difficult c.section

PROF.NARENDRA MALHOTRAM.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G.,F.I.C.S.Prof. Dubrovnick International UniversityV.P. WAPM(world association of prenatal medicinne)President ISARPresiddent Elect ISPATSec Gen SAFOG Member FIGO guidelines committeePresident FOGSI (2008-2009)Dean I.C.M.U. (2008)Director Ian Donald School of UltrasoundNational Tech. Advisor for FOGSI-G.O.I.Mc Arthur Foundation EOC CourseManaging Director GLOBAL RAINBOW HEALTH CAREDirector ART-RAINBOW IVF Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy and Infertility, ART & GeneticsMember and Fellow of many Indian and international organisationsAwarded 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 awardOver 50 published and 200 presented papersOver 100 guest lectures given in India & Abroad and 24 ORATIONSOrganised many workshops, training programmes, travel seminars and conferencesEditor 18 books, many chapters, on editorial board of many journalsEditor of series of STEP by STEP booksRevising editor for Jeatcoates Textbook of Gynaecology 7th and 8th edition (2015)Very active Sports man, Rotarian and Social workerMALHOTRA NURSING & MATERNITY HOME PVT. LTD.GLOBAL RAINBOW HEALTH CARE,AGRA

84, M.G. Road, Agra-282 010Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : 0562-2265194www.malhotrahospitals.com,www.rainbow hospitals.org

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difficult c.sectionnarendra malhotrajaideep malhotraneharika malhotra boradr alpesh gandhi,dr cn purandare,dr suchitra panditmnmhagra3@gmail.comwww.rainbowhospial.org

CAESAREAN SECTION yet another way to get OUT!

CESAREAN BIRTH IS AN UNNATURAL METHOD OF A NATURAL EVENT.

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CESAREAN DELIVERIES BECAME SAFER

1) Better anaesthetic technique. 2) Better antibiotics.

3) Availibility of blood transfusion . 4) Improved surgical techniques.

Common factors responsible for increased caesarean section rateRising maternal age High levels of maternal education Previous caesarean section Obstetric complications Maternal request High income level and social class Prevention of pelvic floor InjuryFear 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

INDICATIONS FOR ELECTIVE CSKnown CPDFetal macrosomia > 4500 gmPlacenta previaVV fistula repairHIVActive herpesRepeat CS

Uterine surgery eg. Hystrotomy, myomectomySevere IUGRBreech Multiple pregnancyTransverse lieCa of the Cx/ TR obstructing the birth canal

INDICATIONS FOR EMERGRENCY CSSevere PETAbruptio placntaeFetal distressFailure to progress in the first stage of labourCord prolapseObstructed labourFailed inductionMalpresentation brow, chin post, shoulder & compound presentations, breechCompromised fetus 2ry to DM, HPT, isoimmunization APH

TYPES OF CSLower segment CSClassical CSIndications for classical incision:Transverse lie with SROMStructural abnormality that makes lower segment approach difficultConstriction ring with neglected labourFibroids in the lower segmentAnt PP & abnormally vascular lower segmentMother dead & rapid delivery is requiredVery preterm fetus in breech presentation

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

Difficulties with Caesarean section

Cesarean section is commonly perceived as a simple and safe alternative to difficult vaginal birth

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.

Difficult Situations in LSCSDifficult abdominal accessDifficulties with uterine incision and closureDifficult baby deliveriesDifficult placental deliveriesDifficulties in controlling haemorrhageDifficult abdominal closure

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DIFFICULTIES WITH THE INCISIONIf 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

Difficult abdominal accessAbdominal incision : Changing trends in surgical techniques from vertical abdominal midline incision to transverse incisionVertical for emergent accessPfannensteil -- Muscle cutting if access restricted (Maylard incision)Meticulous hamostasis to prevent subfascial hematomas

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Difficult abdominal accessAbdominal incision in previous scar Adequate excision of previous surgical scarSpecial care while entering the peritoneal cavity to avoid bladder & bowel injuryPeritoneum to be opened as high as possible

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Opening difficult abdomenOpen 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.

Difficulties with uterine incisionUterine incisionDissect bladder peritoneum Adequate deflection to protect bladderCurvilinear / U or J shaped Maximum available space Protect the uterine vessels Inverted T incision Occasional vertical incision

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Uterine anomalies

two uterus :two babies

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

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Caesarean section deliveryAbnormal Placentation Preoperative check & confirmation of placental locationAnteriorly placed low lying placenta / placenta previaAnticipate poorly formed & vascular lower segment Placenta at incision siteAccess membranes by insinuating fingers between placenta & uterine wall - then rupture membranes to access the fetusIncise placenta & then rapid transplacental access & deliveryDelivery complicated by floating head & obstructive placentaInstrumental delivery or delivery as breech

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difficulties due to palcenta

Anterior Partial Placenta Previa

acreta/percreta

Difficult Baby DeliveriesFloating headDeeply engaged headAbnormal positions and presentationsTransverse lie or breech presentationDeflexed headPrematurityMultiple pregnanciesFetal malformationsConjoined twins

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Caesarean Section Delivery - Floating Head Preoperative check & assessmentConfirmation of placental locationAnticipate poorly formed & vascular lower segment so modify incisionFindings confirmed at laparotomyFetus manipulated into a longitudinal lieSteadied by lateral supportMembranes ruptured & liquor drained & allow the head to descend and deliver after flexionOther 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

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Delivery of a Floating head video courtesy prof v p pailey

Non engaged HEADHowever, 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.

Forceps Application at Caesarean Section Nuances of forceps application for cephalic presentationsSagittal suture placed transverselySlight fundal pressure to push head towards the incision Concavity of the pelvic curve towards the fetal occiputLower blade is applied first followed by the anteriorFlex fetal head with traction aided by fundal pressureCrowning of the fetal head in abdominal incisionDelivery by controlled extension

- Sheriar et al, In Hays Forceps - An Atlas Monograph,1991

Forceps Application at Caesarean Section

Making Instrumental Deliveries SaferInstrumental Delivery at CSForceps application at cesarean section in 253 casesFor floating head, after coming head & prophylacticEnables flexion, controlled delivery & reduced trauma

- Sheriar et al, Asia Oceania J. Obs Gyn, 19:121, 1991

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.

Caesarean Section DeliveryDeeply Engaged HeadPreoperative check & preparationOften second stage proceduresAwareness of signs of impending ruptureTrendlenberg position & uterine relaxant anesthesiaCatheterising the bladder important !Pre plan uterine incisionLow incision :Vaginal disengagement or manual disimpaction Negative pressure overcome by insinuating fingers below presenting partDelivery by breech Vectis, Ellis disimpactor (still under research) or forceps useHigher incision level of fetal shouldersPatwardhan or modified Patwardhan maneuver

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Vectis Delivery at Caesarean Section

Patwardhans method of delivery of impacted head when back is posterior

Modified Patwardhans method of delivering impacted head when back is anterior -

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

Caesarean Section Delivery - Malpresentations Planning delivery in a Tranverse lieExternal cephalic version is an option if membranes intactTransverse lie to be converted to longitudinalCephalic version is an option though conversion to breech by traction on feet preferredKnowledge 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 avoidedNeglected transverse lie is a dangerous situation and possibility of extension of the incision exists. Beware of sepsis if membranes have been ruptured for long !!!

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Breech DeliveryAbdominal delivery no different from vaginal breech extraction with many of the risksLimbs manipulated through natural range of movementTrunk 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 headAvoid trapping of after coming head by the retracting uterus especially in premature breech (Head- trunk ratio)Mauriceau Smellie Veit maneuverForceps application

Caesarean Section DeliveryMultiple Pregnancies Planning deliveryIdentify placental locationJudge the fetal lie & relationshipsPlan delivery of presenting fetusAdequate abdominal & uterine incision Technical nuancesCare taken to deliver floating head or breechOrientation may be distortedMobilize adequate neonatal supportDouble clamp the cord of the first fetus after delivery of first baby to avoid retrograde bleeding from the placentaExperienced neonatologist at hand Aggressive prophylaxis for postpartum hemorrhage

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Twin delivery during CS

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

Difficult placental deliveriesPlacental delivery by controlled cord traction preferred over manual removal of placentaAdherent placentaIn obvious increta / percreta avoid placental removal After ligating the cord close to placental attachment, Uterus can be closedOxytocics given Post-op. adjuvant chemotherapy with Methotrexate to the rate of resorption of placental tissue

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

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Difficulties with uterine closureClosure of uterusTransverse 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

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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.

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Control of intraoperative bleedingLocalized 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.

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Bleeding from angles and suture line

Control of intraoperative bleeding2) Step-Wise Devascularization of The Uterus1st reported from EgyptEffective 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 segmentLow uterine vessels ligation after mobilization of the bladder Unilateral ovarian vessel ligation Bilateral ovarian vessel ligation

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,2005,143-49Modified technique: - Chos squre suture - Haymans modification Equally effective Hayman RG et al Obstet Gynaecol, 2002

4) Internal iliac artery ligationExperiments 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,1964,24:737-39Effective 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

Control of intraoperative bleeding5) Obstetric HysterectomyIndications for Subtotal Hysterectomy - Atonic PPH - Rupture uterus unrepairableIndications for Total Hysterectomy - To control bleeding from Lower segment of the uterus Cervix Vagina

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.

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