Caesarean Section

Definition

• Definition: Caesarean Section is a surgical procedure for delivering a baby through incisions in the mother's abdomen and uterus.

Advantages and Disadvantages

• Advantages:
  • Safest birth method for certain maternal or fetal health complications.
  • Rare occurrence of fetal birth trauma.
• Disadvantages:
  • Potential for postoperative complications.
  • Extended recovery period.

Indications

Maternal indications

• Primary cesarean delivery
  • Placenta praevia totalis
  • Refractory HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), severe preeclampsia
  • Severe uterine abnormalities (e.g., myoma) of the mother
  • Maternal skeletal deformities
  • Relative:
    • Severe maternal disease (e.g., cardiopulmonary disorders, uncontrolled diabetes mellitus)
    • Maternal HIV infection
    • Severe stress reactions
    • Elective cesarean delivery
  • Possible indications :
    • Fetal head is disproportionately large compared to the maternal pelvis.
    • Breech presentation in a nullipara or multiple pregnancy
    • Suspected absolute fetal macrosomia
• Secondary cesarean delivery (after PROM and/or onset of phase 1)
  • Prolonged labor in:
    • Premature birth
    • Intraamniotic infection
    • Abnormal fetal position (e.g., breech presentation, longitudinal position)
    • Maternal exhaustion; ineffective contractions
• Emergency cesarean delivery
  • Immediate threat to life of mother
  • Severe vaginal bleeding of unknown etiology (suspected placental separation)
  • Suspected uterine rupture

Fetal indications

• Primary cesarean delivery
  • Fetal growth retardation with circulatory depression
  • Premature birth, if further risk factors are present, e.g., infection
  • Fetal malformations that hinder a natural birth (e.g., severe hydrocephalus)
  • Multiple pregnancy with a significant difference in fetal weight
• Emergency cesarean delivery
  • Immediate threat to life of fetus
  • Pathological CTG (particularly persistent, severe fetal bradycardia)
  • Fetal acidosis

Contraindications

• There are no absolute contraindications to cesarean birth.

Timing

• Planned primary cesarean birth at term should be performed in the 39thweek of gestation rather than in the 37th or 38th week.
• Medically/obstetrically indicated cesarean births are performed when clinically indicated.

Procedure/Application

• Preoperative Antibiotic Prophylaxis: A single intravenous dose of a narrow-spectrum antibiotic, such as cefazolin, is recommended.
  • Procedure Steps:
    • Skin incision
      

      Type of Incision	Description	Advantages	Disadvantages
      Pfannenstiel	Slightly curved, 2 to 3 cm above the symphysis pubis	Better cosmetic outcomes , Lower risk of hernia formation , Potentially less postoperative pain	May not provide adequate exposure for all situations
      Joel-Cohen	Straight, 3 cm below the anterior superior iliac spine line	Lower rates of fever , Less postoperative pain and analgesia use , Less blood loss , Shorter operating time and hospital stay, Better cosmetic than vertical	Requires more skill for adequate exposure
      Vertical Midline	Vertical incision from the umbilicus to the pubic symphysis	Can be extended for better access , Causes less bleeding and superficial nerve injury, Faster abdominal entry	Higher risk of postoperative complications such as hernia , Less favorable cosmetically

      

       

    • Hysterotomy (uterine incision)

      Type of Incision	Location	Advantages	Disadvantages	Indications
      Transverse	Lower uterine segment	Less blood loss Less need for bladder dissection Easier reapproximation Lower risk of rupture in subsequent pregnancies Preferred for future pregnancy and trial of labor	Limited ability for lateral extension without risking major blood vessel laceration May require "J" or inverted "T" extension for a larger incision	Most cesarean births Patients planning another pregnancy
      Low Vertical	Lower uterine segment	Appears as strong as the low transverse incision Can be used when a larger incision is needed without the risk of lateral vessel laceration	Risk of extension into bladder, cervix, or vagina Difficult to ensure it remains confined to lower segment	Poorly developed lower uterine segment with anticipated normal intrauterine manipulation Lower uterine segment pathology precluding a transverse incision
      Classical	Upper uterine segment/fundus	Allows delivery in situations with pathology in the lower uterine segment or when extensive intrauterine manipulation is expected Useful for delivery of very large fetuses or in postmortem delivery	Higher frequency of uterine dehiscence/rupture in subsequent pregnancies (4-9%) Associated with more maternal morbidity	Extremely preterm breech presentation, back down transverse lie Large leiomyoma, anterior placenta previa or accreta Densely adherent bladder Delivery of a very large fetus

      

    • Fetal extraction, cord clamping, and manual placental removal
    • Wound closure

Postpartum care

• Prophylaxis Against Hemorrhage: Oxytocin is routinely administered to prevent hemorrhage.
• Thromboembolism prophylaxis: Evaluation of thrombosis risk is essential to determine the type, dose, and duration of prophylaxis needed.
• Analgesia: A multimodal, opioid-sparing approach is used, incorporating regular acetaminophen and NSAIDs.
• Bladder Catheter: If used, the catheter is removed as soon as possible postpartum
• Activity and Diet: Early Ambulation, Initiate oral intake within six hours post-delivery
• Wound Care: Dressings removed 6 to 24 hours post-application; showering allowed 48 hours after surgery completion.
• Breastfeeding and Skin-to-Skin Contact: Initiated ideally in the delivery room

Complications

• Fever: Common early post-cesarean causes include endometritis, respiratory tract infections, and pyelonephritis. Uncommon causes for persistent or late-onset fever may include septic pelvic thrombophlebitis, pelvic abscess, and drug fever.
• Endometritis
• Wound Complications
• Hemorrhage
• Surgical Injury
• Venous Thromboembolism (VTE)
• Anesthetic Complications
• Ileus and Colonic Pseudo-Obstruction
• Septic Pelvic Thrombophlebitis and Ovarian Vein Thrombophlebitis
• Fetal and Neonatal Risks: Include iatrogenic prematurity, birth trauma, transient tachypnea of the newborn (TTN), and respiratory distress syndrome (RDS), especially after scheduled cesarean births.

Long-term Risks Associated with Cesarean Birth

• Abnormal Placentation
• Uterine Rupture
• Scar Complications
• Adhesions and Bowel Obstruction
• Subfertility
• Unexplained Stillbirth
• Preterm Birth

Subsequent Deliveries

• Options: Trial of labor after cesarean (TOLAC) or planned repeat cesarean birth (PRCB).
• Decision-Making: Should be patient-centered, considering the resources for cesarean birth, potential complications, patient preferences, past birthing experiences, and the probability of successful VBAC.