Caesarean Section
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Caesarean Section (C. section)

DR. S. Kalaichandran, MBBS, MD, FRCSC,FSOGC (Canada), FRCOG,

Lecturer University of Ottawa
Obstetrics and Gynaecology

Historical:

   Contrary to popular myth, caesarean section has nothing to do with the birth of Julius Caesar. It is believed to have originated from an ancient Roman law, Lex Regia. This law decreed that when a pregnant woman dies undelivered, the baby should be delivered through an abdominal incision and claimed for the state. Corruption of Lex Regia became Lex caesarica and the present Caesarean section.

    A Swiss man, Jacob Nufer, operating on his wife, preformed the earliest recorded C. section on a living woman in 1500.

Definition:

   C. Section is the delivery of the baby through incisions on the abdomen and the uterus.

Incidence:

   The incidence varies from country to country and within a country from region to region and even from hospital to hospital within a region. There has been an increase in C. section rate over time, particularly in North America. The C. section rate in Canada and the USA is between 15 and 25 percent of all deliveries.

 

Reasons for the Increasing Rate of C. Sections:

 

  1. Advances in anaesthesia, antibiotic prophylaxis and transfusion medicine have made C. section a very safe procedure (compared to earlier times).

 

  1. Quality survival of the baby has become paramount. Mothers demand a C. section to avoid the stress of labour on the baby if there is a suspicion of foetal compromise.

 

  1. Obstetric manoeuvres like high forceps, hind water rupture, internal podalic version, breech extraction, (symphysiotomy) and lately assisted breech delivery are all relegated to history. The manual dexterity of the previous generation of obstetricians is lost forever (for better or for worse).

 

  1. Electronic continuous foetal monitoring without foetal blood sampling has been shown to increase C. section rate for suspected foetal compromise.

 

  1. Logistics- In a community hospital with no dedicated OR and in-house staff for STAT sections, C. sections are rightly done for suspected “foetal distress” before a crisis situation.

 

Types of C. sections and Indications

Elective C. sections:

   These are booked C. sections before the onset of labour for the following indications: Two or more C. sections, previous classical C. sections, mal presentations like breech and transverse lie, fibroids or ovarian cysts causing obstruction, previous vaginal repair which may be disrupted by vaginal delivery, placenta praevia, fetal growth restriction, severe oligohydramnios, fetal hydrocephaly, and tumours and multiple pregnancies.

Emergency C. Sections:

   These are emergency procedures in labour often for suspected foetal compromise, failure to progress, ante partum haemorrhage and PIH. Sometimes, patients who are booked for elective C. sections are admitted in labour and have emergency C. sections.

Lower Segment and Classical C. Sections:

   Most C. sections are lower segment transverse C. sections. Occasionally, a vertical incision is made on the lower segment extending into the upper segment. This is employed when the foetus is very small and the lower segment is not formed or the lie is transverse with back down.

    Patients, who have had classical C. section or vertical incision on the lower segment, are not candidates for vaginal birth after C. section (VBAC).

The Procedure C. Section

Anaesthesia:

   The majority of elective C. sections are done under spinal anaesthesia. The patient is awake but feels no pain. Medication for post-operative analgesia is administered at the time of spinal anaesthesia. This provides pain relief for 24 hours. An occasional patient may elect to have general anaesthesia for C. section. Patients with some medical conditions are better served by General anaesthesia.

    At emergency C. section, if the patient has an epidural for analgesia, this may be topped up for C. section. When STAT section is called for, general anaesthesia is often used.

Awareness During Surgery

    It is now accepted that a small proportion of patients will have awareness during surgery under general anaesthesia. This is a particular problem at C. sections. The anaesthesiologist has to play a balancing game with the depth of anaesthesia – deep enough to abolish awareness for the mother but light enough not to depress the baby.

C. Section Photo Gallery and Video:

   This C. section for breech presentation was performed under spinal anaesthesia at the Hotel Dieu Hospital, Cornwall. The patient had consented for the filming and publication (anonymous). I would like to thank the couple, anaesthesiologist, Dr. C. Navaneelan, the OR and OB staff and the hospital for their cooperation. I would like to express my gratitude to Mr. Peter Labelle of YTEK for video taping, editing and producing the images of the procedure for this presentation.

Spinal needle in place for anaesthesia (removed after injection)

Spinal needle in place for anaesthesia (removed after injection)

Abdomen cleaned and sterile drape with clear central area and a pouch to collect blood and amniotic fluid is pasted on to the abdomen.

Abdomen cleaned and sterile drape with clear central area and a pouch to collect blood and amniotic fluid is pasted on to the abdomen.

Transverse supra pubic incision is made through the sterile drape.

Transverse supra pubic incision is made through the sterile drape.
After cutting through the sub cutaneous fat, the rectus sheath is divided transversely.
After separating the rectus muscles, parietal peritoneum is divided vertically, opening into the peritoneal cavity.

Gravid uterus (lower segment) is exposed.

Gravid uterus (lower segment) is exposed.
Incision of the lower segment before the delivery

Baby is delivered as assisted breech.

Baby is delivered as assisted breech.
Baby is delivered as assisted breech.
Baby is delivered as assisted breech.
Baby is delivered as assisted breech.
Baby is delivered as assisted breech.
Air passages of baby cleared with suction tube.
Air passages of baby cleared with suction tube.

Placenta is removed by traction on umbilical cord and compression on uterine fundus.

Placenta is removed by traction on umbilical cord and compression on uterine fundus.

Uterine incision is closed in one layer with # 0 delayed absorbable suture.

Uterine incision is closed in one layer with # 0 delayed absorbable suture.

Rectus sheath is closed with # 1 delayed absorbable suture.

Rectus sheath is closed with # 1 delayed absorbable suture.
Skin closure with staples.
Skin closure with staples.

Skin closure with staples.

Skin closure with staples.

Skin closure with staples.

Skin closure with staples.

Scar 7 Months Later

C. Section Video of a breech presentation

    This brief clip shows insertion of spinal anaesthesia, ante-septic preparation and draping of the abdomen, skin incision, incision of the parietal and utero-vesical peritoneum, transverse incision on the lower segment, delivery of the baby as assisted breech, delivery of the placenta, closure of the uterine incision, rectus sheath of the abdominal wall and closure of the skin with clips.

 

To be completed: Tubal ligation at the time of C. section

Complications of C. sections

VBAC

 

Copyright © 1999 [Dr. Kalaichandran]. All rights reserved.
Revised: May 12, 2003 .