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Cesarean section

Background

Cesarean section is defined as a surgical procedure that involves making an incision on the anterior abdominal wall and the uterus with the aim of delivering the fetus and other products of conception after the age of viability.

Classification Indication
Grade 1: Emergency Cesarean section Immediate threat to the life of the woman or the fetus, eg. uterine rupture
Grade 2: Urgent Cesarean section No immediate risk to the life of the woman or baby but delivery should be achieved as soon as possible eg. membranes are ruptured with meconium-stained liquor
Grade 3: Nonscheduled Delivery is needed but can fit in with delivery suite workload and allow for fasting/steroid administration and some degree of planning, i.e. preterm IUGR
Grade 4: Scheduled Also referred to as elective. No urgency whatsoever, and procedure planned to suit woman, staff and delivery suite

 

 

Discussion
Why do we have increased rates of caesarean sections these days?

Advanced maternal age (women are more career inclined, hence delaying marriage and conception )

Increase in repeat c-sections

Delivering most breech presentation by c/s

Increased diagnosis of intrapartum fetal distress with increase use of intrapartum monitoring tools 

Destructive operations are abandoned in favour of c/s

High forceps and difficult mid forceps are abandoned for c/s

Identification of risks in mothers and fetuses

Increase in pregnancies by in-vitro fertilization (babies are too precious to be allowed to go through the stress of labour)

Attempts to reduce perinatal and maternal mortality

Maternal request / demand

Concern for litigation (especially when malpractice is of concern)

Some indications for Cesarean delivery include

Maternal:

  • More than 2 previous Cesarean sections
  • Preeclampsia with unfavourable cervix
  • Prolonged labor with suspected cephalopelvic disproportion
  • Obstructive lesions in the lower genital tract eg malignancies and leiomyoma
  • Previous extensive uterine surgery (myomectomy)
  • Previous VVF repair 
  • Previous reconstructive vaginal surgery 
  • Large vulva condylomata
  • Active vulva herpes simplex virus
Fetal 
  • Persistent abnormal lie or non-vertex presentation at term
  • Multiple pregnancies: the first twin in a non-vertex presentation, or higher order multiples
  • Some congenital anomalies eg hydrocephalus
  • Fetal distress
  • Cord prolapse
  • Fetal macrosomia
Feto-Maternal
  • Placenta praevia
  • Cephalopelvic disproportion
Indications For Emergency C/S
  • Failure to progress in labour (CPD, malposition, malpresentation) 
  • Fetal distress (especially in  first stage of labour)
  • Imminent uterine rupture
  • Cord prolapse (in first stage of labour)
  • Cord presentation
  • Placenta praevia ( bleeding out of proportion irrespective of gestational age, at or near term)
  • Abruptio placenta with live babies
Preoperative management
  • Preoperative laboratory testing (Complete blood cell count, blood group and cross-match, screening tests for human immunodeficiency virus, hepatitis B and hepatitis C)
  • Evaluation by the senior obstetrician, anesthesiologist and neonatologist,
  • Theatre team preparation and readiness for the surgery
Cesarean delivery

Scrubbing and gowning by the surgeon

Administering of Anaesthetic agent( regional or general depending on the required speed to knock the patient off for the peculiarity of the surgery) by the Anaesthetist

Cleaning and draping of patient

Abdominal incisions, (depending on the required speed  or the technicalities involved to gain access into the peritoneal cavity)  

 

A. Transverse abdominal incision 
  1. Pfannenstiel incision
  2. Joel Cohen incision
  3. Pelosi incision
  4. Maylard incision
  5. Cherny incision

 

B. Longitudinal abdominal incision

Subumbilical vertical midline incision

Uterine incisions

  1. low transverse incision
  2. Classical incision
  3. low vertical incision
  4. J-shaped incision
  5. T- shaped incision
  6. U-shaped incision

 

  • Delivery of fetus and handing over to the neonatologist, delivery of placenta and control of haemorrhage
  • Wound closure (uterine and the anterior abdominal wall in layers) and application of wound dressing
  • Perineal cleaning and routine passage of rectal uterotonics
  • For General Anaesthesia, there is need for reversal of anaesthesia

 

Postoperative management
  • Administration of fluids and medications (antibiotics, analgesics, oxytocics and other medications depending on the peculiarities of the patient) according to postoperative order
  • Ambulation on postoperative day 1
  • Wound check and hematocrit check on day 2
  • Discharge on postoperative day 3, if no complications 
  • Contraception options to prevent unintended pregnancy are discussed before discharge, unless the patient had long acting contraception placed at the time of the procedure.

 

Complications

Some complications that may arise with Cesarean section include anaesthetic complications, hemorrhage, sepsis, injury to contiguous structures, pain, hysterectomy and death

Interesting patient case

A 28-year-old pregnant woman in sub-Saharan Africa developed high blood pressure during her second pregnancy. While in labor at a rural clinic, she showed signs of preeclampsia, a dangerous condition. To protect both her and the baby, the healthcare team decided on an emergency caesarean section (C-section). The surgery was successful, and both mother and baby were healthy. After the procedure, she experienced manageable pain and stayed in the clinic for three days for monitoring. She was advised on follow-up care. This case highlights the importance of emergency surgical care in preventing complications in rural settings.

Further readings
  1. Births – Method of Delivery. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/nchs/fastats/delivery.htm. June 8, 2023; Accessed: September 6, 2023
  2. Naji, O, Abdallah, Y, et al, Glob. libr. women’s med.(ISSN: 1756-2228) 2010; DOI 10.3843/GLOWM.10133
  3. “Safe Prevention of the Primary Cesarean Delivery”. American Congress of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. March 2014. Retrieved 23 January 2022.
  4. Ikeako LC, Nwajiaku L, Ezegwui HU. Caesarean section in a secondary health hospital in Awka, Nigeria. Niger Med J 2009:50:64-67
  5. Hofmeyr GJ, Mathai M, Shah AN,Novikova N.Techniques for caesarean section. CochraneDatabase of Systematic Reviews 2008, Issue 1. Art. No.: CD004662. DOI: 10.1002/14651858.CD004662.pub2.
  6. Jacobs-Jokhan D, Hofmeyr GJ. Extra-abdominal versus intra-abdominal repair of the uterine incision at caesarean section. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD000085. DOI: 10.1002/14651858.CD000085.pub2.
  7. National Institute for Health and Clinical Excellence.2011. Caesarean Section.

Author's details

Reviewer's details

Cesarean section

Cesarean section is defined as a surgical procedure that involves making an incision on the anterior abdominal wall and the uterus with the aim of delivering the fetus and other products of conception after the age of viability.

Classification Indication
Grade 1: Emergency Cesarean section Immediate threat to the life of the woman or the fetus, eg. uterine rupture
Grade 2: Urgent Cesarean section No immediate risk to the life of the woman or baby but delivery should be achieved as soon as possible eg. membranes are ruptured with meconium-stained liquor
Grade 3: Nonscheduled Delivery is needed but can fit in with delivery suite workload and allow for fasting/steroid administration and some degree of planning, i.e. preterm IUGR
Grade 4: Scheduled Also referred to as elective. No urgency whatsoever, and procedure planned to suit woman, staff and delivery suite

 

 

  1. Births – Method of Delivery. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/nchs/fastats/delivery.htm. June 8, 2023; Accessed: September 6, 2023
  2. Naji, O, Abdallah, Y, et al, Glob. libr. women’s med.(ISSN: 1756-2228) 2010; DOI 10.3843/GLOWM.10133
  3. “Safe Prevention of the Primary Cesarean Delivery”. American Congress of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. March 2014. Retrieved 23 January 2022.
  4. Ikeako LC, Nwajiaku L, Ezegwui HU. Caesarean section in a secondary health hospital in Awka, Nigeria. Niger Med J 2009:50:64-67
  5. Hofmeyr GJ, Mathai M, Shah AN,Novikova N.Techniques for caesarean section. CochraneDatabase of Systematic Reviews 2008, Issue 1. Art. No.: CD004662. DOI: 10.1002/14651858.CD004662.pub2.
  6. Jacobs-Jokhan D, Hofmeyr GJ. Extra-abdominal versus intra-abdominal repair of the uterine incision at caesarean section. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD000085. DOI: 10.1002/14651858.CD000085.pub2.
  7. National Institute for Health and Clinical Excellence.2011. Caesarean Section.

Content

Author's details

Reviewer's details

Cesarean section

Cesarean section is defined as a surgical procedure that involves making an incision on the anterior abdominal wall and the uterus with the aim of delivering the fetus and other products of conception after the age of viability.

Classification Indication
Grade 1: Emergency Cesarean section Immediate threat to the life of the woman or the fetus, eg. uterine rupture
Grade 2: Urgent Cesarean section No immediate risk to the life of the woman or baby but delivery should be achieved as soon as possible eg. membranes are ruptured with meconium-stained liquor
Grade 3: Nonscheduled Delivery is needed but can fit in with delivery suite workload and allow for fasting/steroid administration and some degree of planning, i.e. preterm IUGR
Grade 4: Scheduled Also referred to as elective. No urgency whatsoever, and procedure planned to suit woman, staff and delivery suite

 

 

  1. Births – Method of Delivery. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/nchs/fastats/delivery.htm. June 8, 2023; Accessed: September 6, 2023
  2. Naji, O, Abdallah, Y, et al, Glob. libr. women’s med.(ISSN: 1756-2228) 2010; DOI 10.3843/GLOWM.10133
  3. “Safe Prevention of the Primary Cesarean Delivery”. American Congress of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. March 2014. Retrieved 23 January 2022.
  4. Ikeako LC, Nwajiaku L, Ezegwui HU. Caesarean section in a secondary health hospital in Awka, Nigeria. Niger Med J 2009:50:64-67
  5. Hofmeyr GJ, Mathai M, Shah AN,Novikova N.Techniques for caesarean section. CochraneDatabase of Systematic Reviews 2008, Issue 1. Art. No.: CD004662. DOI: 10.1002/14651858.CD004662.pub2.
  6. Jacobs-Jokhan D, Hofmeyr GJ. Extra-abdominal versus intra-abdominal repair of the uterine incision at caesarean section. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD000085. DOI: 10.1002/14651858.CD000085.pub2.
  7. National Institute for Health and Clinical Excellence.2011. Caesarean Section.
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