Cesarean Section: Indications and Techniques

C-Section: Definition & Types - Slice of Life

• Cesarean Section (C-section/CS): Surgical delivery of a fetus through an incision in the mother's abdomen (laparotomy) and uterus (hysterotomy).
• Types based on Uterine Incision:
  • Lower Segment CS (LSCS): Most common; transverse incision in the lower uterine segment. Advantages: ↓blood loss, ↓rupture risk in subsequent pregnancies.
  • Classical CS: Vertical incision in the upper uterine segment; rarely performed due to ↑morbidity.
• Types based on Urgency:
  • Elective: Planned and scheduled before labor onset.
  • Emergency: Performed due to unforeseen complications during labor or pregnancy.

⭐ LSCS is preferred due to lower risk of uterine rupture in future pregnancies compared to classical C-section (0.5-1% vs 4-9%).

C-Section: Indications - Indication Station

• Maternal:
  • Previous uterine surgery:
    • Classical C-section
    • ≥2 previous LSCS (Low Transverse C-Section)
    • Myomectomy (if uterine cavity entered)
  • Cephalopelvic Disproportion (CPD)
  • Obstructed labor / Dystocia (not responding to augmentation)
  • Failed induction of labor
  • Active genital herpes simplex virus (HSV) infection
  • Severe maternal disease (e.g., cardiac; severe PET/eclampsia if induction fails)
  • Maternal request (after informed consent & counseling)
• Fetal:
  • Fetal distress (non-reassuring fetal status)
  • Malpresentation:
    • Breech (persistent, or contraindication to vaginal breech delivery)
    • Transverse lie / Oblique lie
    • Brow, Face (mento-posterior)
  • Cord prolapse
  • Macrosomia (e.g., estimated fetal weight >4.5 kg, or >4 kg in GDM mother)
  • Multiple pregnancy (e.g., non-cephalic first twin, triplets or higher order)
• Placental:
  • Placenta previa (major/complete, or partial covering os at term)
  • Vasa previa
  • Placental abruption (severe, with ongoing fetal/maternal compromise)

⭐ A history of one previous low transverse C-section (LSCS) is NOT an absolute indication for a repeat C-section; Trial of Labor After Cesarean (TOLAC) is often a viable and safe option for suitable candidates (VBAC - Vaginal Birth After Cesarean).

C-Section: Pre-op & Technique - Surgical Symphony

Pre-operative Steps:

• Informed consent; NPO (6-8h solids, 2h clear fluids).
• IV access, bloods (Hb, group & crossmatch).
• Prophylactic antibiotic (e.g., Cefazolin 1-2g IV, 30-60 min pre-incision).
• Antacid (e.g., Ranitidine, Na Citrate); Foley's catheter.
• Anesthesia: Spinal (preferred), Epidural, or GA (emergencies).

Surgical Technique (LSCS - Lower Segment Cesarean Section):

• Skin Incision: Pfannenstiel (transverse, common) or Joel-Cohen.
• Uterine Incision: Transverse in lower segment (Kerr incision - most common). Classical (vertical upper segment) for specific indications (e.g., preterm breech, anterior placenta previa).
• Delivery: Fetal head/breech, then body.
• Placental Delivery: Gentle cord traction; oxytocin infusion.
• Uterine Closure: Typically 2 layers with absorbable sutures (e.g., Vicryl).
• Abdominal Closure: Layer by layer.

⭐ Prophylactic single-dose antibiotics (e.g., Cefazolin 2g IV) given 30-60 minutes before skin incision significantly reduce post-cesarean maternal infections like endometritis and wound infection.

C-Section: Post-op, Complications & VBAC - Healing & Hope

• Post-operative Care:
  • Monitor vitals, lochia, wound.
  • Pain relief (analgesia). Early ambulation.
  • Diet progression. Thromboprophylaxis (high-risk).
  • Wound care; suture removal ~7 days.
• Complications:
  • Early (📌 HITI): Hemorrhage, Infection (endometritis, wound, UTI), Thromboembolism (DVT/PE), Ileus.
  • Late: Adhesions, hernia, chronic pain, placental accreta risk, uterine rupture risk.
• VBAC (Vaginal Birth After Cesarean):
  • TOLAC (Trial of Labor After Cesarean):
    • 1 prior LTCS; adequate pelvis.
    • No other uterine scars/rupture.
    • Emergency C/S facility.
  • Contraindications: Prior classical/T-incision, prior rupture.
  • Success: 60-80%. Risk: Uterine rupture (0.5-0.9% with 1 LTCS).

  ⭐ Prior vaginal delivery (before or after C/S) boosts VBAC success & lowers rupture risk.

High‑Yield Points - ⚡ Biggest Takeaways

• Previous C-section is the leading indication for cesarean delivery.
• LSCS (Lower Segment Transverse) is the most common uterine incision, offering lowest future rupture risk.
• Pfannenstiel is the most frequent cosmetic transverse skin incision.
• Classical uterine incision has the highest risk of subsequent uterine rupture.
• Key absolute indications: CPD, major Placenta Previa, Cord Prolapse.
• Non-reassuring fetal status and failure to progress (dystocia) are common reasons.