

14. Transverse incision
Vertical incision
Cosmetic appeal
More
Less
Postoperative pain
Wound dehiscence
Incisional hernia
Technical skill
Time taken
Access to upper abdomen
Good, can be extended

15. PROCEDURE
OPENING THE ABDOMEN
The skin incision should extend well down into the fatty layers.
Small incision is given in the rectus sheath and is then extended the full length of the skin incision using fingers to separate or the scalpel/dissecting scissors in case of previous scarring or LSCS.
Midline is identified and the recti separated and peritoneum is opened using fingers. Evidence…..
The incision is then extended the entire length of the wound by inserting the index finger of each hand and drawing the hands apart.

16. Once abdomen opened- dextrorotation of uterus corrected making sure incision is made in the middle without opening into lateral vascular bundles.
Doyen retractor- visualize lower segment
Peritoneum over lower segment identified-divided transversely- seperated from bladder by blunt dissection
Small incision in lower segment-extended laterally
Inadequate space- J shaped or inverted T incision
Do not injure uterine vessels lying laterally

17. UTERINE INCISIONS Lower transverse incision (98.5%). Classical (1.1%).
Low vertical (Dee Lee)

18. Incisions
Scar rupture rates
Lower transverse
0.5% (1:200)
Classical
5% (1:20)
Dee Lee
1% (1:100)
Myomectomy
???

19. LOW TRANSVERSE INCISION
Transverse incision at 1-2 cm below the junction of upper and lower segment.
Smiley shaped.
Gentle strokes with scalpel/ Use of Littlewoods to raise the cut edges avoiding fetal injury.
Consider any internal corrections or getting hold of the foot in case of transverse or breech while membranes are intact
Extend the cut incision laterally with curved scissors with curve upward or with index fingers.
Once membrane ruptured, deliver baby within 3 minutes.

22. Cephalic presentation Head is levered out gently
DELIVERY OF BABY
Cephalic presentation
Hand slipped into uterine cavity
Head is levered out gently
Floating head- use forceps to deliver the baby.

23. Breech presentation feet hooked out first rest delivered as vaginal breech delivery

24. Transverse or oblique lie corrected to longitudinal lie before making uterine incision/ rupture of the membrane. Transverse lie with ruptured membranes & undeveloped lower segment T extension of uterine incision required

25. DELIVERY OF PLACENTA Active management of third stage.
Hold uterine angles by green-armitages.
Remove placenta by cord traction.
Avoid manual removal as it increase risk of hemorrhage and infection.
Evidence : Manual removal of the placenta at cesarean delivery results in more operative blood loss and a higher incidence of post-cesarean endometritis. (Baksu A1, Kalan A, Ozkan A, Baksu B, Tekelioğlu M, Goker N The effect of placental removal method and site of uterine repair on postcesarean endometritis and operative blood loss )

26. RCOG RECOMMENDATION
At CS, the placenta should be removed using controlled cord traction and not manual
removal as this reduces the risk of endometritis.

27. EXTERIORIZATION OF UTERUS FOR REPAIR
Better visualization.
Facilitates repair.
Decrease blood loss.
No increase in febrile morbidity.
DISADVANTAGES:
Pain.
Vagal induced vomiting due to stretch.
May cause injury to viscera due to posterior adhesions.

28. RCOG RECOMMENDATIONS
Intraperitoneal repair of the uterus at CS should be undertaken. Exteriorization of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes such as hemorrhage and infection.

29. CLOSURE OF UTERINE INCISION
OXYTOCIN infusion started as soon as baby is delivered
Uterine fundus contracts-placenta and membranes extrudes spontaneously- removed
Wipe with moist pad- ensure uterine cavity is empty and cervical canal is open
Uterine angles - held with ALLIS forceps or GREEN ARMYTAGE forceps or Little woods

30. CLOSURE OF UTERUS Evidence based practices
Suture -Two layers with continuous sutures.
Absorbable suture material.
Second layers buries the first one and makes wound strong and water tight.
Ensure that the first lateral suture is well beyond the lateral margin of angle.
Start suturing at the side away from surgeon.
Sutures generally placed 1cm apart.

31. RCOG RECOMMENDATION
The effectiveness and safety of single layer closure of the uterine incision is uncertain.
Except within a research context, the uterine incision should be sutured with two layers.

32. Chromic catgut or polyglactin used
Second layers buries the first one and makes wound strong and water tight.
Ensure that the first lateral suture is well beyond the lateral margin of angle.
Start suturing at the side away from surgeon.
Sutures generally placed 1cm apart.
Any bleeding points- controlled with figure-of-eight sutures

33. DOUBLE LAYER UTERINE CLOSURE

35. CLOSURE OF ABDOMEN PERITONEUM- closed or not closed
RECTUS SHEATH-non absorbable sutures-proline- to reduce wound dehiscence & incisional hernia
Subcutaneous tissue-closed
SKIN- mattress sutures of silk, subcuticular suture or clips
My opinion non absorbable subcuticular (Monocryl) removed after 5 days provides the best cosmetic effects and superb wound healing.

36. CLOSURE OF VISCERAL PERITONEUM
ADVANTAGES:
Restore anatomy.
Reduction in infection.
Reduction in adhesion formation.
Reduction in wound dehiscence.

37. CLOSURE OF THE VISCERAL AND PARIETAL PERITONEUM

38. CLOSURE OF PARIETAL PERTONEUM

40. RCOG RECOMMENDATION
Neither the visceral nor the parietal peritoneum should be sutured at CS because this reduces operating time, the need for postoperative analgesia and improves maternal satisfaction.

41. CLOSURE OF FAT
Routine closure of the subcutaneous tissue space should not be used, unless the woman has more than 2 cm subcutaneous fat, because it does not reduce the incidence of wound infection.
Superficial wound drains should not be used at CS because they do not decrease the incidence of wound infection or wound hematoma.

42. SKIN CLOSURE
Interrupted suture.
Staples (Rapid but increase pain).
Subcuticular suture. .

43. DO’S OF CAESARIAN ACCORDING TO RCOG
Wear double gloves for CS for women who are HIV-positive
Use a transverse lower abdominal incision (Joel Cohen incision)
Use blunt extension of the uterine incision
Give oxytocin (5iu) by slow intravenous injection
Use controlled cord traction for removal of the placenta

44. DO’S OF CAESARIAN ACCORDING TO RCOG
Close the uterine incision with two suture layers
Check umbilical artery pH if CS performed for fetal compromise
Consider women’s preferences for birth
Facilitate early skin-to-skin contact for mother and baby
Presence of the husband or companion during Cesarean section.

45. DON’TS OF CAESAREAN SECTION
Close subcutaneous space (unless > 2 cm fat)
Use superficial wound drains
Routine use of forceps to deliver babie’s head
Suture either the visceral or the parietal peritoneum
Exteriorize the uterus
Manually remove the placenta

46. POST OPERATIVE CARE

47. Close monitoring for 1st 6-8 hrs
Parenteral fluids
Anticoagulation – To prevent DVT/ PE.
Blood transfusion if needed esp morbid adherent placenta
Analgesics and sedatives
Oral fluids
Early ambulation and deep breathing exercises
Light solid diet as early as 6 hours an laxatives
Discharge 3rd day and suture removal - 5th/6th day

48. POST-OPERATIVE MONITORING
Recovery Area – one-to-one observations until the woman has airway control, cardio respiratory stability and can communicate.
In The Ward – half hourly observations (respiratory rate, heart rate, blood pressure, pain and sedation) for 2 hours, then hourly if stable.
For Epidural Opioids And Patient-controlled Analgesia With Opioids – hourly monitoring during the CS, plus 2 hours after discontinuation.

49. After regional anesthesia remove catheter when woman is mobile (> 12 hours after top-up).
Remove wound dressing after 48 hours, keep wound clean and dry and expose the wound to routine baths. Keep a sanitary pad to keep it clean and dry.
Discuss the reasons for the CS and implications before discharge from hospital.
Offer earlier discharge (after 48 hours) to women who are recovering, with no pyrexia and have no complications.

50. RECOVERY FOLLOWING CS
Offer postnatal care, plus specific post-CS care, and management of pregnancy complications.
Prescribe regular analgesia.
Monitor wound healing.
Inform women they can resume activities (such as driving, exercise) when pain is not distracting or restricting.

51. CONSIDER CS COMPLICATIONS
Endometritis if excessive vaginal bleeding.
Thromboembolism if cough or swollen calf.
Urinary tract infection if urinary symptoms.
Urinary tract trauma (fistula) if leaking urine.

52. COMPLICATIONS OF CAESAREAN SECTION
ANESTHESIA RELATED:
Aspiration syndrome
Hypotension
Spinal Headache

53. HEMORRHAGE Uterine vessels damage Uterine atony
Placenta previa/accreta
Lacerations
Uterine lacerations
Vertical lacerations into vagina
Broad Ligament

54. URINARY TRACT After prolong obstructed labour
Injury to vesico uterine space (Previous cesarean section)
Low vertical uterine incision

55. GASTROINTESTINAL TRACT
Ileus
Early oral intake
Decrease time of return of bowel sounds
Decrease post op stay
Decrease abdominal distension

56. RESPIRATORY TRACT Atelectasis/Pneumonia Treatment
Deep breathing exercise
Postural drainage

57. THROMBOEMBOLSIM Major cause of maternal morbidity/mortality
Increased chances in
* Emergency LSCS
* Advanced Maternal age
* Obesity
* Inherited thrombophilia disorders

58. PROPHYLAXIS Use of mechanical calf compression intra op
Use of calf compression stocking
Subcut heparin (Low molecular wt heparin)

59. Intraoperative complications
Primary haemorrhage
Injury to internal organs
Injury to the baby
Difficulty in delivery of the head
Anaesthetic complications

60. Postoperative complications
Paralytic ileus
Respiratory complications
Infections
Peritonitis
Pelvic abscess
Pelvic thrombophlebitis
Deep vein thrombosis and pulmonary embolism
Wound dehiscence

61. Late sequelae Incisional hernia Scar endometriosis
Vesico-vaginal fistula
Scar rupture/ dehiscence next pregnancy
Subsequent morbidly adherent placenta
Abdominal infection and adhesions
Skin scar related cosmetic, paresthesia, henia
Reduced fertility