A simplified approach to understand the caesarean section starting from the origin to categories, indications, incisions, preoperative preparation, intraoperative considerations, Post-operative care, possible complications, and Vaginal birth after caesarean.

1. Halder Jamal September 24th, 2023
Caesarean Section

2. VBAC-TOLAC
Complications
Post-Operative Care
Surgery
Preparation
Incisions
Why?
Categories
Caesarean Section

3. Caesarean Section
• A surgical procedure in which delivery is done via a
laparotomy & a hysterotomy.
• WHO: globally, 1 of 5 babies delivered by C/S,
expected to rise to 1 of 3 by 2030.

4. • Roman law (Lex Caesarea) in 715 BC
• Caedere is a latin word = to cut
• The first woman surviving a C/S was
around 1500, in Switzerland, done by
Jakob Nufer on his wife for prolonged
obstructed labour.
• Thereafter, it had a high mortality and
was performed only when the mother
was already dead or considered to be
beyond help.
• Inés Ramírez is supposably the only
women who did C/S on herself on
march 5th, 2000, and succeeded (she
and her baby survived)
From antiquity to nowadays

5. Inés Ramírez Pérez:
"I couldn't stand the pain
anymore. If my baby was
going to die, then I decided I
would have to die, too. But if
he was going to grow up, I
was going to see him grow
up, and I was going to be with
my child. I thought that God
would save both our lives."

6. Categories
• Emergency C/S (category 1)
• Urgent C/S (category 2, 3)
• Elective C/S (category 4)
• Caesarean Hysterectomy
• Emergency Caesarean Hysterectomy

7. Why?
• Either for fetal or maternal interest or both.
• Often ≥ 2 risk factors.
• No list can be fully comprehensive.

8. Indications
• Previous C/S: 2 LSCS or 1 classical C/S
• Dystocia
• Maternal medical conditions
• Mal-presentations
• Suspected fetal compromise
• Multifetal gestation
• Fetal disease
• Placental disorders (previa, accreta)
• Cephalopelvic disproportion

9. Abdominal Incisions
Pfannenstiel
Midline Vertical
Maylard
Joel-Cohen

10. Midline Vertical Pfannenstiel

11. Midline Vertical Pfannenstiel

12. Uterine Incisions

13. LSCS is the standard method (98.5%).
• Advantages:….
• Disadvantage: longitudinal lie & a developed lower segment
Classical C/S Indications:
Uterine Incisions
• Transverse lie with the fetal back inferior.
• Preterm delivery with poorly formed lower segment
• Placenta Praevia with large vessels in lower segment.
• Severe adhesions in lower segment reducing accessibility.
• Large cervical fibroid
• Previous classical C/S
• Preliminary to caesarean hysterectomy e.g cervical cancer
• Postmortem C/S

14. Preparation
• Hx
• Ex
• Ix: US, CBC, Blood group, FBS, GUE, LFT, RFT, Virology.
• Informed written consent for surgery, anesthesia &
transfusion.
• Ensure availability of blood & neonatal resuscitation
• Fasting: 6-8 h for foods, 2 h for liquids.
• Stop anti-thrombotics (antiplatelets & anticoagulants)
accordingly.

15. • Anesthesia: mainly regional (spinal/epidural), but can also
use general anesthesia or local infiltration.
• Positioning: supine position 15 degree tilting to left lateral
position.
• Foley’s catheter should be put.
• Medications: injection of PPI, start antibiotics, oxytocin 5
IU infused IV slowly.
• youtu.be/VkxwN8xQz80?si=hdT6YiiRy2cEEh6h
Surgery

16. Post-Operative Care
• Send the patient to ward if stable or HDU/ICU if complicated.
• Observation Chart: consciousness, vitals, bleeding, uterus.
• Fluids or Transfusion.
• Prophylactic antibiotics: cephalosporins, metronidazole.
• Analgesics.
• Wound care.
• Breastfeeding.
• Vitamin C (dietary or medication).

17. • Start oral intake: when bowel sounds positive (often 4-6 h)
• Remove catheter: when she can move lower limbs.
• Remove wound dressing: after 24 h
• Remove stitches: after 7-10 days.
• Go home: after 24-48 h if no problems
• Shower: after 72 h
• Do housewife activities: after 7 days.
• Start sexual intercourse: after 40 days (puerperium)
• Exercise: after 3 months
• Heavy lifting: after 6 months
Frequently asked questions; when can I:

18. Complications
Maternal:
• Intra-operative:
• Post-operative:
• Early:
• Late:
Fetal:
• Iatrogenic prematurity
• Accidental scalpel injury.

19. Intra-operative:
• Hemorrhage; Atony, Lateral extension of incision, broad ligament hematoma.
• Extension to cervix or vagina
• Placenta accreta seen with placenta previa often ends up with hysterectomy.
• Nearby organ injuries; Bladder, Bowel, Ureteral
Post-operative:
• Early:
• Late:
Complications

20. Intra-operative:
Post-operative:
• Early:
• PPH & Shock
• Anesthetic hazards: N&V, Hypotension, Aspiration, spinal headache.
• Infections: endometritis, UTI, peritonitis, pneumonia, septic pelvic thrombophlebitis.
• GIT: Constipation, Intestinal obstruction (paralytic ileus or mechanical)
• DVT & PE.
• Wound: infection, dehiscence, evisceration, delayed healing, bleeding.
• Late:
Complications

21. Intra-operative:
Post-operative:
• Early:
• Late:
• General surgical; Incisional hernia, intestinal obstructions, keloid scar.
• Gynecological; Menstrual irregularities, chronic pelvic/back pain.
• Obstetrical; scar rupture, placenta previa/accreta, scar ectopic.
Complications

22. Vaginal Birth After Cesarean (VBAC): Successful vaginal delivery
rate is up to 80% in carefully selected patients.
Criteria for a trial of labor a after caesarean (TOLAC) include:
• Patient consent
• 1 LSCS
• No repeat indication of C/S
• Clinically adequate pelvis.
• Advanced staff for TOLAC & emergency C/S when needed.
VBAC-TOLAC