CESAREAN SECTION

&
VBAC

January, 2009
Dr Eyasu Mesfin
 Content
 Introduction
 Prevalence
 Classification
 Benefits
 Risks & complications
 Indications
 Postoperative care
 VBAC
• Introduction
• Preconditions / criteria
• contraindications
• Benefits & Risk
• Management
 Introduction
 DEFINITION:
Cesarean delivery is defined as the birth of a
fetus , placenta & membranes through incisions in
the abdominal wall (laparotomy) and the uterine
wall (hysterotomy) after 28 weeks of pregnancy.

 Note: Surgical delivery of fetus prior to age

of viability (28wks) is called
Hysterotomy.
 Introduction contd…
 History:-
• Has been described since ancient times
• The evolution of the term “cesarean” has been
debated over time:-
• Originally believed to have been derived from the birth of
Julius Caesar,
• Roman law under Caesar, Lex Caesarea (715-712 BC),
surgical removal of the fetus before burial of deceased
pregnant women
• Religious edicts required separate burial for the infant and
mother  Latin word “CAEDERE” = to cut.
 History Contd …………
 Cesarean deliveries in the living were first
recommended, and the current name of the
operation used, in the celebrated work of Francois
Rousset (1581)
 1794 - in U S A , both patient and fetus survived
 1805 - Osiander’s Operation Extra Peritonial.
 1881 - Kehrer - L S C S .
Successful Caesarean section performed by indigenous healers in
Kahura, Uganda. As observed by R. W. Felkin in 1879.
 History Contd……………..
 1912 - Kronig lower segment vertical incision.
 1922 – De Lee established this opn.
 1926 - Munrokerr popularised present technique
 20th Century – saw advances in blood transfusion,
anesthesia, antibiotic, and improved technique.
 The introduction of penicillin in 1940 also dramatically
reduced the risks of infection associated with childbirth.
 It is the most common major surgical procedure
undertaken today.
 Prevalence and trend
• From 1965 - 2004, the cesarean delivery rate in USA rose
progressively from only 4.5 % of all deliveries to nearly 30 %
• The reasons why the rate quadrupled include the following:
 Obstetric Factors  Maternal Factors
ed primary cesarean delivery • Increased proportion of women
• Failed / ed labor induction > age 35
 operative vaginal delivery ed nulliparous women
ed macrosomia/ elective • Increased elective primary
cesarean for macrosomia cesarean deliveries
 in vaginal breech delivery • Concern over pelvic floor injury
ed repeat cesarean rate associated with vaginal birth.
• Decreased utilization of VBAC
• The widespread use of electronic  Physician Factors
fetal monitoring . • Malpractice litigation concerns
 Indications For C/S

 Indications can be:-

• Absolute Or Relative; Or
• Maternal Or Fetal; Or
• Common
 The commonnest indications are:-
• Fetal distress
• CPD
• Repeat cesarean
 Indications contd….

 Maternal
• Repaired fistula
• Specific cardiac disease (Marfan's syndrome, unstable
coronary artery disease)
• Specific respiratory disease (Guillian-Barré syndrome)
• Conditions associated with increased intracranial
pressure
• Mechanical obstruction of the lower uterine segment
(tumors, fibroids)
• Mechanical vulvar obstruction (condylomata)
• Ca Cx
 Indications contd….
 Fetal
• Non-reassuring fetal status
• Breech
• EFW >3500gm
• Extended neck
• Footling
• PMTCT
• Maternal genital herpes
• Twin - first non cephalic
• High order multiple pregnancy
• Congenital anomalies
• Cord prolapse,
• Severe I U G R
 Indications contd….
 Maternal-fetal
• Previous Cesarean [ 30 % of all C S ].
• Cephalopelvic disproportion
• Placental abruption
• Placenta previa
• Macrosomia (EFW>4.5kg)
• Obstructed labor,
• Transverse lie
• Failed induction and augmentation
• Cx Dystocia,
 Contraindications

 No absolute contraindications.
 When no indications.
 Benefits must outweigh risks.
 WHO Recommendations

 In 1984, 20 countries with 62 participants, including

the US…Literature review and recommendations.
• C/S 10% in a low risk population
• C/S 15% in a high risk population
 Benefits of C/S
 Reduction in perinatal morbidity and mortality
 Elimination of intrapartum events associated with
perinatal asphyxia (if elective)
 Reduction in traumatic birth injuries
 Reduction in stillbirth beyond 30 weeks' gestation
 Possible protective effect against pelvic floor
dysfunction
 PMTCT
 Risks of C/S
 Increased short-term morbidity
 Increased endometritis, transfusion, venous
thrombosis rates
 Increased length of hospital stay and longer
recovery time
 Increased long term morbidity
 Increased risk for placenta accreta & hysterectomy
with subsequent cesarean deliveries
 Pre - Op Considerations.
 Decision Making & Recording.
 Informed Consent.
 Blood Hct, Hb, ABO & Rh, U/A if not done.
 U/S to rule out Cong Anomaly, Prematurity, EFW and
Fetal Wellbeing.
 Specific Investigations if indicated like RFT, LFT
 Avoid Sedatives once decided C/S .
 Give clear antacids PO or Inj Ranitidine 150 mg I m stat.
 Folley’s Catheter ,
 Prophylactic antibiotics
 Check FHB on table.
 Timing Of C/S
 Cesarean deliveries may be performed because of
maternal or fetal problems that arise during labor, or they
may be planned before the mother goes into labor
• Elective cesarean delivery
• Decisions must take into account the risk to the infant
associated with delivery before 39 weeks' gestation
• Respiratory distress syndrome is indeed seen in "term"
infants
• Emergency cesarean section
• In cases of suspected or confirmed acute fetal
compromise, delivery should be accomplished as soon
as possible.
• The accepted standard (DDI) is within 30 minutes.
 Abdominal entry (incisions)
• Usually either:
• a midline vertical or
• a suprapubic transverse incision is used.
• Only in especial circumstances would a paramedian or
midtransverse incision be employed.
 Uterine Incision
 Extraperitoneal cesarean section; Latzko operation
(Obsolete)
 Intraperitoneal cesarean section
1- Lower segment
A-- A transverse or curved (horizontal), Kerr
operation – (99%)
B--vertical incision in the lower uterus, Selheim
operation
2 - Classical--a vertical incision in the main body of
the uterus. Sanger operation – (<1%)
3 - Inverted T-shaped incision, Delee operation
4 -J shaped
 Anaesthesia
1. General anaesthetic.
2. Regional anaesthesia ( Epidural / Spinal block ).
• Considerably safer than general anaesthesia with respect to
maternal mortality
• It allows the mother to remain awake, experience the birth,
and have immediate contact with her infant
3. Infiltration of local anaesthetic agents.
• Rarely required except in conditions, e.g. deeply sedated Pt.
• Where anesthetist is not available and surgeon has to manage
all alone, local anesthesia is used.
• Drug used is 0.5% Lignocain. Total quantity to be used is not
more than 100 c.c.
• The surgeon may not be as comfortable
 Complications of Cesarean Delivery
 Intraoperative Complications
• Uterine Lacerations
• Bladder Injury
• Ureteral Injury
• Gastrointestinal Tract Injury
• Uterine Atony
• Placenta Accreta
• Maternal morbidity and mortality are increased in cesarean
delivery compared with vaginal birth,
 Maternal Postoperative Morbidity
• Endomyometritis
• Wound Infection
• Thromboembolic Disease
• Septic Pelvic Thrombophlebitis
 Complications contd…
 Pre Existing med or surg illnesses.
 Anesthetic Complications .
 Iatrogenic cut on fetus common.
 Prematuarity,
 Increased R D S .
 Future pregnancies
• Placenta previa
• Adherent placenta
• Repeat cesarean
 Post Op Care Of C/S
 Close watch 6 – 8 hrs.; monitor pulse B P and
amount of bleeding & ht of uterus.
 I V Fluids for 24hrs or till bowel sounds are
heared.
 Oxytocics may be repeated.
 Anti pain,
 Remove urinary catheter when fully awake
 Early ambulation.
 Proper wound care
 Elective Repeat Cesarean
Delivery
 If elective repeat cesarean delivery is
planned, it is essential that the fetus be
mature.
 Delivery is best planned at 39 weeks of
gestation
 See table for ACOG,s criteria
Table . Establishment of Fetal Maturity Prior to Elective Repeat
Delivery
Fetal maturity may be assumed if one of the following criteria is met:
1. Fetal heart sounds have been documented for 20 weeks by
nonelectronic fetoscope or for 30 weeks by Doppler ultrasound
2. It has been 36 weeks since a positive serum or urine HCG
pregnancy test was performed by a reliable laboratory

3. An ultrasound measurement of crown-rump length, obtained at 6–

11 weeks, supports current gestational age of 39 weeks or more

4. Clinical history and physical and ultrasound examination

performed at 12–20 weeks support current gestational age of 39
weeks or more

From the American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists (2002).
 Additional surgical procedures
during cesarean

 Cesarean Hysterectomy
• INDICATION:-
• Uncontrolled PPH,
• Severe infection with or without rupture of uterus.
• TYPE – Total and Subtotal
 Tubal ligation
• Modified Pomeroy
• The Irving Procedure
• The Uchida Procedure
 VBAC
( VAGINAL BIRTH AFTER CESAREAN DELIVERY )
 Introduction
 Few issues in modern obstetrics have been as controversial
as the management of the woman with a prior cesarean
delivery.
 For many decades, a scarred uterus was believed to
contraindicate labor out of fear of uterine rupture.
 In 1916, Cragin made his famous, oft-quoted, and now
seemingly excessive pronouncement, "Once a cesarean,
always a cesarean.“
NB: Classical vertical uterine incision was used almost universally at
that time. And some did not totally agree with his pronouncement ;
nearly 90 years later, the controversy still continues.
 Introduction contd…
 1978 - Merrill and Gibbs:- Subsequent vaginal delivery was safely
attempted in 83 percent of their patients with prior cesarean deliveries.
 American College of Obstetricians and Gynecologists (1988)
recommended that, in the absence of a contraindication, a woman with
one previous low-transverse cesarean delivery be counseled to attempt
labor in a subsequent pregnancy.
 Accordingly, the frequency of VBAC increased significantly
 Between 1988 & 1996, the overall cesarean rate in USA fell from 24.7%
to a nadir of 20.7%, largely attributed to the increased practice of VBAC
 Scott (1991) - suggested an "alternative viewpoint on mandatory trial of
labor,“
 Over the past decade, cesarean rates have steadily climbed and exceed
those of the late 1980s; reflected by an increase in the primary cesarean
rate and a steep drop in the rate of vaginal births after previous cesarean
deliveries.
 Introduction contd…

“ONCE A CESAREAN, ALWAYS A CESAREAN “

has been changed to

“ONCE A CESAREAN ALWAYS A HOSPITALISATION”

also has been changed to

“ONCE A CESAREAN ALWAYS A CONTROVERSY

“
 Criterias for VBAC
 Criteria for vaginal delivery to be fulfilled.
 No more than 1 prior low-transverse cesarean delivery
 No recurring indications for C/S.
 Spontaneous labor [ some centers do induce],
 No indication for C/S in present pregnancy.
 To try only at center where C/S facility exists i.e. physician
capable of performing emergency cesarean delivery
immediately available and availability of anesthesia facility.
 No other uterine scars (eg. Myomectomy) or previous rupture
 Informed Consent
 Singleton pregnancy
 EFW <4000gm
 Contraindication

 When criterias for VBAC not met.

 Estimated fetal weight ≥4000gm
 Classical or T- incision scar
 Myomectomy scar
 Contracted pelvis
 Uterine incision extensions
 Malpresentations & malpositions
 Contraindications for vaginal delivery
 Management
 Interdelivery intervals of 18 months or less were associated
with a threefold increased risk of symptomatic uterine rupture
compared with that of those over 18 months.
 Antenatal
• Routine visits
• Emphasis on
• Screening for the previous C/S situation
• Pelvic assessment at term
• Fetal weight estimation
• Decide eligibility for VBAC – birth planing
• Councelling
 Management contd…

 Intrapartum
• Admit all presenting in labor
• FHB every 15 minutes
• Uterine contraction every 30 minutes
• Closely follow for evidence of scar dehiscence
 Delivery and post partum
• Delivery like others
• Watch for bleeding immediately after delivery
 Success Rate

 The success rate for a trial of labor depends to

some extent on the indication for the previous
cesarean delivery.
 Generally, about 60 to 80 percent of trials of
labor after prior cesarean birth result in vaginal
delivery in properly selected cases.
 Benefits of VBAC
 Decreased anesthesia risk
 No surgical complication
 Less PPH
 Comparable perinatal morbidity and mortality
 Shorter hospital stay
 Lower cost
 Early and smooth mother-infant interaction
(favourable mother and child bonding).
 Risks of VBAC
 The principal risk of VBAC-TOL is uterine
rupture.
• Prior vaginal delivery appears to be protective
against uterine rupture following TOL.
 Failure
 See table
 Table :-- Comparison of Maternal Complications in
VBAC versus Elective Repeat Cesarean Delivery
ELECTIVE
REPEAT
TRIAL OF CESAREAN
LABOR DELIVERY ODDS RATIO
COMPLICATION (N = 17,898) (N = 15,801) (98% CI)
Uterine rupture 124 (0.7) 0 —
Hysterectomy 41 (0.2) 47 (0.3) 0.77 (0.51–1.17)
Thromboembolic 7 (0.04) 10 (0.1) 0.62 (0.24–1.62)
disease
Transfusion 304 (1.7) 158 (1.0) 1.71 (1.41–2.08)
Endometritis 517 (2.9) 285 (1.8) 1.62 (1.40–1.87)
Maternal death 3 (0.02) 7 (0.04) 0.38 (1.10–1.46)
One or more of 978 (5.5) 563 (3.6) 1.56 (1.41–1.74)
the above
 Table. Estimated Risks for Uterine Rupture in Women

with a Prior Cesarean Delivery

Prior Uterine Incision Estimated Rupture (%)
Classical 4–9
T- shaped 4–9
Low-vertical 1–7
Low-transverse 0.2–1.5

From the American College of Obstetricians and Gynecologists (1999),

 Impending scar rupture
 Pain over the scar
 Maternal tachycardia
 Fetal distress
 Poor progress
 Vaginal bleeding
THANK YOU !