CESAREAN SECTIONBy Zahraa majeed .... .25%.... WHO recommends an ideal caesarean rate of 10. Definition does not include removal of fetus from abdominal cavity in case of rupture uterus..DEFINITION The delivery of a viable fetus through an incision in the abdominal wall and uterus.. WHY RATES INCREASED? Increase in repeat caesareans. Difficult instrumental delivery and vaginal breech deliveries Increased diagnosis of intrapartum fetal distress Caesarian on demand Identification of risk of mothers and fetuses Increase in pregnancies by invitro fertilization . the abdomen is opened by a low midline . Involved horizontal incision after reflecting visceral peritoneum. the bladder is reflected from the lower segment and transverse incision is made on the lower uterine segment care being taken not to injured the fetus. (LSCS) is commonest procedure because it easier to incise the lower segement . deliver the fetus from point of incision .TYPES OF CS Lower uterine segment incision (LSCS) : This is the commonest CS procedure.paramedian and more commonly by a pfannenstiel incision and peritoneal cavity opened. The forceps can be used to assist delivery in a cephalic presentation. also blood loss with LSCS is less. and to approximate the layers because of thin muscle layers compared with upper segement .in addtion the peritoneal layer can be closed and was thought to provid advantage against infection . . increased blood loss . Indications for classical incision: Transverse lie with SROM Structural abnormality that makes lower segment approach difficult Constriction ring with neglected labour .operative morbidity and inability to offer a trial of vaginal delivery in the next pregnant due to possible higher incidence of scar rupture . increase post.because the difficulty the making the incision . inadequate approximation at closure .Midline vertical incision Commonly starts in the lower segment as a small buttonhole incision till the uterine cavity is reached and is extended upwards . Fibroids in the lower segment Ant PP & abnormally vascular lower segment Mother dead & rapid delivery is required Very preterm fetus in breech pres . . myomectomy Severe IUGR Breech Multiple pregnancy Transverse lie Ca of the Cx/ TR obstructing the birth canal .INDICATIONS FOR ELECTIVE CS Known CPD Fetal macrosomia > 4500 gm Placenta previa VV fistula repair HIV Active herpes Repeat CS Uterine surgery eg. Hystrotomy. HPT. isoimmunization APH . chin post. breech Compromised fetus 2ry to DM. shoulder & compound presentations.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. Sechualed CS The mother need early delivery but not maternal or fetal compromised there may concern that continuation of pregnancy is likely affect the mothe or fetus in hours or days to come.Urgent CS There is maternal and fetal compromised but not life threatening . .here delivery should be complteted within 60-75 min and cases with FHR abnormalities are those of concern. COMPLICATIONS INTRAOPERATIVE Bleeding & the need for bl transfusion Hysterectomy Complications of anaesthesia Damage to the bladder. colon . retained placental tissue Fetal injury POSTOPERATIVE Gaseous distension Paralytic ileus Wound dehiscence & infection Infectins UTI. pulmonary DVT & pulmonary embolism Death Vesico uterine fistula . ureter. POSTNATAL CARE V/S & blood loss must be monitered Uterine fundus palpated Effective parentral analgesics Deep breathing & coughing encouraged Early mobilization Fluid therapy &diet Bladder & bowel function Wound care Lab Breast care Prophylaxis for thrombembolism . MODE OF DELIVERY IN NEXT PREGNANCY CRITERIA FOR VBAC Pt must agree to the procedure A low transverse uterine incision Non recurrent cause of the previous CS No macrosomia. multiple gestation. malposition. breech Contraindication Previous classical CS 2 or more previous CS Previous other uterine surgery Hx of scar rupture Placentaprevia or transverse lie . 5% for LSCS 4-9% for classical INDICATIONS OF SCAR RUPTURE Fetal distress Ease of fetal palpation Cessation of contractions Elevation of presenting part Scar pain Bleeding / shock .2-1.SCAR RUPTURE O. The end .