BY

Dr. Malleswar Rao Kasina,

MD,DGO.
HOD & CSS, Dept. of GynObs,
ESI Hospital, Sanathnagar, Hyderabad, AP, India
 Cesarean Childbirth Overview

Cesarean delivery, also known as cesarean

section, is a major abdominal surgery
involving 2 incisions (cuts),
One is an incision through the abdominal
wall and the second is an incision
involving the uterus to deliver the baby.
Cesarean Childbirth Overview
Cesarean Childbirth Overview

History : Legend has it that the Roman

leader Julius Caesar was delivered by
this operation, and the procedure was
named after him.
How often used : The rate for cesarean
delivery increased steadily from 4.5% in
1965 to 21% in 1998.
 Cesarean Childbirth Causes

The most frequent reasons for

performing a cesarean delivery are
discussed below.
1 Repeat cesarean delivery:There
are 2 types of uterine incisionsa
low transverse incision and a
vertical uterine incision.
 Cesarean Childbirth Causes

1a) A low transverse uterine incision is

the approach of choice.
1b) A vertical incision on the uterus (low
or high) may be used for delivering
preterm babies, abnormally positioned
placentas, pregnancies with more than
one fetus, and in extreme emergencies.
 Cesarean Childbirth Causes

1a In the last 20 years, studies have

shown that women who have had a
prior cesarean section with a low
transverse incision may safely and
successfully go through labor and
have a vaginal delivery in later
pregnancies. (VBAC)
 Cesarean Childbirth Causes

1b In about 10% of women with

vertical uterine incisions, their
uterus will rupture (break open).
The uterus may rupture even
before labor begins in up to 50%
of these women.
 Uterine rupture can be
dangerous to the fetus even
if delivery is accomplished
immediately after a uterine
rupture.
 Cesarean Childbirth Causes

2 Previous cesarean deliveries:

Women with a prior history of
more than 1 low transverse
cesarean section, a trial of labor
(TOL) is not an option, a repeat
Cesarean delivery is the choice.
 Cesarean Childbirth Causes

3 Lack of labor progression: If the woman is

having adequate contractions but no
change in the cervix beyond 3 cm dilation
or the woman is unable to deliver the fetus
despite complete dilation of the cervix and
"adequate" pushing for 2-3 hours, cesarean
delivery may be performed.
In a normal pregnancy, the baby is
positioned head down in the
uterus.
 Cesarean Childbirth Causes

4 Abnormal position of the fetus & Placental

causes :
i) Breech delivery
ii) Oblique lie
iii) Persistent Occipitoposterior position
iv) Deflexed Head (cord round the neck)
v) Abruptio placenta
vi) Placenta praevia
C-section - : Indications
 Cesarean Childbirth Causes

5 Fetal status: Continuous fetal

heart rate monitoring in labor has
not improved birth outcomes as
once expected.
 Cesarean Childbirth Causes

6 Emergency situations: If the woman

is severely ill or has a life-
threatening injury or illness with
interruption of the normal heart or
lung function, she may be a
candidate for an emergency
cesarean section.
 Cesarean Childbirth Causes

7 Elective sterilization: A desire for

elective sterilization is not an
indication for cesarean delivery.
 C-section : Procedure-1

When the C-section

is planned, the
doctor may order
regional anesthetics
(a spinal or an
epidural), which
numbs only the
lower portion of the
body.
 C-section : Procedure-2

In non-emergency C-
sections, a horizontal
incision (a bikini cut)
across the abdomen, just
above the pubic area.
In an emergency
situation, a vertical cut,
from below the navel to
just above the pubic area.
A vertical cut allows
quicker access to the baby
 C-section : Procedure-3

A vertical uterine
incision causes less
bleeding and better
access to the fetus, but
renders the mother
unable to attempt a
vaginal delivery (must
have another repeat C-
section) in the future.
 C-section : Procedure-3

If you end up with a

horizontal uterine
incision, you will have
the option of either
going through a trial of
labor (TOL) or electing
a repeat c-section.
 C-section : Procedure-3

The reason for the

differences between the
two is that patients with
vertical uterine incisions
have a much higher
chance of rupturing the
uterus (8-10%) in the
future pregnancies,
compared to only 1% in
those with horizontal
incisions.
 C-section : Procedure-4

Finally, the
surgeon cuts through
the amniotic sac
enclosing the baby.
He then allows the
amniotic fluid to
escape.
C-section : Procedure-5
C-section : Procedure-6
 Cesarean Childbirth-Possible
Complications

* Excessive bleeding: This is the

most common complication of a
cesarean delivery and may be
caused by intrapartum and/or
postpartum bleeding.
 Cesarean Childbirth-Possible
Complications
* Infection: The risk of infection of the
uterus is much higher after cesarean
delivery than after vaginal delivery.
Infection of the skin incision is
much more common than infection in
the incision made in the uterus,
although they often occur together.
 Cesarean Childbirth-
Possible Complications

* Clots: Blood clots can form in

the pelvis or the leg.
Therefore, it is imperative that
if you deliver by cesarean
section, you must get up and
walk within 24 hours after the
operation.
 Cesarean Childbirth-
Possible Complications

* Urinary function and bladder injury:

Urinary retention after Cesarean
due to bladder atony could be
relieved by urethral catheter for 24
hours.
Bladder injury during Cesarean
can occur inadvertently.
 Cesarean Childbirth-
Possible Complications
* Bowel function and bowel injury:
Typically, bowel function after a
cesarean section returns quickly.
Unrecognized bowel injury may occur
occasionally and should be managed
appropriately.
 Cesarean Childbirth-Possible
Cesarean Childbirth-
Complications
Possible Complications
* Prolonged hospital stay:
When compared with normal vaginal
delivery, Cesarean delivery requires 5
to 6 days hospital stay.
 Cesarean Childbirth-
Possible Complications
* Anesthesia & pain medications:
Commonly, spinal or epidural
anesthesia is administered.
After surgery, oral and
injection drugs can be used to
help control the pain.
An evidence based update on
the technique of LSCS

Recommended by WHO
Reproductive Health Library as
Minimally Invasive Method for a
commonest surgical procedure
done Worldwide.
Cesarean Delivery Ancient
Medical History
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Caesarean Section has been a part of human culture since
ancient times and there are tales in both western and non-
western culture of this procedure.

From the time when this procedure resulted in 100%

maternal mortality, it has traveled a long distance acquiring
many changes in the technique, anesthesia, sutures,
antibiotics, indications that today we can say that maternal
mortality per se because of LSCS is negligible
Many modifications were put forward some were here to
stay, while others just faded away.
Evidence based Cesarean delivery-
Misgav Ladach Technique
Micheal Stark : Director
Misgav Ladach Hospital,
Israel
a refuge for the oppressed
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Steps Of Cesarean
Section:
Abdominal entry :
Joel Cohens incision

/\
Midway between
umbilicus & symphysis
pubis.
Separation of recti easy
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Principles :
Behind Joel Cohen incision as well as other steps are - the
approach to handling the muscles blood vessels and nerves

They are treated like the strings on the musical instruments, where
the more distant you move from the insertion, the easier is the
lateral stretching due to elasticity, and therefore the damage is
reduced.
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Why ?
Pfannenstiel incision takes longer to make and
longer to repair

Many bleeding vessels have to be controlled

More difficulty in repeat LSCS

More adhesions
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Steps Of C - Section:

Skin & sub-cutis cut

Incision in fat only in

the middle 1 inch

Cut the rectus sheath

also in middle 1 inch
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Steps Of C - Section:
Extend the incision on
either side with scissors;
like a tailor running a
semi opened scissors to
cut cloth

This will ensure a cut

also the fiber of the
sheath
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Steps Of C - Section:
Muscles are separated in
the middle & peritoneum
punctured with fingers

All the three peritoneum,

muscle & the fat are pulled
apart to allow adequate
opening
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Principles :
Because of the placement of the incision where
the fascia is not attached and moves freely over
the muscles, there is no need to separate the
fascia from the muscles.

Tissues are separated along connective tissue

fault lines (Langers lines), thus healing more
completely and rapidly
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Abdominal Packs are not used
Doyens retractor to expose lower segment
Cut the visceral peritoneum about 1-1.5 cms above
the bladder fold with knife
Cut the uterus in the middle of the opened space in
peritoneum with knife
Stretch the uterine opening as needed
Deliver the child and placenta

Exteriorize the uterus

 Evidence based Cesarean delivery-
Misgav Ladach Technique

Start Suturing the edges form near to far

Non-locking continues stitch
Additional stitches only if bleeding presents
Clean Peritoneal cavity of debris
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Rectus sheath is
sutured in the form of
near-far, far-near
pattern
Non-locking continues
stitch
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Skin: 2-3 stitches deep
mattress silk stitches

Space in between
allows draining of
secretions
 Evidence based Cesarean delivery-
Misgav Ladach Technique

Quick recovery
Post operative pain quite less

Fewer adhesions

Bladder not a problem in subsequent CS

Less Blood loss

Smaller scar with less induration
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Adopting Joel-Cohen Concise
techniques of opening
the abdomen Very simple
performing manual Very speedy
manipulations,
minimizing the use of
Results are self
instruments and evident
suturing. - Misgav Ladach
method (Stark 1996)
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Principles : -
Unnecessary steps are simply not done.
No interruptions are necessary for hemostasis
or swabbing
Whole procedure is performed with a
continuous flow of movement, each step
leading naturally to the next.
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Time

More rapid - very short in time

Theatre time and op. time reduced

Total op. time 18 to 20 min - 30-50% less

 Evidence based Cesarean delivery-
Misgav Ladach Technique
Other benefits
Complete healing

Less short term complications such as

hemorrhage, 250ml less.

Febrile morbidity (7.7% vs. 19.8% )

Post op. adhesions less (6.3% vs. 28%)

 Evidence based Cesarean delivery-
Misgav Ladach Technique
Women
Regained controls and recovered more rapidly

and were better able to breast feed and care of their

new born.

Reduced pain and early ambulation

Reduced scarring.
Evidence based Cesarean delivery-
Misgav Ladach Technique
 Evidence based Cesarean delivery-
Misgav Ladach Technique
COST benefits

Cost beneficial

Suture 2.92 3 Vs 4.14 4

15 euros less costly (In European countries)

 Evidence based Cesarean delivery-
Misgav Ladach Technique
Technique of CS : Issues

Exteriorization of uterus
Two layer uterus closure
Peritoneal suturing
Routine antibiotics
Uterotonics/Oxyticics
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Technique of CS : Issues
Regional Vs. General anesthesia
Indwelling vs. intermittent catheter
Lateral tilt to operation table
Manual removal of placenta Deprecated
Post-operative wound drainage
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Extra abdominal vs. intra abdominal repair of uterine
incision
6 trials 1221 cases of Emergency + Elective CS
Outcome measures: Blood loss, Sepsis, Costs,
Satisfaction etc.
Marginal drop in febrile morbidity in exteriorization
group
Hematocrit drop similar
Sepsis similar
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Peritoneal Closure
Authors Conclusion

There was improved short-term postoperative

outcome if the peritoneum was not closed

Long term studies following CS are limited, but data

form other surgical are reassuring. There is at present
no evidence to justify the time taken and cost of
peritoneal closure
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Abdominal Wall Closure

6 trials, 1853 cases

No difference if subcutaneous tissue sutured or

not ,in terms of infection, hematoma, or serious
discharge
 Antibiotic prophylaxis for CS
Smaill F, Hofmeyer GJ,
From The Cochrane Library , Issue 1, 2006.

Authors Conclusion

The reduction of endometritis by 2/3rd to 3 quarters and a

decrease in wound infections justifies a policy of
recommending prophylactic antibiotics to women
undergoing elective or non-elective CS
Both Ampicillin & 1st generation cephalosporin's are similar
in reducing postoperative endometritis.There is no added
benefits in utilizing a more brad spectrum agent or a multiple
dose regimen. There is a need for an appropriately designed
randomized trial to test the optimal timing of administrating
(immediately after the cord is clamped vs. pre-operative)
 Evidence based Cesarean delivery-
Misgav Ladach Technique
Lateral tilt for CS
Chichester, WilkinsinC, Enkin MW
From The Cochrane Library , Issue 1, 2006.

Authors Conclusion

There is not enough evidence from these trials

to evaluate use of tilt during CS
 Early compared with delayed oral fluids
and food after CS
Mangesi L, Hofmeye GJ (From The Cochrane Library , Issue 1,
2006.)

Authors Conclusion

There was no evidence form the limited

randomized trials reviewed, to justify a policy
of withholding oral fluids after uncomplicated
CS. Further research is justified
Visit www.rhlibrary.com
FINALLY Surgical technique
Why has the rate of cesarean delivery climbed
so dramatically in the past 25 years?
1. Lower tolerance for taking risks

2. Fear of malpractice litigation

3. Increased use of epidural anesthesia ?

4. Increased use of electronic fetal monitoring

5. The convenience of physicians

 Who are involved ?

FETUS MOTHER

Childbirth
 Who are involved ?

FETUS MOTHER

Obstetricians Health system

Childbirth

Obstetrical
Midwives Uni-Hospital

Society
 Published rates

W.H.O.: 1
15 %
Maximum desirable rate of cesarean section
No benefit for mother and the fetus for
medical reasons
1 World Health Organisation. Appropriate technology for birth. Lancet 1985;4367.
 Factors involved in decision
1. Fetal mortality and morbidity
2. Newborn health
3. VBAC
4. Cost
5. Pelvic floor damage
6. Maternal mortality
7. Cultural factors
8. Autonomy - C-section on demand?
Factors involved in decision
1. Fetal mortality and morbidity
2. Newborn health
3. VBAC
4. Cost
5. Pelvic floor damage
6. Maternal mortality
7. Cultural factors
8. Autonomy - C-section on demand?
 Unexplained fetal deaths
Cotzias C, Paterson-Brown S, Fisk N. BMJ, 319,31 july
1999

Weeks N of pregnancies Prospective Risk

of fetal death
35 164 860 1:366
36 162 603 1:407
37 158 171 1:474
38 149 181 1:529
39 127 160 1:617
40 93 828 1:680
41 39 316 1:606
42 10 328 1:565
43 1 883 1:465
Could C-S reduce fetal death rate?

5 times more frequent than SIDS

Termination of pregnancy when fetal risks in
tero are larger than the risks of the newborn:
1/500
Most of fetal deaths occur in non-malformed
Cotzias C, et al., BMJ, 319,31 july 1999
fetuses
Could C-S reduce fetal death rate?

5 times more frequent than SIDS

Termination of pregnancy when fetal risks in tero
are larger than the risks of the newborn: 1/500
Most of fetal deaths occur in non-malformed fetuses
Womens preference: C-section of the risk is
> 1:4000 1 Cotzias C, et al., BMJ, 319,31 july 1999
1 Thornton E, et al., J Obstet Gynecol 1989;9:283-8
Factors involved in decision
1. Fetal mortality and morbidity
2. Newborn health
3. VBAC
4. Cost
5. Pelvic floor damage
6. Maternal mortality
7. Cultural factors
8. Autonomy - C-section on demand?
Effect of Mode of Delivery in Nulliparous
Women on Neonatal Intracranial Injury
Towner D et al., NEJM 1999;341:23

1: 664 forceps
1: 860 vacuum extraction
1: 907 c-section during labor
1: 1900 delivered spontaneously
1: 2750 c-section with no labor
Conclusion: The common risk factor for
hemorrhage is abnormal labor
Factors involved in decision
1. Fetal mortality and morbidity
2. Newborn health
3. VBAC
4. Cost
5. Pelvic floor damage
6. Maternal mortality
7. Cultural factors
8. Autonomy - C-section on demand?
Frequency of cesarean section, primary cesarean and vaginal birth
post-c-section between 1989 - 2001

VBAC
30
25
All c-sections
20
% 15 Primary c-section

10
5
0
89 91 93 95 97 99 2001
Ao

Martin JA, et al., National Center for Health Statistics. 2002

 Recomendations

The most conservative recomendations.

ACOG Technical Bulletin. Vaginal delivery after a previous

cesarean birth.

Int J Gynecol Obstet 48:127 129; 1995.

ACOG Vaginal birth after a previous cesarean.

ACOG Practice Bulletin N 5:1 8; 1999.

 VBAC
Over 1000 reports: not one RCT
 VBAC
Over 1000 reports: not one RCT

Economic forces rather than patient

well-being, are driving the goal of fewer
cesarean sections ? 1
1 Clark S., et al., Am J Obstet Gynecol 2000;182:599-602
Factors involved in decision
1. Fetal mortality and morbidity
2. Newborn health
3. VBAC
4. Cost
5. Pelvic floor damage
6. Maternal mortality
7. Cultural factors
8. Autonomy - C-section on demand?
 Costs of deliveries
Cesarean delivery:
Costs more than a vaginal delivery
Longer hospital stay
Use of an operating room.

Labor unit: a prolonged and difficult labor, even

when it results in a vaginal delivery, is more
costly to an institution than a cesarean delivery.
 Costs of deliveries
Beth Israel Deaconess Medical Center, Boston, USA

Elective repeated cesarean delivery $ 7.700

Normal vaginal delivery $ 6.800
Intrapartum Cesarean: $ 10.000
 Costs of deliveries
Beth Israel Deaconess Medical Center, Boston, USA

Elective repeated cesarean delivery $ 7.700

Normal vaginal delivery $ 6.800
Intrapartum Cesarean: $ 10.000
Complication
Mother: + $ 4.000

Child: + $ 2.000
 Factors involved in decision
1. Fetal mortality and morbidity
2. Newborn health
3. VBAC
4. Cost
5. Pelvic floor damage
6. Maternal mortality
7. Cultural factors
8. Autonomy - C-section on demand?
 Pelvic floor

Urinary incontinence

Fecal incontinence

Sexual dysfunction

Organ prolapse
 Pelvic floor

Pudendal nerve damage

Soft tissue trauma
The levator musculature trauma
Anal sphincter trauma
 Pelvic floor

Pudendal nerve damage

Soft tissue trauma
The levator musculature trauma
Anal sphincter trauma
...neurophysiologic studies have demonstrated the etiologic
role of parturition-related nerve damage in development of
pelvic floor disfunction...1
1 Davila GW, et al., Int Urogyneocl J 2001;12:289-291
 Reduction of pelvic floor
damage
Minimizing forceps deliveries

Minimizing episiotomies

Allowing passive descent in the second stage

Selectively recomending elective cesarean

delivery Davila GW, et al., Int Urogyneocl J 2001;12:289-291

 Prevention of pelvic floor
damage
Avoid labor
Avoid passage of the fetus through the pelvis
Shorten second stage
Avoid routine episiotomy
Forget the forceps specially in macrosomia
Repair perineal damage Devine II, Contemporary Ob/Gyn 1999:119
 Factors involved in decision
1. Fetal mortality and morbidity
2. Newborn health
3. VBAC
4. Cost
5. Pelvic floor damage
6. Maternal mortality
7. Cultural factors
8. Autonomy - C-section on demand?
 Risk of maternal death
...the presumed increased risk of maternal death with
elective cesarean delivery traditionally has been the
most compelling reason to reject a policy of universal
cesarean delivery or "cesarean on demand." However,
good evidence is accumulating that this is no longer
true; the maternal morbidity and mortality from
elective cesarean delivery at term before the onset of
labor appear to be similar to those associated with
Hannah ME, Lancet 2000;356:1375-83.
vaginal birth....
 Factors involved in decision
1. Fetal mortality and morbidity
2. Newborn health
3. VBAC
4. Cost
5. Pelvic floor damage
6. Maternal mortality
7. Cultural factors
8. Autonomy - C-section on demand?
 Cultural phenomena - Brazil

All birth are attended by obstetricians

Training
Doctors work in the public and private health
system
Status of c-section: modern and technical
Womens body are perceived as sexual than
maternal
Genitals are perceived for sexual activity than
for childbearing Nuttall C., et al., BMJ 2000;320:1072
 Factors involved in decision
1. Fetal mortality and morbidity
2. Newborn health
3. VBAC
4. Cost
5. Pelvic floor damage
6. Maternal mortality
7. Cultural factors
8. Autonomy - C-section on demand?
Cesarean section on demand

31% of female obstetricians would prefer a

cesarean delivery for themselves 1
1 Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997:73:1-4

World wide debate continues on role of

Cesarian Delivery on Maternal
Request[CDMR].
Cesarean section on demand

31% of female obstetricians would prefer a

cesarean delivery for themselves 1

Italian law mandates that women be given the

option of an elective cesarean, and about 4%
of pregnant women choose it. 2
1 Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997:73:1-4
2 Tranquilli AL, et al., Am J Obstet Gynecol 1997;177:245-246
 Autonomy

Is the governing principle in medicine

We respect with better eyes a womans right

to refuse a cesarean delivery

Nobody is interested in respecting womans

desire to refuse vaginal delivery
Wagner M et al., Lancet 2000;356:1677-80
 Autonomy and informed
consent

...performing cesarean section for non

medical reasons is ethically not
justified....
Committee for the Ethical Aspects of Human Reproduction
and Womens Health of FIGO (1999)
 Conclusion

...perhaps the time has come when the risks,

benefits and costs are so balanced between
cesarean section and vaginal delivery that the
deciding factor should simply be the mothers
preference for how her baby is to be
delivered... William Benson Harer
Dr.Malleswar Rao Kasina,
expresses

Thanks you for your Attention !

E-mail : [email protected]