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Caesarean delivery: Definition

Caesarean delivery is defined as the birth of a foetus through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterotomy) after 28 weeks of pregnancy.

Caesarean delivery: Definition

It is an operative procedure whereby the fetuses after the end of 28th week, are delivered through an incision on the abdominal and uterine walls.

History of Caesarean delivery

The origin of the Caesarean section is somewhat uncertain. The hypothesis that Julius Casear was the product of a Caesarean delivery is unlikely to be true in view of the probability of fatality associated with the procedure in the ancient times and the observation that his mother, Aurelia, corresponded with him during his campaigns in Europe many years later.

History – Cont’d

The term may have as its origin the Latin verb ‘cadere’, to cut; the children of such birth were referred to as caesones. It is also possible that the term stems from the Roman law known as Lex Regis, which mandated postmortem operative delivery so that the mother and child could be buried separately; the specific law is referred to historically as Lex Cesare.

CAESAREAN SECTION IN UGANDA DURING ANCIENT DAYS

Historical Advances

By the mid seventeenth century, French obstetrician F. Mauriceau reported sections on living woman. Although surgeons possessed the anatomic knowledge necessary to perform a Caesarean delivery

Historical Advances – Cont’d

In 1800s, they were limited by their inability to provide anesthesia and control infection. The introduction of diethyl ether and later chloroform as anesthetic agents increased the feasibility of major abdominal surgery.

Historical Advances – Cont’d

Surgical techniques were also a limiting factor. Surgeons were hesitant to reapproximate the uterine incision for fear that permanent sutures would increase the likelihood of infection and cause uterine rupture in subsequent pregnancies. Not surprisingly, women continued to die from blood loss and infection.

Historical Advances – Cont’d

The Porro procedure (1876) combined subtotal Caesarean hysterectomy with marsupilization of the cervical stump. In 1882, Max Sanger in Germany first sutured uterine wall in Caesarean section using silver wire and silk with careful attention to haemostasis. Frank (1907) described extraperitoneal lower segment operation to avoid peritonitis. Beck (1919) and De Lee (1922) introduced lower segment operation by vertical incision. Munro Kerr (1926) gave the transverse lower segment incision for Caesarean delivery the world today.

Incidence

• Reduced parity: almost half of the pregnant women are nulliparous, thus an increased number of caesarean births might be expected for conditions which are more common in primigravida.

• Older women are having children and frequency of caesarean deliveries increases with advancing age.

Incidence – Cont’d• Extensive use of electronic foetal

monitoring and increased caesarean deliveries for non-reassuring foetal heart rate picked up by this technique is compared with intermittent foetal heart rate auscultation.

• By 1990, 83% of all breech presentations were delivered abdominally.

• The incidence of mid pelvic vaginal deliveries (high presentation) has decreased.

Incidence – Cont’d

• Concern for malpractice litigation has contributed significantly to the present caesarean delivery rate• Socioeconomic and demographic factors may play a role in caesarean birth rate.

INDICATIONS

The indications are broadly divided into two categories:

»Absolute»Relative

ABSOLUTE INDICATIONS

• Central placenta praevia• Contracted pelvis or cephalopelvic

disproportion • Pelvic mass causing obstruction

(cervical or broad ligament fibroid)• Advanced carcinoma cervix• Vaginal obstruction (atresia,

stenosis)

RELATIVE INDICATIONS

• Cephalo-pelvic disproportion (relative)• Previous caesarean delivery • Non reassuring FHR (fetal distress)• Dystocia may be due to (three Ps)

relatively large fetus (passenger), small pelvis (passage) / or inefficient uterine contractions (power).

• Antepartum haemorrhage (a) placenta praevia and (b) abruption placenta.

RELATIVE INDICATIONS – CONT’D

• Malpresentations• Failed surgical induction of

labour, Failure to progress in labour.

• Bad obstetric history• Hypertensive disorders• Medical-Gynaecological disorders

Common Indications

Primigravidae:• Cephalopelvic

disproportion (CPD) • Fetal distress (non-

reassuring fetal FHR)

• Dystocia (three Ps)

Multigravidae:• Previous caesarean

delivery (28%)• Antepartum

hemorrhage (Placenta Previa, placental abruption)

• Malpresentation (Breech)

Contraindications

• Very low birth weight baby• Maternal coagulation defects

Time of Operation in Caesarean Delivery

• Elective CS• Emergency CS• Criteria for timing of elective

repeat caesarean delivery• An ultrasound obtained at 12 to 20

weeks confirms the gestational age of at least 39 weeks determined by clinical history and physical examination.

Types of caesarean section

• Lower segment caesarean section (99.8%)• Classical or Upper segment

0.02%.• Caesarean hysterectomy 0.18%.• Extra peritoneal lower segment

operation.

Features of Transverse and Vertical Incision

Transverse (Pfannnensteil) Vertical

More popular due to cosmetic purposes

Less popular

Limited exposture Rapid entry and good exposure

Cherny/maylard modification may be needed, in the presence of previios similar surgery

Median/ paramedian incision can be made

Hernia less common (this usually occurs at the angles)

Post-operative hernia more common (this can occur anywhere along the incision)

Preparation of the mother

• Psychological Preparation• Physical Preparation• Anesthesia• Position

Incision on the Abdomen

A low transverse incision is made about two fingers breadth above the symphysis pubis (modified pfannenstiel) or above the symphysis pubis (pfannenstiel or bikini line incision). Some obstetricians make a vertical infraumbilical or paramedian incision, which extends from about 2.5 cm below the umbilicus to the upper border of the symphysis pubis.

Incision on the Abdomen

The anatomic layers incised are:

•Fat•Rectal sheath•Muscle (rectus abdominis)•Abdominal peritoneum•Uterine muscle.

Advantages and Disadvantages of

Transverse IncisionAdvantages Disadvantages

Postoperative comfort is more Takes a little time and as such unsuitable in acute emergency operation

Fundus of the uterus can be better palpated during immediate post-operative period

Blood loss is little more

Less chance of wound dehiscence

Cosmetic value Requires competency during repeat section

Less chance of incisional hernia Unsuitable for classical operation

Delivery of the Head

The uterine cavity is then opened, the membranes are ruptured and the amniotic fluid is aspirated. The head is delivered by hooking the head with the fingers, which are carefully inserted between the lower uterine flap and the head until the palm is placed below the head.

As the head is drawn to the incision line, the assistant is to apply pressure on the fundus. Obstetric forceps (Wrigley’s forceps) are often used to extract the head from the pelvis.

Delivery of the Trunk

As soon as the head is delivery, the mucus from the mouth, pharynx and nostrils is to be sucked out using rubber catheter attached to an electric sucker. When the baby is born, an oxytocic drug (methergine 0.2 mg) is administered before the placenta and membranes are delivered. The cord is cut between two clamps and the baby is given to the nurse.

Removal of the Placenta and Membranes

The placenta is extracted by traction on the cord with simultaneous pushing on the fundus towards the umbilicus (controlled cord traction). The placenta and membranes are removed intact.

Suturing of the Uterine Wound

The margins of the wound are picked up by Allis tissue forceps or Green Armytage hemostatic clamps. The uterine muscle is sutured in two layers using continuous running sutures, the second of which tends to align the cut edges of the pelvic peritoneum.

Repair of the rectus sheath brings the rectus abdominis into alignment. The subcutaneous fat is sometimes sutured and finally the skin is closed with sutures or clips.

BLUNCH SUTURE FOR CAESAREAN SECTION:

BLUNCH SUTURE FOR CAESAREAN SECTION

Postoperative Care

Immediate Care (4-6 hours):In the immediate recovery period, the

blood pressure is recorded every 15 minutes.

Temperature is recorded every two hours. The wound must be inspected every half

hour to detect any blood loss.

Immediate Care (4-6 hours)

The lochia are also inspected and drainage should be small initially.

Following general anesthesia, the woman is nursed in the left lateral or ‘recovery’ position until she is fully conscious, since the risks of airway obstruction or regurgitation and silent aspiration of stomach contents are still present. Analgesia is given as prescribed.

First 24 hours

• IV fluids (5% dextrose or Ringer’s lactate) are continued. Blood transfusion is helpful in anemic mothers for speedy postoperative recovery.

• Injection methergine 0.2 mg may be repeated intramuscularly.

• Parenteral antibiotic is usually given for the first 48 hours.

First 24 hours – Cont’d

• Analgesics in the form of pethidine 75-100 mg are administered as required.

• Ambulation is encouraged on the day following surgery and baby is brought to her.

After 24 Hours – Cont’d

• The blood pressure, pulse and temperature are usually checked every four hours.

• Oral feeding is started with clear liquids and then advanced to light and regular diet.

• IV fluids are continued for about 48 hours.• Urinary catheter may be for about 48

hours.

• Urinary catheter may be removed on the following day when the woman is able to get up to the toilet the woman is helped to get out of bed as soon as possible and encouraged to become fully mobile.

• The mother must be encouraged to rest as much as possible and needed help is to be given with care for the baby.

• This should preferably take place at the mother’s bedside and should include support with breastfeeding.

• The mother is usually discharged with the baby after the abdominal skin stitches are removed by the 4th or 5th day.

Merits and Demerits of Lower Segment Operation over classical

Lower Segment Classical

Techniques Technically slight difficult Blood loss is less The wall is thin and as

such apposition is perfect Perfect peritonisation is

possible Technical difficulty in

placenta previa or transverse lie.

Technically easy Blood loss is more The wall is thick and

apposition of the margins is not perfect

Not possible Comparatively safer in

such circumstances

Lower Segment Classical

Postoperative Hemorrhage and shock – less

Peritonitis is less even in infected uterus because of perfect peritonisation and if occurs, localized to pelvis.

Peritoneal adhesions and intestinal obstruction are less

Convalescence is better Morbidity and mortality

are much lower.

More Chance of peritonitis is

more in presence of uterine sepsis

More because of imperfect peritonisation

Relatively poor Morbidity and mortality

are high

Lower Segment ClassicalWound healing

The scar is better healed because of The scar is weak because of:- Perfect muscle apposition due

to thin margins- Minimal wound hematoma- The wound remains quiescent

during healing process- Chance of gutter formation is

unlikely

- Imperfect muscle apposition because of thick margins

- More wound hematoma formation

- The wound is in a state of tension due to contraction and relaxation of the upper segment. As a result, the knots may slip or the sutures may become loose

- Chance of gutter formation on the inner aspect is more

During future pregnancy

Scar rupture – is less 0.5 – 1.5%

More risk of scar rupture – 4 to 9%

Postpartum pain Relief after Cesarean Birth

Incisional Pain:• Splint incision with a pillow hen moving or

coughing.• Use relaxation techniques such as music,

breathing and dim lights

Intestinal Gas:• Walk as often as you can• Do not eat or drink gas-forming foods,

carbonated beverages, or whole drink• Do not use straws for drinking fluids.• Take anti flatulence medication if

prescribed• Lie on your left side to expel gas• Rock in a rocking chair

Home Care

Signs of postoperative complications after discharge:

• Report the following signs to your health care provider.

• Temperature exceeding 380 c • Painful urination• Lochia heavier than a normal period• Wound separation• Redness or oozing at the incision site• Severe abdominal pain

Intraoperative Complications

• Extension of uterine incision• Uterine lacerations• Bladder injury• Ureteral injury• Gastrointestinal tract injury• Uterine atony and primary postpartum

hemorrhage• Morbid adherent placenta (placenta

accreta)

Postoperative ComplicationsMaternal

Immediate Remote Postpartum hemorrhage Gynaecological:

Menstrual excess or irregularitiesChronic pelvic pain or backache

Shock General Surgical:Incisional herniaIntestinal obstruction due to adhesions and bands

Anesthetic hazards Future Pregnancy:There is risk of scar rupture Infections

Intestinal obstruction Thromboembolic disorders Wound complications Secondary postpartum

hemorrhage

Fetal ComplicationsIatrogenic prematurity and

development of RDS is not uncommon following caesarean delivery. This is seen when fetal maturity is uncertain.

Evidence based practice

Doshi Haresh, Tripathi Jagruti, Maheshwari Sonal, Gupta Arti (2009) conducted a national survey in Cesarean section – changing trends with the objectives to study the changing trends in indications and techniques of cesarean section in various parts of India. Methods: A clinical survey was carried out amongst 253 obstetricians from all over India selected at random regarding their practices of cesarean section in terms of indications and technics.

Results: Result showed that previous cesarean section, severe pregnancy induced hypertension, failed induction of labor and infertility treated cases is now increasing amongst the indications for cesarean section. In technics, single layer closure (41.11% doctors) and non suturing of peritoneum, visceral or both, (35.96% doctors) are now increasing among obstetricians. Polyglycolic acid sutures (vicryl, centicryl, dexon) are replacing catgut for uterine closure.

Conclusion: Being a common major surgery any changes in technic for better surgical result are always welcome. Changes in indications are mainly due to litigation fear and better neonatal facilities.

ConclusionLow caesarean section rates are

associated with low levels of intervention and high levels of psychological support. It is difficult to decipher whether caesarean section rates have been affected by interventions such are proactive management of labour.