Lower segment ceaserean section
- 1. LOWER SEGMENT CAESAREAN SECTION BIMAL POKHAREL MBBS 4TH BATCH
- 2. It is an operative procedure whereby the fetuses after the end of 28th week are delivered through an incision on the abdominal and uterine walls. Incidence: steadily rising. Factors for rising cesarean section rate: 1) Identification of at risk fetuses before term (IUGR). 2) Identification of at risk mothers. 3) Wider use of repeat CS in cases with previous cesarean delivery. 4) Rising rates of IOL and failure of induction. 5) Decrease in vaginal breech delivery. 6) Increased no. of women with age more than 30 yrs at conception and associated medical complications. 7) Wider use of electronic fetal monitoring and increased diagnosis of fetal distress. 8) Cesarean delivery on demand.
- 3. Indications Absolute Indications 1) Central placenta previa 2) Contracted pelvis or cephalopelvic disproportion 3) Pelvic mass causing obstruction ( cervical or broad ligament fibroid) 4) Advanced carcinoma cervix 5) Vaginal obstructions (atresia, stenosis) Relative indications 1) Previous cesarean delivery 2) Non- reassuring FHR ( fetal distress) 3) Dystocia 4) Antepartum haemorrhage ( placenta previa & abruptio placenta) 5) Malpresentation 6) Failed surgical induction of labor, failure to progress in labor
- 4. 7) Bad obstetric history- with recurrent fetal wastage 8) Hypertensive disorders of pregnancy ( severe pre eclampsia , eclampsia - uncontrolled fits even with anti-seizure therapy. 9) Medical- gynecological disorders a) Uncontrolled diabetes b) Heart disease c) Mechanical obstruction due to benign or malignant pelvic tumors ( carcinoma cervix ) or following repair of VVF
- 5. Time of operation Elective: operation done at pre arranged time during pregnancy to ensure the best quality of obstetrics, anaesthesia, neonatal resuscitation and nursing services. Timing: a) Maturity certain: operation done about 1 week prior to the expected date of delivery b) Maturity uncertain: Amniocentesis is done for L/S ratio to ensure the fetal lung maturity, otherwise spontaneous onset of labor is awaited , then CS is done Emergency LSCS: Operation is done due to acute obstetric emergencies
- 6. Types of operation: a) Lower segment caesarean section b) Classical caesarean section Peculiarities of lower uterine segment: • Peritoneum is more loosely attached to the uterus • Contraction is less than in upper part of uterus • Lower segment is less vascular • Thin muscle layer • Healing is more efficient • Sutures are intact (less problem with suture loosening)
- 7. Merits and demerits of LSCS over classical CS LOWER SEGMENT CLASSICAL Technique 1. Technically slightly difficult 2. Blood loss is less 3. The wall is thin and so apposition is perfect 4. Perfect peritonization is possible 5. Technically difficult in placenta previa or transverse lie 1. Technically easier 2. Blood loss is more 3. The wall is thick and apposition of the margins is not perfect 4. Not possible 5. Comparatively safer in such circumstances Post- operative 1. Haemorrhage and shock- less 2. Chance of peritonitis is less in presence of uterine sepsis 3. Peritoneal adhesions and intestinal obstruction are less 4. Recovery is better 5. Less incidence of morbidity and mortality 1. More 2. Chance of peritonitis is more in presence of uterine sepsis 3. More because of imperfect peritonization 4. Relatively poor 5. Morbidity and mortality are high
- 8. LOWER SEGMENT CLASSICAL Wound healing The scar is better healed because of: 1) Perfect muscle apposition due to thin margins 2) Minimal wound hematoma 3) The wound remains quiescent during healing process 4) Chance of gutter formation is unlikely The scar is weak because of: 1) Imperfect muscle apposition due to thick margins 2) More wound hematoma formation 3) Wound remains in a state of tension due to contraction and relaxation of the upper segment 4) Chance of gutter formation on the inner aspect is more During future pregnancy Scar rupture- less More risk of scar rupture
- 9. • INSTRUMENTS REQUIRED FOR CAESAREAN SECTION: 1) Towel clips 12) Mayo scissors 2) Sponge holding forceps 13) Kidney tray 3) Allis tissue holding forceps 14) Electric cautery 4) Green armytage haemostatic forceps 15) Clamps 5)Artery forceps 6)Toothed forceps 7)Dissecting forceps ( toothed and non- toothed) 8) Needle holder 9) Suction 10) BP handle and blade 11) Doyen’ retractor
- 10. PRE- OPERATIVE PREPARATIONS • Informed written high risk consent for the procedure, anesthesia and arrangement of properly cross matched blood. • Antacid ( sodium citrate 30ml) given orally before transferring the patient to the OT. • Ranitidine 150mg orally night before and is repeated by 50mg iv 1 hr before surgery. • Metoclopramide( 10mg iv) is given to increase the tone of the lower esophageal sphincter. • Bladder is emptied by a Foleys catheter. • FHS should be checked once more at this stage. • Neonatologist should be made available.
- 11. • ANAESTHESIA: May be spinal , epidural or general. POSITION OF THE PATIENT Patient is kept in dorsal position. In susceptible cases, to minimize any adverse effects of venacaval compression, a 15 degree tilt to her left using a wedge till delivery of the baby is benificial. ANTISEPTIC PAINTING Abdomen is painted with 7.5% povidine iodine solution. INCISION ON THE ABDOMEN Either a vertical or transverse skin incision Vertical incision: infraumbilical midline or paramedian Transverse incision: modified pfannensteil incision is made 3 cm above the pubic symphisis.
- 12. Advantages of transverse i.e. pfannensteil incision • Post-operative comfort is more. • Fundus of the uterus can be better palpated during immediate post- operative period. • Less chance of wound dehiscence. • Less chance of incisional hernia. • Cosmetic value.
- 13. Steps • Assessment of the presenting part Identifying the incision line Pfannensteil incision
- 15. Incision to the rectus sheath Open the rectus muscle and retract laterally Opening the peritoneal cavity
- 18. Parietoperitoneum of the bladder and uterus is separated by fingers Doyen’s retractor is introduced and bladder is pushed downwards Recognition of the lower uterine segment is made by the presence of loose peritoneum over it
- 19. The loose peritoneum is incised transversely Lower uterine segment incision is made in the middle, deepened till the membranes are reached and then extended laterally Amniotic sac is ruptured and the Doyen’s retractor is removed The presenting part is hooked by the surgeon and delivered while the assistant applies fundal pressure Green armytage hemostatic forceps are applied to the angles and margins of uterine incision to control bleeding
- 20. Umbilical cord is clamped at two places and cut. Doyen’s retractor is reintroduced and the placenta and membranes are delivered. Uterus is exteriorized and the inside of the uterus is inspected for any abnormalities and completeness of removal of contents
- 21. Suture of the uterine wound in 3 layers 1) suture is placed on the far side in the lateral angle of uterine incision. • suture material is no. 0 chromic catgut suture. • continuous running suture taking deeper muscles 2) second layer: a similar continuous suture is placed taking the superficial muscles and adjacent fascia overlapping the first layer of suture 3) peritoneal flaps are oppposed by continuous inverting suture but it is not necessary to close the visceral and parietal peritoneal layers.
- 22. The mops placed inside are removed and numbers are verified Peritoneal toileting is done and the blood clots are removed Bilateral tubes and ovaries are examined Doyen’s retractor is removed After being satisfied that the uterus is well contracted, the abdomen is closed in layers. Vaginal toileting is done Sterile vulval pad is applied
- 23. Post-operative care First 24 hours • NPO and observation for the first 6-8 hours. • Periodic checkup of pulse, BP, PV bleeding, abdominal distension, input/ output charting, behavior of the uterus • Administration of iv fluids 2 pints each of RL NS AND D5 • Inj oxytocin 10 units in 1 pint RL • Blood transfusion is required if there is more than expected blood loss. • Prophylactic antibiotics ( cephalosporins and metronidazole) for all cesarean delivery for 2-3 days. Therapeutic antibiotic is given when indicated. • Analgesics in the form of pethidine and ketorolac is given. • Baby is put to breastfeeding after 3 to 4 hours when mother is stable and relieved of pain.
- 24. • 1st post-operative day: oral feeding in the form of sips is given. Ambulation is done and patient shifted to ward and oral antibiotics is given. • 2nd post-operative day: soft diet and ambulation. • 3rd post-operative: observation of wound for any soakage and bleeding. Soft to normal diet. • 5th postoperative day: suture out is done and the patient is discharged and contraceptive advice is given.
- 25. complications Intraoperative complications: 1) Extension of the uterine incision: may lead to bleeding from the uterine vessels and formation of broad ligament hematoma. 2) Uterine lacerations at lower uterine segment- may extend laterally and inferiorly into the vagina. 3) Bladder injury 4) Ureteral injury 5) GI tract injury 6) Excessive hemorrhage
- 26. Post-operative complications • Immediate complications 1) post-partum haemorrhage- Due to uterine atony. 2) Shock 3) Anaesthetic hazards: Aspiration of gastric contents , may result in aspiration atelectasis and aspiration pneumonitis. others: hypotension and spinal headache. 4) Infections: endomyometritis, UTI, wound infections, peritonitis 5) Intestinal obstruction: due to formation of adhesions and bands or paralytic ileus following peritonitis. 6) DVT and thromboembolic disorders 7) Wound complications: wound sepsis, haematoma, dehiscence,burst abdomen (involving the peritoneal coat) 8) Secondary PPH
- 27. Remote complications • Gynaecological: Menstrual excess or irregularities, chronic pelvic pain or bachache • General surgical: Incisional hernia, intestinal obstructions due to adhesions or bands • Future pregnancy: risk of scar rupture FETAL COMPLICATIONS • Iatrogenic prematurity and development of RDS
- 28. References • DC Dutta’s textbook of obstretics 8th edition.