Case study

Of
Cesarean section

Prepared by: Mark Kenneth T. Tibig Submitted to: Mr. Leonardo Sanchez IV
UPCN-SN Clinical Instructor

Caesarean section
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A team of obstetricians performing a Caesarean section in a modern hospital.

A Caesarean section, (also C-section, Caesarian section, Cesarean section, Caesar, etc.) is a surgical procedure in
which one or more incisions are made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to
deliver one or more babies, or, rarely, to remove a dead fetus. A late-term abortion using Caesarean section
procedures is termed a hysterotomy abortion and is very rarely performed.

A Caesarean section is usually performed when a vaginal delivery would put the baby's or mother's life or health at
risk, although in recent times it has been also performed upon request for childbirths that could otherwise have
been natural.[1][2][3] In recent years the rate has risen to a record level of 46% in China and to levels of 25% and
above in many Asian countries, Latin America, and the USA.

Types

A Caesarean section in progress.

Suturing of the uterus after extraction.
Pulling out the baby.
Closed Incision for low transverse abdominal incision after stapling has been completed.

There are several types of Caesarean section (CS). An important distinction lies in the type of incision (longitudinal
or latitudinal) made on the uterus, apart from the incision on the skin.

 The classical Caesarean section involves a midline longitudinal incision which allows a larger space to
deliver the baby. However, it is rarely performed today as it is more prone to complications.
 The lower uterine segment section is the procedure most commonly used today; it involves a transverse
cut just above the edge of the bladder and results in less blood loss and is easier to repair.
 An emergency Caesarean section is a Caesarean performed once labor has commenced.
 A crash Caesarean section is a Caesarean performed in an obstetric emergency, where complications of
pregnancy onset suddenly during the process of labor, and swift action is required to prevent the deaths
of mother, child(ren) or both.
 A Caesarean hysterectomy consists of a Caesarean section followed by the removal of the uterus. This
may be done in cases of intractable bleeding or when the placenta cannot be separated from the uterus.
 Traditionally other forms of Caesarean section have been used, such as extra peritoneal Caesarean section
or Porro Caesarean section.
  a repeat Caesarean section is done when a patient had a previous Caesarean section. Typically it is
performed through the old scar.

In many hospitals, especially in Argentina, the United States, United Kingdom, Canada, Norway, Sweden, Australia,
and New Zealand the mother's birth partner is encouraged to attend the surgery to support the mother and share
the experience. The anesthetist will usually lower the drape temporarily as the child is delivered so the parents can
see their newborn

Indications

A 7-week old Caesarean section scar and linea nigra visible on a 31-year-old mother.

Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. Not all of the
listed conditions represent a mandatory indication, and in many cases the obstetrician must use discretion to
decide whether a Caesarean is necessary. Some indications for Caesarean delivery are:

Complications of labor and factors impeding vaginal delivery such as

 prolonged labor or a failure to progress (dystocia)

 fetal distress
 cord prolapse
 uterine rupture
 increased blood pressure (hypertension) in the mother or baby after amniotic rupture
 increased heart rate (tachycardia) in the mother or baby after amniotic rupture
 placental problems (placenta praevia, placental abruption or placenta accreta)
 abnormal presentation (breech or transverse positions)
 failed labor induction
 failed instrumental delivery (by forceps or ventouse. Sometimes a 'trial of forceps/ventouse' is tried out -
This means a forceps/ventouse delivery is attempted, and if the forceps/ventouse delivery is unsuccessful,
it will be switched to a Caesarean section.
 overly large baby (macrosomia)
 umbilical cord abnormalities (vasa previa, multi-lobate including bi-lobate and succenturiate-lobed
placentas, velamentous insertion)
 contracted pelvis

Other complications of pregnancy, preexisting conditions and concomitant disease such as

 pre-eclampsia
 hypertension
 multiple births
 precious (High Risk) Fetus
 HIV infection of the mother
 Sexually transmitted infections such as genital herpes (which can be passed on to the baby if the baby is
born vaginally, but can usually be treated in with medication and do not require a Caesarean section)
 previous Caesarean section (though this is controversial – see discussion below)
 prior problems with the healing of the perineum (from previous childbirth or Crohn's Disease)
 Bi-corniute uterus

Other
  Lack of Obstetric Skill (Obstetricians not being skilled in performing breech births, multiple births, etc. [In
most situations women can birth under these circumstances naturally. However, obstetricians are not
always trained in proper procedures])
 Improper Use of Technology (Electric Fetal Monitoring [EFM])

Risks

One of the most common risks: 2 weeks after the Caesarean section, fluid retention in the wound. Incision had to
be opened to use a negative pressure wound therapy unit to drain the body fluids to prevent infection.

Risks for the mother

The mortality rate for both Caesarian sections and vaginal birth, in the Western world, continues to drop steadily.
In 2000, the mortality rate for Caesareans in the United States were 20 per 1,000,000. The UK National Health
Service gives the risk of death for the mother as three times that of a vaginal birth . However, it is misleading to
directly compare the mortality rates of vaginal and Caesarean deliveries. Women with severe medical conditions,
or higher-risk pregnancies, often require a Caesarean section which can distort the mortality figures.

A study published in the 13 February 2007 issue of the Canadian Medical Association Journal found that the
absolute differences in severe maternal morbidity and mortality was small, but that the additional risk over vaginal
delivery should be considered by women contemplating an elective Caesarean delivery and by their physicians.

As with all types of abdominal surgery, a Caesarean section is associated with risks of post-operative adhesions,
incisional hernias (which may require surgical correction) and wound infections. If a Caesarean is performed under
emergency situations, the risk of the surgery may be increased due to a number of factors. The patient's stomach
may not be empty, increasing the anaesthesia risk. Other risks include severe blood loss (which may require a
blood transfusion) and post spinal headaches.

A study published in the June 2006 issue of the journal Obstetrics and Gynecology found that women who had
multiple Caesarean sections were more likely to have problems with later pregnancies, and recommended that
women who want larger families should not seek Caesarean section as an elective. The risk of placenta accreta, a
potentially life-threatening condition, is only 0.13% after two Caesarean sections but increases to 2.13% after four
and then to 6.74% after six or more surgeries. Along with this is a similar rise in the risk of emergency
hysterectomies at delivery. The findings were based on outcomes from 30,132 Caesarean deliveries.

It is difficult to study the effects of Caesarean sections because it can be difficult to separate out issues caused by
the procedure itself versus issues caused by the conditions that require it. For example, a study published in the
February 2007 issue of the journal Obstetrics and Gynecology found that women who had just one previous
Caesarean section were more likely to have problems with their second birth. Women who delivered their first
child by Caesarean delivery had increased risks for malpresentation, placenta previa, antepartum hemorrhage,
placenta accreta, prolonged labor, uterine rupture, preterm birth, low birth weight, and stillbirth in their second
delivery. However, the authors conclude that some risks may be due to confounding factors related to the
indication for the first Caesarean, rather than due to the procedure itself.

Risks for the child

This list is currently incomplete and should not be taken as comprehensive or reflective of current research. It
covers some of the most commonly discussed risks to the child posed by the procedure itself rather than the
medical indications that may call for it. Some risks are rare, and as with most medical procedures the likelihood of
any risk is highly dependent on individual factors such as whether other pregnancy complications exist, whether
the operation is planned or done as an emergency measure, and how and where it is performed.

 Lower apgar scores/ neonatal depression: babies may experience a period of inactivity or sluggishness
after delivery, possibly due to an adverse reaction to the anesthesia given to the mother.
  Potential for infant injury: it is possible though very rare for surgical tools used for the uterine incision to
injure the infant.

 Wet lung: retention of fluid in the lungs can occur if not expelled by the pressure of contractions during
labor.

 Potential for early delivery and complications: Pre-term delivery is possible if due date calculation is
inaccurate. One study found an increased risk of complications if a repeat elective Caesarean section is
performed even a few days before the recommended 39 weeks.

 Higher infant mortality risk: in c-sections which are performed with no indicated risk (singleton at full
term in a head-down position), the risk of death in the first 28 days of life has been cited as 1.77 per 1,000
live births among women who had c-sections, compared to 0.62 per 1,000 for women who delivered
vaginally

Risks for both mother and child

Due to extended hospital stays, both the mother and child are at risk for developing a hospital-borne infection.

Studies have shown that mothers who have their babies delivered by Caesarean take longer to first interact with
their child when compared with mothers who had their babies vaginally.

The Nine Abdominal Regions &

The Organs Found Therein
 Right Hypochondriac Epigastric Left Hypochondriac
Right Lumbar Umbilical Left Lumbar
Right Iliac Hypogastric Left Iliac

The Nine Abdominal Regions

Right Hypochondriac Top      Epigastric     Top Left Hypochondriac
Digestive: Digestive: Digestive:
     Liver      Esophagus      Stomach
       Gall Bladder       Stomach        Liver (tip)
       Small Intestine       Liver        Pancreas (tail of)
       Ascending Colon       Pancreas        Small Intestine
       Transverse Colon       Small Intestine        Transverse Colon
      Transverse Colon        Descending Colon
Endocrine:
     Right Kidney Endocrine: Endocrine:
     Right & Left Adrenal Glands        Pancreas
Excretory:       Pancreas      Left Kidney
     Right Kidney      Right & Left Kidneys
Excretory:
Lymphatic: Excretory:      Left Kidney
     NONE      Right & Left Kidneys
     Right & Left Ureters Lymphatic:
Reproductive:      Spleen
     NONE Lymphatic:
     Spleen Reproductive:
Other Body Systems      NONE
Reproductive:
      NONE Other Body Systems

Other Body Systems

Right Lumbar Top      Umbilical     Top Left Lumbar

Digestive: Digestive: Digestive:
     Liver (tip)      Stomach        Small Intestine
       Gall Bladder       Pancreas        Descending Colon
       Small Intestine       Small Intestine
       Ascending Colon       Transverse Colon Endocrine:
     Left Kidney (tip)
Endocrine: Endocrine:
     Right Kidney       Pancreas Excretory:
     Right & Left Kidneys      Left Kidney (tip)
Excretory:
     Right Kidney Excretory: Lymphatic:
     Right & Left Kidneys      NONE
Lymphatic:      Right & Left Ureters
     NONE Reproductive:
Lymphatic:      NONE
Reproductive:      Cisterna chyli
     NONE Other Body Systems
Reproductive:
Other Body Systems      NONE

Other Body Systems

Right Iliac Top      Hypogastric     Top Left Iliac

Digestive: Digestive: Digestive:
       Small Intestine       Small Intestine        Small Intestine
       Appendix       Sigmoid Colon        Descending Colon
       Cecum & Ascending Colon       Rectum        Sigmoid Colon

Endocrine: Endocrine: Endocrine:

       Right Ovary (Females)               Right & Left Ovaries (Fem.)        Left Ovary (Females)

Excretory: Excretory: Excretory:

     NONE      Right & Left Ureters      NONE
      Urinary Bladder
Lymphatic: Lymphatic:
     NONE Lymphatic:      NONE
     NONE
Reproductive: Reproductive:
       Female - Reproductive:        Female -
              Right Ovary       Female -               Left Ovary
              Right Fallopian Tube           Uterus *               Left Fallopian Tube
     Male -               Right & Left Ovaries      Male -
              NONE               Right & Left Fallopian Tubes               NONE
     Male -
Other Body Systems             Vas Deferens Other Body Systems
            Seminal Vessicle
              Prostate

Other Body Systems