ObGyn

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CAESARIAN DELIVERY
BY Dr. Malleswar Rao Kasina, MD,DGO. HOD CSS,
Dept. of GynObs, ESI Hospital, Sanathnagar,
Hyderabad, AP, India
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Cesarean Childbirth Overview

• Cesarean delivery, also known as cesarean
  section, is a major abdominal surgery involving 2
  incisions (cuts),
• One is an incision through the abdominal wall and
  the second is an incision involving the uterus to
  deliver the baby.

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Cesarean Childbirth Overview
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Cesarean Childbirth Overview

• History Legend has it that the Roman leader
  Julius Caesar was delivered by this operation,
  and the procedure was named after him.
• How often used The rate for cesarean delivery
  increased steadily from 4.5 in 1965 to 21 in
  1998.

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Cesarean Childbirth Causes
The most frequent reasons for performing a
cesarean delivery are discussed below. 1 Repeat
cesarean deliveryThere are 2 types of uterine
incisionsa low transverse incision and a
vertical uterine incision.
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Cesarean Childbirth Causes

• 1a) A low transverse uterine incision is the
  approach of choice.
• 1b) A vertical incision on the uterus (low or
  high) may be used for delivering preterm babies,
  abnormally positioned placentas, pregnancies with
  more than one fetus, and in extreme emergencies.

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Cesarean Childbirth Causes

• 1a In the last 20 years, studies have shown that
  women who have had a prior cesarean section with
  a low transverse incision may safely and
  successfully go through labor and have a vaginal
  delivery in later pregnancies. (VBAC)

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Cesarean Childbirth Causes

• 1b In about 10 of women with vertical uterine
  incisions, their uterus will rupture (break
  open).
• The uterus may rupture even before labor begins
  in up to 50 of these women.

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Uterine rupture can be dangerous to the fetus
even if delivery is accomplished immediately
after a uterine rupture.
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Cesarean Childbirth Causes
2 Previous cesarean deliveries Women with a
prior history of more than 1 low transverse
cesarean section, a trial of labor (TOL) is not
an option, a repeat Cesarean delivery is the
choice.
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Cesarean Childbirth Causes

• 3 Lack of labor progression If the woman is
  having adequate contractions but no change in the
  cervix beyond 3 cm dilation or the woman is
  unable to deliver the fetus despite complete
  dilation of the cervix and "adequate" pushing for
  2-3 hours, cesarean delivery may be performed.

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In a normal pregnancy, the baby is positioned
head down in the uterus.
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Cesarean Childbirth Causes

• 4 Abnormal position of the fetus Placental
  causes
• i) Breech delivery
• ii) Oblique lie
• iii) Persistent Occipitoposterior position
• iv) Deflexed Head (cord round the neck)
• v) Abruptio placenta
• vi) Placenta praevia

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C-section - Indications
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Cesarean Childbirth Causes

• 5 Fetal status Continuous fetal heart rate
  monitoring in labor has not improved birth
  outcomes as once expected.

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Cesarean Childbirth Causes

• 6 Emergency situations If the woman is severely
  ill or has a life-threatening injury or illness
  with interruption of the normal heart or lung
  function, she may be a candidate for an emergency
  cesarean section.

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Cesarean Childbirth Causes

• 7 Elective sterilization A desire for elective
  sterilization is not an indication for cesarean
  delivery.

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C-section Procedure-1

• When the C-section is planned, the doctor may
  order regional anesthetics (a spinal or an
  epidural), which numbs only the lower portion of
  the body.

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C-section Procedure-2

• In non-emergency C-sections, a horizontal
  incision (a bikini cut) across the abdomen, just
  above the pubic area.
• In an emergency situation, a vertical cut, from
  below the navel to just above the pubic area. A
  vertical cut allows quicker access to the baby

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C-section Procedure-3

• A vertical uterine incision causes less
  bleeding and better access to the fetus, but
  renders the mother unable to attempt a vaginal
  delivery (must have another repeat C-section) in
  the future.

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C-section Procedure-3

• If you end up with a horizontal uterine
  incision, you will have the option of either
  going through a trial of labor (TOL) or electing
  a repeat c-section.

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C-section Procedure-3

• The reason for the differences between the two
  is that patients with vertical uterine incisions
  have a much higher chance of rupturing the uterus
  (8-10) in the future pregnancies, compared to
  only 1 in those with horizontal incisions.

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C-section Procedure-4

• Finally, the surgeon cuts through the amniotic
  sac enclosing the baby. He then allows the
  amniotic fluid to escape.

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C-section Procedure-5
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C-section Procedure-6
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Cesarean Childbirth-Possible Complications

• Excessive bleeding This is the most common
  complication of a cesarean delivery and may be
  caused by intrapartum and/or postpartum bleeding.

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Cesarean Childbirth-Possible Complications

• Infection The risk of infection of the uterus
  is much higher after cesarean delivery than after
  vaginal delivery.
• Infection of the skin incision is much more
  common than infection in the incision made in the
  uterus, although they often occur together.

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Cesarean Childbirth-Possible Complications

• Clots Blood clots can form in the pelvis or
  the leg.
• Therefore, it is imperative that if you deliver
  by cesarean section, you must get up and walk
  within 24 hours after the operation.

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Cesarean Childbirth-Possible Complications

• Urinary function and bladder injury Urinary
  retention after Cesarean due to bladder atony
  could be relieved by urethral catheter for 24
  hours.
• Bladder injury during Cesarean can occur
  inadvertently.

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Cesarean Childbirth-Possible Complications

• Bowel function and bowel injury Typically,
  bowel function after a cesarean section returns
  quickly. Unrecognized bowel injury may occur
  occasionally and should be managed appropriately.

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Cesarean Childbirth-Possible Complications
Cesarean Childbirth-Possible Complications

• Prolonged hospital stay
• When compared with normal vaginal delivery,
  Cesarean delivery requires 5 to 6 days hospital
  stay.

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Cesarean Childbirth-Possible Complications

• Anesthesia pain medications Commonly,
  spinal or epidural anesthesia is administered.
• After surgery, oral and injection drugs can be
  used to help control the pain.

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An evidence based update on the technique of LSCS

• Recommended by WHO Reproductive Health Library as
  Minimally Invasive Method for a commonest
  surgical procedure done Worldwide.

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Cesarean Delivery Ancient Medical History
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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Caesarean Section has been a part of human
  culture since ancient times and there are tales
  in both western and non-western culture of this
  procedure.
• From the time when this procedure resulted in
  100 maternal mortality, it has traveled a long
  distance acquiring many changes in the
  technique, anesthesia, sutures, antibiotics,
  indications that today we can say that maternal
  mortality per se because of LSCS is negligible
  Many modifications were put forward some were
  here to stay, while others just faded away.

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Micheal Stark Director
• Misgav Ladach Hospital, Israel
• a refuge for the oppressed

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Steps Of Cesarean Section
• Abdominal entry
• Joel Cohens incision
• /\
• Midway between umbilicus symphysis
• pubis.
• Separation of recti easy

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Principles
• Behind Joel Cohen incision as well as other
  steps are - the
• approach to handling the muscles blood vessels
  and nerves
• They are treated like the strings on the musical
  instruments, where the more distant you move from
  the insertion, the easier is the lateral
  stretching due to elasticity, and therefore the
  damage is reduced.

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Why ?
• Pfannenstiel incision takes longer to make and
  longer to repair
• Many bleeding vessels have to be controlled
• More difficulty in repeat LSCS
• More adhesions

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Steps Of C - Section
• Skin sub-cutis cut
• Incision in fat only in
• the middle 1 inch
• Cut the rectus sheath
• also in middle 1 inch

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Steps Of C - Section
• Extend the incision on either side with scissors
  like a tailor running a semi opened scissors to
  cut cloth
• This will ensure a cut also the fiber of the
  sheath

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Evidence based Cesarean delivery-Misgav Ladach
TechniqueSteps Of C - Section

• Muscles are separated in the middle peritoneum
  punctured with fingers
• All the three peritoneum, muscle the fat are
  pulled apart to allow adequate opening

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Principles
• Because of the placement of the incision where
  the fascia is not attached and moves freely over
  the muscles, there is no need to separate the
  fascia from the muscles.
• Tissues are separated along connective tissue
  fault lines (Langers lines), thus healing more
  completely and rapidly

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Abdominal Packs are not used
• Doyens retractor to expose lower segment
• Cut the visceral peritoneum about 1-1.5 cms above
  the bladder fold with knife
• Cut the uterus in the middle of the opened space
  in peritoneum with knife
• Stretch the uterine opening as needed
• Deliver the child and placenta
• Exteriorize the uterus

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Start Suturing the edges form near to far
• Non-locking continues stitch
• Additional stitches only if bleeding presents
• Clean Peritoneal cavity of debris

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Rectus sheath is sutured in the form of near-far,
  far-near pattern
• Non-locking continues stitch

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Skin 2-3 stitches deep mattress silk stitches
• Space in between allows draining of secretions

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Quick recovery
• Post operative pain quite less
• Fewer adhesions
• Bladder not a problem in subsequent CS
• Less Blood loss
• Smaller scar with less induration

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Adopting Joel-Cohen techniques of opening the
  abdomen performing manual manipulations,
  minimizing the use of instruments and suturing.

• Concise
• Very simple
• Very speedy

• Results are self evident
• - Misgav Ladach method (Stark 1996)

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Principles -
• Unnecessary steps are simply not done.
• No interruptions are necessary for hemostasis or
  swabbing
• Whole procedure is performed with a continuous
  flow of movement, each step leading naturally to
  the next.

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Time
• More rapid - very short in time
• Theatre time and op. time reduced
• Total op. time 18 to 20 min - 30-50 less

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Other benefits
• Complete healing
• Less short term complications such as
• hemorrhage, 250ml less.
• Febrile morbidity (7.7 vs. 19.8 )
• Post op. adhesions less (6.3 vs. 28)

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Women
• Regained controls and recovered more rapidly
• and were better able to breast feed and care of
  their new born.
• Reduced pain and early ambulation
• Reduced scarring.

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Evidence based Cesarean delivery-Misgav Ladach
Technique
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Evidence based Cesarean delivery-Misgav Ladach
Technique

• COST benefits
• Cost beneficial
• Suture 2.92 3 Vs 4.14 4
• 15 euros less costly (In European countries)

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Technique of CS Issues
• Exteriorization of uterus
• Two layer uterus closure
• Peritoneal suturing
• Routine antibiotics
• Uterotonics/Oxyticics

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Technique of CS Issues
• Regional Vs. General anesthesia
• Indwelling vs. intermittent catheter
• Lateral tilt to operation table
• Manual removal of placenta Deprecated
• Post-operative wound drainage

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Extra abdominal vs. intra abdominal repair of
  uterine incision
• 6 trials 1221 cases of Emergency Elective CS
• Outcome measures Blood loss, Sepsis, Costs,
  Satisfaction etc.
• Marginal drop in febrile morbidity in
  exteriorization group
• Hematocrit drop similar
• Sepsis similar

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Peritoneal Closure
• Authors Conclusion
• There was improved short-term postoperative
  outcome if the peritoneum was not closed
• Long term studies following CS are limited, but
  data form other surgical are reassuring. There is
  at present no evidence to justify the time taken
  and cost of peritoneal closure

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Abdominal Wall Closure
• 6 trials, 1853 cases
• No difference if subcutaneous tissue sutured or
  not ,in terms of infection, hematoma, or serious
  discharge

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Antibiotic prophylaxis for CSSmaill F, Hofmeyer
GJ, From The Cochrane Library , Issue 1, 2006.

• Authors Conclusion
• The reduction of endometritis by 2/3rd to 3
  quarters and a decrease in wound infections
  justifies a policy of recommending prophylactic
  antibiotics to women undergoing elective or
  non-elective CS
• Both Ampicillin 1st generation cephalosporin's
  are similar in reducing postoperative
  endometritis.There is no added benefits in
  utilizing a more brad spectrum agent or a
  multiple dose regimen. There is a need for an
  appropriately designed randomized trial to test
  the optimal timing of administrating (immediately
  after the cord is clamped vs. pre-operative)

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Evidence based Cesarean delivery-Misgav Ladach
Technique

• Lateral tilt for CS
• Chichester, WilkinsinC, Enkin MW
• From The Cochrane Library , Issue 1, 2006.
• Authors Conclusion
• There is not enough evidence from these trials to
  evaluate use of tilt during CS

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Early compared with delayed oral fluids and food
after CS Mangesi L, Hofmeye GJ (From The
Cochrane Library , Issue 1, 2006.)

• Authors Conclusion
• There was no evidence form the limited randomized
  trials reviewed, to justify a policy of
  withholding oral fluids after uncomplicated CS.
  Further research is justified

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Visit www.rhlibrary.com
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FINALLY Surgical technique

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• Why has the rate of cesarean delivery climbed so
  dramatically in the past 25 years?
• Lower tolerance for taking risks
• Fear of malpractice litigation
• Increased use of epidural anesthesia ?
• Increased use of electronic fetal monitoring
• The convenience of physicians

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Who are involved ?
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Who are involved ?
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Published rates

• W.H.O. 1
• 15
• Maximum desirable rate of cesarean section
• No benefit for mother and the fetus for medical
  reasons

1 World Health Organisation. Appropriate
technology for birth. Lancet 19854367.
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Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

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Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

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Cotzias C, Paterson-Brown S, Fisk N. BMJ, 319,31
july 1999
Unexplained fetal deaths
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Could C-S reduce fetal death rate?

• 5 times more frequent than SIDS
• Termination of pregnancy when fetal risks in
  útero are larger than the risks of the newborn
  1/500
• Most of fetal deaths occur in non-malformed
  fetuses

• Cotzias C, et al., BMJ, 319,31 july 1999

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Could C-S reduce fetal death rate?

• 5 times more frequent than SIDS
• Termination of pregnancy when fetal risks in
  útero are larger than the risks of the newborn
  1/500
• Most of fetal deaths occur in non-malformed
  fetuses
• Womens preference C-section of the risk is
• gt 14000 1

• Cotzias C, et al., BMJ, 319,31 july 1999
• 1 Thornton E, et al., J Obstet Gynecol
  19899283-8

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Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

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Effect of Mode of Delivery in Nulliparous Women
on Neonatal Intracranial Injury
Towner D et al., NEJM 199934123

• 1 664 forceps
• 1 860 vacuum extraction
• 1 907 c-section during labor
• 1 1900 delivered spontaneously
• 1 2750 c-section with no labor

Conclusion The common risk factor for hemorrhage
is abnormal labor
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Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

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Frequency of cesarean section, primary cesarean
and vaginal birth post-c-section between 1989 -
2001
VBAC
All c-sections
Primary c-section
Martin JA, et al., National Center for Health
Statistics. 2002
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Recomendations

• The most conservative recomendations.
• ACOG Technical Bulletin. Vaginal delivery after a
  previous cesarean birth.
  
• Int J Gynecol Obstet 48127 129 1995.
• ACOG Vaginal birth after a previous cesarean.
  
• ACOG Practice Bulletin N 51 8 1999.

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VBAC

• Over 1000 reports not one RCT

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VBAC

• Over 1000 reports not one RCT
• Economic forces rather than patient well-being,
  are driving the goal of fewer
  cesarean sections ? 1

1 Clark S., et al., Am J Obstet Gynecol
2000182599-602
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Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

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Costs of deliveries

• Cesarean delivery
• Costs more than a vaginal delivery
• Longer hospital stay
• Use of an operating room.
• Labor unit a prolonged and difficult labor,
  even when it results in a vaginal delivery, is
  more costly to an institution than a cesarean
  delivery.

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Beth Israel Deaconess Medical Center, Boston,
USA
Costs of deliveries

• Elective repeated cesarean delivery 7.700
• Normal vaginal delivery
  6.800
• Intrapartum Cesarean
  10.000

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Beth Israel Deaconess Medical Center, Boston,
USA
Costs of deliveries

• Elective repeated cesarean delivery 7.700
• Normal vaginal delivery
  6.800
• Intrapartum Cesarean
  10.000
• Complication
• Mother 4.000
• Child 2.000

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Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

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Pelvic floor

• Urinary incontinence
• Fecal incontinence
• Sexual dysfunction
• Organ prolapse

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Pelvic floor

• Pudendal nerve damage
• Soft tissue trauma
• The levator musculature trauma
• Anal sphincter trauma

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Pelvic floor

• Pudendal nerve damage
• Soft tissue trauma
• The levator musculature trauma
• Anal sphincter trauma

...neurophysiologic studies have demonstrated
the etiologic role of parturition-related nerve
damage in development of pelvic floor
disfunction...1
1 Davila GW, et al., Int Urogyneocl J
200112289-291
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Reduction of pelvic floor damage

• Minimizing forceps deliveries
• Minimizing episiotomies
• Allowing passive descent in the second stage
• Selectively recomending elective cesarean delivery

Davila GW, et al., Int Urogyneocl J
200112289-291
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Prevention of pelvic floor damage

• Avoid labor
• Avoid passage of the fetus through the pelvis
• Shorten second stage
• Avoid routine episiotomy
• Forget the forceps specially in macrosomia
• Repair perineal damage

Devine II, Contemporary Ob/Gyn 1999119
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Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

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Risk of maternal death

• ...the presumed increased risk of maternal death
  with elective cesarean delivery traditionally has
  been the most compelling reason to reject a
  policy of universal cesarean delivery or
  "cesarean on demand." However, good evidence is
  accumulating that this is no longer true the
  maternal morbidity and mortality from elective
  cesarean delivery at term before the onset of
  labor appear to be similar to those associated
  with vaginal birth....

Hannah ME, Lancet 20003561375-83.
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Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

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Cultural phenomena - Brazil

• All birth are attended by obstetricians
• Training
• Doctors work in the public and private health
  system
• Status of c-section modern and technical
• Womens body are perceived as sexual than
  maternal
• Genitals are perceived for sexual activity than
  for childbearing

Nuttall C., et al., BMJ 20003201072
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Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

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Cesarean section on demand

• 31 of female obstetricians would prefer a
  cesarean delivery for themselves 1
• World wide debate continues on role of Cesarian
  Delivery on Maternal RequestCDMR.

1 Al-Muffti et al. Eur J Obstet Gynecol Reprod
Biol 1997731-4
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Cesarean section on demand

• 31 of female obstetricians would prefer a
  cesarean delivery for themselves 1
• Italian law mandates that women be given the
  option of an elective cesarean, and about 4 of
  pregnant women choose it. 2

1 Al-Muffti et al. Eur J Obstet Gynecol Reprod
Biol 1997731-4 2 Tranquilli AL, et al., Am J
Obstet Gynecol 1997177245-246
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Autonomy

• Is the governing principle in medicine
• We respect with better eyes a womans right to
  refuse a cesarean delivery
• Nobody is interested in respecting womans desire
  to refuse vaginal delivery

Wagner M et al., Lancet 20003561677-80
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Autonomy and informed consent

• ...performing cesarean section for non medical
  reasons is ethically not justified....

Committee for the Ethical Aspects of Human
Reproduction and Womens Health of FIGO (1999)
101
Conclusion

• ...perhaps the time has come when the risks,
  benefits and costs are so balanced between
  cesarean section and vaginal delivery that the
  deciding factor should simply be the mothers
  preference for how her baby is to be delivered...

William Benson Harer
102
Dr.Malleswar Rao Kasina, expresses
Thanks you for your Attention !
E-mail kasinamrao_at_gmail.com