Casarean section

procedure: Steps
and techniques
S ANJANA SOMASUNDAR
65
DEFINITION of Casarean
section :
It is an operative procedure whereby the fetuses after the end of
28th weeks are delivered through an incision on the :
1. abdominal walls (laparotomy)and
2. uterine walls (hysterotomy)

excludes delivery through an abdominal incision where the fetus, lying free in the
abdominal cavity following uterine rupture or in secondary abdominal pregnancy.

LAPAROTOMY
 (NICE) NATIONAL INSTITUTE OF HEALTH CARE AND EXCELLENCE : For
classification of urgency for caesarean birth
CATEG Decision-to-birth Inference EXAMPLES
ORIES interval

1 within 30 minutes Immediate threat to the life Acute fetal distress/ fetal bradycardia ( < 80 bpm ),cord prolapse
of making the of the woman or fetus with bradycardia, severe placenta abruption, APH with maternal
decision. hypovolemia, suspected uterine rupture & scar dehiscence, failed
(EMERGENCY) instrumental delivery with fetal distress.

2 within 75 minutes Maternal or fetal Cord prolapse with normal fetal HR, Malposition in labour, APH
of making the compromise which is not without hypovolemia, Failed IOL
decision immediatelylife-threatening.
( URGENT )

3 SCHEDULED No maternal or fetal Early labour in a woman scheduled for and elective C section, large
compromise but needs early for gestational age, breech presentation,
birth ( SCHEDULED )

4 ELECTIVE Birth timed to suit woman Previously dectected Malpresentaions, multiple pregnancy ( first
and healthcare provider fetus not cephalic presentation ) , LSCS on demand.
( ELECTIVE )
PREOPERATIVE PREPARATION
Informed written consent for procedure, anesthesia and
blood transfusion to be obtained.

Blood group determination for blood transfusion to be

done. Other investigations for comorbidities

Foley’s catherization to empty bladder to reduce risk of

injury
PREOPERATIVE PREPARATION
Antacid :
• Nonparticulate antacid (0.3 molar sodium citrate, 30 mL) is given orally
before transferring the patient to theater. 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
PREOPERATIVE PREPARATION
Metoclopramide (10 mg IV): 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 preoxygenation in the theater.
Above done due to Aspiration pneumonitis , GERD ,
decreased GI motility
Prophylactic antibiotics should be given (IV) : given 1 hr before
incision 2 g cefazolin ( if allergic clindamycin with gentamycin ) ;
repeat dose when duration is more than 3 hrs or blood loss more
than 1.5 L
PREOPERATIVE PREPARATION
IV cannula: Sited to administer fluids (Ringer’s solution, 5%
dextrose).
 Position of the patient : 15 degree left lateral tilt – to minimize
compression of IVC due to the weight of fetus on it.
 Anesthesia— usually regional ( spinal or epidural ) but rarely
General.
Antiseptic painting: The abdomen is painted with 7.5% povidone-
iodine solution or savlon lotion and to be properly draped with
sterile towels.
Steps
1. Laparotomy
2. Hysterotomy The optimum interval between uterine
incision and delivery should be less than
3. Delivery of the head 90 seconds.
4. Delivery of the trunk:
Interval > 90 seconds are associated with
5. Removal of the placenta and membranes:
poor Apgar scores.
6. Suture of the uterine wound
7. Peritoneal lavage There is reflex uterine vasoconstriction
following uterine incision and
8. Closure of abdominal wall manipulation.
9. Vaginal disinfection
Technique ; Laparotomy :
1. First, the skin is incised,
2. followed by the subcutaneous
tissues.
3. The next layer is the fascia overlying
the rectus abdominis muscles.
4. After separating the rectus muscles
the surgeon enters the abdominal
cavity through the parietal
peritoneum.
Laparotomy :
Abdominal incisions
A. Pfannenstiel incision should be made in a
curvilinear fashion approximately 2–3 cm above
the pubic symphysis. ( 10 – 15 cm length)
B. Joel-Cohen incision should be made in a linear
fashion approximately 2–3 cm above the
traditional placement of the Pfannenstiel
incision.
C. Midline vertical incision should be made in the
midline and extend from just below the umbilicus
to just above the symphysis pubis and may be
continued around the umbilicus if more exposure
is necessary.
 Technique : Packing
The Doyen’s retractor (Fig. 42.14) is introduced. The peritoneal cavity is now packed off using
two taped large swabs. The tape ends are attached to artery forceps. This will minimize spilling
of the uterine contents into the general peritoneal cavity.
Technique : Hysterotomy ;
Peritoneal incision
Small incision or cut
Cut as high as possible
The loose peritoneum of the uterovesical pouch is cut transversely
across the lower segment with convexity downwards at about 1.25 cm
(0.5”) below its firm attachment to the uterus.
The lower flap of the peritoneum is pushed down a little.
This exposes the lower uterine segment
Steps of LSCS:
(A) The loose
peritoneum on the
lower segment is
cut transversely
(B) A short incision
is made in the
midline down to
the membranes
(C) The incision of
the lower segment
is being enlarged
using index finger
of both hands
Technique : Hysterotomy ;
Muscle incision
A. Low-transverse uterine incision should be made through the
thin, noncontractile portion of the lower uterine segment in a
curvilinear fashion.

B. low-vertical incision, which is made through the

noncontractile lower uterine segment in a vertical fashion.
TYPES OF C SECTION BASED ON
Uterine INCISION
Technique : Hysterotomy ;
Muscle incision
C. J-extension of the low-transverse incision.
the low-transverse incision can be extended laterally and
cephalad to increase the length of the incision
D. Another option in this situation is to use a T-extension in the
midline.
E. The classical uterine incision is made through the contractile
portion of the myometrium above the bladder reflection.
Technique : Delivery of the
head:
The membranes are ruptured if insinuated between the lower
still intact. uterine flap and the head until the
The blood mixed amniotic fluid is palm is placed below the head.
sucked out by continuous suction. The head is delivered by elevation
The Doyen’s retractor is removed. and flexion using the palm to act as
a fulcrum.
The head is delivered by hooking
the head with the fingers which As the head is drawn to the incision
are carefully line, the assistant is to apply
pressure on the fundus.
Steps of LSCS contd:
(D) Sagittal section showing
insinuation of the fingers
between the lower uterine flap
and the fetal head until the
posterior surface is reached

(E) Methods of delivery of the

head

(F) Placenta is being

delivered
Technique : Delivery of the
head:
If the head is jammed, an The head can also be delivered using either Wrigley’s
(SHORT CURVED OBSTETRIC FORCEPS) or Barton’s
assistant may push up the head forceps
by sterile gloved fingers
introduced into the vagina.
 Technique : Delivery of the
trunk:
As soon as the head is delivered, the mucus from the mouth, pharynx and
nostrils is sucked out using rubber catheter attached to an electric sucker.
After the delivery of the shoulders, intravenous oxytocin 20 units or
methergine 0.2 mg is to be administered.
The rest of the body is delivered slowly and the baby is placed in a tray placed
in between the mother’s thighs with the head tilted down for gravitational
drainage.
The cord is cut in between two clamps and the baby is handed over to the
pediatrician.
The Doyen’s retractor is reintroduced.
 Technique : Removal of the
placenta and membranes
By this time, the placenta is separated Advantages of spontaneous placental
spontaneously. separation are: less blood loss and less
The placenta is extracted by traction risk of endometritis.
on the cord with simultaneous The membranes are carefully removed
pushing of the uterus towards the preferably intact and even a small
umbilicus per abdomen using the left piece, if attached to the decidua should
hand (controlled cord traction). be removed using a dry gauze.
Routine manual removal should not Dilatation of the internal os is not
be done. required.
Exploration of the uterine cavity is
desirable.
 Technique : Suture of the
uterine wound; For two-layer
closure
1. the first layer includes the deep myometrial edge with minimal decidua. A
continuous locking technique is hemostatic and equally distributes the
tension, making the suture less likely to cut through (especially useful with
friable or thin lower segments).
2. The second layer completes the myometrial approximation and hemostasis.
It effectively buries the first layer but this cosmetic effect is not its purpose
which is to maintain the scar integrity and prevent future deficiency.
( Similar method of continuous suture taking
superficial muscles and fascia down to the first
layer of suture )
( Inserting the continuous catgut (No. ‘0’) suture
taking deeper muscles excluding the decidua )
Concluding part: for LSCS
Ensure homeostasis, the blood clots are removed meticulously
Peritoneal toileting is done,
The mops placed inside are removed and the number verified.
 The tubes and ovaries are examined.
Doyen’s retractor is removed.
After being satisfied that the uterus is well contracted, the
abdomen is closed in layers.
 The vagina is cleansed of blood clots and a sterile vulval pad is
placed.
CLASSICAL CESAREAN
SECTION
Abdominal incision is always longitudinal (paramedian) and
about 15 cm (6") in length, 1/3rd of which extends above the
umbilicus.
A longitudinal incision of about 12.5 cm (5") is made on the
midline of the anterior wall of the uterus starting from below
the fundus.
The incision is deepened along its entire length until the
membranes are exposed which are punctured.
 CLASSICAL CESAREAN
SECTION
In about 40% cases, the placenta is encountered.
In such cases, fingers are slipped between the placenta and the uterine
wall until the membranes are reached.
The baby is delivered commonly as breech extraction.
Intravenous oxytocin 5 IU IV (slow) or methergine 0.2 mg is
administered following delivery of the baby. The uterus is eventrated.
The placenta is extracted by traction on the cord or removed manually.
POSTOPERATIVE CARE : First 24
hours: (Day 0)
Observation for the first 6–8 hours is important. Periodic
checkup of pulse, BP, amount of vaginal bleeding and behavior of
the uterus (in low transverse incision) is done and recorded.
 Fluid: Sodium chloride (0.9%) or Ringer’s lactate drip is
continued until at least 2.0–2.5 L of the solutions are infused.
Blood transfusion is helpful in anemic mothers for a speedy post-
operative recovery. Blood transfusion is required if the blood loss
is more than average during the operation (average blood loss in
cesarean section is approximately 0.5–1.0 L)
POSTOPERATIVE CARE : First 24
hours: (Day 0)
Oxytocics: Injection oxytocin 5 units IM or IV (slow) or
methergine 0.2 mg IM is given and maybe repeated.
 Prophylactic antibiotics (cephalosporins,
metronidazole) for all cesarean delivery (see p. 726) is
given for 2–4 doses. Therapeutic antibiotic is given when
indicated.
Analgesics in the form of pethidine hydrochloride 75–
100 mg is administered and may have to be repeated.
POSTOPERATIVE CARE : First 24
hours: (Day 0)
Ambulation: The patient can sit on the bed or even get out
of bed to evacuate the bladder, provided the general
condition permits. She is encouraged to move her legs and
ankles and to breathe deeply to minimize leg vein
thrombosis and pulmonary embolism.
Baby is put to the breast for feeding after 3–4 hours when
mother is stable and relieved of pain.
POSTOPERATIVE CARE : > 24
HRS
Day 1: Oral feeding in the form of plain or electrolyte water or raw
tea may be given. Active bowel sounds are observed by the end of
the day.
Day 2:
Light solid diet of the patient’s choice is given.
Bowel care: 3–4 teaspoons of lactulose is given at bed time, if the
bowels do not move spontaneously.
POSTOPERATIVE CARE : > 24
HRS
Day 5 or day 6: The abdominal skin stitches are to be
removed on the D-5 (in transverse) or D-6 (in longitudinal).
Discharge: The patient is discharged on the day following
removal of the stitches, if otherwise fit. Usual advices like
those following vaginal delivery are given. Depending on
postoperative recovery and availability of care at home,
patient may be discharged as early as third to as late as
seventh postoperative days.
REFERENCES
 DC-duttas-textbook-of-obstetrics 9TH EDITION
 Recommendations _ Caesarean birth _ Guidance _ NICE
 Caesarean section_ step by step – O&G Magazine
 Cesarean Birth: Surgical Techniques | GLOWM
 Cesarean Section - StatPearls - NCBI Bookshelf
THANKS