Caesarean Section

About
Nomenclature: Caesarean section, Classical Caesarean section, Lower Segment Caesarean Section, LSCS, Caesar, C-Section.

Caesarean Section is a surgical method of delivering the baby from the pregnant mother. This is usually done around 9-10th month of pregnancy as an elective or planned procedure once the baby is mature. It could also be done as an emergency when life threatening complications to mother or baby occur.

The operation originated many centuries ago when the mother was on her death bed, in an effort to save the baby from dying in the mother’s womb. From the 20th century onwards it became an accepted technique in difficult labors, complicated maternal health and situations when the baby's well being was getting compromised.

Nowadays, it is a fairly common mode of delivery resorted to when the mother suffers from medical problems or illnesses, diabetes, uncontrolled blood pressure, placenta previa, breech presentation, twins, triplets, and previous caesarean delivery.

The mother is prepared as for any major surgery and anesthesia. A spinal or epidural or general anesthetic is administered, while the mother's heart, lungs and circulation are monitored as is the baby's heart beat. The baby is delivered by opening the mother’s abdomen, followed by opening the uterus in its lower portion. The operation usually is completed in less than an hour.

Complications can range from mild ones like fever, vomiting to major ones like massive hemorrhage, injury to the neighboring structures like urinary bladder or intestines or pulmonary embolism.

Recovery can be fairly quick and the mother can return to normalcy within three to four weeks.

History and Anatomy
The Latin word 'cedere' means 'to cut' and the word caesarean probably originated from this word. 'Caesarean section' means to 'cut out'.

Caesarean section existed among ancient Hindus and Egyptians who performed it to save the baby if the mother died. In the pre-Christian era, the Jews practiced it even when the mother was alive. In the nineteenth century, European travelers have described Caesarean section being performed by African tribes, using alcohol to anaesthetize the mother and herbs for wound healing. It was established as a mode of delivery by the latter part of the 19th century.

Anatomy
The baby lies within the mother's womb usually with its head abutting against the mother's lower portion of the uterus. In majority of the deliveries, it is the head of the baby, which emerges first from the mother's womb into the world. In some cases the baby’s buttock may lie against the mother's lower portion and may emerge first during delivery, when it is referred to as a breech presentation. The baby is extracted from the womb by cutting open the lower portion of the uterus, after the mother’s abdomen has been cut open over this region.

Types and Indications of C-Section
1. Classical Caesarean- Here the upper portion of the uterus is opened by an incision and the baby is then extracted. This is not practiced anymore due to a higher incidence of complications.

2. Lower Segment Caesarean Section- In this case, the uterus is opened in the lower segment and the baby’s head or breech as the case may be is delivered.

3. Emergency C Section- When there is suspected danger to the mother's or baby’s condition an emergency section is resorted to.

4. Elective Caesarean Section (Planned C-Section)- The caesarean is planned and done on a specific date chosen by the patient and the doctor after assessing the maturity of the baby.
Caesarean Section

Indications:

1. Emergency Caesarean section:
Fetal distress- During the course of labor or even before the onset of labour, if a baby at or near full term, is found to have a slow or irregular heart rate, it signals distress for the baby. The baby may also send SOS signals by passing meconium, which becomes evident when the amniotic fluid leaks out. This could happen due to separation of the placenta and bleeding, or many other problematic situations affecting the mother. Likewise, if the umbilical cord slips out during labor the blood supply to the baby could be hampered. If the baby is not delivered immediately at this point of time, it could baby die even before being born. This is an emergency situation and the baby has to be delivered immediately.
  • Maternal distress- If the mother is subjected to life-threatening eventuality during or before labour, like excess bleeding or surge of blood pressure, an emergency caesarean has to be done to save the mother’s life.
  • Mechanical impedance to the progress of labor- The mother's birth passage being too narrow, or the baby being oversized for the mother’s birth canal or failure of the contractions to progress as they should all lead to failure of the normal vaginal birth and can endanger the baby's life necessitating Caesarean section.

2. Elective Caesarean section:


  • Previous Caesarean section quite often becomes an indication to deliver the next child also by a caesarean section. Concerns about previous scar on the uterus giving way during normal labor often leads to this decision.
  • Previous Classical Caesarean section also leads to a repeat Caesarean as these scars tend to be rather weak and may tear open during a normal vaginal delivery.
  • Placenta praevia grade 4
  • Abnormal position of the baby such as breech or transverse lie where the baby lies across the mother’s womb.
  • Tumors within the mother's pelvic cavity, or large ovarian cysts
  • Genital herpes in the mother– Here a Caesarean is resorted to so that the mother’s infection does not pass on to the baby during its journey in the mother’s birth canal
  • Medical problems in the mother like high blood pressure, diabetes etc. are also dealt with by Caesarean in centres
  • Triplets or more number of babies
  • HIV infection in the mother is another instance when Cesarean section is done to prevent transmission of the infection to the baby in the course of a normal delivery.
Indications

1. Emergency Caesarean section:

 

  • Fetal distress-during the course of labor or even before the onset of labour, if a baby at or near full term, is found to have a slow or irregular heart rate, it signals distress for the baby. The baby may also send SOS signals by passing meconium, which becomes evident when the amniotic fluid leaks out. This could happen due to separation of the placenta and bleeding,  Likewise, if the umbilical cord slips out during labor which is known as the prolapse of the cord, the blood supply to the baby could be hampered. This is an emergency situation and the baby has to be delivered immediately at this point in time.

 

  • Maternal distress-if the pregnant woman experiences life-threatening emergencies before or during labour, like excess bleeding or an alarming increase of blood pressure inspite of medical treatment, an emergency caesarean has to be done to save the mother's life.

 

  • Mechanical impedance to the progress of labor -This could be in terms of the birth passage of the pregnant woman being too narrow;  the baby being oversized for the mother’s birth canal; failure of labour to progress in terms of the descent of the baby . All these conditions would lead to failure of the normal vaginal birth and necessitate Caesarean section.

 

2. Elective Caesarean section:

 

  • Previous delivery by Caesarean section quite often becomes an indication to deliver the next child also by a caesarean section. This is due to the concern that the previous scar on the uterus might give way during a successive normal vaginal delivery.

 

  • Previous delivery by Classical Caesarean section also leads to a repeat Caesarean as these scars tend to be more weak and could rupture during a vaginal delivery.

 

  • Placenta praevia grade 4

 

  • Abnormal position of the baby such as a transverse lie where the baby lies transversely across the mother’s womb.

 

  • Tumors within the pregnant woman's pelvic cavity, or large ovarian cysts

 

  • Genital herpes in the mother –here a Caesarean is resorted to so that the mother’s infection does not pass on to the baby during its journey in the mother’s birth canal

 

  • Medical problems in the pregnant woman like high blood pressure, diabetes etc. are also dealt with by Caesarean in some instituitions

 

  • Triplets or more number of babies

 

HIV- In women with HIV infection Caesarian section is done, as the maximum chances of spread from the mother to the baby occurs around the time of vaginal delivery.

Preparation for Caesarean Section

Preparation is done as for any major operation -

Blood tests:

• Hemoglobin, Packed cell volume

• Blood sugar

• Blood grouping

• Thyroid hormone levels
Urine test:

For protein and sugar are some of the basic tests done

Further tests depending on the pregnant woman's condition is also done.

  • Blood is typed and cross-matched in case there is excess bleeding and blood transfusion is required.
  • The pregnant woman should not have anything to eat or drink for at least six hours prior to the surgery.
  • She will be given medications to reduce the acidity of the stomach and will have an Intravenous fluid infusion commenced. To maintain the hydration at an optimum level.
  • The abdomen will be cleaned by means of an antiseptic solution.
  • A soft tube is passed into the urinary bladder to help the mother to pass urine after the delivery, as she may not be able to move about for the first 24 hours.
  • The baby’s heartbeat is monitored with the fetal monitor, as are the mother’s pulse, BP and ECG.
Anesthesia For Caesarean Section

Before any operation, the patient has to be anesthetized so that she does not feel the pain and likewise for a caesarean section, the anesthesia is administered before the operation.

 

The anesthesia can be of the following types:



1. General Anesthesia

 

2. Spinal Anesthesia

 

3. Epidural Anesthesia

 


Spinal Anesthesia is the commonest type of anesthesia used the world over because of its ease of administration, safety for the mother and the baby, and early return to normal activities including feeding the baby by the mother.

Epidural anesthesia is used in situations when it is already in place for a painless labor, or in certain heart conditions wherein an epidural is safer than even a spinal anesthetic.

General Anesthesia is administered when there are bleeding or clotting problems in the woman which prevent a spinal or epidural or in cases of fetal distress, when there isn't sufficient time to administer spinal anesthesia.

Operation

1. Once the abdomen has been disinfected by means of an antiseptic solution, it is opened via a curvilinear incision in the lower part of the abdomen, (laparotomy) a few centimeters above the pubic hairline. (Bikini incision)

2. The muscles over this region are incised and then the uterus is opened at its lower portion. (Hysterotomy). Before the uterus is opened, care in taken not to injure the urinary bladder, which lies very close to the uterus at this point. The bladder is pushed downward and away from the area to be operated.

3. Once the uterus has been opened, the waters surrounding the baby is sucked out and then the surgeon passes his hand into the uterus and grasps the “presenting part” of the baby. This is the lowermost part of the baby present within the uterus-it could be the baby’s head or breech, or occasionally its back.

Once the presenting part is within the doctor’s grasp, he gently pulls the baby out. The baby’s mouth is immediately sucked to remove any water it may have swallowed.

4. The umbilical cord is then clamped and cut to free the baby from the mother. The baby is wrapped and taken under the pediatrician's care. The delivery of the baby in a Cesarean section is accomplished in about 5 minutes or less to minimize the effect of anesthesia and surgery on the baby.

5. Meanwhile, the placenta or ‘after-birth’ is then removed from the mother's uterus. The inside of the uterus is wiped clean to remove any bits of placental membrane sticking to it. The opening in the uterus is then stitched up.

6. At this point the obstetrician may request the anesthetist to administer medicines it shrink the expanded uterus quickly in size, almost to the pre-pregnancy level. This will ensure that there is less bleeding from the uterus.

7. The abdomen is then closed and a sterile dressing is applied over the incision.

8. The mother is recovered from anesthesia and moved out of the operating theatre. She is allowed to commence breast-feeding as early as possible.

Complications

Even though Caesarean as a surgical procedure has become a safe procedure in the right hands, complications can arise during or after the operation.

Complications that could occur during the operation are:

1. Hemorrhage or Excess bleeding

2. Injury to the nearby structures like- ureters, urinary bladder, intestines.

3. Perforation or hole in the uterus.

4. Aspiration or inhalation of the contents of the stomach into the lungs during anesthesia is the most dreaded complication of general anesthesia during a caesarean section. This can be avoided to some extent by ensuring a minimum starvation period of six hours for solid food and milk. This precaution may have to be bypassed during an emergency

5. Amniotic fluid embolism is entry of amniotic fluid from the mother's womb into the blood stream and then into the lungs. This complication carries a very high mortality but fortunately it is also very rare. It cannot be prevented.

6. Shock due to excess bleeding

Post-operative late complications include:

1. Bleeding

2. Infection of the wound site

3. Thrombosis or clot formation in the large veins of the leg or hips can occur. If these clots get dislodged from the leg and move into the lung, they can cause a fatal complication called pulmonary embolus

4. Ileus or paralysis of the bowels for a couple of days which then recovers.

5. Atelectasis is collapse of a portion of the lungs, which is quite common after an abdominal surgery under anesthesia.

6. Urinary tract infection is also a possible complication in the post-operative period

7. Fever can also annoy the mother occasionally

8. Headache due to the spinal anesthesia

9. Depression can also happen in the post-op period.

Recovery and recuperation

• The patient is given antibiotics to prevent infection, painkillers to combat the pain, medicines to counter the vomiting tendency, as well as medicines to shrink the uterus to normal size.

• After 24 hours she can start moving around and can even commence on a soft diet.

• The sutures are removed on the 4th day and if all is well, the mother is allowed to go home.

Each individual requires 3-4 weeks to get back to normal. The mother can resume normal activities after about a month.

FAQs

1.What is classical Caesarean section?

Here the uterine incision is done in the upper portion of the uterus. This is not practised nowadays as it is more prone to rupture during a subsequent procedure or labor.

2. If my first child was born via Caesarean section, can I not undergo a normal delivery for my next child?

One can have a vaginal birth after Caesarean (VBAC) except for those cases where the first Caesarian was performed for conditions like small, deformed pelvis and so on. Your obstetrician will be best person to judge whether or not you can undergo a normal delivery.

3. After a caesarean section should I not lift heavy weights?

You can lead a normal life by the end of one month. Until then you can avoid doing heavy manual work

4.What is the best anesthesia to have for a Caesar?

Spinal and epidural are safe for the mother as well as the baby. General anesthesia is associated with more complications but may have to be the anesthesia of choice in certain maternal conditions

5. I have heard that a spinal or epidural can cause backache in the future-is this true?

A spinal or epidural cannot give rise to a backache which did not exist before. Every woman who goes through pregnancy and childbirth, be it normal vaginal delivery, Caesarean section under general anesthesia or Caesar under spinal anesthesia is at a high risk category of developing backache due to the altered mechanics of the back during pregnancy. Weight gain, bearing extra weight of the fetus, alteration of the curve of the backbone during pregnancy, stretching of muscles of ligaments all contribute to the occurrence of backache following pregnancy. The backache cannot be attributed to the spinal or epidural anesthesia. It is therefore imperative to do post-natal exercises to strengthen the back and abdominal muscles and regain the lost tone to minimize the occurrence of backache.

6.My colleague who underwent a C-section for her baby’s delivery had to undergo a hysterectomy (uterus removal) at the same time. What is that due to?

Rarely the mother may bleed excessively during a c-section. At such times, when all measures to stop the massive blood loss have been tried and has failed, a hysterectomy or removal of the uterus is done as a last resort to save the mother from dying due to excess hemorrhage. This scenario is also fortunately very rare.

7.Following a caesarean section, will I be in position to feed my baby?

You may have pain in the post operative period which can be taken care of by means of medications given either via the epidural catheter, or as a suppository or as injections and you will then be able to feed your baby.

8.Would I require a blood transfusion during C-section?



If you have lost a lot of blood, you may require a packed cell transfusion. If the bleeding is not easily controlled, you may require a transfusion of the clotting factors or platelet cells.

Glossary

Laparotomy- Opening the abdominal cavity.

Hysterotomy- Opening the uterine cavity.

Hysterectomy- Removing the uterus.

Placenta praevia- Placenta lying low in the uterus, sometimes covering the mouth of the uterus completely so as to prevent the baby’s passage into the birth canal.

Abruptio placentae or placental abruption- Separation of the placenta from its uterine bed, causing mild or at times life threatening bleeding in the mother, compromising the fetal well being as well.

Meconium- Sticky blackish stool that the baby passes during the newborn period.

Pulmonary embolus- This can be a life threatening complication-it is a clot that has traveled from the leg veins up into the heart and blocked the blood supply to the lungs.

Hemorrhage- Bleeding from any site-at times heavily.

References:-


1. The impact of cesarean delivery on transmission of infectious agents to the neonate.
Sharma D, Spearman P.
Clin Perinatol. 2008 Jun;35(2):407-20, vii-viii

2. U.S. Public Health Service Task Force recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV-1 transmission in the United States.
MMWR Recomm Rep. 2002 Nov 22;51(RR-18):1-38;

3. Bladder injuries during cesarean section in a University Hospital: a 25-year review. Arch Gynecol Obstet. 2008 Jul 22

Compiled by: Dr. Gayathri

 

Reviewed by: Dr. Sunil Shroff

 


Uploaded by: Lingaraj

    

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