CESAREAN CESAREAN SECTION CSSECTION CS

CESAREAN SECTION CsCESAREAN SECTION Cs

Ghadeer Al-ShaikhGhadeer Al-Shaikh, , MD, FRCSCMD, FRCSCAssistant Professor & ConsultantAssistant Professor & Consultant

Obstetrics & GynecologyObstetrics & GynecologyUrogynecology & Pelvic Reconstructive SurgeryUrogynecology & Pelvic Reconstructive Surgery

TYPES OF CSTYPES OF CS

Lower segment CSLower segment CS Classical CSClassical CS

Indications for classical CSIndications for classical CS

Transverse lie back down (with SROM)Transverse lie back down (with SROM) Structural abnormality that makes lower Structural abnormality that makes lower

segment approach difficult (Fibroids)segment approach difficult (Fibroids) Anterior Placenta Previa & abnormally Anterior Placenta Previa & abnormally

vascular lower segmentvascular lower segment Poorly developed lower segment in Very Poorly developed lower segment in Very

preterm fetus in breech presentationpreterm fetus in breech presentation Cervical cancerCervical cancer

INDICATIONS FOR ELECTIVE CSINDICATIONS FOR ELECTIVE CS

Repeat CSRepeat CS Placenta previaPlacenta previa VV fistula repairVV fistula repair HIV (poor HIV (poor

controlled)controlled) Active herpesActive herpes Fetal macrosomia Fetal macrosomia > >

4500 gm4500 gm

Uterine surgery eg. Uterine surgery eg. Hystrotomy, Hystrotomy, myomectomymyomectomy

Severe IUGRSevere IUGR Breech Breech Multiple pregnancyMultiple pregnancy Transverse lieTransverse lie Ca of the Cx/ TR Ca of the Cx/ TR

obstructing the birth obstructing the birth canalcanal

INDICATIONS FOR EMERGRENCY CSINDICATIONS FOR EMERGRENCY CS

Severe PETSevere PET Abruptio placenta (APH)Abruptio placenta (APH) Fetal distressFetal distress Failure to progress in the first stage of labourFailure to progress in the first stage of labour Cord prolapseCord prolapse Obstructed labourObstructed labour Failed inductionFailed induction Malpresentation Malpresentation brow, chin post, shoulder brow, chin post, shoulder

& compound presentations, breech& compound presentations, breech Compromised fetus 2ry to DM, HPT, Compromised fetus 2ry to DM, HPT,

isoimmunization isoimmunization

TIMING OF ELECTIVE CSTIMING OF ELECTIVE CS

Usually at 38-39 wks Usually at 38-39 wks

Before Emergency CSBefore Emergency CS

Explain to the Pt & husband & obtain consent Explain to the Pt & husband & obtain consent

Inform anesthetist, OR staff, pedInform anesthetist, OR staff, ped

100% oxygen mask in case of fetal distress100% oxygen mask in case of fetal distress

Sodium citrate 20 ml , metoclopramide 10 mg Sodium citrate 20 ml , metoclopramide 10 mg IVIV

Transfer to the theatre, IV , take blood for Hb, Transfer to the theatre, IV , take blood for Hb, x-match 2 U of bloodx-match 2 U of blood

Preferable to use spinal or epidural anaethesiaPreferable to use spinal or epidural anaethesia

Catheterize the bladder Catheterize the bladder Tilt the mother 15 Tilt the mother 15 º by using wedgeº by using wedge Pneumatic inflatable boots or Ted stockingsPneumatic inflatable boots or Ted stockings Prophylactic Ab Prophylactic Ab ↓↓ incidence of infection↓↓ incidence of infection Inform ped if the mother had opiates in the last 4 Inform ped if the mother had opiates in the last 4

hrshrs Halothane should not be used Halothane should not be used uterine relaxation uterine relaxation

& bleeding& bleeding

COMPLICATIONSCOMPLICATIONS

INTRAOPERATIVEINTRAOPERATIVE Bleeding & the need for bl transfusionBleeding & the need for bl transfusion HysterectomyHysterectomy Complications of anaesthesiaComplications of anaesthesia Damage to the bladder, ureter, colon , Damage to the bladder, ureter, colon ,

retained placental tissueretained placental tissue Fetal injuryFetal injury

COMPLICATIONSCOMPLICATIONS

POSTOPERATIVE POSTOPERATIVE Paralytic ileusParalytic ileus Wound dehiscence & infectionWound dehiscence & infection Infectins Infectins UTI, pnemonea UTI, pnemonea DVT & pulmonary embolismDVT & pulmonary embolism FistulaFistula DeathDeath

POSTNATAL CAREPOSTNATAL CARE

V/S & blood loss must be moniteredV/S & blood loss must be monitered Uterine fundus palpated Uterine fundus palpated Effective parentral analgesicsEffective parentral analgesics Deep breathing & coughing encouragedDeep breathing & coughing encouraged Early mobilizationEarly mobilization Fluid therapy &dietFluid therapy &diet Bladder & bowel functionBladder & bowel function Wound careWound care LabLab Breast careBreast care Prophylaxis for thrombembolismProphylaxis for thrombembolism

MODE OF DELIVERY IN NEXT MODE OF DELIVERY IN NEXT PREGNANCYPREGNANCY

CRITERIA FOR VBACCRITERIA FOR VBAC Pt must agree to the procedurePt must agree to the procedure A low transverse uterine incisionA low transverse uterine incision Non recurrent cause of the previous CSNon recurrent cause of the previous CS No macrosomia, malposition, multiple No macrosomia, malposition, multiple

gestation, breechgestation, breech

MODE OF DELIVERY IN NEXT MODE OF DELIVERY IN NEXT PREGNANCYPREGNANCY

ContraindicationContraindication Previous classical CSPrevious classical CS 2 or more previous CS2 or more previous CS Previous other uterine surgeryPrevious other uterine surgery Hx of scar ruptureHx of scar rupture Placentaprevia or transverse liePlacentaprevia or transverse lie

CONDUCT OF LABOURCONDUCT OF LABOUR

Observe forObserve for ProgressProgress Fetal wellbeingFetal wellbeing Maternal well beingMaternal well being Epidural Epidural HOSPITAL SHOULD PROVIDE BLOOD , HOSPITAL SHOULD PROVIDE BLOOD ,

OPERATING ROOM 24 HRS, NEONATAL OPERATING ROOM 24 HRS, NEONATAL RESUSCITATION, NURSING ANAESTHESIA RESUSCITATION, NURSING ANAESTHESIA &SURGICAL PERSONNEL CAN START CS &SURGICAL PERSONNEL CAN START CS WITHIN 30 MIN WITHIN 30 MIN

Risk of SCAR RUPTURERisk of SCAR RUPTURE

O.5% for LSCSO.5% for LSCS 4-9% for classical4-9% for classical

SCAR RUPTURESCAR RUPTURE

Signs OF SCAR RUPTURESigns OF SCAR RUPTURE Fetal distressFetal distress Ease of fetal palpationEase of fetal palpation Cessation of contractionsCessation of contractions Elevation of presenting partElevation of presenting part Scar painScar pain Bleeding / shockBleeding / shock

ABNORMAL ABNORMAL LABOUR/DYSTOCIA/FAILURE TO LABOUR/DYSTOCIA/FAILURE TO

PROGRESS IN LABOURPROGRESS IN LABOUR

CAUSESCAUSES

1-Abnormalities of the pasage 1-Abnormalities of the pasage

Alteration in the shape of the pelvisAlteration in the shape of the pelvis Mass occupying the birth canalMass occupying the birth canal

ABNORMAL ABNORMAL LABOUR/DYSTOCIA/FAILURE TO LABOUR/DYSTOCIA/FAILURE TO

PROGRESS IN LABOURPROGRESS IN LABOUR2-Abnormalities in the passenger2-Abnormalities in the passenger Abnormal lie Abnormal lie Abnormal presentationAbnormal presentation

occiput-postrior, occiput-transverseocciput-postrior, occiput-transverse

browbrow

faceface

breechbreech Macrosomia , perinatal mortality 5* higher Macrosomia , perinatal mortality 5* higher

than N Wtthan N Wt Congenital malformationCongenital malformation Multiple gestationMultiple gestation

ABNORMAL ABNORMAL LABOUR/DYSTOCIA/FAILURE TO LABOUR/DYSTOCIA/FAILURE TO

PROGRESS IN LABOURPROGRESS IN LABOUR3-Abnormalities in the powers3-Abnormalities in the powers Ineffective uterine activityIneffective uterine activity Lack of voluntary expulsive efforts in the 2Lack of voluntary expulsive efforts in the 2ndnd

stagestage

DYSTOCIA IS THE MOST COMMON INDICATION DYSTOCIA IS THE MOST COMMON INDICATION FOR CSFOR CS