Caesarian Delivery

CAESARIAN
DELIV
BY ERY
Dr. Malleswar Rao Kasina,
MD,DGO.
HOD & CSS, Dept. of GynObs,
ESI Hospital, Sanathnagar, Hyderabad, AP,
India
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.
Cesarean Childbirth
Overview
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.
Cesarean Childbirth
Causes
The most frequent reasons for

performing a cesarean delivery are
discussed below.
1 Repeat cesarean delivery:There
are 2 types of uterine incisions—a
low transverse incision and a
vertical uterine incision.
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,
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)
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.
Uterine rupture can be
dangerous to the fetus
even if delivery is
accomplished immediately
after a uterine rupture.
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.
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.
In a normal pregnancy, the baby is
positioned head down in the
uterus.
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
C-section - : Indications
Cesarean Childbirth
Causes
5 Fetal status: Continuous fetal
heart rate monitoring in labor has
not improved birth outcomes as
once expected.
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.
Cesarean Childbirth
Causes
7 Elective sterilization: A desire for

elective sterilization is not an
indication for cesarean delivery.
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.
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

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.

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.

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.

Finally, the
surgeon cuts through
the amniotic sac
enclosing the baby.
He then allows the
amniotic fluid to
escape.
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.
* 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.
* 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.
* 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.
* 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.
Cesarean
Childbirth-
Possible
Complications

* Prolonged hospital stay:

When compared with normal vaginal
delivery, Cesarean delivery requires 5
to 6 days hospital stay.
* Anesthesia & pain medications:
Commonly, spinal or epidural
anesthesia is administered.
After surgery, oral and
injection drugs can be used to
help control the pain.
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.
Cesarean Delivery – Ancient
Medical History
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.
■ Micheal Stark : Director
■ Misgav Ladach Hospital,
Israel
■ “a refuge for the oppressed”
Steps Of Cesarean
Section:
Abdominal entry :
■ Joel Cohen’s incision
/\
■ Midway between
umbilicus & symphysis
pubis.
■ Separation of recti easy
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.
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
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
■ 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
■ Muscles are separated in
the middle & peritoneum
punctured with fingers
All the three – peritoneum,

muscle & the fat are pulled
apart to allow adequate
opening
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 (Langer’s lines), thus healing more
completely and rapidly
• Abdominal Packs are not used
■ Doyen’s 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
• Start Suturing the edges form near to far

• Non-locking continues stitch
• Additional stitches only if bleeding presents
• Clean Peritoneal cavity of debris
• Rectus sheath is
sutured in the form of
near-far, far-near
pattern
• Non-locking continues
stitch
• Skin: 2-3 stitches deep
mattress silk stitches
• Space in between
allows draining of
secretions
• Quick recovery
■ Post operative pain – quite less
■ Fewer adhesions
■ Bladder not a problem in subsequent CS
• Less Blood loss

• Smaller scar with less induration
■ Adopting Joel-Cohen • Concise
techniques of opening
the abdomen • Very simple
performing manual • Very speedy
manipulations,
minimizing the use of
Results are –
instruments and self evident
suturing. - Misgav – Ladach
method (Stark 1996)
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.
Time
■ More rapid - very short in time
■ Theatre time and op. time – reduced
■ Total op. time 18 to 20 min - 30-50% less

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%)
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.
COST benefits
■ Cost beneficial
■ Suture 2.92 ≈ 3 Vs 4.14 ≈ 4
■ 15 euros less costly (In European countries)
Technique of CS : Issues

Exteriorization of uterus
• Two layer uterus closure
• Peritoneal suturing
■ Routine antibiotics
• Uterotonics/Oxyticics
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
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
Peritoneal Closure
■ Author’s Conclusion
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
Abdominal Wall Closure
■ 6 trials, 1853 cases
■ No difference if subcutaneous tissue sutured or
not ,in terms of infection, hematoma, or serious
discharge
Antibiotic prophylaxis for CS
Smaill F, Hofmeyer GJ,
From The Cochrane Library , Issue 1, 2006.
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)
■ Lateral tilt for CS
Chichester, WilkinsinC, Enkin MW
From The Cochrane Library , Issue 1, 2006.
Conclusion
■ There is not enough evidence from these trials
to evaluate use of tilt during CS
Early compared with delayed oral fluids
and food after CS
Mangesi L, Hofmeye GJ (From The Cochrane Library , Issue 1,
2006.)
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
Visit www.rhlibrary.com
FINALLY Surgical technique
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

Who are involved ?
FETUS MOTHER
Childbirth
Who are involved ?
FETUS MOTHER
Obstetricians Health system

Childbirth
Obstetrical
Midwives Uni-Hospital
Society
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 1985;436-7.
Factors involved in decision
 Fetal mortality and morbidity
 Newborn health
 VBAC
 Cost
 Pelvic floor damage
 Maternal mortality
 Cultural factors
 Autonomy - C-section on demand?
 Newborn health
 VBAC
 Cost

“Unexplained fetal deaths”
Cotzias C, Paterson-Brown S, Fisk N. BMJ, 319,31 july
1999
Weeks Nº of pregnancies Prospective Risk

of fetal death
35 164 860 1:366
36 162 603 1:407
37 158 171 1:474
38 149 181 1:529
39 127 160 1:617
40 93 828 1:680
41 39 316 1:606
42 10 328 1:565
43 1 883 1:465
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
Cotzias C, et al., BMJ, 319,31 july 1999
fetuses
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
■ Women’s preference: C-section of the risk is
> 1:4000 1 Cotzias C, et al., BMJ, 319,31 july 1999
1
Thornton E, et al., J Obstet Gynecol 1989;9:283-8
 Newborn health
 VBAC
 Cost
“Effect of Mode of Delivery in Nulliparous
Women on Neonatal Intracranial Injury”
Towner D et al., NEJM 1999;341:23
■ 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
 Newborn health
 VBAC
 Cost
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

Recomendations
■ The most conservative recomendations.
– ACOG Technical Bulletin. Vaginal delivery after a previous
cesarean birth.
• Int J Gynecol Obstet 48:127 – 129; 1995.
– ACOG Vaginal birth after a previous cesarean.

VBAC
■ Over 1000 reports: not one RCT
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 2000;182:599-602
 Newborn health
 VBAC
 Cost
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.
Costs of deliveries
Beth Israel Deaconess Medical Center, Boston, USA
■ Elective repeated cesarean delivery $ 7.700
■ Normal vaginal delivery $ 6.800
■ Intrapartum Cesarean: $ 10.000
Costs of deliveries
Beth Israel Deaconess Medical Center, Boston, USA
■ Elective repeated cesarean delivery $ 7.700
■ Normal vaginal delivery $ 6.800
■ Intrapartum Cesarean: $ 10.000
■ Complication
– Mother: + $ 4.000
– Child: + $ 2.000
 Newborn health
 VBAC
 Cost
Pelvic floor
■ Urinary incontinence
■ Fecal incontinence
■ Sexual dysfunction
■ Organ prolapse
Pelvic floor
■ Pudendal nerve damage
■ Soft tissue trauma
■ The levator musculature trauma
■ Anal sphincter trauma
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 2001;12:289-291
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 2001;12:289-291

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 1999:119
 Newborn health
 VBAC
 Cost
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
Hannah ME, Lancet 2000;356:1375-83.
vaginal birth....”
 Newborn health
 VBAC
 Cost
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
■ Women’s body are perceived as sexual than
maternal
■ Genitals are perceived for sexual activity than
for childbearing Nuttall C., et al., BMJ 2000;320:1072
 Newborn health
 VBAC
 Cost
Cesarean section on demand
■ 31% of female obstetricians would prefer a
cesarean delivery for themselves 1
1
Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997:73:1-4
■ World wide debate continues on role of
Cesarian Delivery on Maternal
Request[CDMR].
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 1997:73:1-4
2
Tranquilli AL, et al., Am J Obstet Gynecol 1997;177:245-246
Autonomy
■ Is the governing principle in medicine
■ We respect with better eyes a woman’s right
to refuse a cesarean delivery
■ Nobody is interested in respecting woman’s
desire to refuse vaginal delivery
Wagner M et al., Lancet 2000;356:1677-80
Autonomy and informed
consent
“...performing cesarean section for non

medical reasons is ethically not
justified....”
Committee for the Ethical Aspects of Human Reproduction
and Women’s Health of FIGO (1999)
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 mother’s
preference for how her baby is to be
delivered...” William Benson Harer
Dr.Malleswar Rao Kasina,
expresses
Thanks you for your Attention !
E-mail : kasinamrao@gmail.com

Caesarian Delivery

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CAESARIAN

Cesarean delivery, also known as cesarean

The most frequent reasons for

1a In the last 20 years, studies have

1b In about 10% of women with

2 Previous cesarean deliveries:

7 Elective sterilization: A desire for

* Excessive bleeding: This is the

* Infection: The risk of infection of the

* Clots: Blood clots can form in

* Urinary function and bladder injury:

■ Many bleeding vessels have to be controlled

■ More difficulty in repeat LSCS

■ Skin & sub-cutis cut

■ Incision in fat only in

■ Cut the rectus sheath

■ This will ensure a cut

All the three – peritoneum,

Tissues are separated along connective tissue

• Start Suturing the edges form near to far

■ Bladder not a problem in subsequent CS

• Less Blood loss

■ Theatre time and op. time – reduced

■ Total op. time 18 to 20 min - 30-50% less

■ and were better able to breast feed and care of their

■ Reduced pain and early ambulation

■ 6 trials, 1853 cases

 Fear of malpractice litigation

 Increased use of epidural anesthesia ?

 Increased use of electronic fetal monitoring

 The convenience of physicians

Obstetricians Health system

Weeks Nº of pregnancies Prospective Risk

Martin JA, et al., National Center for Health Statistics. 2002

delivery Davila GW, et al., Int Urogyneocl J 2001;12:289-291

“...performing cesarean section for non

Thanks you for your Attention !

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