Cesarean section
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Cesarean Section. Definition. CS is an attempt to deliver a fetus, placenta and membrane after 28 weeks of gestation, through an incision on the abdominal wall and the intact uterus

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Definition
Definition

  • CS is an attempt to deliver a fetus, placenta and membrane after 28 weeks of gestation, through an incision on the abdominal wall and the intact uterus

  • Removal of a fetus outside the uterus (abdominal pregnancy) or through a ruptured uterus or before 28 weeks is then not a CS.


Objective
Objective

1. To reduce infant and maternal morbidity

2. To reduce infant and maternal mortality


Indications
Indications

  • A. Based on urgency

  • Absolute or Relative

  • Emergency or Elective

  • B. Based on prognosis

    • Maternal indication

    • Fetal indication

    • Combined

  • C. General indications, based on certain clinical situation or diagnosis


General indications based on diagnosis
General indications based on diagnosis

  • Fetopelvic or cephalo pelvic disproportion

  • Obstruction of birth canal

  • Uterine disfunction

  • Malposition or malpresentation

  • Maternal diseases

  • Scarred uterus or anomaly of the uterus

  • Cancer of the cervix


Fetal indications i
Fetal indications (I)

  • Fetal distress

  • Malpresentation or malposition

  • Failed vacuum or forceps

  • Expensive child

  • Cord prolapsed

  • Placental insufficiency (IUGR)


Fetal indications ii
Fetal indications (II)

  • Incompatibility of rhesus

  • Post term pregnancy

  • Genital herpes

  • Diabetes mellitus

  • Elderly primigravida (>35 th)

  • Poor obstetric history

  • Giant fetus (> 4000 grams)


Maternal indication fetus already died
Maternal indication (Fetus already died)

  • Total placenta previa

  • Severe PE or Eclampsia, failed induction

  • Threatened Uterine Rupture, transverse lie


Combined indications
Combined indications

  • Placenta previa

  • Abruptio placenta, alive fetus

  • Severe Preeclampsia /Eclampsia

  • FPD/CPD

  • Threatened Uterine Rupture (Over stimulation)


Contraindications
Contraindications

  • Severe chorioamnionitis

  • Very poor fetal prognosis, exp: extremely premature, severe congenital anomaly.

  • Fetal death, except in case of placenta previa

  • No adequate facilities for surgical procedure


Types of cesarean section
Types of Cesarean Section

  • Based on incision

    • 1. Classical or corporal (vertical incision)

    • 2. Low segment (horizontal incision)

  • Based on time

    • 1. Emergency CS

    • 2. Elective CS

  • Other

    • 1. Extraperitoneal CS

    • 2. Cesarean hysterectomy


Clasic cs indications 1
Clasic CS, Indications (1)

1. Difficult to reach the LUS

2. Transverse lie

3. Fetal distress

4. Placenta previa, anterior implantation

5. Followed by sterilization


Classic cs advantages
Classic CS, Advantages

1. Faster

2. Easier


Classic cs disadvantages
Classic CS, Disadvantages

1. Bleeding may be more profuse

2. Difficult to luxate fetal head

3. Reperitonisation is incomplete

4. Risk of rupture during future pregnancy


Low segment cs indications
Low segment CS, Indications

  • Longitudinal lie

  • No problem with the LUS

  • Future pregnancy is expected


Low segment cs advantages
Low segment CS (Advantages)

  • Less bleeding

  • Incision to placenta is avoided

  • Easy to luxate fetal head

  • Easy to close (suture)

  • Good reperitonization

  • Risk of rupture in the next pregnancy is minimal


Low segment cs disadvantages
Low segment CS (Disadvantages)

  • Takes more time

  • Bleeding may be more severe, if the incision runs too laterally

  • Injury to the bladder may happen, if the incision is too low

  • During repeated CS, post laparotomy, or post infection, LUS may be too difficult to identify


Cesarean histerectomy 1
Cesarean histerectomy (1)

  • Definition: Cesarean section followed by hysterectomy

  • Indications:

    • Uncontrolled bleeding

    • Placenta acreta, increta dan percreta

    • Multiple mioma

    • Cervical or ovarial ca

    • Unrepairable uterine rupture

    • Infection


Cesarean histerectomy 2
Cesarean histerectomy(2)

  • Complications

    • Morbidity and mortality is higher:

      • Takes more time

      • Trauma to gut and bladder is higher

      • More bleeding

  • Psychological effects

    • No menstruation

    • Becomes steril


Complication of cs
Complication of CS

  • Bleeding (Atonia, Too large incision)

  • Infection (Incision site, peritonitis)

  • Trombophlebitis

  • Trauma (Gut, Bladder, Baby)

  • Ileus

  • Complications due to anesthesia and surgical action


Delivery after cs
Delivery after CS

  • Once cesarean always cesarean

  • Trial of vaginal delivery

    • Labor will progress easily

    • No significant complication to mother and baby


Contraindications to vaginal delivery
Contraindications to vaginal delivery:

  • Repeated cesarean section

  • Vertical incision

  • Absolut indication for CS

  • Malposition and mal presentation

  • Maternal diseases (DM, Toxaemia)

  • Fetal distress, expenssive child etc.


Maternal death due to cs
Maternal Death due to CS

  • 10-30 cases per 100.000

  • Causes

    • Bleeding

    • Infection

    • Anesthesia

    • Pulmonary emboli

    • Heart and renal failure due to prolonged hipotension


Maternal death due to cs risk factor
Maternal Death due to CS (Risk Factor)

  • Elderly women

  • Grandemulti gravida

  • Obesity

  • PROM

  • Maternal diseases

  • Complicated pregnancy

  • Low social economic condition


Infant mortality
Infant Mortality

  • Theoretically it is not higher

  • Practically it is higher, because:

    • Complication of pregnancy

    • Misdetermination of age

    • Fetal distress


Preparation for cs
Preparation for CS

  • Hemoglobin min. 10 g/dL

  • Heart, lung, electrolyte, liver and kidney, are normal

  • Fast 6-8 hours

  • Match Blood, 250-500 ml

  • Antacid (30 ml) 1 hour before

  • Ampicillin 1 gram iv, 15-30 minutes before operation


Monitoring post operation
Monitoring post operation

  • Stop oral feeding until peristaltics is good

  • Ivfd: Dextrose 5% and Na Cl 3:1

  • Closed monitoring of vital sign and fluids balance

  • Antibiotics: Ampicillin 3 X 1000 mg and Gentamycin 2 X 80 mg for 3 days

  • Vitamin

  • Mobilisation on day 2

  • Removal of suture on day 7

  • Discharge on day 8.


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