C S

Front 1

Work on skin and subcutaneous tissue in midline vertical incision

Back 1

Extends from the pubic symphysis to within 2 cm of the umbilicus.

Front 2

Prevelance

Back 2

Varies between 15-25% of all deliveries

Front 3

Pre-operative preparation:

Back 3

▪Admit all patients 48 hours before surgery and obtain a written informed consent.

▪Take history and perform general and obstetrical examination; and identify problems e.g. placenta previa, diabetes.

▪Assess gestational age carefully (LMP, early or late U/S, fundal height).

▪Investigations .

▪Further preparations

- Fasting .- Catheterization .- Check fetal heart .- Prophylactic antibiotics .

▪Anaesthesia: Spinal anaesthesia is safer and more effective than general anaesthesia .

▪ 4 before surgery .

Front 4

Investigation for Uncomplicated patient

Back 4

▪CBC

▪Urine

▪Blood sugar

▪HIV-Hepatitis antibodies screening

▪Blood grouping and cross-matching and prepare at least 2 pints of blood.

Front 5

Investigation for Complicated patients

Back 5

☆Diabetes mellitus, renal, hypertension, bronchial asthma, heart disease, thyroid disease, sickle cell anaemia, placenta previa, DVT etco Do: CBC, Urine, Blood sugar, HIV-Hepatitis antibodies, blood grouping and prepare 4-6 pints of blood. o Assess condition of patient properly; and order relevant investigations e.g. LFT, renal function tests, ECG, Echo, X-ray chest, blood sugar. Consult physician and anaesthetist.

o Postpone operation for 1-2 days if her medical problem is not controlled e.g. diabetic ketoacidosis, attack of acute bronchial asthma.

Front 6

Fasting befor CS

Back 6

Fasting over night or for at least 6 hours I.V fluids dextrose saline 125 ml/hour at 7 a.m.

Front 7

Catheterization

Back 7

Clean the vagina in the operating room with Iodine (Yamidine) - Catheterization in the theatre under aseptic conditions

Front 8

Prophylactic antibiotics

Back 8

▪Third generation cephalosporin 1 g intravenous half an hour before surgery an 1 g intravenous 12 hours later.

▪second generation cephalosporin I.V 1 g after clamping the cord.

▪Ampiclox 2 g after clamping the cord

▪Gentamycin 160 mg I.V+500mg metronidazole infusion ½ an hour before surgery .

Front 9

Four before surgery

Back 9

▪Check: Pulse, BP and respiratory rate before surgery. ▪Position: lateral tilt. ▪Emergency C/S in labour : Do PV examination, may be in advanced second stage and could be delivered by forceps. ▪Check : fetal heart before surgey

Front 10

Technique of C/S

Back 10

1. Skin washing: Iodine (Yamidine) 2. The abdominal incision : - Pfannenstiel incision

- Midline vertical incision

3.The Uterine incision: - Lower segment transverse incision

- Classical/Vertical incision

Front 11

Benefit of Pfannenstiel incision

Back 11

▪Cosmetic appearance

▪low incidence of wound dehiscence and hernia formation

▪ It is not suitable for complicated cases (placenta previa, obstructed labour).

Front 12

Journey up to uterus in Pfannenstiel incision

Back 12

▪The skin and subcutaneous tissue ▪The rectus sheath

▪The rectus muscle

▪Transversalis facia

▪Peritoneum

▪Peritoneal cavity

▪Uterus

Front 13

Work on skin and subcutaneous tissue in Pfannenstiel incision

Back 13

▪Are incised transversely slightly curvilinear at the level of pubic hair

▪2 fingers above symphysis pubis along the skin crease .

▪Extended beyond the lateral borders of the rectus muscle .

▪Approx length of incision 15 cm.

Front 14

Work on The rectus sheath in Pfannenstiel incision

Back 14

▪ Opened by scalpel and extended by scissor

▪ separated from the underlying rectus muscle superiorly (level of umbilicus) and inferiorly by blunt dissection.

▪Perforated blood vessels are ligated.

Front 15

Work on The rectus muscles in Pfannenstiel incision

Back 15

▪ separated

Front 16

Work in the transversalis facia and peritoneum in Pfannenstiel incision

Back 16

▪ Opened (scalpel or blunt) and peritoneal cavity and uterus exposed

Front 17

Pfannenstiel incision

Back 17

▪The skin and subcutaneous tissue are incised transversely slightly curvilinear at the level of pubic hair (2 fingers above symphysis pubis along the skin crease) and extended beyond the lateral borders of the rectus muscle (approx length of incision 15 cm).

▪ The rectus sheath is opened by scalpel and extended by scissor, then separated from the underlying rectus muscle superiorly (level of umbilicus) and inferiorly by blunt dissection. Perforated blood vessels are ligated.

▪The rectus muscles are separated, the transversalis facia and peritoneum are opened (scalpel or blunt) and peritoneal cavity and uterus exposed.

Front 18

Indication for midline vertical incision

Back 18

▪Previous midline vertical incision

▪Obesity

▪placenta praevia

▪Abnormal lie

▪Emergency C/S

Front 19

Ch

Back 19

▪ The skin and subcutaneous tissue incised from the pubic symphysis to within 2 cm of the umbilicus.

▪The fascia is elevated and sharply dissected from pubis to umbilicus

▪The rectus sheath is incised with a scalpel and completed with scissors.

▪ Then the recti are separated, transversals facia and peritoneum are incised.

Front 20

From inspection to reflection of bladder in LSTI

Back 20

▪ The uterus is inspected for fibroids, varicose veins and adhesions.

▪ The two round ligaments are identified.

▪Then the uterus is palpated for fibroids and the presenting part. ▪Moistened laparotomy packs may be placed in the para-colic gutters. ▪A Doyne retractor is inserted inferiorly.

▪The loose serosa overlying the lower segment of the uterus is held in the middle with toothed tissue forceps and cut with scissor and opened transversely just above (2 cm) the upper margin of the bladder.

▪ The bladder is then reflected from the underlying lower uterine segment, the bladder flap is held beneath the symphysis pubis with the retractor.

Front 21

From transverse uterine incision to delivery of the baby in LSTI

Back 21

▪ A transverse uterine incision is made by scalpel, avoid injury of fetus and extended the scissor (or fingers) laterally and upward medial to the round ligament.

▪In case of transverse lie the incision is sometimes extended upward (J shape).

▪The amniotic membrane is opened gently, continous suction is useful to assist visualization and avoid fetal injuries.

▪Then the retractor is removed and if the fetal presentation is cephalic it should be delivered by elevation through the uterine incision manually. ▪Fundal pressure should not be applied until the presenting part is firmly in the incisional opening as otherwise the lie of the fetus may turn to transverse.

▪If the head is engaged in the maternal pelvis, disimpaction by upward pressure per vagina is required.

▪The nose and oropharynx of the baby are suctioned. and the baby delivered by gentle traction.

▪ The infant is maintained at the level of the maternal abdomen

Front 22

From delivery of the baby to Exteriorization of uterus in LSTI

Back 22

▪Once the fetus is delivered oxytocin is administered 10 IU bolus dose I.V and synotocinon infusion 40 IU in 500 ml normal saline over 3 hours (80 milliunit/minute). ▪The placenta is delivered by control cord traction-AFTER BEING CERTAIN THAT UTERUS IS CONTRACTED to avoid acute inversion of uterus. Manual removed of placenta is associated with increased blood loss and postpartum infection. The swab the uterine cavity and dilate the cervix by ring forceps. ▪Placement of Green Armytage at uterine angles and the inferior uterine edge reduces the intraopretative blood loss. ▪Exteriorization of uterus assist visualization and technically facilitate repair especially if there have been lateral extensions.