Caesarean section

Definition:
It is abdominal delivery of fetus through incision over mother’s abdomen and then on uterus after 28 weeks of delivery.

As per our general knowledge, we can say that it is an abnormal delivery through abdomen of term, pre term, or post term fetus because fetus may be in transverse position or there may be placenta praevia or may be due to more than one baby.

History:
The word caesarean was popular during 715 B.C. as a “lex cesarea”.
It was actually a law that provided either caesarean in a dying lady with a hope to deliver a live baby OR to perform separate burial for mother or baby.
According to French obstetrics named François Mauriceau in 1668.
He used Latin proverb ‘caedere’ which means ‘to cut’.

Indication:
It is mainly done when labour is contra indicated or vaginal birth is injurious to mother or baby.

For easy understanding indication are divided in two parts maternal and fetal.

1. Maternal:
• Failed induction of labour
• Contracted pelvis: in major contraction lower segment caesarean section (LSCS) is advised.
• In past more than 2 LSCS were done.
• In past 1 LSCS was done with some obstetrics problems this time
• Selected cases of diabetes
• Major degree placenta praevia
• Cases associated with pelvic inflammatory disease

2. Fetal:
• Fetal distress during first stage of labour
• Malpresentations like breech and shoulder
• Obstetrics history like repeated intra uterine death and recurrent pregnancy wastage
• Some cases of twin pregnancy
• Some selected cases of Rh incompatibility
• When mother is a known case of HIV positive, then to prevent vertical transmission to baby
• Prolapse of cord before full cervical dilatation

Type of operation:
1. Elective: this is one type of procedure in which all the operative needs are fulfilled before surgery
2. Emergency: here nothing is planned because here type of surgery is chosen after seeing the condition of patient.

Now some detail about caesarean section

1. Classical caesarean section

It has various complication and disadvantage so rarely used now-a-days.
Here vertically in the midline in upper uterine segment the incision is put though in modern obstetrics it has some indication.
• There is a fibroids in lower uterine segment
• Severe adhesions in lower uterine segment
• When hysterectomy is contemplated at the same time.
• Carcinomas of cervix.

2.. Lower segment caesarean section

It is done under general, local or spinal anesthesia.
Steps:
First do pre operative procedure and painting & draping after giving anesthesia.
Abdomen is opened layer by layer till the uterus is seen.
Remove parietal and visceral peritoneum.
With the help of Doyen’s retractor bladder is retracted.
Then open the uterus in lower segment with the help of knife.
Then hand is passed below the head, Doyen’s retractor is removed, head is flexed under fundal pressure.
Rest of the portion is delivered simply by gentle traction on the head aided by fundal pressure.
Now uterus is closed in 2 layers by chromic catgut by taking interrupted sutures.
Visceral peritoneum is closed in continuous manner.
Then abdomen is closed layer by layer.

Complication of LSCS:
1. Maternal:
• Post partum hemorrhage
• Haematoma
• Extension of incision with irregular tearing of lower uterine segment
• Heamaturia
• Post operative retention of urine
• Sepsis and shock
• Pulmonary embolism
• Disseminated intra vascular coagulation

2. Fetal:
• Respiratory distress syndrome
• Injury to fetus by knife
• Asphyxia due to anesthetic agent
• Fetal blood loss if placenta is cut during delivery
• Intracranial hemorrhage by difficult delivery through small incision which further leads to secondary hypoxia

Late complication:
1. Scar on the uterus can lead to rupture during next pregnancy
2. If placenta is implanted on scar the risk of rupture is increased
3. Abdominal scar leads to incisional hernia

Advantages of LSCS over classical caesarean section:
1. Less bleeding due to less vascularity
2. Minimal intra peritoneal adhesion
3. Muscle fibers are transverse so it is anatomical
4. There are no chances of infection
5. Abdominal distension and paralytic ileus are less common
6. Overall mortality is less
7. Less chances of placenta to be implanted over a scar tissue in future pregnancy
8. There is a minimal handling of uterus and abdominal content
9. Scar is strong because lower segment of uterus is quiescent part in the post operative period

Disadvantages of LSCS:
1. Injury to bladder or ureter
2. Profuse bleeding due to lateral extension of incision
3. Time consuming and difficult
4. In case of a large fetus and limited space, delivery may be difficult

Vaginal birth after caesarean section:
1. In case of previous one CS if the indication is recurrent means contracted uterus
2. So the new dictum is “Previous caesarean/caesareans hospital delivery, if vaginal delivery careful observation”
3. If there are no high risk factors for scare rupture patient may be admitted in the hospital only after labour pain start.
4. After vaginal delivery there is no need to check for scar rigidity.
5. The patient is watched for signs and symptoms of threatened scar rupture.

High risk factor for scar rupture in next pregnancy:
1. If previous CS is classical type then chances of rupture is high then LSCS.
2. Post operative infection leads to weak scar.
3. Implantation of placenta over the scar in this pregnancy.
4. Repeated vaginal delivery after CS leads to weakness of scar and there is risk for rupture.
5. Distension of uterus due to large fetus, hydramnios, and multiple pregnancies also leads to scar rupture.
6. Surgical technique at previous CS due to excessive foreign body reaction due to thick suture material.
7. There may be tissue ischemia due to interlocking suture.
8. If USG with full bladder show scar thickness <2.5 mm it points again trial of vaginal birth after caesarean section.
9. Implantation of placenta at the site of incision of previous CS leads to weak scar due to unsatisfactory suturing
10. There is ischemia of cervical tissue due to low placed incision leads to weak scar.

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