Cesarean Section

Ass. Prof.
Angalva Elena
Nikolaevna
MD, PhD.

Cesarean Section
The term cesarean delivery is defined as the
delivery of a fetus through a surgical incision
through the abdominal wall (laparotomy) and
uterine wall (hysterotomy) .
The exact origin of the term cesarean is unclear.
The term cesarean may have arisen in the
Middle Ages from the Latin verb caedere (to
cut). Children of such births were referred to
as caesones

Indications

Maternal

Maternal medical conditions

Fetal

Women with an abdominal cerclage in place.

Obstructive lesions in the lower genital tract
Women with prior vaginal colporrhaphy and major anal involvement from
inflammatory bowel disease

Malpresentation, multiple gestation

Congenital anomalies
Nonreassuring fetal heart rate
Fetal distress/prolapse cord
Genital herpes infections/HIV infection

Maternal & Fetal

Abnormal placentation Placenta praevia/abruptio

Abnormal labor due to cephalopelvic disproportion
In presence of contraindications for labor
Postmortem cesarean section

Procedures

Abdominal incisions

Midline infraumbilical incision to enter the peritoneal cavity

Transverse incision through the lower abdomen (Maylard
incision or Pfannenstiel incision)

The Pfannenstiel incision is curved slightly cephalad at the level of the

pubic hairline. The incision extends slightly beyond the lateral borders
of the rectus muscle bilaterally and is carried to the fascia. Then, the
fascia is incised bilaterally for the full length of the incision. Then, the
underlying rectus muscle is separated from the fascia both superiorly
and inferiorly with blunt and sharp dissection. Clamp and ligate any
blood vessels encountered. The rectus muscles are separated in the
midline, and the peritoneum is entered
A Maylard incision is made approximately 2-3 cm above the symphysis
and is quicker than a Pfannenstiel incision. It involves a transverse
incision of the anterior rectus sheath and rectus muscle bilaterally.
Identify and possibly ligate the superficial inferior epigastric vessels
(located in the lateral third of each rectus).

Procedures

The visceral peritoneum is grasped just above

The bladder and incised in the midline.

Procedure

A. The Visceral Peritoneum

is undermined, and
B. Incised laterally with
Metzenbaum scissors

Procedures
Uterine Incision
Upon entering the peritoneal cavity, inspect the lower abdomen. The uterus is
palpated and commonly is found to be dextrorotated such that the left
round ligament is more anterior and closer to the midline. Dissect the
bladder free of the lower uterine segment. Grasp the loose uterovesical
peritoneum with forceps, and incise it with Metzenbaum scissors. The
incision is extended bilaterally in an upward curvilinear fashion. The lower
flap is grasped gently, and the bladder is separated from the lower uterus
with blunt and sharp dissection. A bladder blade is placed to both displace
and protect the bladder inferiorly and to provide exposure for the lower
uterine segment (the acontractile portion of the uterus).
One of essentially 2 incisions can be made on the uterus, either a transverse or
vertical incision. The decision for the type of incision is based on several
factors, including fetal presentation, gestational age, placental location, and
presence of a well-developed lower uterine segment.
In more than 90% of cesarean deliveries, a low transverse (Monroe-Kerr)
incision is made. The incision is made 1-2 cm above the original upper
margin of the bladder with a scalpel. The initial incision is small and is
continued into the uterine wall until either the fetal membranes are
visualized or the cavity is entered (take care to not injure the underlying
fetus

Procedure

Procedure

Uterine Incisions

Procedure
Delivery
When the fetus is delivered, the umbilical cord is doubly clamped and
cut. Blood is obtained from the cord for fetal blood typing, and a
segment of cord is placed aside for attaining blood gas results if a
concern exists regarding fetal status. Following delivery, oxytocin
(20 U) is placed in the intravenous fluid to increase contractions of
the uterus. The placenta usually is delivered manually. Awaiting
spontaneous delivery of the placenta with gentle traction is more time
consuming but is associated with decreased blood loss, lower risk of
endometritis, and lower maternal exposure to fetal red blood cells,
which can be important to Rh-negative mothers delivering an Rhpositive fetus.
After delivery of the baby, administer prophylactic antibiotics. A single
dose of ampicillin or a first-generation or second-generation
cephalosporin is appropriate. If the surgery is prolonged, a second
dose can be administered later. If the patient has chorioamnionitis,
broader-spectrum antibiotics, such as gentamicin and clindamycin or
Unasyn, are indicated and should be continued in the postoperative
period until the patient is afebrile.

Procedure

Procedure

The Fetal Occiput

is lifted toward
the incision

Procedure
Body Delivery

Procedure
Placental
Delivery

Repair of uterine incision

Repair of a low transverse uterine incision can be

performed in either a 1-layer or 2-layer fashion with
zero or double-zero chromic or Vicryl suture. The first
layer should include stitches placed lateral to each
angle, with prior palpation of the location of the lateral
uterine vessels. Most physicians use a continuous
locking stitch. If the first layer is hemostatic, a second
layer (Lembert stitch), which is used to imbricate the
incision, does not need to be placed.
Closure of a vertical incision usually requires several
layers because the incision is through a thicker portion
of the uterus. Again, a heavy suture material is used,
and usually the first layer closes the inner half of the
incision, with a second and possible third layer used to
close the outer half and serosal edges.

Complications

Intraoperative Complications

Uterine lacerations
Bladder injury
Ureteral injury
Bowel injury
Uterine atony

Postoperative Complications

Postpartum endomyometritis
Wound infection
Fascial dehiscence
Urinary tract infection
Thromboembolic complications
Pelvic thrombophlebitis