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Caesarean Section (C – section), types and Indications

Caesarean section, indications, contraindications, types, procedure

Definition- It is an operative procedure whereby the Fetuses after the end of 28th week are delivered through an incision on the abdominal and Uterine wall.

The first operation performed on a patient is referred to a primary caesarean section. When the operation is performed in subsequent pregnancies, it is called repeat caesarean section.

◾Indications-

Primigravidae-

  1. Failed Induction
  2. Fetal distress
  3. Cephalo pelvic disproportion (CPD)
  4. Dystocia- nonprogess of labour
  5. Malposition and Malpresentation

Multigravidae-

  1. Previous caesarean delivery
  2. Antepartum Haemorrhage
  3. Malpresentation

Some other indications-

  • Failed surgical induction of labour
  • Bad obstetric history- with recurrent fetal wastage
  • Hypertensive disorders
  • Medical- Gynaecology disorders- Diabetes, heart disease, Mechanical Obstruction

◾Time of operation-

  1. Elective- When operation is done at a prearranged time during pregnancy to ensure the best quality of obstetrics, anaesthesia, neonatal resuscitation and nursing services.

Time- a) Maturity is certain- operation is done one week prior to expected date of confinement.

b) Maturity is uncertain- Ultrasound sound Assessment and amniocentesis is done to ensure fetal Maturity. Otherwise spontaneous Onset of labour is awaited and then CS is done.

2. Emergency- When the Operation is performed dur to unforeness or acute obstetric emergencies.

◾Types of operations-

  1. Lower Segment Caesarean 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 practised in present day obstetrics and used, wherever caesarean type is not specified.
  2. Classical- In the Operation, the baby is extracted through an incision made in the upper segment of the Uterus.
  3. Perimortem caesarean section- It is done to have a live baby (rare). Perimortem section is an extreme emergency procedure.

Lower Segment Caesarean Section

◾Preoperative Preparation- Informed written permission for the procedure, anaesthesia and blood transfusion is obtained.

  • Abdomen is scrubbed with soap and non organic iodide lotion. Hair may be clipped.
  • Premedicative sedative must not be given.
  • Non particulate antacid (0.3 molar sodium citrate, 30 ml) is given orally before transferring the patient to theatre. It is given to neutralise the existing gastric acid.
  • Ranitidine (H2 blocker) 150 mg is given orally night before (elective procedure) and it is repeated (50 mg IM or IV) one hour before the surgery to raise the gastric pH.
  • Metoclopramide (10 mg IV) is given to increase the tone of the lower esophageal sphincter as well as to reduce the stomach contents.
  • The stomach should be emptied, if necessary by a stomach tube(emergancy procedure).
  • Bladder should be emptied by a Foley catheter, should be kept in place in the perioperative period.
  • FHS should be checked once more at this stage.
  • Neonatologist should be made available.
  • Cross match blood when above average blood loss (placenta praevia, prior multiple caesarean delivery)is anticipated.

Anaesthesia- may be spinal, epidural or general.

Position of patient- dorsal position

Antiseptic painting- Abdomen is painted with 7.5% povidone iodine solution or savlon lotion.

Incision on the abdomen- Vertical Incision may be ‘infraumbilical midline’ or paramedian. Transverse incision, modified ‘Pfannenstiel’ is made 3 cm above the symphysis pubis. Transverse incision has certain benefits.

Uterine incisions for Caesarean section

A. Lower segment transverse
B. Lower Segment vertical
C. ‘J’ Incision
D. Classical Incision
E. Inverted T incision

◾Steps of LCSC-

  1. The loose peritoneum on the lower segment is cut transversely
  2. A short Incision is made in the midline down to the membranes
  3. The incision of the lower segment being enlarged using index finger of both hands.
  4. Saggital Section showing insinuation of the fingers between the lower Uterine flap and the Fetal head until the posterior surface is reached.
  5. Delivery of the head of fetus.
  6. Delivery of the trunk.
  7. Then Placenta is delivered.
  8. Then insert continuous catgut (No. ‘0’) suture taking deeper muscles excluding the decidua
  9. Continuous sutures taking Superficial muscles and fascia down to the first layer of suture
  10. Continuous peritoneal catgut suture

Appropriate Postoperative care is given.

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