Cesarean section (CS)

Caesarean section or c-section, is a

delivary of the foetus through incisions in
anterior abdominal (laparotomy) and
uterine wall (hysterotomy)
 It is usually performed when a vaginal delivery would put the
baby's or mother's life or health at risk.

The following indications are the most frequent:

1. Extreme dgree of contracted pelvic (one or more of the diameters is

reduced and interferes with normal mechanism of labour.
Degrees of contracted pelvis:
Minor degree: the true conjugate is 9-10 cm.
Modrate degree: the true conjugate is 8-9 cm.
Sever degree: the true conjugate is 6-8 cm.
Extreme degree: the true conjugate is less than 6 cm.
2. Cephalopelvic disproportion: the head of the foetus is too largeto
come through the pelvis.
3. Uterine Inertia: Inefficient uterine contraction.
4. Placenta pravia: Implamtation of placenta in the lower uterine
segment.
5. Premature separation of placena: Cesarean
section is indicated when,the foetel distress
occurs, when effective labour does not follow
rupture of membrane and when vaginal can not be
anticipeted within 2 hours.
6. Malposition and malpresentation
7. Pre-eclamsia
8. Diabetes ( causes over size of the foetus. Cesarean
section should be done in the 1st four weeks in
primigravidae.
9. Cardiac diseases.
10. Vaginal scaring.
11. Carcinoma of the cervix.
12. Cervical dystoctia (failure of the cervix to dilate
in spite of strong contraction of the uterus).
13. A previous uterine incision.
14. Prolapse of the umbilical.
15. Foetal distress.
16. Bad post obstetric history (baby habitually dies in
the uterus.
17. Failure of labour to progress despite adequate
stimulation.
Dead of foetus
1) Elective timing: (before the onset of labour
by one week.
2) Selective timing: (after the onset of labour, it
is preferred.
 The classical caesarean section:
A midline longitudinal (vertical) incision which allows a
larger space to deliver the baby. However, it is rarely
performed today as it is more prone to complications.

The lower uterine segment section:

It is the a procedure most commonly used today; it involves a
transverse cut just above the edge of the bladder and results in
less blood loss and is easier to repair.
 Indications of classical
caesarean section

1. when the lower segment is abnormally vascular.

2. when the lower segment can not identified due to
adhesion.
3. when caesarean section is done after mothers death.
4. Cases needs rapid delivery.
5. When the foetus lie is transverse and can not be
corrected.
6. When hysterectomy will follow caesarean section
Advantages of the lower segment:
The wound is extra peritoneal so less risk of infection.
Healing scar is better.
The risk of rupture of the scar is less.
Hemorrhage is less.
Placenta is away from the incision.
Disadvantages of the lower segment:
The operation requires more skill and experience.
The incision may extend down to the bladder.
Disadvantages of classical operation:
More liable to chest infection.
More liable to intestinal distension.
The scar is more liable to rupture.
 Respiratory complications: due to inhibitory effects of pain,
immobilization in post operative period and anaesthesia.
So
encourage deep breathing exercises.
teach the patient huffing and coughing (the abdomen must
be supported by the patients hands and/or towel)
Excessive abdominal pain due to:
Wound infection.
Haematoma.
Excessive localized edema.
Nerve entrapment syndrome (ilioinguinal or iliohypogastric nerve)
Deep venous thrombosis due to (hypercoagulability, decrease
venous tone
 Signs and symptoms of DVT: in about 50%
Edmatous limb.
Erythrocyanotic appearance.
Dilated superficial veins.
Elevated skin temperature.
Prophylactic role to prevent DVT:
o Application of compression stocking.
o Early ambulation.
o Avoidance of pressure under thighs and calves
o Avoidance of sitting with knees acutely flexed.
o Deep breathing exercises.

o Circulatory and leg exercises.

 Dependent edema. (generalized retension of fluid)
aggravated by decreased movements of the lower
limb muscles.
to prevent dependent edema:
Vigorous foot and ankle exercises.
elevation of L.L.

If sever apply stoking and intermittent pressure.

Intestinal complications.
Haemorrhage.
 It is done when there is inability to stop
bleeding from the uterine incision or
multiple fibroids in old patient.
 It is an excision of a portion of both
fallopian tube.
It is done after 3rd or 4th cesarean section.
 It is done after mothers death, to save the
life of a living foetus, It is done within 10
minutes of maternal death.
 For elective cases, prior to surgery the
mother is pain free and alert, to prepare her
emotionally and physically for post operative
delivery.
Pre-operative goals:
1. Improve pulmonary function and prevent post operative
pulmonary complications( pneumonia.)
2. Improve circulation and prevent post operative circulatory
complications (DVD, edema .)

3. Prepare patient emotionally and physically

 Methods:
Discussion to minimize or eliminate negative feeling about delivery.
Demonstrate the patient how to mobilize early with minimum amount of
strain or pain.
Teach the patient how to cough and huff to get red of expectoration.
Deep breathing exercises.
Circulatory exercise.
Post- operative management:
In recovery area. Observation of level of consciousness, blood
pressure, heart rate, respiration and vaginal blood loss.
Nursing care, including regular assessment of temperature, blood
pressure, heart rate, color, lochia, wound appearance, bleeding, bladder
function and urine output, oral fluid intake.
Post-operative goals:
1. Improve pulmonary function and prevent post operative
pulmonary complications( pneumonia.)
2. Improve circulation and prevent post operative
circulatory complications (DVD, edema .)
3. Decrease incisional pain associated with coughing,
movement or breast feeding.
4. Improve healing of incision and prevent adhesion
formation.
5. Prevent pelvic floor dysfunction.
6. Improve lactation and prevent sagging of the breast.
7. Correct posture.
Methods:
Deep breathing exercises.
Circulatory exercise.
Early ambulation.
Arm exercises.
Postural correction.
Pelvic floor exercises.
Abdominal strengthening exercises.
Electrotherapy to decrease incisional pain and to
promote wound healing.
Positioning instruction.
 Physical therapy for
early post-operative days
1st day:
Breathing exs.
Circulatory exs.
Leg exs.
Static abdominal contraction.
2nd day:
Repeat previous exs, add the following:
Early ambulation to:
Prevent muscle wasting.
Prevent constipation.
Prevent retension of urine
Prevent respiratory and vascular complication.
Arm exs. Half lying position.
3rd day:
Repeat previous exs, add the following:
Pelvic floor exs
 4th day:
Repeat previous exs, add the following:
Pelvic rocking exs
Scapular retraction.
5th day:
Repeat previous exs, add the following:
Hip shrugging.
Postural correction exs.
6th day:
Repeat previous exs, add the following:
Pelvic rotation exs.
7th day:
Repeat previous exs, add the following:
Lateral flexion (1st step)
Trunk rotation (1st step)
Trunk flexion (1st step).