Caeserian section – types , indications and contraindications. Flashcards
what are the absolute indications for c section ?
placenta previa , cephalo pelvic diproportion , active gential herpes , advanced cervix carcinoma , cord prolapse , severe eclampsia
what are the types f c section ?
Lower segment
Classical or upper segment
describe the lower segment approach in c section ?
In this operation, the extraction of the baby is done through an incision made in the lower segment through a transperitoneal approach. It is the only method practiced in present day obstetrics and unless specified
describe the classical approach ?
In this operation, the baby is extracted through an incision made in the upper segment of the uterus.
when are the only times classical approach employed ?
Lower segment approach is difficult:(1)Dense adhesions due to previous abdominal operation (2) severe contracted pelvis (osteomalacic or rachitic) with pendulous abdomen.
Lower segment approach is risky: (1) Big fibroid on the lower segment—blood loss is more (2) carcinoma cervix—to prevent dissemination of the growth
complete anterior placenta previa with engorged vessels in the lower segment
Perimortem cesarean section:- in a woman who has suffered a cardiac arrest. The infant may survive if delivery is done within 10 minutes
PREOPERATIVE PREPARATION for lower segment c section?
Nonparticulate antacid is given orally before transferringt to theater.
Ranitidine given orally night before (elective procedure) and it is repeated IM or IV 1 hour before the surgery to raise the gastric pH.
stomach should be emptied,if necessary by a stomach tube (emergency procedure).
Metoclopramide IV)is given to increase the tone of the lower esophageal sphincter as well as to reduce the stomach contents. It is administered after about 3 minutes of preoxygenation in the theater.
Bladder should be emptied by a Foley catheter
Prophylactic antibiotics should be given
IV cannula: Sited to administer fluids (Ringer’s solution
Anesthesia—may be spinal, epidural or general
Antiseptic painting: The abdomen is painted povidone-iodine
what are the different incision types for LSCS ?
vertical
incision made through an infraumbilical midline
transverse skin incision.
is made 3 cm above the symphysis pubis.- PREFERED
describe the steps of LSCS ?
transverse incision using scapula until reaching rectus sheath
and stretch the tissues in a diagonal fashion
insert finger through the midline of rectus muscle
and stretch this cavity horizontally
apply doyen retractor
lower uterine identified by the loose visceral peritoneum
The loose peritoneum of the uterovesical pouch is cut transversel
2cm smiley face transverse incision in the lower uterine muscle segment
Two index fingers are then inserted
through the small incision down to the membranes and the muscles of the lower segment are split transversely across the fibers. This method minimizes the blood loss but requires experience
The blood mixed amniotic fluid is sucked out by continuous suction. The Doyen’s retractor is removed.
insert the hand into the uterus
identify the head
and flex it to achieve the smallest diameter
and lift the bab’s head simultaneously without bending your wrist
the assistant applies fundal pressure and delivers the baby
After the delivery of the shoulders, intravenous oxytocin 20 units or methergine 0.2 mg is to be administered
cord is cut in between two clamps and remove the placenta through cord traction
with simultaneous pushing of the uterus towards the umbilicus per abdomen
Routine manual removal should not be done
The Doyen’s retractor is reintroduced.
The optimum interval between uterine incision and delivery should be less than 90 seconds
check that the cavity of the uterus is empty
suturing of the uterine wound ?
Green Armytage hemostatic clamps (four are required, one each for angle and one for each margin).
The uterine incision is sutured in three layers.
The first stitch is placed on the far side in the lateral angle of the uterine incision and is tied. The suture material chromic catgut
A continuous running suture taking deeper muscles ensures effective apposition of the tissues;
A second layer of interrupted sutures (1 cm apart)
taking the entire
depth of superficial muscles down to the first layer of suture.
third layer: continuous suture taking the peritoneum with the adjacent muscles
explain a classical c section ?
relatively easy to perform
Abdominal incision is always longitudinal extending 15 cm extending above the umbilicus. A longitudinal incision of about 12.5cm is made on the midline of the anterior wall of the uterus starting below the fundus.
until the membranes are exposed which are punctured.
In about 40% cases, the placenta is encountered. In such cases, fingers are slipped between the placenta and the uterine wall until the membranes are reached.
The baby is delivered commonly as breech extraction.
Intravenous oxytocin 5 IU IV (slow) or methergine 0.2 mg is administered following delivery of the baby.
. The placenta is extracted by traction on the cord or removed manually.
what are the advantages of a lower segment c section over classical ?
Blood loss is less
Peritonitis is less even in infected uterus because of perfect peritonization and if occurs, localized to pelvis
Peritoneal adhesions and intestinal obstructions are less
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the scar heals better because :
muscle apposition due to thin margins
Minimal wound hematoma
The wound remains quiescent during
(for classical : Imperfect muscle apposition because of thick margins
More wound hematoma formation
The wound is in a state of tension due to contraction and relaxation of the upper segment. As a result, the knots may slip or the sutures may become loose)
During future pregnancy
Scar rupture is less
why is LS transverse preferred over vertical ?
transverse
Extension of incision
May occur to involve the uterine vessels
Bladder dissection
Minimal
Uterine closure
Easy
Muscle apposition
Good
Reperitonization
Complete
less wound hematoma
Subsequent adhesions
Less
wound remains quiescent during healing
risk of scar rupture is less
what are the intraoperative complications of c section ?
Extension of uterine incision to one or both the sides. This may involve the uterine vessels to cause severe hemorrhage, may lead to broad ligament hematoma formation.
Bladder injury
Ureteral injury
what are the post op complications ?
Abdominal wound sepsis is quite common. on removal of the skin stitches,: (1) sanguineous or pus (2) hematoma (3) dehiscence
Postpartum hemorrhage
Infections: The common sites are uterus (endomyometritis), urinary tract, peritoneal cavity
Deep vein thrombosis and thromboembolic disorders
Septic thrombophlebitis
post op care for c section?
Observation for the first6–8hours
ringer lactate continued
oxytocin 5u slow / methergine
Prophylactic antibiotics (cephalosporins, metronidazole) for all cesarean delivery
Analgesics in the form of pethidine hydrochloride
