CESAREAN

SECTION
Gemechu G. (BSC, MSC)

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 At the end of lesson you will be able to:

• Define cesarean section

• Identify indication and contraindication of CS
• Understand complication of CS
• Provide pre and post operative care for patient
undergoing CS
• Evaluate pregnant woman with previous C/Section
for vaginal delivery

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 Definition
• Defined as the birth of a fetus through incisions in
the abdominal wall (laparotomy) and the uterine
wall (hysterotomy)
– Laparotomy + Hysterotomy

– after viability (≥ 28 weeks)

• This definition does not include removal of the

fetus from the abdominal cavity in the case of
ruptured uterus

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 Prevalence of CS
• USA,2005
– 30% of all deliveries(62% are primary)
– The highest rate ever recorded
• Mean CD in developed countries=21%
• Only 2% in least developed countries
• WHO recommendation
– Rate of 5-15% appears to give best maternal outcome
• In Ethiopia: 29.6%, highest in AA at 40.4%
(Gedefaw, 2020 )-meta-analysis from 23 studies

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 Factors increasing Cesarean Delivery Rate
• Increased diagnosis of dystocia (major indication for
CD)
• Fewer VBAC
• more induction of labor
• Caesarean delivery on maternal request
• Medicolegal issues
• Increasing maternal age at delivery
• Increasing incidence of multiple pregnancy
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 Factors increasing CD…

• Decreased utilization of forceps and vacuum

• Increased elective CD for macrosomia
• Decline in vaginal breech delivery
• Increased rates of CD for women with preeclampsia
• Increased repeat CD rate
– VBAC has decreased from 26% in 1996 to 8.5% in
2007 due to both safety and Medicolegal concerns

• The use of electronic fetal monitoring

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 History of CS
• The history of caesarean section (C-section) dates
back as far as Ancient Roman times.
• The origin of the word cesarean arose after Julius
Caesar was born in this manner.
• Latin origins
– "caedare," meaning to cut"
– "caesones" that was applied to infants born by
postmortem operations

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 History of CS…

• Gaius Julius Caesar was a Roman general and

statesman

– Roman law under Caesar decreed that all women

who were so fated by childbirth must be cut
open; hence, cesarean

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 Classification

• Many ways

– Type of uterine incision

– Timing of operation

– Number of C/S

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 Type of Uterine Incision

• Classical C/S
• Lower uterine segment
transverse (LUST) C/S
• De Lee incision
– Vertical incision over
LUS
• J incision(Right or left)
• Inverted T incision

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 Number of CD

• Primary
– 1st CD
• Repeat
– After previous CD

• Total CD=sum of above two

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 Timing of operation
• Emergency

– After problem occur

• Elective CD

– Planned during ANC

– Adequate patient preparation

• Blood, NPO, fetal maturity assured, treatment

of intercurrent disease

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Classification of the degree of Urgency of CS
Category Definition

I-Emergency immediate threat to life (maternal or

fetal); D-D not >30 min

II-Urgent maternal or fetal compromise that is not

immediately life-threatening

III-Scheduled needing early delivery but no maternal or

fetal compromise

IV-Elective delivery at the convenience of the patient

or obstetric team
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 Indication
a. Maternal indication
i. Medical

– Specific cardiac disease (unstable coronary artery

disease, Marfan's syndrome)

– Specific respiratory disease (Guillian-Barré

syndrome)

– Conditions associated with increased intracranial

pressure
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 Maternal indication…

ii. Mechanical

– Obstruction of the lower uterine segment

(tumors, fibroids)

– Lower segment myomata or ovarian neoplasm

– Massive condylomata may require CS

– Vulvar obstruction (condylomata)

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 Fetal indication
• Non-reassuring fetal heart rate status

• breech-related indications:

– Footling breech (if not 2nd stage)

– Estimated fetal weight of >3800 gm

– Extended or deflexed neck

• Transverse lie

• Congenital anomalies; e.g. Hydrocephalus

• Twin A non vertex in twin

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 Feto-maternal indication

– Cephalopelvic disproportion

– Placental abruption

– Placenta previa

– Elective cesarean delivery

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 Indication for elective CS
• Gross CPD • Colporrhaphy
• Previous classical CD • High risk pregnancy
• Previous CD + other obstetric Advantage:
complication(DM, APH, • less risk of complication
breech)
Prerequisites
• Two previous CD (commonest)
• Assure fetal maturity by ACOG
• Tumor previa criteria
• Repaired VVF

• Previous myomectomy,
metroplasty
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 Indication for emergency CS
• Obstructed labor
• I-D time=less than 4 min
• AP
• D-D time=15 min
• NRFHRP

• Cord presentation or
prolapse

• Malpresentation
• Footling
• Failed VBAC
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• There are many different reasons for performing a
delivery by caesarean section.
• The four major indications accounting for greater
than 70% of operations are:
– Previous caesarean section
– Malpresentation (mainly breech)
– Failure to progress in labor
– NRFHR pattern

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• The principle for CS:

– Whenever the risk to the mother and/or the

fetus from vaginal delivery exceeds that from
abdominal delivery, a caesarean section should
be undertaken!

• Absolute indications for recommending delivery

by caesarean section are few, almost all indications
are relative

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 Cesarean Delivery on Maternal Request

• Refers to a CD performed because the mother

requests in the absence of conventional medical or
obstetric indications.

• Prevalence: 0.2 to 42% of all deliveries

• Uncomplicated pregnancy

– Should be scheduled at 39 to 40 weeks

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 Reasons for choosing CD on maternal
request

• Convenience of scheduled delivery

• Fear of the pain, process, length, and/or

complications of labor and vaginal birth

• Prior poor labor experiences

• Concerns about fetal harm from labor and vaginal

birth

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 Reasons for choosing CD on maternal
request…

• Concerns about trauma to the pelvic floor from

labor and vaginal birth, and subsequent
development of symptoms associated with pelvic
organ prolapse, urinary and fecal incontinence

• Concerns about the need for and risks of

emergency cesarean or operative vaginal delivery

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 Preoperative care/issues
• Informed consent
• Assess fetal pulmonary maturity
• Laboratory testing
• Open IV line
• Antibiotic prophylaxis
• Bladder catheterization
• Thromboembolism Prophylaxis
• Skin preparation
• Vaginal preparation
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 Informed consent
• woman’s awareness of her diagnosis
• Contains a discussion of medical and surgical care
alternatives, procedure goals and limitations, and
surgical risks
• Desire for permanent sterilization or intrauterine
device insertion
• woman’s decision-making autonomy must be
respected
• Jehovah’s Witnesses – Blood ??
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 Assess fetal pulmonary maturity
Confirmation of GA of 39 wks by at least one of the ff:
 FHR documented for ≥20 wks by fetoscope or greater
or equal to 30 wks by doppler
 Positive HCG documentation for ≥36 wks
 U/S CRL at 6-11 wks that indicate current GA of
greater or equal to 39 wks
 U/S measure at 12-20 wks that supports GA greater
or equal to 39 wks

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 Antibiotic prophylaxis
• Reduce frequency of:
– Post operative fever, endometritis, wound infection,
UTI
• Principle:
– Single-dose therapy, Cheap
• Preferred agents:
– Single dose of 1st generation cephalosporin (cefazolin)
1 g (<80 kg); 2 g (≥80 kg); 3 g (≥120 kg)
– ampicillin 2 g
• Timing of Antibiotic prophylaxis

– within 60 minutes before making the skin incision

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 Antibiotic prophylaxis…

• Positive GBS prophylaxis

– No need if no labour/ROM

– ACOG: Universal antepartum GBS screening at

36+0 to 37+6 wk, for elective CS

– Labour or prelabour ROM

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 Antibiotic prophylaxis-Special populations
• History of serious forms of penicillin allergy
– Clindamycin 900 mg intravenously +
– Gentamicin 5 mg/kg intravenously
– Add – azithromycin 500 mg if CS is done in labor or
after ROM
• Woman receiving GBS prophylaxis
– do not add a cephalosporin or switch to ampicillin for
surgical prophylaxis
– Rather add a dose of azithromycin

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 Thromboembolism Prophylaxis
• Pregnant /postpartum period risk of PE/VTE
increases to – 4X to 5X
– Thrombotic event (ischemic stroke, acute
myocardial infarction, venous thromboembolism)
• Low-Risk women
– Pneumatic compression if not in pharmacologic
thromboprophylaxis before CD
– Pneumatic compression until the patient is fully
ambulatory
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 Thromboembolism Prophylaxis
• High-Risk women
– Previous VTE, any thrombophilia (inherited or
acquired), Body mass index (BMI) >35 kg/m2
– mechanical or pharmacologic thromboprophylaxis
– Early ambulation as soon as eight hours
– Postoperatively
• Timing of pharmacologic therapy
– 6 to 12 hours postoperatively

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 Bladder catheterization
• Minimize bladder injury
• Prevent bladder distension, which could impede
exposure of the LUS
• For instilling dye if a cystotomy is suspected
• For monitoring urine output
• Potential harms:
– Increased risk of UTI
– Urethral pain
– Voiding difficulties after removal of the catheter
– Delayed ambulation
– Longer hospital stay
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 Skin preparation
• Chlorhexidine-alcohol scrub

• Iodine-alcohol skin preparation

• Alcohol-based surgical prep solutions

• Hair removal:

– no difference in the rate of SSI

– If hair needs to be removed, it should be clipped

rather than shaved as patients who are shaved
are more likely to develop SSI
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 Vaginal preparation
• 4% chlorhexidine gluconate vaginal scrub with a
sponge with three passes to lower SSI risk

• Povidone-iodine is an alternative option but was

less effective

• Preparations with a high alcohol content should

be avoided in the vagina because alcohol irritates
mucous membranes

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 Techniques/steps
1. Skin and subcutaneous incision

2. Uterine incision

3. Rupture of membranes

4. Foetal delivery

5. Oxytocic drug administration

6. Placental delivery

7. Closure of the uterus

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 Skin incision
• Langer lines (orientation of dermal fibers within the skin)

• In the anterior abdominal wall, they are arranged

transversely

• As a result of Langer lines:

– vertical skin incisions sustain greater lateral tension

and thus, develop wider scars

– low transverse incisions follow Langer lines and lead

to superior cosmetic results

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 Most Common skin incision

• Vertical: Midline incision

• Transverse

– Pfannenstiel's incision:
the most common
incision

– Joel-Cohen incision

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 Pfannenstiel Incision

• The most common

incision
• 2-3 cm above symphysis
pubis
• 8-to 10-cm transverse
incision
• excellent strength and
cosmesis

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 Joel Cohen incision

• straight transverse incision

• slightly more cephalad than
Pfannenstiel
• lower rates of fever,
postoperative pain, and use of
analgesia; less blood loss, and
shorter operating time
compared with Pfannenstiel
Incision

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 Transverse skin incision
Advantage Disadvantage

• Better cosmetic • More time consuming

appearance • More blood loss
• Better healing • Gives less exposure
• Less incidence of
incisional hernia

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 The infra-umbilical incision
Preferred in:
– extreme obesity
– Access to uterine fundus may be required
Advantage:
– Faster abdominal enter
– Less bleeding and nerve injury
– Can be easily extended cephalad if more space is needed
for access
Main indications: exploratory laparotomy (eg, trauma,
abdominal sepsis)

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 Supraumbilical incision

• In severely obese women, a supraumbilical

incision may be preferable to a suprapubic
incision

• Rarely used

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Factors that influence the type of abdominal
incision
• Urgency of the delivery

• Prior incision type

• Potential need to explore the upper abdomen

for non obstetric pathology

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 Subcutaneous
• Blunt dissection (with fingers) is preferred over sharp
dissection (with the knife)

– blunt dissection has been associated with less chance

of injury to vessels, and less postoperative pain

– The tissue is opened from medial to lateral

• Primary incision - sharp/blunt; Repeat scar - always sharp

• Subcutaneous tissue is closed if:

– It will facilitate skin closure or fat thickness >2 cm

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 Fascia and peritoneum
• A small transverse incision is usually made medially
with the scalpel → extended laterally with scissors ➔
primary (blunt); secondary (sharp)

• Rectus muscle layer – Maylard/cherney technique

• In closing the fascia: placement of sutures should be

at a minimum 1-1.5 cm from the margin of the
incision.

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 Bladder flap

• Don’t do routinely

• caudad separation of bladder should not exceed

5 cm except in Cesarean hysterectomy to
decrease the risk of cystotomy

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 Uterine incision
• blunt rather than sharp expansion of the hysterotomy
incision is preferred
• Types
– Lower transverse uterine incision
90 percent of cases
– Lower vertical uterine (De Lee) incision
– Upper vertical uterine incision(Classical)
– J incision
– T incision
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 Choice of incision is based on:
• Fetal presentation

• Gestational age

• Placental location

• Presence of a well-developed lower uterine segment

• BMI

Note: direction of skin incision does not indicate the type

of uterine incision!

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 Vertical incision
• Two types
risk of rupture: 1-7%
a. Low vertical (De Lee or Cornell)
– If the lower segment is poorly developed

– If more room is needed➔ extended upward into upper

uterine segment

– Major disadvantage: extension cephalad in to the uterine

fundus(classical) and caudally in to the bladder, cervix or
vagina

b. Classical: entirely within UUS

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 Indications for Vertical Uterine Incision
• Underdeveloped lower uterine segment

• Prolapsed arm

• transverse lie with dorso- inferior (back down)

• Lower segment anterior myoma: leiomyomata

obstructing the lower segment

• complete anterior placenta previa

• preterm breech delivery

• Post mortem delivery

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 Advantage of classical incision

• Excellent exposure

• Useful when lower segment is not developed

(useful breech or transverse lie, prematurity)

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 Disadvantage of classical incision

• Increased blood loss

• Risk of uterine rupture (4-9%) prior to or during

labour in a subsequent pregnancy

• Difficult to suture (due to thick myometrial layer)

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 Transverse Incisions

• The operation of choice (> 90%)

• Made 1-2 cm above the original upper margin of

the bladder

• Described by Kerr in 1921

• Also called Pfannenstiel-Kerr technique

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 Advantage of transverse incisions

• Less blood loss

• Low incidence of dehiscence
• Easier reapproximating
• lower risk of rupture (0.2-1.5% ) in subsequent
pregnancies
• Does not promote adherence of bowel or omentum
to the incisional line

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 Placental extraction
• Spontaneous delivery

– Gentle traction on the cord and use of oxytocin to

enhance uterine contractile expulsive effort

– Preferable as it has less postop endometritis and blood

loss

• Manual extraction

– Increase rate of postoperative endometritis

– greater blood loss

– Lower postpartum hematocrit

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 Uterine Closure
• Exteriorizing the uterus
• a two-layer, continuous full-thickness closure with
delayed absorbable synthetic suture
– 1st layer incorporates the myometrium plus the
decidual edge to achieve hemostasis
– 2nd imbricating layer covers the exposed
myometrial edges
• Triple layer (thick myometrium, in classical, De lee)
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 Uterine Closure…

• Choice of suture material

– 0- or no. 1 absorbable suture = chromic catgut

– 0-delayed absorbable synthetic monofilament

(eg, Monocryl) or braided (eg, Vicryl) suture is
commonly used

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 Fascia and SC closure
• Optimal closure of fascia involves use of:
– A continuous (not interrupted) technique
– Slowly (not rapidly) absorbable suture
– Mass (not layered) closure
– Suture length to wound length ratio of 4 to 1
– Sutures placed ~ 1 cm from the edge of incision
and 1 cm apart, without excessive tension
• Subcutaneous tissue – closed if ≥ 2 cm thick
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Reapproximating peritoneum
– Traditionally with a continuous 2–0 chromic
catgut
– Non-closure saves time
– No convincing evidence of harm (increased
adhesion formation)

Reapproximating of rectus sheath

– cause unnecessary pain
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 Skin Closure and dressing
• Subcuticular suture rather than staples
• Suture: poliglecaprone (monofilament) or
polyglactin (braided)
• Dressing
– Postoperative surgical incisions (clean, clean-
contaminated) are typically covered with a dry
dressing that is held in place with an adhesive
tape
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 Dressing

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 Maneuvers for fetal extraction
a. Reverse breech extraction (pull method)
– preferred approach for deeply engaged, impacted fetal
head
b. Abdomino-vaginal delivery (push method)
– Pushing through vagina
c. Patwardhan technique (Shoulder first method)
– Anterior shoulder is delivered → posterior shoulder →
trunk of the baby gently with both thumbs parallel to
spine, and, with fundal pressure given by the assistant, the
buttocks are delivered, followed by legs →baby's head
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 Fetal head elevator

• Coyne spoon, the Sellheim spoon, and Murless

head extractor

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 Post operative care
• Maternal monitoring:

– Vital signs (every 5 min for the first 30 min, then

every 30 min for 2 hours and hourly thereafter)

– Uterine tone

– Vaginal and incisional bleeding

– Urine output

– HCT after 8 hr

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 Maternal monitoring…

• Provide medications as ordered

• Discontinue IV fluids once started fluid diet unless

there is other IV medication as ordered

• Initiate breast-feeding and skin-to skin contact with

the baby as soon as the mother is awake

• Administer anti D Immunoglobulin 300μgm IM stat if

Rh negative (within 72 hours)

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 Post op…
• Bladder catheter
– Removing the catheter as soon as possible (i.e.
immediately after the skin is closed) minimizes the risk
of infection
– Removed commonly after 8 hour
• Ambulation
– As early as possible – ambulate for at least 5 to 10
minutes at least four times per day

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 Post op…
• Diet
– Support the patient to start sips of fluid after ascertaining
that she is conscious and bowel sounds are active
– Early oral intake may enhance the return of bowel
function by stimulating the gastrocolic reflex
• Lifting weight
– avoid lifting > 6 kg from the floor for 4 – 6 weeks following
abdominal surgery to minimize stress on the healing fascia

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 Post op…
• Exercise
– slowly increase aerobic training activities, depending on
their level of discomfort and postpartum complications
• Breastfeeding
– can be initiated in the delivery room
• Nausea and vomiting
– chewing gum, prophylactic antiemetic therapy
• Sexual activity
– may resume when the patient is ready (commonly after 6
week)

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 Wound care
• In a clean surgical wound, epithelialization typically
occurs in the 48 hours after surgery

Dressing

• Prevent bacterial contamination

• remove the initial dressing after 24 hours after CD

(since - no detrimental effect on epithelialization)

• skin around the edge of the dressing should be

checked for redness or blistering
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 Wound care…

• The skin sutures can be removed on the sixth day

after surgery if non-absorbable (can be done at the
outpatient department if the woman is discharged
earlier)
• Removal of absorbable subcuticular suture is
unnecessary

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 Wound care…
• Shower:

– no conclusive evidence of harm from

postoperative showering within 48 hours of
surgery in patients with closed surgical wounds

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 Intraoperative Complications

• Haemorrhage and injury to adjacent organs

• Injury to the bowel, bladder, and ureters

• Uterine Lacerations

• Uterine Atony

• Maternal Mortality

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 Postoperative complications
• Immediate complications
– Intraoperative damage to organs such as the
bladder or ureters
– Anesthetic complications including aspiration
pneumonia
– Hemorrhage
– Wound Infection (1 to 5% of CD)

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 Postoperative complications …
• Long-term risks
– Uterine rupture in subsequent pregnancies
– Limitation of number of children
– Placenta previa
– Placental abruption
– Placenta accrete (MAP)
– Thromboembolism
– Fascial dehiscence
– Septic Pelvic Thrombophlebitis

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 5 W's of postoperative fever

• Wind: Atelectasis

• Water: UTI, anastomotic leak

• Wound: SSI

• Walking: DVT, Thrombophlebitis

• Wonder Drugs

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 Causes of fever according to time of onset

Day 1 Day Two

• Local causes • Respiratory/Catheter
• Atelectasis causes
• Wound cellulitis • Pneumonia
• Urinary tract infection • Urinary tract infection
• Indwelling catheter • Wound cellulitis
• Transfusion reaction • Necrotizing fasciitis or
• Thrombophlebitis clostridial myositis

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 Causes of fever according to time of onset

Day Three > 7days

• Systemic causes • Surgical complications
• Thrombophlebitis • undiagnosed disease
• DVT • Deep wound infection
• Wound infection • Abscess
• Cholecystitis • DVT or thrombophlebitis
• Pancreatitis • Clostridium difficile
• Systemic diarrhoea
bacteraemia/fungemia/vi • Collagen/Vascular disease
remia • Neoplasm

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 Disadvantage of CS over SVD

• Increased risk of • Prolonged hospital stay

Infection • Long recovery time
• Hemorrhage
• delay the initiation of
• Thromboembolism breastfeeding
• Respiratory distress
• Poor cosmetic result
syndrome (RDS)
• Anesthesia effect
• Intraoperative injury

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 Discharge counselling and Education
• A woman who delivered by CS should be explained
about the indication (CPD) and the need for repeat CS
in future pregnancy

• Besides verbal explanation, a written note should be

given that could also serve as referral feedback to
referring health centers.

• Previous CS for CPD can be followed at a nearby

health center and referred after 36 - 37 weeks of
gestation.
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 Vaginal Birth After Cesarean
Section (VBAC)

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 Definition
• Trial of labor after cesarean delivery (TOLAC)

 Is planned attempt to deliver vaginally by women

who had previous C/S, regardless of the outcome

• Vaginal birth after cesarean section (VBAC)

 Successful TOLAC

• If CD becomes necessary during the trial, then it is

termed a “failed TOLAC”

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 Factors that influence a successful TOLAC
High Favor success Increased failure rate High risk
success
Transverse Teaching hospital AMA Classical or T-
incision incision
Prior SVD White race Macrosomia Prior rupture
Appropriate Spontaneous Obesity Inadequate
counselling labor Breech facilities
Sufficient Non-recurrent Multifetal px Patient refusal
personnel & indication GA: >40 weeks
equipment
Previous 1-2 transverse Low vertical incision Trans fundal
seccuessful uterine incision Short inter delivery surgery
VBAC interval

Medical diseases OBS

complication e.g,
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previa 86
 Benefit of VBAC

• Decreased maternal morbidity (infection and

others)

• Reduced length of hospital stay

• Decreased need for blood transfusion

• Decreased risk of abnormal placentation and

need for successive CD

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 Indication for TOLAC
• One previous lower segment transverse scar

• Nonrecurring indication for prior CD

• Adequate pelvic

• Spontaneous onset of labor

• Availability of resources (anesthesia, blood

transfusion and theater) for emergency CD

• Informed consent of the woman

• Singleton fetus
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 Contraindication for TOLAC
• Previous classical or inverted T-shaped uterine incision

• Previous two or more lower segment CD

• Pelvis contracted or suspected CPD

• Presence of other complications in pregnancy: Obstetric

(preeclampsia, malpresentation, placenta previa) or medical

• Resources limited for emergency CD

• Patient refusal

• History of prior uterine rupture

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 Complications of Unsuccessful VBAC-TOLAC

Maternal
Uterine wound dehiscence

Uterine rupture

Increased blood transfusion

Increased risks of hysterectomy due to uterine

rupture

Infections, increased maternal morbidity

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 Complications of Unsuccessful VBAC-TOLAC

Fetal
Low APGAR score

admission to NICU

hypoxic ischemic encephalopathy (HIE)

neonatal death

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