THIS WAS PRESENTED AT SAFOG MOGS "SMART CONFERENCE "IN MUMBAI PREPARED WITH HELP OF DR SUCHITRA PANDIT,DR CN PURANDARE AND DR ALPESH GANDHI.....VIDEOS CAN BE SEEN AT U TUBE

1. PROF.NARENDRA MALHOTRA
M.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G.,F.I.C.S.
• Prof. Dubrovnick International University
• V.P. WAPM(world association of prenatal medicinne)
• President ISAR
• Presiddent Elect ISPAT
• Sec Gen SAFOG
• Member FIGO guidelines committee
• President FOGSI (2008-2009)
• Dean I.C.M.U. (2008)
• Director Ian Donald School of Ultrasound
• National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course
• Managing Director GLOBAL RAINBOW HEALTH CARE
• Director ART-RAINBOW –IVF
• Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy
and Infertility, ART & Genetics
• Member and Fellow of many Indian and international organisations
• Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award,
Corion award, Man of the year award, Best Citizens of India award
• Over 50 published and 200 presented papers
• Over 100 guest lectures given in India & Abroad and 24 ORATIONS
• Organised many workshops, training programmes, travel seminars and conferences
• Editor 18 books, many chapters, on editorial board of many journals
• Editor of series of STEP by STEP books
• Revising editor for Jeatcoate’s Textbook of Gynaecology 7th and 8th edition (2015)
• Very active Sports man, Rotarian and Social worker
MALHOTRA NURSING & MATERNITY HOME PVT. LTD.
GLOBAL RAINBOW HEALTH CARE,AGRA
84, M.G. Road, Agra-282 010
Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : 0562-2265194

2. difficult c.section
narendra malhotra
jaideep malhotra
neharika malhotra bora
dr alpesh gandhi,dr cn purandare,dr suchitra pandit
mnmhagra3@gmail.com
www.rainbowhospial.org

3. CAESAREAN SECTION
“yet another way to get OUT!”CESAREAN BIRTH IS AN UNNATURAL
METHOD OF A NATURAL EVENT.

4. CESAREAN DELIVERIES
BECAME SAFER
1) Better anaesthetic technique.
2) Better antibiotics.
3) Availibility of blood transfusion .
4) Improved surgical techniques.

5. Common factors responsible for increased
caesarean section rate
• Rising maternal age
• High levels of maternal education
• Previous caesarean section
• Obstetric complications
• Maternal request
• High income level and social class
• Prevention of pelvic floor Injury
• Fear of litigation
Tatar M et al Soc Sci Med 2000; 50 : 1227-33.
Lynch CM et al Eur J Obstet Gynaecol Reprod Biol 2002; 432 : 1-4

6. INDICATIONS FOR ELECTIVE CS
• Known CPD
• Fetal macrosomia > 4500
gm
• Placenta previa
• VV fistula repair
• HIV
• Active herpes
• Repeat CS
• Uterine surgery eg.
Hystrotomy, myomectomy
• Severe IUGR
• Breech
• Multiple pregnancy
• Transverse lie
• Ca of the Cx/ TR
obstructing the birth canal

7. INDICATIONS FOR EMERGRENCY CS
• Severe PET
• Abruptio placntae
• Fetal distress
• Failure to progress in the first stage of labour
• Cord prolapse
• Obstructed labour
• Failed induction
• Malpresentation  brow, chin post, shoulder &
compound presentations, breech
• Compromised fetus 2ry to DM, HPT, isoimmunization
• APH

8. TYPES OF CS
• Lower segment CS
• Classical CS
Indications for classical incision:
• Transverse lie with SROM
• Structural abnormality that makes lower segment
approach difficult
• Constriction ring with neglected labour
• Fibroids in the lower segment
• Ant PP & abnormally vascular lower segment
• Mother dead & rapid delivery is required
• Very preterm fetus in breech presentation

9. RCOG, Oct 2001:
70% of caesarean sections indications
were
 Dystocia
 Foetal distress
 Breech
 Previous caesarean section
RCOG Clinical Effectiveness support unit October 2007; 3.
Cesarean Section Rate

10. DIFFICULTIES WITH CAESAREAN SECTION
Cesarean section is commonly perceived as a
simple and safe alternative to difficult
vaginal birth

11. Difficulties
• Many difficulties attend Caesarean section, and many
disasters can follow it, so the list below is long.
1.Torrential bleeding when you cut through a placenta
praevia can kill a mother.
2.Disasters with the urinary tract are usually the result of
very poor technique.
3.Fortunately, most of the others are rare. S
• Some of these many difficulties are only seen in the
developing world, where inexpert operators find
themselves working under difficult circumstances.

12. Difficult Situations in LSCS
• Difficult abdominal access
• Difficulties with uterine incision and closure
• Difficult baby deliveries
• Difficult placental deliveries
• Difficulties in controlling haemorrhage
• Difficult abdominal closure

13. DIFFICULTIES WITH THE INCISION
• If a patient has had a PREVIOUS
CAESAREAN SECTION, dense adhesions
may have formed between her uterus
and her abdominal wall.
• They would have been much less likely
to have formed, if her omentum had
been placed between her uterus and her
abdominal wall, at the last operation.
• Excise the scar in her abdominal wall
with an elliptical incision.
• If the sides of this might be difficult to
join up accurately, make some scratch
marks across it and align them later

14. Difficult abdominal access
 Abdominal incision :
 Changing trends in surgical
techniques from vertical abdominal
midline incision to transverse
incision
 Vertical for emergent access
 Pfannensteil
-- Muscle cutting if access restricted
(Maylard incision)
 Meticulous hamostasis to prevent
subfascial hematomas

15. Difficult abdominal access
 Abdominal incision in previous scar
 Adequate excision of previous surgical
scar
 Special care while entering the peritoneal
cavity to avoid bladder & bowel injury
 Peritoneum to be opened as high as
possible

16. Opening difficult abdomen
• Open her parietal peritoneum
as far as you can.
• Lift it between haemostats to
stretch the adhesions, and
divide them with the points of
scissors directed at her uterus.
• If you find a plane of loose
connective tissue, free it with a
finger or swab.
• Cut fibrous bands.
• If dissecting the adhesions is
very difficult (unusual), give up
and make an upper segment
incision.

17. Difficulties with uterine incision
 Uterine incision
 Dissect bladder
peritoneum
 Adequate deflection to
protect bladder
 Curvilinear / U or J
shaped
♦ Maximum available
space
♦ Protect the uterine
vessels
 Inverted T incision
 Occasional vertical
incision

18. Uterine anomalies

19. two uterus :two babies

20. Difficulties with uterine incision
 Uterine incision
Classical C. section
vertical incision in very
selected cases of
 Multiple previous surgeries
 Densely adherent bladder
 Leiomyoma on lower
segment
 Cervical Carcinoma

21. Caesarean section delivery
Abnormal Placentation
Preoperative check & confirmation of placental location
• Anteriorly placed low lying placenta / placenta previa
• Anticipate poorly formed & vascular lower segment
Placenta at incision site
• Access membranes by insinuating fingers between
placenta & uterine wall - then rupture membranes to access
the fetus
• Incise placenta & then rapid transplacental access &
delivery
• Delivery complicated by floating head & obstructive
placenta
• Instrumental delivery or delivery as breech

22. difficulties due to palcenta

23. Anterior Partial Placenta Previa

24. acreta/percreta

25. Difficult Baby Deliveries
• Floating head
• Deeply engaged head
• Abnormal positions and
presentations
• Transverse lie or
breech presentation
• Deflexed head
• Prematurity
• Multiple pregnancies
• Fetal malformations
• Conjoined twins

26. Caesarean Section Delivery - Floating Head
Preoperative check & assessment
• Confirmation of placental location
• Anticipate poorly formed & vascular lower segment so
modify incision
• Findings confirmed at laparotomy
• Fetus manipulated into a longitudinal lie
• Steadied by lateral support
• Membranes ruptured & liquor drained & allow the head to
descend and deliver after flexion
• Other options -Manipulate into occipito anterior or posterior
position followed by instrumental delivery by vectis, forceps
or vacuum (Metal or Silastic Vacuum cup )
• Delivery of a floating head

27. Delivery of a Floating head
video courtesy prof v p pailey

28. Non engaged HEAD
• However, several trends in obstetrical practice may act in concert to
cause impaction of the fetal head during the second stage of labor
or, more commonly, following failed instrumental delivery.
Subsequently, difficult and potentially traumatic disengagement of
the deeply wedged head during cesarean section occurs. The
maneuvers to disengage the wedged head include pushing
(bimanual or by an assistant) the head through the vagina or,
alternatively, pulling the infant's feet through the uterine incision.
Although both methods may cause serious maternal and neonatal
complications, available data seem to favor the pulling method and
better outcome seems to depend on adequate uterine relaxation,
the patient's position during operation, and special attention to the
uterine incision. More data are needed to establish the frequency
and extent of intraoperative disengagement dystocia and to
determine the management protocol that carries the lowest risk in
such circumstances.

29. Forceps Application at Caesarean
Section
Nuances of forceps application for cephalic
presentations
• Sagittal suture placed transversely
• Slight fundal pressure to push head towards the incision
• Concavity of the pelvic curve towards the fetal occiput
• Lower blade is applied first followed by the anterior
• Flex fetal head with traction aided by fundal pressure
• Crowning of the fetal head in abdominal incision
• Delivery by controlled extension
- Sheriar et al, In Hay’s Forceps - An Atlas Monograph,1991

30. Forceps Application at Caesarean Section

31. Making Instrumental Deliveries
Safer
Instrumental Delivery at CS
• Forceps application at
cesarean section in 253
cases
• For floating head, after
coming head & prophylactic
• Enables flexion, controlled
delivery & reduced trauma
- Sheriar et al, Asia Oceania J. Obs
Gyn, 19:121, 1991

32. Ventouse application at CS
Vacuum devices can be used at the
time of cesarean delivery to effect
delivery of a high unengaged fetal
head or as an alternative to extension
of the hysterotomy when delivery of
the vertex is difficult. Once the head is
visible through the uterine incision,
the vacuum device can be applied
directly to the vertex and delivery
achieved with gentle upward traction
in concert with fundal pressure.
Although such an approach may
reduce the risk of extension of the
original hysterotomy, it is not
recommended for all cesarean
deliveries.

33. Caesarean Section Delivery
Deeply Engaged Head
Preoperative check & preparation
• Often second stage procedures
• Awareness of signs of impending rupture
• Trendlenberg position & uterine relaxant anesthesia
• Catheterising the bladder important !
Pre plan uterine incision
• Low incision :
– Vaginal disengagement or manual disimpaction
– Negative pressure overcome by insinuating
fingers below presenting part
– Delivery by breech
– Vectis, Ellis disimpactor (still under research) or
forceps use
• Higher incision – level of fetal shoulders
– Patwardhan or modified Patwardhan maneuver

34. Vectis Delivery at Caesarean Section

35. Patwardhan’s method of delivery of
impacted head when back is posterior

36. Modified Patwardhan’s method of delivering impacted
head when back is anterior -

37. J Perinat Med. 2004;32(6):465-9.
Difficult delivery of the impacted fetal
head during cesarean section:
intraoperative disengagement
dystocia.

38. Caesarean Section Delivery - Malpresentations
Planning delivery in a Tranverse lie
• External cephalic version is an option if membranes intact
• Transverse lie to be converted to longitudinal
• Cephalic version is an option though conversion to breech by
traction on feet preferred
• Knowledge of position of fetal head is important . A liberal J shaped
incision in LUS is usually required if baby is term with or without
PROM
• Inverted ‘T’ incision to be avoided
• Neglected transverse lie is a dangerous situation and possibility of
extension of the incision exists.
• Beware of sepsis if membranes have been ruptured for long !!!

39. Breech Delivery
• Abdominal delivery no different from vaginal breech
extraction with many of the risks
• Limbs manipulated through natural range of movement
• Trunk supported by the pelvic girdle to encourage suitable
rotation .The premature breech is more prone to injury as
the lower segment is thick walled, narrow & retractile
Delivery of after coming head
• Avoid trapping of after coming head by the retracting
• uterus especially in premature breech (Head- trunk ratio)
• Mauriceau Smellie Veit maneuver
• Forceps application

40. Caesarean Section Delivery
Multiple Pregnancies
Planning delivery
• Identify placental location
• Judge the fetal lie & relationships
• Plan delivery of presenting fetus
• Adequate abdominal & uterine incision
Technical nuances
• Care taken to deliver floating head or breech
• Orientation may be distorted
• Mobilize adequate neonatal support
• Double clamp the cord of the first fetus after delivery of first baby
to avoid retrograde bleeding from the placenta
• Experienced neonatologist at hand
• Aggressive prophylaxis for postpartum hemorrhage

41. Twin delivery during CS

42. “Atraumatic delivery is the goal of an
obstetrician”
Possible causes of injury:
• Deep or uncontrolled uterine incision lacerating the
fetal parts.
• Inappropriate or inadequate uterine incision
trapping the fetal parts.
• Haste or difficulty in fetal extraction.
Injuries of Newborn

43. Difficult placental deliveries
• Placental delivery by controlled
cord traction preferred over
manual removal of placenta
• Adherent placenta
• In obvious increta / percreta
avoid placental removal
• After ligating the cord close to
placental attachment, Uterus
can be closed
• Oxytocics given
• Post-op. adjuvant chemotherapy
with Methotrexate to  the rate
of resorption of placental tissue

44. Difficult placental deliveries
 Haemorrhage due to partially separated
placenta
 Resuscitative measures
 Bilateral uterine artery ligation
 Bilateral Internal iliac artery ligation
 Cesarean hysterectomy

45. Difficulties with uterine closure
 Closure of uterus
 Transverse LSU incision with single layer
& further haemostatic sutures if required
 Vaginal entry can occur if
 Placing the incision too low
 Following prolonged labor when cervix
fully dilated
 Repair of a vaginal incision with proper
haemostasis

46. Difficulties in controlling haemorrhage
 Strategies to minimize intraoperative blood loss
 Loose UV peritoneum is incised and not
fascia over the uterine incision
 Avoid wide lateral dissection of the bladder
 Plan the uterine incision properly
 Careful delivering of fetal head to avoid
extension of the uterine incision
 Prefer spont. expulsion of placenta
 Prophylactic use of oxytocics drugs
 Clamping the cut edges of uterine incision
with haemostatic forceps.

47. Control of intraoperative bleeding
1. Localized site : Pressure by a sponge on
holder or pack to isolate the bleeding site
and then deep interrupted sutures to ligate
bleeding preferably with chromic catgut No.
1 as with delayed absorbable sutures
cutting through tissue is common.

48. Bleeding from angles and suture line

49. Control of intraoperative bleeding
2) Step-Wise Devascularization of The Uterus
• 1st reported from Egypt
• Effective in controlling PPH in 80% of cases
- Shobhana TOGS, vol.2; No.3, April-May 2006
• Unilateral uterine artery ligation
• Bilateral uterine artery ligation at the upper part of the
lower uterine segment
• Low uterine vessels ligation after mobilization of the
bladder
• Unilateral ovarian vessel ligation
• Bilateral ovarian vessel ligation

51. Control of intraoperative
bleeding3) B-Lynch Suture
• Simple, effective, relatively safe and requires
minimal expertise.
• A woman meets the criteria for the B-Lynch
compression suture if bimanual compression
decreases the amount of uterine bleeding by
abdominal and perineal inspection.
• Worldwide more than 1300 successful
application of the technique
EL Hamomy J OBGY, Vol 25,No 2 Feb,2005,143-49
• Modified technique:
- Cho’s squre suture
- Hayman’s modification
Equally effective
Hayman RG et al Obstet Gynaecol, 2002

52. 4) Internal iliac artery ligation
• Experiments in the 1960s by Burchell ascertained
that the effect of ligation of the Internal iliac
(Hypogastric) artery was to convert the affected
pelvic circulation to a venous system, thereby
allowing clotting to develop and persist resulting into
control of PPH.
- Burchell RC Obstet
Gynaecol,1964,24:737-39
• Effective in uterine atony, midline perforation, large
broad ligament or lateral pelvic haematoma, multiple
cervical tears, lower segment bleeding
• Less effective in placenta accreta.
• Not useful for uterine laceration.
Control of intraoperative bleeding

53. Control of intraoperative bleeding
5) Obstetric Hysterectomy
• Indications for Subtotal Hysterectomy
- Atonic PPH
- Rupture uterus unrepairable
• Indications for Total Hysterectomy
- To control bleeding from
Lower segment of the uterus
Cervix
Vagina

54. Conclusion
• As an obstetricians, it is our endeavor to
have a healthy mother and healthy baby at
the end of pregnancy. If LSCS is the better
mode to achieve this, we may opt for it while
keeping in mind the inherent risks and
difficulties of it as a surgical procedure.

55. SUGGESTED READING

56. some of our books of AICOG