Caesarean section Flashcards
Indications in modern obstetrics-Classical Caesarean section
Upper segment of uterus in incised vertically
- Extreme prematurity
- Multiple fibroids
- Transverse lie
Advantages of Transverse incisions C Section
- Cosmetic
- Less painful
- Less interference with postoperative respirations
- Greater strength
Disadvantages of Transverse incisions C Section
- More time consuming/more blood loss
- less access to upper abdominal cavity
- Potential haematoma
What is Pfannenstiel incision-?
- Introduced by Pfannenstiel in 1900
- curved incision is approximately 10–15 cm long and 2 cm above the pubic symphysis.
- The skin and rectus sheath are opened transversely using sharp dissection.
- The rectus muscles are not cut and the fascia is dissected along the rectus muscles.
What is Joel-Cohen incision?
used for caesarean section
•straight transverse incision through the skin, 3 cm below the level of the anterior superior iliac spines (higher than the Pfannenstiel incision
•subcutaneous tissues and fascia are opened in the midline and extended laterally with blunt finger dissection.
• Blunt dissection is used to separate the rectus muscles vertically and then open the peritoneum.
Advantages of vertical incisions C Section
- Excellent exposure
- Easily extendable
- Minimum nerve damage
- Median incision has less blood loss
- Rapid entry into abdomen
Disadvantages of vertical incisions C Section
- Wound dehiscence and hernia more frequent
- Poor cosmetic results
- High infection/bleeding with paramedian incision
Outline steps of C section Technique
- Abdomen is opened by Joel-Cohen incision
- Uterus is opened by transverse incision in lower segment
- Deliver the baby and placenta
- Uterus is closed with vicryl in 2 layers
- Peritoneum is not closed
- Rectus sheath closed with continuous vicryl
- Skin closed with either non absorbable or absorbable sutures example- Prolene/staples/Monocryl
Absorbable sutures
- Catgut
- Polyglactin (Vicryl)
- Vicryl rapide
- PDS (Polydiaxone)
- Monocryl
Non-Absorbable sutures
- Silk
- Nylon
- Prolene
Indications for LSCS
- Prolonged first stage of labour
- Prolonged second stage and criteria for instrumental delivery are not met ( cephalo pelvic disproportion/malpositions)
- Fetal distress- CTG abnormalities and abnormal fetal blood sampling
- Abruptio placenta
- Cord proplase
- Suspected Scar dehiscence
Indications for Elective caesarean section
Performed at 39weeks •Placenta previa •Severe antenatal fetal compromise •Abnormal lie- breech •Previous classical caesarean section •Gross pelvic deformity
Relative indications-
•Severe IUGR
•Twin pregnancy
•Previous caesarean section
NICE guidance on Maternal request caesarean section
- When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner. [NICE, 2011]
- For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS. [NICE, 2011]
How do we classify urgency of C sections
Emergency: Immediate threat to mother or fetus-fetal distress
Urgent: Maternal or fetal compromise not immediately life threatening- dystocia
Scheduled: Needing early delivery but no compromise
Elective: At time suiting mother or team
Peri/postmortem: For mother during maternal cardiac arrest /fetus after maternal death
Maternal Complications of LSCS
More when emergency than elective
Serious risks- •emergency hysterectomy •need for further surgery at a later date •admission to intensive care unit •thromboembolic disease •bladder injury •ureteric injury •death
Frequent risks
•persistent wound and abdominal discomfort
•increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
•readmission to hospital
•haemorrhage
•infection
Counsel on Future pregnancies after LSCS
- increased risk of uterine rupture during subsequent pregnancies/deliveries
- increased risk of antepartum stillbirth
- increased risk in subsequent pregnancies of placenta praevia and placenta accreta
Placenta accreta
an abnormal adherence of either in whole or part of the placenta to the under lying uterine wall
Placenta increta
placenta invades deeply into myometrium
Placenta percreta:
Penetration to uterine serosa, may invade bladder and adjacent structures
Pre-operative preparation for LSCS
- Indication
- History- previous surgeries/previous problems at operations like wound infection
- History of DVT and risk access for VTE and plan for appropriate prophylaxis
- Medical disorders/mediation used / if on fragmin stop 24 hrs before LSCS
- BMI – increased risks of operation for high BMI >30
- Previous PPH
- Check haemoglobin/blood group and save sample
- Obtain valid consent / TED stockings/anaesthetic review
- Check placental site on scan
- Check for presentation if LSCS for breech
Define Breech presentation
- Presentation refers to the part of fetus that occupies lower uterine segment.
- Presentation of the buttocks is breech presentation • 3-4% pregnancies at term
- 25% around 30weeks
Aetiology of breech presentation
- No cause
- Previous breech in 8%
- Prematurity
- Fetal/uterine abnormalities • Twin pregnancies
- Placenta previa
- Pelvic tumours
- Pelvic deformities
How is breech presentation diagnosed?
• Important after 37 weeks • Hard head at fundus / ballotable Ultrasound- confirms the diagnosis • Also to rule out placenta previa/tumours • Type of breech • Estimated weight • Liquor volume
Types of breech
• Extended breech ( frank breech)- • Flexed at hips • Extended at knees Complete (flexed breech ) • Babies knees and hips are flexed Footling breech • Babies feet are presenting
Complications of breech presentation
- Perinatal mortality and morbidity are increased • Fetal abnormalities are more common
- Labour- hypoxia/birth trauma
- High rates of long term neurological handicap
Explain External cephalic version
• From 37 weeks • Can attempt to turn the baby to cephalic • Success rate 50% • 3% will turn back Technique- • With out anaesthetic • Labour ward • With uterine relaxant • Ultrasound guidance • Breech is disengaged and moved up • Forward somersault movement • CTG is performed straight after • Injection Anti D if given if rhesus negative
Complications of External cephalic version
Complications-
• Placental abruption
• Uterine rupture
• Urgent LSCS may be needed in 0.5%
ECV Factors affecting success rate-
- Nulliparous
- Breech engaged
- Obesity
- Liquor reduced
- Big baby
Contraindications to ECV
- Fetal distress
- Placenta previa
- Twins
- Recent bleeding
- Membranes have ruptured • Uterine/fetal anomalies
- One pre LSCS is not an contraindication
Mode of delivery for breech
• If ECV fails – elective caesarean section at 39 weeks
Caesarean section-
• Reduces perinatal mortality
• Birth trauma
• Neonatal admission
• Low Apgar scores
• Some women may prefer vaginal breech delivery / second twin may be breech
Vaginal breech delivery protocol
• Risky if fetal weight >3.8kg • Extended head
• Footling breech
• Fetal distress
Pushing is discouraged until buttocks are visible Good analgesia like epidural
• Once back of the neck is visible,
• Entire baby rests on the arm with finger in the mouth to
promote flexion
• The other hand presses on the occiput- to promote flexion
• This is called- Mauriceau-Smellie-Veit manoeuvre
• If this fails- apply forceps
• Deliver in all fours
