Cesarean Section (C/S)

Done by: Husam Khasati, Mohamad Nabeel, Mohammed Habboush, Sarah

Al-Zboun.
Definition

 Delivery of viable fetus (>24 wk) by surgical means through the abdominal wall
(laparatomy) and uterine incision (hysterotomy).

 If the procedure was done before 24 weeks of pregnancy, then its called hysterotomy.
Types

 Emergency Cesarean: C/S performed usually in labor already in progress.

 Elective Cesarean: C/S that is planned by the obstetrician on a specific date

 Cesarean Hysterectomy: A C/S followed by the removal of the Uterus.

 Repeat C/S: A C/S performed due to prior C/S operated on the uterus. Typically
performed through the old scar.
Key steps in reducing mortality

 Adherence to principles of asepsis.

 Introduction of uterine suturing by max sanger in 1882.
 Anesthetic advances.
 Blood transfusion.
 Antibiotic treatment and prophylaxis.
The Caesarean section rate has risen
rapidly in the last 25 years, due to:
 The increased use of electronic fetal monitoring has increased our awareness of fetal
distress.

 The evidence that breech presentation babies have a reduced morbidity and mortality if
delivered by elective Caesarean section.

 An increasing demand from women for elective Caesarean sections with no medical
reason (e.g., tocophobia).
 C/S vs. Vaginal

C/S Vaginal

 Abdominal pain  Perineal pain

 Thrombombolism  Urinary incontinence
 Bladder/ureter  prolapse
injury
 Hysterectomy
 Rarely; maternal
death
Indications

 Previous C/S
 Malpresentation (mainly Breech)
 Failure to progress in labor
 Suspected fetal compromise in labour
 Others; multiple pregnancy, placental abruption, placenta previa, fetal disease and
maternal disease.
Approach
Abdominal Incision
Laparotomy

The layers we need to incise before reaching the uterus:

- skin
- subcutaneous layer
- fascia
- rectus muscles
- peritoneum
Types of Incisions

Vertical Incision:
-midline infraumbilical incision

Horizontal/Transverse Incision: (common)

- Pfannenstiel (more common)
Vertical Incision
Indications
 Extreme maternal obesity.
 Suspicion of other intrabdominal pathology necessitating surgical intervention.
 Access to the uterine fundus may be required.
 Transverse incision is not possible.

 Provides greater access to the pelvic and intra-abdominal organs and may be enlarged
more easily.
 Increased incidence of wound dehiscence.
Vertical Incision Advantages

Easier examination of the upper abdomen

If
there are significant intra-abdominal adhesions from previous operations,
may provide easier access and better visualization.
Transverse Incision
Usually less painful
Smaller risk of developing an incisional hernia
Preferred cosmetically
Excellent visualization of the pelvis
Pfannenstiel Incision
 The skin and SC tissues are incised using a transverse curvilinear incision 2
fingerbreadths above the symphysis pubis extending from and to points lateral to the
lateral margins of the abdominal rectus muscles.
Pfannenstiel Incision
Uterine Incision
Lower uterine - transverse
 Used in 95% of cases due to:
 Ease of repair
 Reduced blood loss
 Low incidence of dehiscence or rupture in subsequent pregnancies.
Classical
 Indications:
 Lower uterine segment obscured by fibroids.
 Lower segment covered with dense adhesions.
 Placenta previa, transverse lie with the back down, fetal abnormality (e.g., conjoined twins), C/S in the presence
of a carcinoma of the cervix, preterm breech, planned hysterectomy to follow the C/S.
 Low vertical Low transverse Classical

It’s a vertical incision Lower uterine segment .. longitudinal incision in the anterior Site
begins in the noncontractile portion of fundus
noncontractile lower the uterus.
segment but usually
extends into the
contractile upper
segment.
In between Lower risk High risk Risk of rupture

Lower risk of bleeding High risk of bleeding, Rupture, Risk of

and other comlications adhesions and other complications complications

when a transverse Invasive cervical cancer . Myomas When to use it

incision is not feasible or transverse lie of baby

Most common type of Infrequently How frequent

incision
Inbetween Easier ( thin muscles of Difficult muscular fundus Closure
lower segment)
a bladder flap.. potential Quickest extra
extension into the No need for a bladder flap
uterine vessels laterally
and into the cervix and
vagina inferiorly
 After the shoulders are delivered, an intravenous infusion containing
about two ampules or 20 units of oxytocin per liter of crystalloid is
infused at 10 mL/min until the uterus contracts satisfactorily
 The rest of the body readily follows.

 The placenta is delivered using controlled cord traction

 The uterine incision is observed for any vigorously bleeding sites
Preoperative Issues
 Elective term cesarean delivery should be scheduled for >39 weeks of gestation.
Preoperative Testing and Preparation for
CS
 Pregnant women should be offered a hemoglobin assessment before CS (major
surgery) which is expected to result in significant blood loss.
 Pregnant women having CS for antepartum hemorrhage, abruption, uterine rupture
and placenta previa are at increased risk of blood loss greater than 1000 ml and
should have the CS carried out at a maternity unit with on-site blood transfusion
services.
 Risk factors for transfusion: (placental abnormalities, eclampsia, HELLP syndrome,
preoperative HCT <25%, general anesthesia, history of >=5 cesareans.)
 To reduce the risk of aspiration pneumonitis: Empty stomach, Pre-medication with an
antacid (sodium citrate 0.3% 30 mL or magnesium trisilicate 300 mg) + Cimetidine IV
1 hr before CS
 Guidelines recommend a minimum pre-op fasting of at least
 1) 2 hrs for clear fluids
 2) 6 hrs for a light meal
 3) 8 hrs for a regular meal
 Women having CS with regional anesthesia require an indwelling urinary
catheter to prevent over-distension of the bladder, because the anesthetic
block interferes with normal bladder function

 Skin cleansing: using chlorhexidine-alcohol is superior to povidone iodine for

preventing surgical site infection after surgery.
Antibiotic Prophylaxis
Prescribe antibiotics (one dose of first-generation cephalosporin or ampicillin)
Prophylaxis significantly reduces incidence of postoperative fever,
endometritis, wound infection, UTI.
For women in labor already on antibiotics for GBS no additional antibiotics
needed
Thromboembolism Prophylaxis

 The American College of Chest Physicians evidence-based clinical practice

guidelines do not recommend prophylaxis for women whose only risk factors
for VTE are pregnancy and cesarean delivery.
 They recommend prophylaxis for women with additional risk factors
1- women with one additional risk factor should receive thromboprophylaxis,
graduated compression stocking.
2- women with multiple risk factors should receive thromboprophylaxis plus
graduated compression stockings and/or pneumatic compression device while in
hospital following delivery.
 Risk factors include:
Obesity (BMI>30), smoking, inherited or acquired thrombophilia, malignancy, HF,
immobility (bed rest >4 days, lower body orthopedic cast), Hx of
thromboembolism, Age >35, recent trauma, emergency cesarean, nephrotic
syndrome.
Fetal heart rate monitoring (CTG)
Fetal presentation and placental
location. (U/S)
Anesthesia

 Regional anesthesia is used for 95% of planned cesarean deliveries in the

United States.
 The 3 main regional anesthetic techniques are spinal, epidural, and combined
spinal epidural.
 Every patient is evaluated for general anesthesia in case an emergency
should arise and establishment of an airway becomes necessary.
Anesthesia

 The dermatomal level of anesthesia required for cesarean delivery is higher

than that required for labor analgesia. A sensory block to the 10th thoracic
dermatome is sufficient to achieve analgesia for labor, but for cesarean, the
anesthetic level must be extended cephalad to at least the fourth thoracic
dermatome to prevent nociceptive input from the peritoneal manipulation.
Anesthesia

 GA
 Mandelson’s syndrome
 Maternal and fetal
respiratory distress
 Delayed recovery
 Risk of uterine atony
and PPH
Contraindications of Regional anesthesia

 PATIENT REFUSAL
 Hypotension
 Coagulopathy or on anticoagulant
 Infection at the site of injection
 Skeletal deformity
 Neurological disease
Immediate post-operative care

 Monitoring in the recovery area (vital sign /1hr for the first 4hrs, )
 Ensure that the uterus remains contracted, that there is no excessive vaginal
bleeding or bleeding at the incision site, that there is adequate urine output,
and to monitor routine vital signs (blood pressure, temperature, breathing).
Pain medication is also given
 IV fluid replacement within the1st 24 hrs.
 Pain control and it is not that much issue in the 1st 24hrs if the regional
anesthesia was adequate.
 Antibiotics : First dose post operation is given after clamping the umbilical
cord in order to prevent the passage of the antibiotic to the baby. It decrease
the risk of infection by 80%, If there were signs of infection or the woman
currently has fever, continue antibiotics until the woman is fever-free for 48
hours.

 Drinking : Oral intake is initiated according to the type of anesthesia.

 Catheter removal: Removal of the urinary bladder catheter should be carried
out once a woman is mobile after a regional anesthetic and not sooner than
12-24 hours after the last epidural ‘top up’ dose.
 Ambulation : Ambulation started 6-12 hours post-op. Ambulation enhances
circulation, encourages deep breathing and stimulates return of normal
gastrointestinal function. Encourage foot and leg exercises and mobilize as
soon as possible, usually within 24 hours
 Discharge : Patient is usually discharged 2-4 days postOp

 Follow Up : Patient is asked to visit the clinic 1 wk postop to examine the wound.
Cesarean Section Complications
 The risk of both early and long term complications
are increased in c/s delivery when compared with
NVD.
 Theoverall maternal mortality rate is 6-22 deaths
per 100,000 live births.
 Themain problems are thromboembolism, infection
and hemorrhage which can be minimized by
appropriate prophylaxis and surgical skill.
Intraoperative complications
• Hemorrhage
• Maternal Death
• Emergency Hysterectomy
• Uterine laceration
• Urinary tract injury (bladder and ureter).
• Bowel injury
Short-term Risks of Cesarean Delivery (early
postoperative)
• Thromboembolism event
• Infection (Endometritis, UTI , Wound)
• Extended Hospitalization
• Pain
Long-term Risks of Cesarean Delivery (Delayed
postoperative)
• Readmission to the Hospital
• Adhesion Formation
• Infertility/Subfertility
Risks for the Newborn of Cesarean Delivery
• Neonatal Death
• Respiratory Difficulties (TTN)
• Asthma
• Iatrogenic Prematurity
• Birth Trauma

Risks of Cesarean Delivery to Future Pregnancies

• Uterine Rupture
• Abnormal Placentation
• Hysterectomy
Gastrointestinal Complications
 Paralytic ileus
 Abdominal distention
 Nausea and vomiting
 Failure to pass flatus
 Physical exam may reveal the absence of bowel sounds
** Treatment: involves withholding oral intake waiting the return of bowel
function, and providing adequate fluids and electrolytes, early mobilization.
Early Post-Operative
Complications
Post operative fever
45
Urinary Tract Infection
 the second most common infectious complication following cesarean delivery after
endomyometritis.
 Incidence varies from 2% to 16%.
 the process of placing an indwelling catheter for the surgery is a risk factor in itself.
 the incidence of UTIs is increased in patients with diabetes
 Treatment should be initiated with broad-spectrum antibiotics, and subsequent
antibiotic therapy based on urine culture and sensitivity results.
 Endometritis (Endomyometritis)

A clinical diagnosis that presents with : Risk 1. low socioeconomic status.

1. Lower abdominal pain and uterine tenderness Factors
2. Fever (most common cause of puerperal sepsis) 2. prolonged labor.
3. Abnormal vaginal bleeding or discharge.
* 5 – 20 fold higher risk (vs. vaginal delivery). 3. prolonged duration of ruptured
membranes.
* Infection is polymicrobial (E.Coli , GBS , G-ve rods..)
* 10% +ve blood culture 4. number of pelvic examinations.

5. the presence of chorioamnionitis

prior to initiating cesarean delivery.
Treatment
 Multiple-Agent antibiotic (e.g. gentamycin and clindamycin) to cover polymicrobial
genital tract flora.

 Use of prophylactic antibiotics at the time of the procedure decreases incidence.

With the use of modern, broad-spectrum antibiotics the incidence of serious
complications is less than 5%.

 A small percentage of patients will develop septic thrombophlebitis, pelvic abscess,

and peritonitis.
Wound Infection

 Wound infection is diagnosed in 2.5 to 16 percent Risk 1. longer operation time

of patients. Factors
2. PROM
 Generally four to seven days post C/S
 Wound infection presents with erythema and
3. Chorioamnionitis
tenderness, and may develop purulence and 4.Meconium staining liqour
fever.

5.Morbid obesity
Common isolates include Staphylococcus aureus,
Escherichia coli, Proteus mirabilis, Bacteroides 6.Anemia
species and group B streptococci.
7.Diabetes mellitus
8. absence of antibiotic
prophylaxis
9. Prolonged labor
Wound Dehiscence

 Fascial dehiscence is an infrequent complication of a wound breakdown but

constitutes a surgical emergency when it occurs.
 It develops in approximately 5% of patients with a wound infection and is
suggested when excessive discharge from the wound is present.
 if a fascial dehiscence is observed, the patient should be taken immediately to
the operating room, where the wound can be opened, debrided, and reclosed in
a sterile environment
Treatment
 Treatment includes broad-spectrum antibiotics and vigorous wound care.
 The wound may need to be probed, opened, irrigated, and necrotic tissue
debrided ,Then the open wound can be packed and cleaned several times a day. The
wound can be allowed to heal by secondary intention, or, when it has begun to
granulate, it can be closed.
Thromboembolic Complications
 The incidence is 0.24% of deliveries.
 Deep venous thrombosis (DVT) is three to five times more common after cesarean
delivery than vaginal delivery.
 DVT can progress to pulmonary embolus if untreated.
 Many cases are silent but present as swelling of the leg, tenderness of the calf muscle
and increased warmth, confusion, breathlessness and chest pain.
 Diagnosis: -venography or Doppler ultrasound(DVT)
-ventilation/perfusion scanning and/or pulmonary
angiography or dynamic CT.
Septic Thrombophlebitis
 Septic thrombophlebitis is a diagnosis of exclusion.
 usually present within a few days after delivery or surgery with unexplained fever
that persists despite antibiotics, in the absence of radiographic evidence of
thrombosis.
 Treatment include either broad-spectrum antibiotic alone or with anticoagulant
(heparin)
DELAYED POST-OPERATIVE COMPLICATIONS
1. Uterine Dehiscence and/or Rupture
* A dehiscence is a frequently asymptomatic separation and is found
incidentally at the time of repeat cesarean or on palpation after a
vaginal birth.
* Uterine rupture: sudden separation of the uterine scar and
expulsion of the uterine contents into the abdominal cavity. Fetal
distress is usually the first sign of rupture, followed by severe
abdominal pain and bleeding.
2. Repeat Cesarean Delivery
* Over 90 % of women who undergo cesarean delivery have a repeat
procedure in subsequent pregnancies.
* Increase risk of adhesions formation , abnormal placentation,
incisional hernia,,,,etc
3. Placenta Accreta
 Severe obstetric complication involving an
abnormally deep attachment of the placenta to
the myometrium without penetrating it.
 1 in 4 patients who undergoes repeat cesarean
delivery because of placenta previa will require
cesarean hysterectomy for hemorrhage caused by
placenta accreta.
 Incidence : 4% with no C/S, 25% with 1 C/S, and 40%
with 2 C/S
 In focal placenta accreta, the placental bed can be
curetted and over sewn with interrupted sutures
placed around the area of hemorrhage.
 If not successful, then complete hysterectomy may
be necessary
4. Cesarean Hysterectomy
 Hysterectomy after cesarean delivery is an emergency procedure that occurs in less
than 1 in 1000 of cesarean sections.
 Indications include :
 Uncontrollable maternal Hemorrhage (most common) , uterine atony (43%),
placenta accreta (30%), uterine rupture (13%), extension of a low transverse
incision (10%) and large fibroids (prevent closure or hemostasis)
 VBAC
Vaginal Birth After Cesarean Section
 Previous
C/S

TOLAC ERCD

VBAC RCD
 Definition
 A trial of labor after cesarean (TOLAC) is a planned attempt to labor by a woman who has
previously undergone a cesarean delivery and desires a subsequent vaginal delivery, It can either be
associated with spontaneous labor or with an induction of labor.
 A TOLAC may result in either a “successful” VBAC or a “failed” trial of labor resulting in a repeat
cesarean delivery.

 A VBAC is a “successful” trial of labor resulting in a vaginal birth.

 A repeat cesarean delivery (RCD) may be planned and scheduled before , called elective repeat
cesarean delivery (ERCD).
 Advantages Disadvantages
*from avoidance of the risks associated with * from avoidance of the risks associated with
repeat cesarean delivery, (esp. multiple C/S) TOLAC.
1. Uterine rupture : 1 in 200
1-Maternal : 2.Peripartum hysterectomy
*Lower rates of maternal morbidity, intrapartum 3. Higher risk of Fetal death : 1 in 750
hemorrhage Postpartum fever, Wound infection, Blood
transfusion , Hysterectomy, postoperative pain and * If VBAC is unsuccessful (failed TOLAC), increased
thromboembolic events. risks of complications as compared to ERCS ,i.e.
*shorter hospital stay and quicker return to normal
double risk of infection.
activities. 4. Induction with prostaglandins or misoprostol
*lower risk of subsequent pregnancy complications contraindicated
(placenta previa and accreta)
2- Fetal :
*Decrease risk of neonatal respiratory distress and NICU
admission rate
 • Optimum outcome
Optimal • highest success rate

Candidates for
TOLAC

Possibly
Inappropriate
appropriate • Relative
• Absolute
Contraindications Contraindications
• TOLAC is prohibited • TOLAC with caution
Candidates for TOLAC (Optimal)
One prior low transverse uterine incision :
 TOLAC success rate of 60 -80 %
 estimated uterine rupture rate of 0.4 - 0.7 %.

 Characteristics that increase the probability of successful TOLAC in this population:

1. A successful vaginal delivery before or after their primary cesarean delivery
2. A nonrecurring indication for their primary cesarean delivery (malpresentation)
3. Spontaneous labor on admission to the labor unit
4. Fetal weight less than 4000 g
5. Demographic factors ( higher success rate in non-Hispanic white women, <35 years old, increase
maternal height and BMI level <30 kg/m2 )
6. Interpregnancy interval more than six months (or 18 months)
7. Absence of maternal medical disease
8. Delivery in a university hospital with immediate availability of OR, anesthesiologist, and
obstetrician.
Candidates for TOLAC (Possibly
appropriate)
Prior low vertical uterine incision :
Data are limited and inconclusive , risk of rupture 1.5-2%
Two prior low transverse uterine incisions (vs. one prior) :
likelihood of successful TOLAC appears to be similar
have a higher rate of uterine rupture (0.72 versus 1.59 percent)*
Unknown type of uterine incision:
most women with a prior uterine incision for common obstetrical indications have had a low-
transverse hysterotomy incision.
similar rate of uterine rupture as those with a known prior low transverse uterine incision (0.5%
vs. 0.7%)
Pregnancy more than 40 weeks of gestation
are less likely to successfully deliver vaginally , with 2 to 3 percent risk of uterine rupture.
Twin gestation
the overall success rate and risk of uterine rupture in this population appears to be similar to that in singleton
gestations undergoing TOLAC
ACOG has opined that women with twin pregnancies and one previous low transverse cesarean delivery are
candidates for TOLAC if they have no contraindications to vaginal birth.
 Macrosomia
ACOG has opined that suspected fetal macrosomia (EFW ≥4000 grams) alone should not preclude the option of
a TOLAC with considering whether the woman has had a previous vaginal delivery, past birth weight(s) and
outcomes, and the predicted birth weight in the current pregnancy.
However, prophylactic cesarean delivery has been suggested when the estimated fetal weight is ≥5000 grams
in women without diabetes and ≥4500 grams in women with diabetes
 Maternal diabetes
Rates of successful TOLAC in women with gestational and pregestational diabetes appear to be lower.
 Maternal obesity
The rate of failed trial of labor was 15 percent in normal-weight women, 30 percent in obese women, and 39
percent in severely obese women.
The rate of uterine dehiscence/rupture for the three groups was 0.9, 1.4, and 2.1 percent
No guidelines have addressed whether TOLAC should be avoided in severely obese women or at any threshold
BMI
Candidates for TOLAC (Inappropriate)
1. High-risk uterine scars:

** Prior classical , T , or J hysterotomy (incision) , Thin lower

uterine segment thickness , previous transfundal myomectomy
2. Prior uterine rupture
3. Prior uterine dehiscence
4. Contraindication to vaginal delivery
5. Inability to perform emergency C-section (unavailable surgeon, anesthesia, sufficient staff or
facility).

 Special populations
Fetal demise — The balance of risks and benefits is different in the setting of fetal demise since
PRCD has no perinatal benefit. Decision-making on the route of delivery in these cases is
reviewed separately
 Predictors of VBAC Success or Failure
Increased Chance of Success Decreased Chance of Success
Prior vaginal delivery Maternal obesity
Prior VBAC Short maternal stature
Spontaneous labor Macrosomia
Favorable cervix Increased maternal age (>40 y)
Nonrecurring indication (breech presentation,
Induction of labor
placenta previa, herpes)
Recurring indication (cephalopelvic disproportion, failed
Preterm delivery
second stage)
Increased interpregnancy weight gain
Latina or African American race/ethnicity
Gestational age ≥41 wk
Preconceptional or gestational diabetes mellitus
Induction of labor in attempted VBAC
• Spontaneous labor is most successful & has lowest rate of uterine rupture
• Misoprostol should never be used
• Follys Catheter to ripen the cervix
• Rates of rupture shown in U.W. study (2001 NEJM) differed by method of induction:
• Spontaneous labor - 0.52%
• Induction without prostaglandins - 0.72%
• Induction with prostaglandins – 2.45%
 The risk of uterine rupture was not increased in those who
underwent either amniotomy/oxytocin or foley catheter
induction
 but was significantly increased in those who underwent a
prostaglandin E2 induction
Other issues in attempted VBAC
• External cephalic version probably safe
• Amnioinfusion considered safe
• Epidural anesthesia is considered safe
• Continuous EFM recommended throughout labor
• Ultrasound or MR imaging of lower uterine segment may
prove helpful in predicting risk of uterine rupture