1. Presentation on Caesarean delivery
By Daniel Angamo, IEOS year – I
Instructor: Dr. Yisihak Tesemma, Obstetrician &
Gynecologist
Venue: Mizan Aman General Hospital

2. Caesarean section
Definition:
The delivery of a viable fetus through an
incision in the abdominal wall and uterus,
usually carried out after viability has been
reached i.e. 28 – 38 weeks of gestation
onwards.
Definition does not include removal of fetus
from abdominal cavity in case of rupture
uterus.
WHO recommends an ideal caesarean rate
of 15-20%.

3. Why called so??
The technique was not widely used until the 1920s.
According to legend, Julius caesar was born by this
operation
There is disagreement concerning the adjective
‘cesarean’ describing this procedure did not
emanate from Julius Caesar's reign but rather from
Numa Pompilius II, who in 730 BC decreed the
procedure be performed upon women dying in the
last few weeks of pregnancy in the hope of saving
the child.
The term may arise from a combination of the latin
verbs (caedere) and (Seco) both meaning to cut.
It was a fatal operation until beginning of 20th
century.
Now the most common operation performed
worldwide

4. INCIDENCE:
 The incidence of caesarean section is
steadly raising.
 During the last decade there has been 2 – 3
folds rise in the inciddence from the initial
rate of about 5% – 10%.
 The incidence of the procedure was stable(3-5%)
for many years, yet since 1960s, the rate of CS
was rising steadily reaching (20-25%) in late
1980s.

5. Why rates increasing?
An increase in the rate is due to:
• Increased awareness of fetal well being and
idenification of risk factors have caused
reduction of difficult operation or
manipulative vaginal deliveries – high
forceps and difficult mid forceps are
abandoned in favour of Caesarean Section.
• Increased safety of operation due to
improved anesthesia, availability of blood
transfusion and antibiotics.
• Increase in repeat caesareans(>50%
increase).

6. • Increased diagnosis of intrapartum fetal
distress(10-15% increase).
• Increase in pregnancies by invitro
fertilization
• Increased repeated C.S due to
increased primary C.S.
• Destructive operations are abandoned
in favour of C.S.
• Demand of client and malpractice suites.
• Decreased morbidity and mortality with
C.S encourages its use.
• Dystocia (30% increase).
Why rates increasing?

7. Types of C/S based on time of
operation
A. Elective caesarean section:
The operation is done at a pre-
selected time before onset of labour,
usually at completed 39 weeks.
It means pre-planning for doing
caesarean section.
Indication:
CPD
Placenta previa at ANC
Bad obstetric history

8. Advantages of elective caesarean
section;
* Pre-operative good preparation as
regard sterilisation and antiseptic
measures, fasting and bowel
preparation.
* The risk of puerperal sepsis is
minimised.
* The operation is scheduled and
working is in ease.
Types of C/S based on time of operation
…

9. Disadvantage of Elective caesarean section;
* The risk of immaturity of the foetus or its lung
is present.
* Higher incidence of respiratory distress
syndrome.
* The lower segment may be not well formed.
* Postpartum haemorrhage is more liable to
occur.
* Imperfect drainage of lochia as the cervix is
closed so it should be dilated by the index
finger introduced abdominally through the
uterine incision.
Types of C/S based on time of operation
…

10. B. Emergency caesarean
delivery:
When the operation is performed due
to unforseen complication arising
either during pregnancy or labour
without wasting time following the
decision.
Indication:
Cord prolapse, fetal distress
Uterine rupture
Eclampsia
Prolonged first stage of labour
Abnormal uterine contraction
Types of C/S based on time of operation
…

11. a. Lower segment caesarean section (LSCS):
‒ It is the commonest type.
‒ The incision is done in the lower uterine segment
and may be transverse (the usual) or
vertical(rarely).
b. Upper segment caesarean section (classical
C/S):
‒ The incision is done in the upper uterine segment
and it is always vertical.
Types … based on site of uterine incision
…

12. a. Primary caesarean section:
‒ Done for the first time.
b. Repeated caesarean section:
‒ There is previous caesarean section(s).
Types … based on number of operation …

13. a. Transperitoneal: The ordinary
operation where the peritoneal cavity
is opened before incising the uterus.
b. Extraperitoneal: The peritoneal cavity
is not opened and the lower uterine
segment is reached either laterally or
inferiorly by reflecting the peritoneum
of the vesico-uterine pouch . It is
indicated in case of infected uterine
contents as chorioamnionitis.
Types … relation to peritoneal cavity …

14. Indication for Caesarean section
1. Absolute:
• Vaginal atresia, previous successful repair of vesico-vaginal
fistula.
• Advanced carcinoma of cervix
• Severe degree of contracted pelvis.
2. Relative:
• Cephalopelvic disproporton,
• Previous uterine scar and other uterine scar threatening uterine
rupture.
• Multiple fetal pregnancy and/or fetal distress.
• Malpresentations and/or cord prolapse
• Antepartum hemorrhage
• Elderly primigravidae
• Chronic hypertension, Diabetes
• Pelvis atresia
• Dystocia or dysfunctional labour
• Placental insufficiency
• Caesarian section on demand – Gossman and associates
(2005) estimated that 2.5 percent of all births in the United
States in 2003 were defined as cesarean delivery on maternal
request (CDMR).

15. Bad obstetric history as recurrent
intrauterine foetal death in last weeks of
pregnancy or repeated intranatal foetal
death.
Failed induction
Failed instrument
Post-mortem C.S. done within 10 minutes
of maternal death to save a living baby.
Other indications for C/S …

16. The previous C/S be an indication if,
a. The cause of the previous section is permanent
e.g. contracted pelvis.
b. Previous section was upper segment.
c. Suspected weak scar as evidenced by:
‒ History of puerperal infection after the previous
section.
‒ Hysterosalpingography or hysteroscopy done after
the previous section reveals a defect in the scar.
‒ Vaginal bleeding during current labour.
‒ Marked tenderness over the scar during current
labour.
‒ Associated conditions as antepartumhaemorrhage
or malpresentations.
Previous C/S as indication

17. 1. Dead foetus: except in;
a. Extreme degree of pelvic contraction.
b. Neglected shoulder.
c. Severe accidental haemorrhage.
2. Disseminated intravascular coagulation
– to minimise blood loss.
3. Extensive scar or pyogenic infection in
the abdominal wall e.g. in burns.
4. Baby is too much premature
5. Presence of blood coagulation disorder
Contraindications for C/s

18. Preoperative preparation
• Prepare mother psychologically by providing
assurance and explaining the indication,
procedure and need of caesarean section.
• Blood grouped and cross matched for emergency
requirement.
• Antibiotic prophylaxis
• Heparin as thromboprophylaxis
• Patients scheduled for elective procedure should be
kept fasting for at least 8 hours and ranitidine 150mg
should be given orally in the night before and
repeated one hour before surgery to prevent
gastric PH
• Plans to decrease potential morbidity associated with
aspiration of gastric contents should be carried out in
non-elective procedure including administration of
oral antacid (Magnesium Citrate within 1h of start of
anesthesia).

19. • Patient should be cleaned and be in clean
gown, valuable ornament should be taken off
and all make up should be removed.
• Bladder should be empty by inserting foleys
catheter – this may be done before and after
induction of anaesthesia.
• Administration of IV infusion to avoid
hypotension following spinal anaesthesia, the
infusion line is maintained patent by an intra
venous cannula.
• Parts cleansed with antiseptic solution
• Left lateral position – reduce aortocaval
compression, reduce risk of supine
hypotension
Preoperative preparation

20. Regardless of the type of abdominal wound
1. The incision should be covered with a compression
dressing and should be checked through the bandage for
bleeding & the vital signs are measured for signs of
hemorrhage.
‒ In general, the morning of the first postoperative day,
bandages are removed whether skin clips, subcuticular
closure, or mattress silk sutures have been used.
2. Care is taken to assess for the development of
hematomas, seromas, or wound infections. Areas of
redness and palpable masses or extraordinary tenderness
or induration are carefully assessed twice daily.
‒ Signs of cellulitis require cultures and antibiotic
therapy.
3. The notation of a watery discharge from the wound may
herald impending wound dehiscence and should be
treated as an emergency.
Post OP care

21. 3. With primary transverse CS, the skin clips and
mattress sutures are removed on the fourth or fifth
postoperative day or according to wound condition.
4. As after any major surgical procedure, the potential for
severe maternal postoperative complications is present.
Because of the hypercoagulable state of pregnancy, the
hazard of postoperative embolization is increased:
* Patients are encouraged to ambulate on the first
postoperative day and are made to turn, cough, and
deep-breathe immediately after surgery.
*The diet is progressed from clear liquids on the evening
of the operative day if surgery was in the morning,
usually beginning about 8 to 12 hours after surgery.
*Adequate pain medication is an essential component of
postoperative management.
Post OP care …

22. Supplies/ Equipment for
C/S1. Extra drape sheet
2. Towels
3. Receiving pack for baby
4. C-section tray
5. Delivery forceps
6. Cord clamp
7. Basin set
8. Blades
9. Neonatal receiving unit
10. Self-contained oxygen
11. I.D bands
12. Suction
13. Bulb syringe
14. Solutions
15. Suture

23. Anaesthesia
• Anaesthesia: General inhalation anaesthesia
with nitrous oxide + oxygen (the most
commonly used), regional (epidural, spinal), or
rarely local infiltration anaesthesia.
* Position: Tilting the patient 15⁰ to the left in the
dorsal position minimise the aorto-caval
compression.
• Mendelson’s syndrome – GA given as
emergency- risk of aspiration – chemical
pneumonitis.
• To counteract the effect, antacids given during
labour, oral fluids withheld, 30 ml 0.3 molar
sodium citrate given orally – 1/2 hr before
surgery.
• Sellick’s manoeuvre- endotracheal intubation
accompained by pressure on cricoid cartilage

24. Operation procedure – general
The non gravid uterus is a pelvic organ
closely covered by a layer of pelvic
peritoneum.
As pregnancy advances, the uterus
grows up into the abdomen and this
peritoneum rises up with the uterus and
comes into contact with the abdominal
peritoneum.
Each of these layers must be incision
and repaired.
The abdominal peritoneum is situated

25. Operation procedure - general…
The anatominal layers are:
a) Skin
b) Fat
c) Rectus sheath
d) Rectus abdominis
e) Abdominal peritoneum
f) pelvic peritoneum
g) Uterine muscles

26. • Once abdomen opened – dextrorotation
of uterus is corrected
• Doyen’s retractor- visualize lower
segment
• Peritoneum over lower segment
identified-divided transversely-
seperated from bladder by blunt
dissection
• Small incision in lower segment-
extended laterally
• Do not injure uterine vessels lying
laterally
Operation procedure - general…

27. The operation most commonly carried out is the
lower segment caesarean section.
The lower segment incision is in the less
muscular and active part of the uterus and
heals better.
The main reason for preferring the lower uterine
segment technique is the reduced incidence of
dehiscent pregnancy.
The abdomen is opened and the loose folds of
the peritoneum over the anterior aspect of the
lower uterine segment and above the bladder is
incised.
The operator continues to incise this further to
visualize the fundus of bladder which is then
Operation procedure - general…

28. The surgeon direct the fetal head out while
the assistant applies fundal pressure to hip
the delivery of the baby.
Oxytocins may be given by the anesthetist
after delivery of the baby and clamping the
cord.
When the baby and placental have been
delivered the uterus is sutured.
Uterine fundus contracts – placenta and
membranes extrudes spontaneously
removed
Operation procedure - general…

29. Uterine edges – held with ALLIS forceps
or GREEN ARMYTAGE forceps –
incision closed in 2 layers continuous
sutures
The peritoneum then be closed over
uterine wound to exclude it from the
peritoneal cavity.
The rectus sheath is closed then the
layers of fat and finally the skin is
sutured with the surgeons choice of
materials; commonly vicryl a braided
polyglactin preparation is used for this.
Operation procedure - general…

30. a. Anterior placenta praevia – try to
pass beside the placenta to reach
the foetus if this is impossible cut
through it but severe bleeding will
result which may affect the foetus.
Problems encountered during the
procedure and special techniques to
manage

31. b. Narrow uterine incision
Extension of the lower uterine segment incision
may be done by:
* "J" shaped or hockey-stick incision: i.e.
extension of one end of the transverse
semilunar incision upwards.
* "U"- shaped or trap-door incision: i.e.
extension of both ends upwards.
* An inverted T incision: i.e. cutting upwards
from the middle of the transverse incision.
This is the worst choice because of its difficult
repair and poor healing.
Problems encountered during the
procedure and special techniques to
manage

32. 1. Lower segment caesarean section:
• It is the commonest type
• After Pfannenstiel(transverse suprapubic) or
bikini line skin incision, the lower uterine
segment is incised transversely as described
by Kerr in 1921 – occasionally, a low-segment
vertical incision as described by Krӧnig in
1912 may be used.
• vertical in the following conditions;
‒ Presence of lateral varicosities.
‒ Constriction ring hindering to cut through it.
‒ Deeply engaged head.
Lower Segment Caesarean
Section

33.  Advantage of lower segment uterine incision:
• Transverse incision is made in the lower segment
heals faster and sucessfully than an incision in
the upper segment of the uterus.
• Less bleeding unless extended (as the lower
segment is less vascular and away from
implantation),
• There is less muscle and more fibrous tissue in
lower segment which reduces the risk of rupture
in a subsequent pregnancy (0.2 – 0.4%).
• Less ileus, stomach dilatation,
 Disadvantage – the LST uterine incision has a
greater tendency to extend laterally into the
uterine vessels at the time of operation.
Lower Segment Caesarean
Section …

34.  Pfannenstiel or transverse suprapubic skin
incision:
The incision is made at the level of the pubic
hairline and is extended somewhat beyond the
lateral borders of the rectus muscles.
Sharp dissection is continued through the
subcutaneous layer to the level of the fascia.
The superficial epigastric vessels can usually
be identified halfway between the skin and
fascia, several centimeters from the midline. If
lacerated, these may be suture ligated or
coagulated with an electrosurgical blade.
Lower Segment Caesarean
Section …

35. After the subcutaneous tissue has been separated from
the underlying fascia for 1 cm or so on each side, the
fascia is incised.
At this level, the anterior abdominal fascia is typically
composed of two visible layers, the aponeuroses from
the external oblique muscle and a fused layer containing
aponeuroses of the internal oblique and transverse
abdominis muscles.
Ideally, the two layers are individually incised during
lateral extension of the fascial incision.
The inferior epigastric vessels typically lie outside the
lateral border of the rectus abdominis muscle and
beneath the fused aponeuroses of the internal oblique
and transverse abdominis muscles. Thus, extension of
the fascial incision further laterally may cut these
vessels.
Therefore, if lateral extension is required, these vessels
should be identified and cauterizedor ligated to prevent
bleeding and vessel retraction if lacerated.
Lower Segment Caesarean
Section …

36. Advantage of Pfannenstiel or transverse
suprapubic skin incision:
• Follows Langer lines of skin tension
and has a better cosmetic
appearance, better healing and less
incidence of incisional hernia but it is
more time consuming when there is
more blood loss and gives less
exposure.
Lower Segment Caesarean
Section …

37. What if inadequate space in transverse
skin incision with LSCS?
*When a transverse incision is desired
and more room is needed, the
Maylard incision provides a safe
option (Ayers and Morley, 1987;
Giacalone and colleagues, 2002).
*In this incision, the rectus muscles
are divided sharply or with
electrocautery.
* The incision also may be especially
useful in women with significant
scarring from previous transverse
incisions.

38. *The subcutaneous fat is incised.
*The anterior rectus sheath is incised
transversely in case of Pfannenstiel
incision and longitudinally in case of
vertical incisions
* The rectus muscles: are separated in
the midline in Pfannenstiel incision or
retracted laterally in case of vertical
incisions
* The parietal peritoneum: is opened
vertically.
Lower Segment Caesarean
Section …

39. *The uterus is centralised, the bowel and
omentum are packed off with moist
laparotomy pads, however this is usually
unnecessary.
*The loose peritoneum over the lower
uterine segment is held and incised
transversely, for about 10 cm in a
semilunar fashion with its edges directed
upwards.
* The bladder is dissected downward and
is retained behind a Doyne retractor
placed over the symphysis.
Lower Segment Caesarean
Section …

40. * Transverse or oblique lie be corrected to
longitudinal lie before making uterine
incision.
* Transverse lie with ruptured membranes
& undeveloped lower segment require
extension of uterine incision
* A stay suture may be taken superficially
in the lower segment below the assumed
site of uterine incision to help in its
identification after evacuation of the
uterus.
Lower Segment Caesarean
Section …

41. The uterus is incised: in the same semilunar
fashion by one of the following methods:
• A semilunar mark is made by the scalpel cutting
partially through the myometrium for 10 cm.
• A short (3cm) cut is made in the middle of this
incision mark reaching up to but not through the
membranes.
• The incision (the short 3cm cut) is completed by the
2 index fingers along the incision mark or may be
enlarged by a bandage scissors over 2 fingers
introduced into the uterus to protect the foetus.
• If the lower uterine segment is very thin, injury of the
foetus can be avoided by using the handle of the
scalpel or a haemostat (an artery forceps) to open
the uterus.
Lower Segment Caesarean
Section …

42. * Membranes are ruptured by toothed or
Kocher’s forceps.
* Suction for the foetus is carried out
before delivery of the head.
* In breech or transverse lie the foetus
is extracted as breech.
Lower Segment Caesarean
Section …

43.  Delivery of the baby
• In cephalic presentation the head is delivered by;
a. Introducing the right hand gently below the head and
lifting it up helped by fundal pressure done by the
assistant,
b. using one blade of the forceps or,
c. using Wrigley’s forceps.
• If the head is deep in the pelvis it can be pushed up
vaginally by an assistant.
• The Doyen’s retractor is removed after the hand or forceps
blade is applied and before head extraction.
• Breech presentation
• Feet hooked out first
• The rest delivered as vaginal breech delivery
 The placenta is removed.
Lower Segment Caesarean
Section …

44. * Closure of the uterine incision is done in 3 layers.
• Chromic catgut or polyglactin used
• Any bleeding points – controlled with figure-of-eight
sutures
• The first is a continuous locking suture taking most of
the myometrium but not passing through the decidua to
guard against endometriosis and weakness of the scar.
• The second is a continuous or interrupted one inverting
the first layer.
• The third is a continuous or interrupted layer to close
the visceral peritoneum of the uterus – cSlosure of
visceral and/or parietal peritoneum is omitted by some
surgeons.
* The abdomen is then closed in layers .
• Parietal peritoneum – closed or not closed
• RECTUS SHEATH – non absorbable sutures-proline- to
reduce wound dehiscence & incisional hernia
Lower Segment Caesarean
Section …

45. * Less blood loss: due to less vascularity
and the placental bed is away from the
incision.
* Easier to repair.
*The resultant uterine scar is stronger
*Less subsequent adhesions to the bowel
and omentum.
*Less liability to acute gastric dilatation
and paralytic ileus.
* Less liability to peritonitis due to better
peritonization and healing.
Advantages of the lower segment
over the upper segment operation

46. 2. Upper segment caesarean section:
◦ Also called classical caesarean section – is a
vertical incision into the body of the uterus above
the lower uterine segment and reaches the uterine
fundus – it is always vertical(midline or paramedian).
◦ Is rarely performed.
 Indications:
* Dense adhesions due to previous abdominal
operation, extensive varicosity or myoma in the
lower uterine segment making its exposure or
incising through it difficult or when the lower segment
is not developed.
* Impacted shoulder presentation.
* Anterior placenta praevia.
Upper Segment Caesarean
Section

47. Indications …
* Cancer of cervix.
* Constriction ring
* Rapid delivery is indicated – fetal distress.
* Post-mortem hysterectomy or if a
concomitant tubal sterilisation will be done.
* Previous successful repair of high vesico-
vaginal or cervico-vaginal fistula.
• It may be also performed for transverse lie, fetal
major malformation (sacrococcygeal tumor,
severe hydrocephalus, etc).
Upper Segment Caesarean
Section

48. Procedure:
* Abdominal incision: is vertical.
* Uterine incision: 10 cm vertical incision is made
in the midline of upper uterine segment without
incising the peritoneal coat separately as it is
adherent in the upper segment.
* Extraction of the foetus: as a breech in cephalic
presentation.
* The last layer of the uterine incision closure
includes the superficial part of the myometrium
with the peritoneal covering.
* The remainder of the procedure is as lower
segment C.S.
Upper Segment Caesarean
Section

49. Parameters Transverse
incision
Vertical incision
Cosmetic appeal More Less
Postoperative
pain
Less More
Wound
dehiscence
Less More
Incisional hernia Less More
Technical skill More Less
Time taken More Less
Access to upper
abdomen
Less Good, can be
extended
Transverse Vs vertical skin
incision

50. 3. Others types of C/S & associated
procedures:
The lower segment vertical incision
Extra peritoneal CS
Caesarean hysterectomy
Caesarean sterilization

51. 3.1 Lower segment vertical incision
Indications:Constriction ring, lower
segment not formed
Disadv:
• Possible downward extension with injury to
cervix, vagina,bladder
• Extends into the upper uterine segment and
has been thought to have a greater
incidence of rupture during subsequent
pregnancies when compared with the LST
incision, although this has not been
substantiated.

52. 3.2 Extraperitonial caesarean
The peritoneal cavity is not opened and
the lower uterine segment is reached
either laterally or inferiorly by reflecting
the peritoneum of the vesico-uterine
pouch .
It is indicated in case of infected uterine
contents as chorioamnionitis.
(Space of Retzius)

53. 3.3 Caesarean hysterectomy
 Indications
• Hysterectomy is carried out after caesarean section for
one of the following reasons:
* Uncontrollable postpartum haemorrhage – Severe
atonic PPH
* Unrepairable rupture uterus.
* Sepsis
* Multiple large myomas
* Operable cancer of cervix.
* Placenta accreta,increta,percreta
* Couvelaire uterus.
* Severe uterine infection particularly that caused by Cl.
welchii.
*Multiple uterine myomas in a woman not desiring future
pregnancy although it is preferred to do it 3 months
later.
 Can be total or subtotal/supracervical

54. Tubal sterilisation is usually advised
during the fourth caesarean section.
3.4 Caesarean Sterilisation

55. The rule that "caesarean always
caesarean" had been replaced since a
long time by "caesarean always
hospital delivery".
If the cause of the previous section is
not permanent as contracted pelvis,
vaginal delivery can be tried.
Mode of Delivery in Subsequent
Pregnancies

56.  Vaginal birth after Cesarean Section(VBAC):
• Because more than 25% of cesarean sections are
repeat procedures, vaginal births after cesarean
section (VBAC) have become increasingly
supported by the medical community.
• The success rate for VBAC has been reported to
be from about 60% for patients who were
previously delivered for pelvic dystocia to more
than 70% for patients who were delivered by
cesarean birth for nonrecurring conditions; such
as breech presentation or fetal distress.
Mode of Delivery in Subsequent
Pregnancies

57. The advantages of vaginal birth include
decreased maternal and neonatal
morbidity as well as decreased hospital
time for both mother and baby.
The use of oxytocin or epidural
anesthesia is not contraindicated in
VBAC.
A trial of labor should be offered for all
with a nonclassical uterine incision.
Mode of Delivery in Subsequent
Pregnancies

58. 1. Immediate care (4-6 hours):
• In the immediate recovery period,the blood
pressure is recorded in every 2 hourly.
• The wound must be inspected half hourly to
detect any blood loss.
• The lochia are inspected and drainage should be
small initially,
• Following general anaesthesia, the women is
nursed in left lateral or recovery position until she
is fully conscious.
• Analgesic is given as prescribed.
Post OP care …

59. 2. First 24 hours:
IV fluids are continued, blood
transfusion is helpful in case of anemia.
Parental antibiotic is usually given for 1st
48 hours,analgesics is the form of
pethidine 75-100mg are given as
needed.
Ambulation is encouraged following day
of surgery and baby is given to mother.
Post OP care …

60. 3. After 24 hours:
TPR are usually checked every 4 hourly
Orally feeding is started with clear liquid and
then advanced to normal diet (usually
beginning about 8 to 12 hours after surgery) and
IV fluid are continued for about 48 hours.
Catheter may be removed on following day
when the women is able to get up to the
toilet.
She should be helped to get out of bed.
The mother must be encouraged to provide
care to the baby and should breast feed the
baby.
The notation of a watery discharge from the
wound may herald impending wound dehiscence
and should be treated as an emergency.
Post OP care …

61. Obstetrics and Medico-Legal aspects
Legally, obstetricians and hospitals are
at risk if the outcome of any birth is less
than perfect, particularly if a cesarean
birth was not performed.

62. Maternal Morbidity:
• Although maternal morbidity has decreased
significantly with cesarean section, it is still
between 8 and 12 times higher than for a
vaginal birth.
• It may result from anesthetic complications, or
those that arise in the intraopertative period as
injury (bladder, ureter, bowel), bleeding with
consequent anemia, infectious or
thromboembolic complications.
Complications of caesarean section

63.  Maternal Mortality:
• Improved surgical and anesthesia skills,
antibiotics, aseptic techniques, and blood product
availability have decreased the risks of this
procedure.
• However, caesarean birth still holds a much greater
risk for the mother, with a maternal mortality rate
of 20 per 100,000 births in the United States
compared with a maternal mortality rate from
vaginal delivery of 2.5 per 100,000 births.
• Anaesthetic accidents, including aspiration
pneumonia, severe sepsis and thromboembolic and
hemorrhagic complication are the main cause of
maternal death.
Complications of caesarean section
…

64.  Fetal/Neonatal Mortality and Morbidity:
• The safety of cesarean birth for the neonate has increased
dramatically over the past 2 decades.
• Elective cesarean sections are the major cause of
iatrogenic preterm delivery (1% to 20% of hyaline
membrane disease (HMD) cases are products of elective
cesarean delivery).
• When abdominal delivery must be performed prior to
fetal maturity, it is imperative to document, confirm or be
assured of pulmonary maturity.
• Elective cesarean delivery no earlier than 39 weeks is
advised by the American College of Obstetricians and
Gynecologists.
• If the patient has insulin-requiring diabetes mellitus
during pregnancy, or dating cannot be firmly established,
an amniocentesis is recommended to confirm lung
maturity via a series of lung phospholipid studies if
delivery is to be undertaken prior to 39 weeks' gestation.
Complications of caesarean section
…

65. Complications of caesarean section
…
Intraoperative complications:
• Primary haemorrhage
• Injury to internal organs
• Difficulty in delivery of the head
• Anaesthetic complications to the mother
• Shocks related to blood loss.
• Iatrogenic prematurity.
• Respiratory distress syndrome to the baby.
• Injury to the baby due to surgical knife.
• Birth asphyxia of the baby due to anaesthesia.

66. Management of intra op
complications:
• Atonic uterus;
‒ give oxytocin 20units in 500ml
ergometrine 0.25mg im or iv
‒ prostaglandin F2 alpha 250micgram im and
intramurally
‒ PGE1 200micgram rectally
• Traumatic – ligation of concerned vessels
• Placenta accreta
Complications of caesarean section
…

67. Postoperative complications:
• Paralytic ileus
• Respiratory complications
• Infections/sepsis – postoperative febrile morbidity
(10%-50%), depending on whether the cesarean birth is
performed electively or during labor with ruptured
membranes – markedly decreased with vaginal delivery
(1%-3%).
‒ Endometritis, urinary tract infection, and wound infections are the
major causes of postoperative morbidity following cesarean births.
• Peritonitis
• Pelvic abscess
• Pelvic thrombophlebitis
• Deep vein thrombosis and pulmonary embolism
• Wound dehiscence
Complications of caesarean section
…

68. Late sequelae:
• Secondary PPH
• Incisional hernia
• Scar endometriosis
• Vesico-vaginal fistula
• Scar rupture in the next pregnancy
• Menstrual irregularity
• Chronic pelvic pain
• Backache
• Adhesive intestinal obstruction, ruptured uterine scar
in next pregnancy, placenta praevia & placenta
accerta to previous scar and incisionnal hernia more
common with midline subumbilical vertical incision.
Complications of caesarean section
…

69. References
1. Gabbe__Obstetrics: Normal and
Problem Pregnancies__5th Edition
2. Williams__Obstetrics__23rd Edition
3. www.freelivedoctor.com