Caesarean section and instrumental delivery. Dr. samira abudia. Caesarean section. Definition :
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it’s a surgical procedure that permits delivery of the infant through incision in the abdominal and uterine wall after 28th weeks of pregnancy (a similar procedure before that time is referred to a hysterotomy).
Caesarean section to deliver the baby of the mother who has died has been documented in ancient Egypt , Asia and Europe.
The first caesarean carried out on alive woman is though to be that of the wife if jacob nufer, she was in obstructed labour.
•The history of the operation thereafter is fascinating with a wide range of isolated cases being documented with a various techniques being investigated to decrease the risk of death due to hemorrhage and sepsis .
The incidence of the procedure was stable (3-5%) for many years , yet since 1960s the rate was rising steadily reaching (20-25%) in late 1980s.
1) maternal indications :
• Fetal distress
• Certain cases of malpresentation
• Macrosomia and extreme prematurity
• It may be elective (before the onset of labour pain) , or selective (the decision taken during labour) .
A) upper segment C.S (classical C.S) :
USCS done through a vertical incision in upper uterine segment allows rapid entry , buy it connects with complications as increase blood loss and increase risk of uterine rupture in subsequent pregnancy.
a) fibroids at lower uterine segment
b) Dense adhesions cover the lower ut. Segment.
• It’s the most commonly performed incision.
• Lower incidence of hemorrhage because it’s thinner , less vascular and away from the normal site of placenta.
• Stronger uterine scar with lower incidence of ut. Rupture in a subsequent pregnancy 0.4% (USCS 4%) , because the lower segment is relaxed during puerperium and approximation of edges during surgery as it’s relatively thin.
• Post operative adhesions , infection and ileus are less likely to occur.
• Preoperative visit by anesthesiologist is important to asses the patient’s anesthesia status and the risk of complications during and after surgery.
• Patient in elective procedure should be kept fasting.
• A large intravenous line prior to anesthesia and an infusion of crystalloid solution.
• Blood group and cross matched blood.
• Urinary bladder catheterization.
• Preparation of abdominal and perineal area.
• Anesthesia : G.A or regional anesthesia.
Improved surgical and anesthetic skills , antibiotic , septic techniques and blood products availability have decreased the complication of C.S , despite significant decrease the maternal morbidity still 8-12 times than vaginal birth.
• Anesthetic complications (mainly in G.A) as aspiration pneumonia , intra-operative as (hemorrhage and injury U.B , uterus or bowel) , thromboembolic diseases and postoperative febrile complications as endometritis and UTI.
• Remote morbidity includes adhesive intestinal obstructions , rupture uterine scar , placenta previa at the site of previous scar and incisional hernia.
1-placenta accreta , ,increta and percreta 50%
2-uterine atony 20%
3-intractable hemorrhage 15%
4-uterine rupture 10%
It’s instrument designed to extract the head of living baby.
• It’s used either to accelerate delivery or to overcome certain abnormalities in the cephalo-pelvic relationship the interfere with advancement of the head in labour.
Maternal indications :The most common indications are maternal distress , exhaustion and prolonged 2nd stage of labour.
Maternal diseases as heart and chest diseases.
• It consists of two matched parts that articulate and lock to each other (blades) , each blade of made of the blade proper , shank , lock and handle.
• The blades are usually fenestrated for lightness to minimize the compression of fetal head and obtain form grip.
Each blade has two parts the flat one to fit the fetal head (the cephalic curve) and the curved one in the edge to fit the concavity of the sacrum (the pelvic curve)
The shank : each blade is joined to the handle by the shank (variable lengths)
Special types forceps: e.g. Kielland’s forceps , for rotation of the vertex 90 degree or more .
The use of forceps is permissible only when all the following condition prevail , regardless of the urgent need for delivery :
1849- James young Simpson , introduced his (structured tractor) and attempted to popularize vacuum operated delivery device as an alternation to forceps for cephalic and breech presentation .
1950-Malmstrom, inverted his rigid cup design namely , traction , an a metal cup designed suction creates an artificial caput or chignon , within the cup holds firmly and allows adequate traction .
-the classic malmstrom stainless steel vacuum cup .
-rigid plastic cup extractors (mimic malmstrom)
-disposable polyethylene cup designs .
-combined polyethylene-silastic cup designs .
-vacuum release valve
Basically these are the same as for forceps deliveries , but :
1) it must not be used for face deliveries
2) it can not be used for after coming head of breech presentation.
3) should not be used in case of prematurity and with large caput or much moulding.
1) delayed 2nd stage of labour
2) fetal and maternal distress in 2nd stage of labour
• Informed consent.
• Prepared physician : physician should have knowledge of the instrument chosen.
• Prepared patient :
-No suspicion of CPD
-Fetal position and station
• Maternal complications :
-cervix or vaginal wall may be included in the cup and lacerations may occur.
-applications before full dilatation of the cervix and traction may cause annular detachment of the cervix and may predispose to utero-vaginal prolapse.
-scalp : abrasions and necrosis
-skull fractures or cephalic hematoma
-brain : neurological signs , meningeal tear , retinal hemorrhage or intracranial hemorrhage.
• Use of instrument is easy to learn
• Risks of maternal injuries are less than with forceps
• Less general anesthesia is needed
• Spontaneous rotation of the fetal head
• Less force (traction) can be exerted on the fetal head
• The vacuum cup doesn’t take up any room in the pelvis
Operator in experience
• inability to achieve a correct application
• Uncertainty concerning fetal position and station
• Suspicion of cephalo-pelvic disproportion
• Fetal mal-position e.g. breech , face and brow.
• Known or suspected fetal coagulation defects
• Dead baby