Cesarean Section
By
Hesham Mahmoud Adel
Assistant Professor Ob/Gyn
Faculty of Medicine, University of Alexandria
Definition
• Delivery of the fetus through an abdominal and uterine wall incision
after the age of medicolegal viability
• Cesarean Section represents the largest source of controversy in
modern obstetrics
History
• Accidental or postmortem
• Lex regia (Royal law) → Lex caesarea
• Major progress milestones (causes of dramatic improvement in
outcome)
• Anesthesia
• Suturing
• Antibiotics
• Technique
• Early intervention with better diagnostic modalities (maternal and fetal)
Causes of increased rates and
indications for cesarean section
• Better anesthetic techniques
• Availability of blood transfusions and thromboprophylaxis
• Improved surgical techniques
• Lower expertise in operative vaginal delivery
• Unaccepted operative vaginal delivery complications
• Advances of diagnostic modalities of fetal compromise
Causes of increased rates and
indications for cesarean section
• Advanced maternal age
• Infertility treatment options
• Improved neonatal care and neonatal outcome for preterm deliveries
• Wanted cesarean sections
• Perfect perinatal expectations for both the mother and fetus (both
socially and medicolegally)
Indications
Absolute:
• Severe and absolute degrees of pelvic contraction
• Central placenta previa
• Pelvic mass obstructing the birth canal ( soft tissue or bony)
• Advanced cervical carcinoma
• Successful repair of a fistula
• Abdominal cerclage
Indications
Relative:
• Cephalopelvic disproportion
• Previous uterine surgery
• Fetal distress
• Antepartum hemorrhage
Indications
• Dystocia
• Failure of progress
• Failed induction of labor
• Failed operative vaginal delivery
• Associated medical disorders
• Abnormal presentations
Classification of Urgency
1. Immediate threat to the life of mother or fetus → immediate
delivery e.g. rupture uterus, cord prolapse, prolonged fetal
bradycardia….
2. Maternal or fetal non life threatening compromise → ≤ 30 minutes
e.g. antepartum hemorrhage and obstructed labor
Classification of Urgency
3. No compromise but early delivery is required → within 75 minutes
e.g. ruptured membranes ( decided to do C section), failure of
progress in labor
4. Elective planned C section → according to the convenience of the
woman and medical staff
Types of Cesarean Section
• Classical cesarean section
• Low vertical cesarean section
• Low transverse cesarean section
Classical Cesarean section
When delivery of the fetus through the lower segment is not possible, a
vertical incision is made in the upper segment of the uterus. Done in few
conditions as dense adhesions over the lower segment, large fibroid in the
lower segment or invasive cervical cancer, or in cases of fear of massive blood
loss in cases of increased lower segment vascularity in cases of anterior
placenta previa with or without placenta accreta spectrum presence.
It may be resorted to in cases of delivery before 34 weeks gestation when
there is no developed lower segment to allow for a transverse incision
sufficient to deliver a fragile premature baby.
Low vertical cesarean section
Rarely used, potential advantage is doing a lower segment incision
without risk of injuring major vessels and still enough for delivery of the
fragile preterm infant, and if needed can be extended to the upper
segment.
Objection to it is mainly it can easily extend to the upper segment with
all of its drawbacks.
Used in:
Delivery of a preterm breech
Constriction ring dystocia (hourglass contraction)
Low transverse cesarean section
Gold standard for cesarean section
Done in almost all cases (with previous exceptions)
Advantages:
Less blood loss
In the thin passive part of the myometrium
Better myometrial apposition
Less chance of rupture in future pregnancies
Low transverse cesarean section
Advantages:
Possibility of perfect peritonization →
Less chance of sepsis
Lower risk of adhesion formation
Smoother postoperative period
Low transverse cesarean section
Disvantages:
Slightly more technical difficulty
Risk of injury of uterine vessels
Risk of injury to the bladder especially in cases with previous sections
and bladder adhesions
Risk of excessive bleeding in placenta previa
Difficult in cases of transverse lie and/or obstructed labor
Anesthesia
• Regional
Spinal
Epidural
Combined spinal/epidural
• General
Preoperative preparation
• Consent ( especially in elective and more so in wanted sections)
• Fasting
• Antacid
• Shaving ??
• Foley’s catheter
• Position:
• 15 degrees left lateral tilt to avoid aorto-caval compression
• Flat supine
• Skin disinfection
• Draping
Surgical technique
• Abdominal wall incision:
• Site
• Shape
• Size
Surgical technique
• Abdominal wall incision:
• Site
• Shape
• Size
Surgical technique
• Division of the rectus sheath
• Muscle separation
• Parietal Peritoneal incision
• Retractor placement
• Creation of a bladder flap
Surgical technique
• Uterine incision:
• Site
• Technique
• Risks and tips
• Modifications
Surgical technique
• Fetal delivery
• Cord clamping
• Placental Delivery
• Cleaning the uterus
Surgical technique
• Uterine closure:
• In situ or with uterine exteriorization
• Suture material
• Number of layers
• Type of sutures
• Continuous or interrupted
• Locked or unlocked
Surgical technique
• Peritoneal closure (visceral and parietal)???
• Muscle closure
• Closure of the anterior abdominal wall
Postoperative Care
• Fluids
• Analgesia
• Antibiotics???
• Ecbolics
• Observation
Complications
Maternal
• Intraoperative:
• Anesthetic complications:
• Failed spinal
• Total spinal
• Aspiration
• Failure of fetal delivery (difficulties in fetal head extraction)
• Fetal injury
Complications
• Intraoperative:
• Hemorrhage
• Bladder injury
• Extension of uterine incision
• Intestinal injury
• Hematoma formation
Complications
• Early postoperative complications:
• Hemorrhage
• Shock
• Sepsis
• Intestinal obstruction
• Ileus
• Thromboembolic complications
• Wound infection
Complications
• Late postoperative complications:
• Obstetric:
• Rupture uterus
• Placenta accreta spectrum
• Difficult repeat C section
Complications
• Late postoperative complications:
• Gynecological
• Infertility
• Complications of Niche (DUB, infertility)
• C scar ectopic
• Chronic pelvic pain
• Menstrual irregularities
• Endometriosis ???
Complications
• Late postoperative complications:
• General:
• Incisional hernia
• Intestinal adhesions
• Intestinal obstruction
Complications
Fetal
• Injury
• Prematurity
• RDS
• TTN
• Still Birth
Vaginal Birth After Cesarean Section
(VBAC)
Points to consider before taking the decision:
• Proper counselling with informed consent
• Number of previous cesarean sections
• Duration of previous cesarean section
• Gestational age at previous cesarean section
• Indication of previous cesarean section
Vaginal Birth After Cesarean Section
(VBAC)
Points to consider before taking the decision:
• Type of incision
• Postoperative history (esp. of sepsis)
• History of previous vaginal delivery
• Measurement of lower uterine segment thickness
• Number of fetuses
Vaginal Birth After Cesarean Section
(VBAC)
Points to consider before taking the decision:
• Number of further wanted children
• Blood availability
• Efficiency of attending doctors in managing obstetric catastrophes
• Good hospital facilities
Vaginal Birth After Cesarean Section
(VBAC)
Points to consider during the trial of VBAC:
• Antenatal care
• Close monitoring of progress of labor
• Continuous electronic fetal monitoring
• Aim at spontaneous labor
• Induction
• Augmentation
Vaginal Birth After Cesarean Section
(VBAC)
Points to consider during the trial of VBAC:
• Assisted delivery (prophylactic forceps or vacuum)
• Evaluation of the scar after delivery
THANK YOU
