Cesarean Section Techniques

Indications for CS - Why The Cut?

Absolute Indications (CS mandatory):

• Placenta Previa (major)
• Absolute CPD
• Transverse Lie (labor)
• Cord Prolapse (viable fetus, cervix not full)
• Obstructing Pelvic Mass
• Active Genital Herpes (primary)

Relative/Common Indications (CS often chosen/needed):

• Fetal Distress
• Failure to Progress
• Previous CS (≥2 LSCS / classical)
• Malpresentations (Breech, Face MP)
• APH (e.g., Abruption)
• Multiple Gestation (some cases)

⭐ > In India, previous Cesarean section is a leading indication for repeat CS, contributing significantly to rising CS rates.

Pre-Op & Anesthesia for CS - Ready, Set, Numb!

• Pre-Operative Steps:
  • Informed consent documented.
  • Labs: Hb (aim >10 g/dL), blood group/crossmatch.
  • Correct significant anemia (Hb <10 g/dL).

  ⭐ Prophylactic antibiotic: Cefazolin 2g IV (30-60 min pre-skin incision). Alt: Clindamycin 900mg IV for allergy.

  • Aspiration prophylaxis: Ranitidine 150mg & Metoclopramide 10mg.
  • Urinary catheterization.
• Anesthesia:
  • Regional (Spinal/Epidural): Preferred method.
    • Pros: Awake mother, ↓neonatal depression, ↓maternal blood loss.
    • Cons: Maternal hypotension, PDPH.
  • General (GA): For emergencies/contraindications.
    • Pros: Rapid onset, airway control.
    • Cons: Maternal aspiration risk, neonatal depression.

CS Surgical Steps - Layer by Layer Magic

Abdominal Entry:

• Skin Incisions:
  • Pfannenstiel: Transverse, cosmetic, ~2 cm above pubic symphysis.
  • Joel-Cohen: Straight transverse, 3 cm below ASIS-to-ASIS line, quicker entry.
• Layers (Outside to Inside): Skin → Subcutaneous tissue (Camper's fascia, Scarpa's fascia) → Anterior Rectus Sheath → Rectus abdominis muscles (separated/retracted) → Transversalis fascia → Extraperitoneal connective tissue → Parietal Peritoneum.

Uterine Incisions:

Surgical Sequence & Key Actions:

• Uterine Access: Bladder flap (optional). LSCS (e.g., Kerr - transverse) preferred over Classical.
• Fetal Delivery: Gentle traction; fundal pressure if needed.
• Oxytocin: 5-10 IU IV (slow) post-delivery of anterior shoulder/baby for uterine tone.
• Placental Delivery: Controlled Cord Traction (CCT); ensure completeness.

⭐ Key advantage of LSCS over Classical CS: Significantly lower risk of uterine rupture in subsequent pregnancies, permitting Trial of Labor After Cesarean (TOLAC).

CS Closure, Post-Op & Complications - Stitch, Heal, Watch!

• Uterine Closure:
  • Double-layer preferred over single, esp. for VBAC (↓rupture risk).
• Other Layers:
  • Peritoneum: Optional closure. Rectus sheath: Essential.
  • Subcutaneous: Close if >2cm; skin staples/subcuticular.
• Immediate Post-Op Care:
  • Vitals: q15min x1hr, q30min x2hrs, then hourly.
  • Urine output (Foley 12-24h). Pain: Multimodal analgesia.
  • Mobilize 6-12h (↓DVT); diet as tolerated.
• Common Complications: 📌 HI-BAD: Hemorrhage, Infection, Injury (bowel/bladder), Adhesions, DVT.
  • Hemorrhage: Atony, tears.
  • Infection: Endometritis (>38°C), wound.
  • DVT/PE; organ injury (rare).
• VBAC (Vaginal Birth After Cesarean):
  • Success 60-80%; Rupture ~0.5-0.9% (1 prior LTCS).

  ⭐ Prior classical or T-shaped incision = highest VBAC rupture risk.

  • VBAC Criteria & Contraindications:

High‑Yield Points - ⚡ Biggest Takeaways

• Pfannenstiel incision: Most common transverse skin incision.
• Kerr incision (low transverse uterine): Preferred for LSCS; ↓ blood loss, ↓ future rupture risk.
• Classical uterine incision: For preterm breech (poorly formed lower segment), select placenta previa, or large lower fibroids.
• Uterine closure: Single-layer faster; double-layer may ↓ rupture risk.
• Prophylactic antibiotics: Give ≤60 minutes before skin incision (e.g., Cefazolin).
• Misgav Ladach technique: Emphasizes blunt dissection, aiming for faster recovery and less pain.