Caesarean Section: Indications, Procedure, Advantages And Complications

Cesarean delivery (C-section) is a childbirth technique in which incisions are made in the abdomen and uterus.

It may be necessary to get ready for a C-section if certain pregnancy problems occur. After a previous C-section, some women may undergo another one. However, frequently the requirement for a first-time C-section cannot be determined without labour.

Knowing what to expect before, during, and after a C-section might help you prepare if you're expecting.

Indications of CS 

Maternal Indications

• Previous CS
• Abnormal placentation
• Classical CS
• Scar dehiscence
• Full thickness Myomectomy
• Genital tract Obstructive mass
• Invasive Cervical cancer (combine with hysterectomy)
• Prior Trachelectomy
• Permanent cerclage
• Reconstructive Surgeries
• Pelvic deformities
• HSV or HIV Infection (only when Viral load is high)
• Cardiac & pulmonary disorders
• Cerebral aneurysm
• Perimortem CS

Maternal - Fetal Indications

• Cephalopelvic Disproportion
• Failed Operative Vaginal delivery
• Placenta Previa
• Abruption with fetal distress

Fetal Indications 

• Non-assuring fetal heart pattern / Fetal distress
• Mal-presentation
• Congenital anomalies
• Abnormal Doppler studies (REDF
• Reverse End Diastolic Flow) 
• Prior Fetal birth trauma

Procedure of C-section 

Preparation

1. Consent
2. Antacid 30 ml  to prevent MENDELSON SYNDROME (Aspiration Pneumonitis)
3. Regional anesthesia (Neuraxial)
4. Sensory block should be at T4 level and below (Epidural anesthesia in normal delivery should be at T10 to L1 & S2-S4)
5. Best position is Supine with wedge under the right hip
6. Prophylactic Antibiotics like Cephalosporin (Cefazoline 1gm once). No routine continuous Antibiotics, no routine Catheterization
7. Preparation of Abdomen- Shaving is not done as it increases risk of infections whereas Clipping of pubic hair can be done
8. Check the Fetal heart sound prior to incision in OT
9. Decision to delivery should not be more than 30 minutes in case of emergency cesarean

Abdominal Incision

• Easy & fast incision is Vertical
• Preferred incision is Low Transverse / Bikini incision / Pfannensteil incision / Maylards incision
• Side effects of Lower Abdominal Incision
  • Ilioinguinal nerve injury
  • Ilio-hypogastric nerve injury
  • Superior & inferior epigastric vessel injury

Classical CS: Upper Segment CS Indications

1. Bladder Fibrosis (MC indication)
2. Lower segment tumor like fibroid, Ca Cervix
3. Post Mortem CS
4. Old VVF repair

Incision on Uterus

1. Kerr’s Incision
   • Transverse Incision
   • MC Incision on Uterus
2. Kronig Incision: Vertical Incision

Advantage of Transverse incision

• Cosmetically better
• Pfannenstiel incision –Rectus sheath not cut, only separated 
• Maylards incision- Rectus sheath cut

Cesarean Section Complications

Previous LSCS Scenario

• VBAC [Vaginal Birth after Cesarean]
• TOLAC [Trial of labor after Cesarean]
• Trial of scar
• Rupture of Uterus can happen
  • Partial rupture/ Scar Dehiscence: Uterine Scar is separated but Peritoneum & bag of membranes is intact  
  • Total Rupture of Uterus : Uterine Scar, Peritoneum & bag of membranes all have ruptured and baby may be found floating in abdomen
• Signs of Rupture of Uterus in a VBAC/TOLAC  are:
  • Maternal Tachycardia (1^st sign)
  • Vaginal bleeding, ↓↓ BP
  • Fetal distress (Late sign)
  • Loss of Uterine contractions & labor pains
  • Loss of Uterine contour 
  • Fetal parts felt more superficial in abdomen & they might be in sideways & not in midline

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