{"id":2132,"date":"2020-08-06T13:31:26","date_gmt":"2020-08-06T13:31:26","guid":{"rendered":"https:\/\/ayurvedanetworkbhu.com\/?p=2132"},"modified":"2022-02-22T06:12:38","modified_gmt":"2022-02-22T06:12:38","slug":"lecture-on-caesarean-section-part-1-by-dr-vishwesh-bn","status":"publish","type":"post","link":"https:\/\/ayurvedanetworkbhu.com\/?p=2132","title":{"rendered":"Module on &#8220;Caesarean section (Part-1)&#8221; by Dr. Vishwesh BN"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/orl2rwZg5bI\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p style=\"text-align: center;\"><strong>CAESAREAN DELIVERY-(Part-I)<\/strong><\/p>\n<p style=\"text-align: justify;\"><strong>Definition, indication, preoperative procedures and instruments required:<\/strong><\/p>\n<p style=\"text-align: justify;\"><strong>Definition:<\/strong> It is an operative procedure whereby the foetuses after the end of 28th weeks are delivered through an incision on the abdominal and uterine walls. The first operation performed on a patient is referred to as a primary cesarean section. When the operation is performed in subsequent pregnancies, it is called repeat cesarean section.<\/p>\n<p style=\"text-align: justify;\"><strong>Nomenclature and history: <\/strong><\/p>\n<p style=\"text-align: justify;\">Amidst controversy, it appears that the operation derives its name from a Roman law, supposedly created in the 8th century BC by Numa Pompilius, ordering that the procedure be performed upon women dying in the last few weeks of pregnancy in the hope of saving the child. This <em>lex regia<\/em>\u2014king&#8217;s rule or law\u2014later became the <em>lex caesarea<\/em> under the emperors, and the operation itself became known as the caesarean operation. The German term <em>Kaiserschnitt<\/em>\u2014Kaiser cut\u2014reflects this derivation.<\/p>\n<p style=\"text-align: justify;\">One more explanation is that the word <em>caesarean<\/em> was derived sometime in the Middle Age from the Latin verb <em>caedere, to cut.<\/em> This explanation seems most logical, but exactly when it was first applied to the operation is uncertain. Because <em>section<\/em> is derived from the Latin verb <em>seco,<\/em> which also means <em>cut,<\/em> the term <em>caesarean section<\/em> seems tautological\u2014thus <em>cesarean delivery<\/em> is used. French obstetrician, Francois Mauriceau first reported cesarean section in 1668. In 1876, Porro performed subtotal hysterectomy. It was Max Sanger in 1882, who first sutured the uterine walls. In 1907, Frank described the extraperitoneal operation. Kronig in 1912, introduced lower segment vertical incision and it was popularized by De Lee (1922). Although Kehrer in 1881 did the transverse lower segment operation for the first time, Munro Kerr in 1926 not only reintroduced the present technique of lower segment operation but also popularized it.<\/p>\n<p style=\"text-align: justify;\"><strong>Reasons for increase in the rate of Cesarean delivery:<\/strong><\/p>\n<p style=\"text-align: justify;\">Cesarean delivery has played a major role in lowering both maternal and perinatal morbidity and mortality rates during the past century. The initial purpose of the operation was to preserve the life of the mother with obstructed labor, but indications expanded over the years to include delivery for a variety of more subtle dangers to the mother or fetus. Contributing to its more frequent use is increased safety that is largely due to better surgical technique, improved anaesthesia, effective antibiotics, and availability of blood transfusions. Women are having fewer children, thus, a greater percentage of births are among <em>nulliparas,<\/em> who are at increased risk for cesarean delivery. The average <em>maternal age<\/em> is rising, and older women, especially nulliparas, are at increased risk of cesarean delivery. The use of <em>electronic fetal monitoring<\/em> is widespread. This technique is associated with an increased cesarean delivery rate compared with intermittent fetal heart rate auscultation. Although cesarean delivery performed primarily for &#8220;fetal distress&#8221; comprises only a minority of all such procedures, in many more cases concern for an abnormal, or &#8220;nonreassuring,&#8221; fetal heart rate tracing lowers the threshold for cesarean deliveries performed for abnormal progress of labor. The vast majority of fetuses presenting as <em>breech<\/em> are now delivered by cesarean. The incidence of <em>midpelvic forceps and vacuum deliveries<\/em> has decreased. Rates of <em>labor induction<\/em> continue to rise, and induced labor, especially among nulliparas, increases the risk of cesarean delivery. The prevalence of <em>obesity<\/em> has risen dramatically, and obesity also increases the risk of cesarean delivery. Some elective cesarean deliveries are now performed due to concern over pelvic floor injury associated with vaginal birth. Facing increasing medicolegal pressures, obstetricians gradually abandoned most vaginal breech and forceps deliveries, broadened the definition of intrapartum fetal distress, and liberalized the diagnosis of dystocia. This escalation in cesareans also increased during the past decade as enthusiasm for vaginal birth after cesarean (VBAC) waned and was replaced by the more frequent use of repeat cesarean. Finally, a recent trend toward primary elective cesarean delivery requested by the mother has now become a reality in many areas of the world.<\/p>\n<p style=\"text-align: justify;\"><strong>Indications:<\/strong><\/p>\n<p style=\"text-align: justify;\">The indications of vaginal delivery can be of two types- absolute and relative.<\/p>\n<ol style=\"text-align: justify;\">\n<li><strong>Absolute indication<\/strong> is when there is no possibility of vaginal delivery and cesarean delivery is compulsory, even if the foetus is dead. A few indications which are absolute include: Central Placenta previa, contracted pelvis or cephalo-pelvic disproportion, pelvic mass such as cervical or broad ligament fibroid causing obstruction, advanced cervical cancer, vaginal obstruction due to conditions like atresia, stenosis etc.<\/li>\n<li><strong>Relative indication<\/strong>: vaginal delivery may be possible, but risks to the mother and baby are high. Certain conditions included under this category are &#8211; cephalo-pelvic disproportion, previous cesarean delivery, non reassuring FHR, dystocia due to relatively large foetus, small pelvis or inefficient uterine contraction. Antepartum haemorrhage due to conditions like placenta previa and abruption placenta, malpresentations like breech, shoulder, brow etc, failure in the progress of labour, bad obstetric history with recurrent foetal loss, hypertensive disorders like eclampsia ad preeclampsia or some gynaecological disorders like uncontrolled diabetes, heart diseases, Marfan\u2019s syndrome, history of vesico-vaginal fistula etc are some more relative indications of cesarean delivery.<\/li>\n<\/ol>\n<p style=\"text-align: justify;\"><strong>Preoperative Preparation<\/strong><\/p>\n<p style=\"text-align: justify;\">Informed written permission for the procedure, anaesthesia and blood transfusion is obtained.\u00a0 Premedicative sedative must not be given. Non particulate antacid (0.3 molar sodium citrate, 30 mL)\u00a0 is\u00a0 given\u00a0 orally\u00a0 before transferring the patient to theatre. It is given to neutralize the existing gastric acid.\u00a0 Ranitidine (H2 blocker) 150 mg is given orally night before (elective procedure) and it is repeated (50 mg IM or IV) 1 hour before the surgery to raise the gastric pH. The stomach should be emptied, if necessary by a stomach tube (emergency procedure).\u00a0 Metoclopramide\u00a0 (10\u00a0 mg\u00a0 IV)\u00a0 is\u00a0 given\u00a0 to increase the tone of the lower oesophageal sphincter as well as to reduce the stomach contents. It is administered after about 3 minutes of pre oxygenation in the theatre. Bladder should be emptied by a Foley catheter which is kept in place in the peri operative period. FHS should be checked once more at this stage.\u0084\u00a0 Neonatologist should be made available. Cross match blood when above average blood loss (placenta previa, prior multiple cesarean delivery) is anticipated. Prophylactic antibiotics should be given (IV) before making the skin incision. IV cannula is sited to administer fluids (Ringer\u2019s solution, 5% dextrose). Anaesthesia\u2014may be spinal, epidural or general. However, choice of the patient and urgency of delivery are also considered.<\/p>\n<p style=\"text-align: justify;\">Instruments needed for the surgery:<\/p>\n<p style=\"text-align: justify;\">The following are the instruments needed for the surgery:<\/p>\n<table>\n<tbody>\n<tr>\n<td width=\"73\"><strong>S.No<\/strong><\/td>\n<td width=\"189\"><strong>Instrument name<\/strong><\/td>\n<td width=\"246\"><strong>Instrument<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"73\">1.<\/td>\n<td width=\"189\">Sponge holder-2<\/td>\n<td width=\"246\"><\/td>\n<\/tr>\n<tr>\n<td width=\"73\">2.<\/td>\n<td width=\"189\">Towel clip-6<\/td>\n<td width=\"246\"><\/td>\n<\/tr>\n<tr>\n<td width=\"73\">3.<\/td>\n<td width=\"189\">Knife handle (scalpal),<\/td>\n<td width=\"246\"><\/td>\n<\/tr>\n<tr>\n<td width=\"73\">4.<\/td>\n<td width=\"189\">Blades 22\/23\/24 no.<\/td>\n<td width=\"246\"><\/td>\n<\/tr>\n<tr>\n<td width=\"73\">5.<\/td>\n<td width=\"189\">Toothed dissecting forcep-2<\/td>\n<td width=\"246\"><\/td>\n<\/tr>\n<tr>\n<td width=\"73\">6.<\/td>\n<td width=\"189\">Non toothed dissecting forcep-1<\/td>\n<td width=\"246\"><\/td>\n<\/tr>\n<tr>\n<td width=\"73\">7.<\/td>\n<td width=\"189\">Curved Artery forcep-6<\/td>\n<td width=\"246\"><\/td>\n<\/tr>\n<tr>\n<td width=\"73\">8.<\/td>\n<td width=\"189\">Straight scissor<\/td>\n<td width=\"246\"><\/td>\n<\/tr>\n<tr>\n<td width=\"73\">9.<\/td>\n<td width=\"189\">Mayo scissor<\/td>\n<td width=\"246\"><\/td>\n<\/tr>\n<tr>\n<td width=\"73\">10.<\/td>\n<td width=\"189\">Allis forcep<\/td>\n<td width=\"246\"><\/td>\n<\/tr>\n<tr>\n<td width=\"73\">11.<\/td>\n<td width=\"189\">Needle holder<\/td>\n<td width=\"246\"><\/td>\n<\/tr>\n<tr>\n<td width=\"73\">12.<\/td>\n<td width=\"189\">Green armytage forceps<\/td>\n<td width=\"246\"><\/td>\n<\/tr>\n<tr>\n<td width=\"73\">13.<\/td>\n<td width=\"189\">Babcock forceps<\/td>\n<td width=\"246\"><\/td>\n<\/tr>\n<tr>\n<td width=\"73\">14.<\/td>\n<td width=\"189\">Doyen retractor<\/td>\n<td width=\"246\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<p><strong>Other materials required:<\/strong><\/p>\n<ul>\n<li>Diathermy cautery<\/li>\n<li>Cord clamp(klik clamp)<\/li>\n<li>Suction apparatus with tube, nozzle.<\/li>\n<li>Kidney tray<\/li>\n<li>Antiseptic solution<\/li>\n<li>Sterile gloves<\/li>\n<li>Sterile drapes<\/li>\n<li>Normal saline<\/li>\n<li>Abdominal pads<\/li>\n<li>Gauge swabs.<\/li>\n<li>Chromic catgut 2, 1, 1-0 used to suture Uterus, Peritoneum<\/li>\n<li>Cotton thread\/silk- used to suture Skin<\/li>\n<li>Polypropylene 1-0, 2-0 \u2013 used to suture Rectus sheath<\/li>\n<li>Polyglactin , 1, 1-0, 2-0 \u2013 used to suture Rectus sheath<\/li>\n<li>Abdominal drain<\/li>\n<li>Cord clamp (klik clamp)<\/li>\n<li>Ergometrine<\/li>\n<li>Oxytocin<\/li>\n<li>Prostaglandins<\/li>\n<li>Heamostatics<\/li>\n<li>Drugs of Anaesthesia .<\/li>\n<\/ul>\n<p>Short questions on LSCS- Part I:<\/p>\n<ol>\n<li style=\"text-align: justify;\"><strong>How do you define a Cesarean delivery?<\/strong><\/li>\n<\/ol>\n<p style=\"text-align: justify;\">It is an operative procedure whereby the foetuses after the end of 28th weeks are\u00a0delivered through an incision on the abdominal and uterine walls.<\/p>\n<ol style=\"text-align: justify;\" start=\"2\">\n<li><strong>What is the difference between a primary cesarean section and a repeat cesarean section?<\/strong><\/li>\n<\/ol>\n<p style=\"text-align: justify;\">The first operation performed on a patient is referred to as a primary cesarean section. When the operation is performed in subsequent pregnancies, it is called repeat cesarean section.<\/p>\n<ol style=\"text-align: justify;\" start=\"3\">\n<li><strong>What do you mean by an absolute indication and a relative indication for a cesarean section?<\/strong><\/li>\n<\/ol>\n<p style=\"text-align: justify;\">Absolute indication is when there is no possibility of vaginal delivery and cesarean delivery is compulsory, even if the foetus is dead. Relative indication is when a vaginal delivery may be possible, but risks to the mother and baby are high\u00a0 and so LSCS is opted.<\/p>\n<ol style=\"text-align: justify;\" start=\"4\">\n<li><strong>Discuss the role of antacids in the preoperative procedure of a cesarean section?<\/strong><\/li>\n<\/ol>\n<p style=\"text-align: justify;\">Nonparticulate antacid (0.3 molar sodium citrate, 30 mL)\u00a0 is\u00a0 given\u00a0 orally\u00a0 before transferring the patient to theatre. It is given to neutralize the existing gastric acid.\u00a0 Ranitidine (H2 blocker) 150 mg is given orally night before (elective procedure) and it is repeated (50 mg IM or IV) 1 hour before the surgery to raise the gastric pH.<\/p>\n<ol style=\"text-align: justify;\" start=\"5\">\n<li><strong>Why is Metoclopramide given\u00a0 during the preoperative procedure of a cesarean section?<\/strong><\/li>\n<\/ol>\n<p style=\"text-align: justify;\">Metoclopramide\u00a0 (10\u00a0 mg\u00a0 IV)\u00a0 is\u00a0 given\u00a0 to increase the tone of the lower esophageal sphincter as well as to reduce the stomach contents. It is administered after about 3 minutes of pre oxygenation in the OT.<\/p>\n<ol style=\"text-align: justify;\" start=\"6\">\n<li><strong>When is the Prophylactic antibiotics given during the cesarean section?<\/strong><\/li>\n<\/ol>\n<p style=\"text-align: justify;\">Prophylactic antibiotics should be given (IV) before 1 hour making the skin incision, during the preoperative procedure of a cesarean section<\/p>\n<ol style=\"text-align: justify;\" start=\"7\">\n<li><strong>Which is the commonest method of anaesthesia followed in a Cesarean delivery?<\/strong><\/li>\n<\/ol>\n<p style=\"text-align: justify;\">The commonest method of anaesthesia followed in India for a Cesarean delivery may be spinal, followed by general and then by epidural anaesthesia.<\/p>\n<ol style=\"text-align: justify;\" start=\"8\">\n<li><strong>Name some Absolute indications of a Cesarean delivery.<\/strong><\/li>\n<\/ol>\n<p style=\"text-align: justify;\">Central Placenta previa, contracted pelvis or cephalo-pelvic disproportion, pelvic mass such as cervical or broad ligament fibroid causing obstruction, advanced cervical cancer, vaginal obstruction due to conditions like atresia, stenosis etc are some Absolute indications of a Cesarean delivery.<\/p>\n<ol style=\"text-align: justify;\" start=\"9\">\n<li><strong>Name some <\/strong><strong>Relative indication <\/strong><strong>of a Cesarean delivery.<\/strong><\/li>\n<\/ol>\n<p style=\"text-align: justify;\">Cephalo-pelvic disproportion, previous cesarean delivery, non reassuring FHR, dystocia due to relatively large foetus, small pelvis or inefficient uterine contraction. Antepartum haemorrhage due to conditions like placenta previa and abruption placenta, malpresentations like breech, shoulder, brow etc, failure in the progress of labour, bad obstetric history with recurrent foetal loss, hypertensive disorders like eclampsia ad preeclampsia or some gynaecological disorders like uncontrolled diabetes, heart diseases, Marfan\u2019s syndrome, history of vesico-vaginal fistula etc are some more relative indications of cesarean delivery.<\/p>\n<ol style=\"text-align: justify;\" start=\"10\">\n<li><strong>Name some important instruments needed for a Cesarean delivery.<\/strong><\/li>\n<\/ol>\n<p style=\"text-align: justify;\">Some important instruments needed for a Cesarean delivery include- Sponge holder, Towel clip, toothed and Non toothed dissecting forceps, Curved Artery forcep, scissors, Allis forcep, Needle holder, Green armytage forceps, Babcock forceps, Doyen retractor etc.<\/p>\n<p><strong>References:<\/strong><\/p>\n<ol>\n<li style=\"text-align: justify;\">Cecilia Bottomley and Janice Rymer. 100 cases in Obstetrics and Gynaecology. 2<sup>nd<\/sup> Series editor: Janice Rymer. CRC Press: Taylor &amp; Francis Group; 2015.<\/li>\n<li style=\"text-align: justify;\">Andrew T. Raftery, Michael S. Delbridge, Marcus J.D. Wagstaff and Katherine I. Bridge, Editors: Churchill\u2019s Pocketbooks Surgery. 5<sup>th<\/sup> Elsevier; 2017<\/li>\n<li style=\"text-align: justify;\">Hiralal Konar Editor: Textbook of DC Dutta\u2019s obstetrics. 8<sup>th<\/sup> New Delhi: Jaypee Brothers Medical Publishers; 2015.<\/li>\n<li style=\"text-align: justify;\">Hiralal Konar Editor: Dutta\u2019s Bedside Clinics and Viva-Voce in Obstetrics and Gynecology. Sixth Edition. New Delhi: Jaypee Brothers Medical Publishers; 2016.<\/li>\n<li style=\"text-align: justify;\">Sakshi Arora. Pre Neet Obstetrics and Gynaecology. First Edition. New Delhi: Jaypee \u00a0Brothers Medical Publishers; 2013.<\/li>\n<li style=\"text-align: justify;\">Narendra Malhotra, Pratap Kumar, Jaideep Malhotra, Neharika Malhotra Bora and Parul Mittal M. Revised and updated. Jeffcoate\u2019s Principles Of Gynaecology. Eighth Edition New Delhi: Jaypee Brothers Medical Publishers; 2014.<\/li>\n<li style=\"text-align: justify;\">Ronald D. Miller. Editor. Miller\u2019s Anesthesia. Eighth edition. Elsevier; 2015<\/li>\n<li style=\"text-align: justify;\">Sarala Gopalan, S.Rathnakumar and Vanita Jain editors. Mudaliar and Menons Clinical Obstetrics. 7<sup>th<\/sup> Revised Edition. Orient Longman, Bombay.<\/li>\n<li style=\"text-align: justify;\">Cunningham, Leveno, Bloom, Spong, Dashe, Hoffman, Casey, Sheffield. Williams Obstetrics. 24<sup>th<\/sup> McGraw Hill Education; 2014.<\/li>\n<li style=\"text-align: justify;\">Keith Edmonds. Editor .Dewhurst\u2019s Textbook of Obstetrics &amp; Gynaecology. Seventh edition, Blackwell Publishing; 2007.<\/li>\n<li style=\"text-align: justify;\">Textbook of Obstetrics. DC Dutta . Jaypee Brothers Medical Publishers (P) Ltd. 8<sup>th<\/sup> edition 2016.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>CAESAREAN DELIVERY-(Part-I) Definition, indication, preoperative procedures and instruments required: Definition: It is an operative procedure whereby the foetuses after the end of 28th weeks are delivered through an incision on the abdominal and uterine walls. The first operation performed on a patient is referred to as a primary cesarean section. 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