CAESAREAN SECTION

•	Definition.
•	Indications. 
•	History of previous LSCS.
•	Trial of scar.

Defintion

1.	Caesarean section is the operation by which the fetus is delivered through an incision in the abdominal wall and uterus after 28 weeks of pregnancy. 

2.	Types:

a.	Elective or emergency.

b.	Lower segment or classical:

	Classical	LSCS	
Incision	Vertical through upper segment.	Horizontal: transverse through lower segment.	
Type of operation	Abdominal	Pelvic	
Bleeding	Greater	Less	
Wound healing	Disruptive	Better	
Bowel adhesions	Greater	Less	
Bladder injury	Less	Greater	
Post-op recovery	Later	Earlier	
Rupture in subsequent pregnancy	75% (3rd trimester)	12.5% (during labor)	
Fetal mortality	10%	0.5%	

c.	GA or epidural.

Indications

1.	5 absolute indications:

a.	2 previous LSCS.

b.	Placenta praevia major.

c.	CPD / contracted pelvis.

d.	Fetal distress.

e.	Malpresentation.

2.	Other non-absolute indications:

a.	Abruptio placentae.

b.	Severe pre-eclampsia.

c.	Diabetes mellitus.

d.	Cord prolapse.

e.	Failed induction of labor.

3.	Indications for Classic CS:

a.	Central fibroid.

b.	Invasive cervical carcinoma.

c.	Previous classical CS.

d.	Transverse / shoulder presentation.

e.	Conjoined twins.

f.	Anterior placenta praevia.

g.	Postmortem CS.

History of previous LSCS

1.	Problems:

a.	Indications of another LSCS during this pregnancy.

b.	Trial of scar.

2.	Antepartum:

a.	Number of LSCS done before.

b.	Type of incision.

c.	Indications then.

3.	Intrapartum:

a.	Elective or emergency LSCS.

b.	Spontaneous or induced labor.

c.	Duration of labor.

d.	Use of forceps or vacuum before LSCS.

4.	Postpartum:

a.	Complications: fever, discharge, bleeding.

b.	Duration of hospital stay.

c.	Any X-ray pelvimetry done. 

Trial of Scar

1.	Antepartum:

a.	Admit patient and screen for maternal and fetal indications for LSCS.

b.	Decide:

i.	trial of scar.

ii.	another LSCS.

c.	Instruct patient to come to hospital stay if:

i.	she goes into labor.

ii.	there is scar tenderness and abdominal pain.

d.	X-ray pelvimetry at 37 weeks.

e.	Timing of delivery:

i.	admit at 38 – 39 weeks.

ii.	earlier if classical LSCS (36 weeks). 

iii.	trial of scar: await spontaneous labor. 

2.	Stage 1 of labor:

a.	Admit to high risk labor ward.

b.	CXM, IV drip, shave.

c.	Check lie, presentation, engagement.

d.	Monitor mother for signs of uterine rupture.

e.	Fetus on continuous CTG>

f.	Allow only 4 – 5 hours for progression of labor. 

g.	Avoid epidural.

3.	Stage 2 of labor:

a.	Shorten by prophylactic Wrigley’s lift up forceps.

b.	Syntometrine only at anterior shoulder delivery.

4.	Stage 3 of labor:

a.	Prevent PPH.

b.	Digital exploration of whether subsequent pregnancy requires LSCS. 

Procedure

1.	Standard procedure now: transperitoneal lower segment operation with transverse incision in uterus.

2.	Anaesthesia:

a.	GA / epidural.

b.	Gastric tube: empty stomach before anaesthesia.

c.	Sodium citrate: ½ hour before anaesthesia; prevents aspiration of gastric contents. 

3.	Clean, drape and catheterize.

4.	IV glucose / saline drip.

5.	Skin incision:

	Pfannestial	Midline subumbilical	
Advantages	Better healing.
Cosmetically better looking.
Less postop pain.	Better access.
Faster.
Less adhesions.	
Disadvantages	Poor access.
Increased adhesions.
Poor visualization.	Poorer healing. 
Increased postop pain. 	

a.	Abdomen open in layers.

b.	Retract downwards lower end of incision with Doyen’s retractor.

c.	Identify uterovesical fold and incise visceral peritoneum transversely 10cm. 

d.	Make transverse incision 3cm long in midline of lower segment and deepen until membranes bulge and rupture membrane.

6.	Delivery:

a.	Suck liquor and delivery baby; IV syntocinon as head is delivered.

b.	Deliver placenta through wound.

c.	If os is not dilated, use finger / Hegar dilators to dilate cervix via uterine cavity to allow passage of blood.

d.	Secure haemetasis.

e.	Close up uterus in 2 layers, bring uterovesical fold back to position and repaired and close abdomen in layers. 

7.	Post-op:

a.	Watch for PPH: pad chart.

b.	NBM.

c.	IV fluids + IV 5% dextrose.

d.	IM pethidine 50mg hourly for 24hr.

e.	3rd POD: UFEME, Hb. 

Complications

1.	Increased mortality than after NVD affected by:

a.	Indications for operation.

b.	Health before and during pregnancy.

c.	Previous attempts at delivery and length of labor.

d.	Skill of surgeon and anaesthetist.

2.	Immediate risks:

a.	Risks of anaesthesia.

b.	Haemorrhage and shock.

c.	Infection.

d.	Pulmonary embolism.

3.	Remote risks:

a.	Rupture of caesarean scar.

b.	Adhesions leading to intestinal obstructions. 

4.	Fetal problems:

a.	Respiratory depression.

b.	Intracranial damage.