Module on “Caesarean section (Part-1)” by Dr. Vishwesh BN

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. When the operation is performed in subsequent pregnancies, it is called repeat cesarean section.

Nomenclature and history:

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 lex regia—king’s rule or law—later became the lex caesarea under the emperors, and the operation itself became known as the caesarean operation. The German term Kaiserschnitt—Kaiser cut—reflects this derivation.

One more explanation is that the word caesarean was derived sometime in the Middle Age from the Latin verb caedere, to cut. This explanation seems most logical, but exactly when it was first applied to the operation is uncertain. Because section is derived from the Latin verb seco, which also means cut, the term caesarean section seems tautological—thus cesarean delivery 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.

Reasons for increase in the rate of Cesarean delivery:

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 nulliparas, who are at increased risk for cesarean delivery. The average maternal age is rising, and older women, especially nulliparas, are at increased risk of cesarean delivery. The use of electronic fetal monitoring 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 “fetal distress” comprises only a minority of all such procedures, in many more cases concern for an abnormal, or “nonreassuring,” fetal heart rate tracing lowers the threshold for cesarean deliveries performed for abnormal progress of labor. The vast majority of fetuses presenting as breech are now delivered by cesarean. The incidence of midpelvic forceps and vacuum deliveries has decreased. Rates of labor induction continue to rise, and induced labor, especially among nulliparas, increases the risk of cesarean delivery. The prevalence of obesity 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.

Indications:

The indications of vaginal delivery can be of two types- absolute and relative.

1. Absolute indication 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.
2. Relative indication: vaginal delivery may be possible, but risks to the mother and baby are high. Certain conditions included under this category are – 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’s syndrome, history of vesico-vaginal fistula etc are some more relative indications of cesarean delivery.

Preoperative Preparation

Informed written permission for the procedure, anaesthesia and blood transfusion is obtained.  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 neutralize 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) 1 hour before the surgery to raise the gastric pH. The stomach should be emptied, if necessary by a stomach tube (emergency procedure).  Metoclopramide  (10  mg  IV)  is  given  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.„  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’s solution, 5% dextrose). Anaesthesia—may be spinal, epidural or general. However, choice of the patient and urgency of delivery are also considered.

Instruments needed for the surgery:

The following are the instruments needed for the surgery:

Other materials required:

• Diathermy cautery
• Cord clamp(klik clamp)
• Suction apparatus with tube, nozzle.
• Kidney tray
• Antiseptic solution
• Sterile gloves
• Sterile drapes
• Normal saline
• Abdominal pads
• Gauge swabs.
• Chromic catgut 2, 1, 1-0 used to suture Uterus, Peritoneum
• Cotton thread/silk- used to suture Skin
• Polypropylene 1-0, 2-0 – used to suture Rectus sheath
• Polyglactin , 1, 1-0, 2-0 – used to suture Rectus sheath
• Abdominal drain
• Cord clamp (klik clamp)
• Ergometrine
• Oxytocin
• Prostaglandins
• Heamostatics
• Drugs of Anaesthesia .

Short questions on LSCS- Part I:

1. How do you define a Cesarean delivery?

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.

2. What is the difference between a primary cesarean section and a repeat cesarean section?

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.

3. What do you mean by an absolute indication and a relative indication for a cesarean section?

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  and so LSCS is opted.

4. Discuss the role of antacids in the preoperative procedure of a cesarean section?

Nonparticulate antacid (0.3 molar sodium citrate, 30 mL)  is  given  orally  before transferring the patient to theatre. It is given to neutralize 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) 1 hour before the surgery to raise the gastric pH.

5. Why is Metoclopramide given  during the preoperative procedure of a cesarean section?

Metoclopramide  (10  mg  IV)  is  given  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.

6. When is the Prophylactic antibiotics given during the cesarean section?

Prophylactic antibiotics should be given (IV) before 1 hour making the skin incision, during the preoperative procedure of a cesarean section

7. Which is the commonest method of anaesthesia followed in a Cesarean delivery?

The commonest method of anaesthesia followed in India for a Cesarean delivery may be spinal, followed by general and then by epidural anaesthesia.

8. Name some Absolute indications of a Cesarean delivery.

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.

9. Name some Relative indication of a Cesarean delivery.

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’s syndrome, history of vesico-vaginal fistula etc are some more relative indications of cesarean delivery.

10. Name some important instruments needed for a Cesarean delivery.

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.

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