Cesarean section
DefinitionTOP after age of viability through both abdominal & uterine incisions
* Before fetal viability Hysterotomy
* Abdominal pregnancy or after rupture uterus Laparatomy
Incidence ( variable ) ( 3 5 % ) at 1960 ( 20 25 % ) at 1990 d.t.
* Repeat CS malpractice* CPD ( dystoica ) . More diagnosed ( partogram )
* Breech . Is managed directly by CS
* Patient request !!!!
Indications
Pregnancy- Antepartum hemorrhage ( placenta previa )
- Brecious baby ( long period of infertility , or elderly PG )
- Continuation of pregnancy is hazardous on M or F ( e.g. severe PET )
- Diabetes mellitus ( if macrosomia or previous unexplained IUFD )
Labor
* Passenger
- Bony CPD ( 2nd or failed trial of labor )
- Soft tissue tumors , cervical rigidity , vaginal stenosis
* Power
- Abnormal uterine action & 2ry arrest of labor .
- Maternal distress < full cervical dilatation .
* Passenger
- Malpresentations ( breech , Tr., Brow , face , some OP )
- Macrosomia
- Fetal distress < full cx dilatation , e.g. IUGR , prolapsed pulsating cord .
Previous obstetric operation ( CS ) if
- More than 1 LSCS- Previous 1 USCS or hysterotomy
- Previous repair of rupture uterus
- Previous perforation of uterus
Previous gynecological operations
- Repair of Vesico-vaginal fistula- Repair of SUI
- Fothergill operation
- Sometimes after my myomectomy .
Indications for CS may be
- Absolute ( no other alternative ) severe CPD , P. Praevia centrails- Relative ( vaginal delivery may take pace but CS is safer )
Contraindications relative ( none absolute )
- Fetal death , Major malformations .- Cardiac , coagulopathy
Timing of operation
- Elective ( Planned ) before the onset labor pains .- Selective ( emergency ) during labor .
Types of operations
1. Upper segment CS ( classical )2. Lower segment CS ( Best )
3. Extraperitoneal CS type of LSCS but the peritoneum is not opened
Technique of LSCS
Anesthesia General or spinal or epidural ( best )Local infiltration in heart failure
Catheterization of bladder
- FHS are heard ( Dont miss this ! )
- Sterilization
Skin incision : Transverse suprapubic ( Pfannenstiel )
- Separate recti muscles- Open parietal peritoneum .
- Centralize the uterus
Bladder is retracted by Doyen retractor
- Incise the lower segment transversely ( C- shaped incision )Deliver the fetus. The head may be delivered by
- Scooping by the hand ( the hand is introduced below the head and push itupwards helped by fundal pressure ) .
- By one blade of short forceps Simpson or better Wrigley )
- Deliver the placenta .
Closure of uterine incision in 2 layers ( 3 in USCS )
- Peritoneum is closed as a separate layer .- Close abdomen & remove any blood clots in the vagina .
- Catheter is removed whenever the patient is ambulant .
Vertical LSCS
Advantage Less :- Hge ( midline is less vascular )
- Liable to injure vessels & ureter
Disadvantages may extend downwards to bladder or vagina
Indication Constriction ring
USCS-Classical
Advantage easy , takes shorter timeIndications difficult to perform or reach LS e.g.
- Fibroids , varicose veins
- Impacted shoulder , obstructed labor .
- Dense fibrosis ( previous repair of V-V fistula )
Cesarean hysterectomy
Uncontrolled PPhge ( atonic , rupture , morbid adherence of placenta )Severe infection ( failed to control , old age , MP ) .
Multiple fibroid in old patient completed her family ( rare )
Complications of CS
Operative
- Anesthetic complications Mendelson syndrome
- Hge ( 1ry ) shock .
- Injury urinary bladder or ureter
- Neonate more liability to HMD ??
Postoperative
- Thrombosis & embolism- Pulmonary complications bronchitis , pneumonia .
- Intestine paralytic iteus , adhesions , intestinal obstruction
- Urinary tract infection , retention of urine , fistula
- Genital endometritis , parametritis
- Wound infection , burst abdomen , rupture scar in next pregn.
Mortality < 0.1 %
- Mainly d.t. (1. Anesthetic comp . 2. Hge , DVT .. 3. Severe sepsis )- d.t. improvement in ( anesth . blood banking . antibiotics )
Although improved , however still
** Mortality is 20 / 100.000 ( as compared to 2.5 in VD )** Morbidity is 8 12 x higher ( as compared to VD )
د. أسيل الحلفي
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