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difficult c.section

difficult c.section. Dr . Shahnaz Ahmadi Iran University Of Medical Science. CESAREAN BIRTH IS AN UNNATURAL METHOD OF A NATURAL EVENT. “yet another way to get OUT!”. CAESAREAN SECTION. CESAREAN DELIVERIES BECAME SAFER. Better anaesthetic technique. Better antibiotics.

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difficult c.section

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  1. difficultc.section Dr .ShahnazAhmadi Iran University Of Medical Science

  2. CESAREAN BIRTH IS AN UNNATURAL METHOD OF A NATURAL EVENT. “yet another way toget OUT!” CAESAREANSECTION

  3. CESAREAN DELIVERIES BECAMESAFER • Better anaesthetictechnique. • Betterantibiotics. • Availibilityofbloodtransfusion. • Improved surgicaltechniques.

  4. Common factors responsible forincreased caesarean sectionrate • Rising maternalage • High levels of maternaleducation • Previous caesareansection • Obstetriccomplications • Maternalrequest • High income level and socialclass • Prevention of pelvic floorInjury • Fear oflitigation

  5. INDICATIONS FOR ELECTIVECS • Uterine surgery eg. Hystrotomy,myomectomy • SevereIUGR • Multiplepregnancy • Caof the Cx/ TR obstructing the birthcanal • Cord prolapse • Ftal distress • KnownCPD • Fetal macrosomia >4500 gm • Placentaprevia • HIV • Activeherpes • RepeatCS • Malpresentation )Breech, Transverselie

  6. 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 TYPES OF CS

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

  8. If a patient has had a previous C.S, 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 DIFFICULTIES WITH THE INCISION

  9. Abdominal incision: • Changing trends in surgical techniques from verticalabdominal midline incision to transverse incision • Vertical for emergentaccess • Pfannensteil • -- Muscle cutting if access restricted (Maylardincision( • Meticulous hamostasis to prevent subfascialhematomas • Supraumblical incision in fatty abdomen Difficult abdominalaccess

  10. Abdominal incision in previousscar • Adequateexcisionofprevioussurgical scar • Special care while entering the peritoneal cavity to avoid bladder & bowel injury • Peritoneumto be openedashighas possible • Lift it between haemostatsto stretch the adhesions, and dividethemwiththepointsof scissors directed at heruterus Difficult abdominal access

  11. If you find a plane of loose connective tissue, free itwith a finger orswab. • Cut fibrousbands. • If dissecting the adhesions is very difficult (unusual), giveup and make an upper segment incision.

  12. Uterineincision • Dissectbladderperitoneum • Adequate deflectionto protectbladder • Curvilinear / U orJshaped ♦ Maximumavailablespace ♦ Protect theuterinevesseles • Inverted Tincision • Occasionalvertical incision

  13. BLADDER ADHERED TO THELOWERUTERINESEGMENT • The incidence of bladder injury during caesarean section ranges from 0.08 to 0.94%. • Most commonly bladder injury occurs in cases of previousLSCS. • A very common problem encountered in cases of previous operation is thatthebladder gets adhered to lowersegment. • If such is the case, peritoneum should be incised on uterus about 2-3cm above the bladder so that UV fold could be mobilize with a finger or aswab.

  14. previous classical cesarean section scar In cases of previous classical caesarean section, it is wiser to do a lower segment operation.

  15. UTERINEANOMALY • In cases of bicornuate uterus or didelphys uterus, it is important to recognize both the horns. Lateral extensions of the uterine incision should be watched • A mop curettage of the uterine cavity should be done, especially in cases of septate uterus, • so that any adhered membranes and • placentalare not leftbehind.

  16. A classical caesarean sectionmight be required if a large leiomyoma in lower segment, prevents adequateexposure. • Caesarean myomectomycan be done if the fibroid is subserous, at the incision site and can easily beremoved. LEIOMYOMA IN LOWERSEGMENTOR CERVICALCANCER

  17. Uterineincision Classical C. section: verticalincisionin very selected casesof • Multiple previoussurgeries • Densely adherentbladder • Leiomyoma onlower segment • CervicalCarcinoma

  18. Difficult BabyDeliveries presentations • Floatinghead • Deeply engagedhead • Abnormal positionsand • Transverse lieor breech • Deflexedhead • Prematurity • Multiplepregnancies • Fetalmalformation

  19. 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, intrnalpodalic version • 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 Caesarean Section Delivery - FloatingHead

  20. FLOATINGHEAD Delivery of floating, non- engaged head can be facilitated by: 1. Vacuum, Vectis 2.forceps extraction

  21. Forceps Application at CaesareanSection

  22. 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 headis 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 fundalpressure. Although such an approach may reduce the risk of extension ofthe original hysterotomy, it is not recommendedfor all Ventouse application atCS

  23. DEEPLY ENGAGED HEAD • Two common pitfalls • The most common error:hystrotomy too low • Second most common error:acting too hastily and forcefully • Operator should avoid flexing her wrist against the myometrium between incision and cervix

  24. The best methods to dislodging the deeply engaged foetal headinclude: Reverse breech Abdominovaginally delivery Patwardhans shoulder maneuver DEEPLYENGAGEDHEAD

  25. PATWARDHAN’SMANOEUVRE • 1. BOTHSHOULDERS • 2. BACK &TRUNK • 3.BUTTOCKS • 4. LOWERLIMBS

  26. Planning delivery in a Tranverselie • Externalcephalic version is an option ifmembranes intact • Transverse lie to be converted tolongitudinal • Cephalic version is an option though conversion to breech by traction on feetpreferred • Knowledge of position of fetal head is important . A liberal Jshaped incision in LUS is usually required if baby is term with or without PROM • Inverted ‘T’ incision to beavoided • Neglected transverse lie is a dangeroussituationand possibilityof • extension of the incisionexists. • Beware of sepsis if membranes have been ruptured for long!!! Caesarean Section Delivery -Malpresentations

  27. Abdominal delivery no different from vaginal breech extraction with many of therisks • Limbs manipulated through natural range ofmovement • 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 cominghead • Avoid trapping of after comingheadby theretracting • uterus especially in premature breech (Head- trunkratio) • Mauriceau Smellie Veitmaneuver • Forceps application BreechDelivery

  28. Planning delivery • Identify placentallocation • Judge the fetal lie &relationships • Plan delivery of presentingfetus • Adequate abdominal & uterineincision • Technicalnuances • Care taken to deliver floating head orbreech • Orientation may be distorted • Mobilize adequate neonatalsupport • Double clamp the cord of thefirstfetus after delivery of firstbaby • to avoid retrograde bleedingfromthe placenta • Experienced neonatologist athand • Aggressive prophylaxis for postpartumhemorrhage Caesarean SectionDelivery MultiplePregnancies

  29. Placentapraevia carries a risk of massive obstetric haemorrhage and hysterectomy. The elements considered to be reflective of good care were: • Consultant obstetrician planned and directly supervisingdelivery. • Consultant anaesthetist planned and directly supervising anaesthetic atdelivery. • Blood and blood productsavailable. • Multidisciplinary involvement in pre-opplanning. • Discussion and consent includes possible interventions (such as hysterectomy, leaving the placenta in place, cell salvage and interventionradiology). PLACENTAPRAEVIA

  30. PLACENTAPRAEVIA • De Lee incision is preferred (lower vertical incision)if • Poorly developed lower segment, which would not allow a transverse incision of adequate length. • A very vascular lower segment with largeveinsonit. • The presenting part is high, and baby is lying transversely, indicating that the placenta praevia is probablycentral.

  31. PLACENTAPRAEVIA • If the placenta fails to separate withthe usual measures, closing the uterus and proceeding to a hysterectomy are both associated with less bloodloss. • If the placenta separates, sutures can be taken on the placentalbed.

  32. Placental delivery by controlled cord traction preferred over manual removal ofplacenta • Adherentplacenta • In obvious increta / percreta avoid placentalremoval • After ligating the cord close to placental attachment, Uterus can beclosed • Oxytocicsgiven Difficult placentaldeliveries

  33. Haemorrhagedue to partially separated placenta • Resuscitativemeasures • Bilateral uterine arteryligation • Bilateral Internal iliac arteryligation • Cesareanhysterectomy difficultplacentaldeliveries

  34. Difficulties with uterineclosure • Closure ofuterus • Transverse LSU incision with single layer & further haemostatic sutures ifrequired • Vaginal entry can occurif • Placing the incision toolow • Following prolonged labor when cervix fullydilated • Repair of a vaginal incision with proper haemostasis

  35. Strategies to minimize intraoperative bloodloss • 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. Difficulties in controllinghaemorrhage

  36. Control of introperativebleeding 1. Localized site : Pressure by a spongeon holder or pack to isolate the bleeding site and then deep interrupted sutures to ligate bleeding preferably with chromic catgut No. 1as with delayed absorbable sutures cutting through tissue iscommon.

  37. 2) Step-Wise Devascularization of The Uterus • 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 Control of intraoperativebleeding

  38. 3) B-LynchSuture • Simple, effective, relatively safe andrequires • minimalexpertise. • A woman meets the criteria for the B-Lynch compression suture if bimanual compression decreases the amount of uterine bleeding by abdominal and perinealinspection. • Modifiedtechnique: • Cho’s squresuture • Hayman’s modification Equally effective Control ofintraoperative bleeding

  39. ObstetricHysterectomy • Indications for SubtotalHysterectomy • AtonicPPH • Rupture uterusunrepairable • Indications for TotalHysterectomy • To control bleeding from Lower segment of theuterus Cervix • Vagina Control of intraoperativebleeding

  40. The incidence of bladder injury during caesarean section ranges from 0.08 to0.94%. • Most commonly bladder injury occurs incases of previousLSCS. • Ninety-five (95) % of bladder injuries during caesarean section occur at the dome of the bladder.

  41. The most likely time bladder injury occurs is duringthe • 1. Creation of a bladder flap • (43%) • 2. Time of entry into the peritoneal cavity • (33% • 3. During uterine incision ordelivery.

  42. A simple rent is normally repaired in two layers, with the first layer consisting of a simple running closure of the mucosa with a 3–0 absorbablesuture. • The second layer may be closed continuous stitch using either 2–0 or 3–0 absorbable suture to include the submucosa andmuscularis. • Foley catheter for at least 7–10 dayspostoperatively.

  43. 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 surgicalprocedure. Conclusion

  44. Man needs his difficulties because they are necessary to enjoy success.

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