AJAZ AHMAD KHAN
BSC OTT 3RD YEAR
LOWER SEGMENT CAESAREAN
Definition, Indications, Types etc.
• Operation procedure where by the fetus after the
end of 28th week is delivered through an incision on
the abdominal and uterine wall.
• In this operation the extraction of the baby is done
through an incision made in the lower segment (3rd
and 4th quadrant, 2-2.5 inches) above the
Vaginal delivery is not possible. Caesarean section is needed
even with a dead fetus
Central placenta praevia
Contracted pelvis or Cephalo pelvic disproportion(absolute)
Pelvic mass causing obstruction(cervical or broad ligament
Vaginal obstruction(atresia, stenosis)
Cephalo pelvic disproportion
Non reassuring FHR(fetal distress)
Dystocia due to (three p’s) relatively large fetus(passenger), small
pelvis(passage), or inefficient uterine contractions(power)
Antepartum haemorrhage-placenta praevia and abruptio placenta
Malpresentation-Breech, Shoulder(transverse lie), Brow
Failed surgical induction of labour, Failure to progress in labour
Bad obstetric history-with recurrent fetal wastage
Hypertensive disorders-Severe pre eclampsia, Eclampsia-uncontrolled
fits even with antiseizure therapy
TIME OF OPERATION
1. ELECTIVE:- When the operation is done at a prearranged
time during pregnancy to ensure the best quality of
obstetrics, anesthesia, neonatal resuscitation and nursing
services. The operation is done at least one week before
the expected date of delivery.
1. EMERGENCY:- When the operation is performed due to
unforeseen or acute obstetric emergencies. It is done 30
minutes before the rupture of membrane .
TYPES OF OPERATIONS
LOWER SEGMENT- In this operation the extraction of
baby is done through an incision made in the lower
segment through a trans peritoneal approach.
CLASSICAL- In this operation the baby is extracted
through an incision made in the upper segment in uterus.
Abdomen is scrubbed with soap and nonorganic iodine lotion. Hair
may be clipped off.
Premedicative seddative must not be given.
Non particulate antacid (0.3 molar sodium citrate ,30 ml) is given
orally before transferring the patient to theatre. It is given to
neutralise the existing gastric acid.
Ranitidine(H2 blocker) 150 mg is given orally night before(elective
procedure) and is repeated (50 mg I.M or I.V) one hour before the
surgery to raise the gastric pH.
Metoclopramide (10 mg I.V) is given to increase the tone of the lower
esophageal sphincter as well as to reduce the stomach contents. It is
administered after about 3 minutes of pre-oxygenation in the
The stomach should be emptied, if necessary by a stomach
Bladder should be emptied by a soft rubber catheter which
is kept in place till the end of operation.
FHS should be checked once more at this stage.
Neonatologist should be made available.
ANESTHESIA:- Spinal, epidural or general. However, choice
of the patient and urgency of delivery are also considered.
POSITION:- Dorsal position
INCISION:- The surgeon may choose either a vertical or
transverse incision. Vertical incision may be infraumblical
midline or paramedian. Transverse incision, modified
pfannenstiel is made 3 cm above symphisis pubis.
First incision is made on the abdominal layer followed by
clamping it with hemostatic forceps.
The next incision is provided to the fat layer with a pin
point scalpel (pfannensteil incision).
Place the Doyen’s retractor after the peritoneal layer is
incised. The loose peritoneum of uterovesical pouch is cut
transversely with convexity downwards (1.25 cm) below
which is attachment to the uterus.
Then the uterine layer is identified and packs are placed
properly at all the four sides of peritoneum in order to
avoid the mixing of peritoneal fluid into the amniotic cavity.
A transverse or S shaped incision is given to the uterine
membrane. The small incision may extend 3.5cm in length, 2
index fingers are the inserted through the incision and split
transversely across the fetus, this will minimize the spilling of
DELIVERY OF HEAD
The membranes are ruptured if still intact. The blood mixed
amniotic fluid is sucked out by continuous suction. The
doyen’s retractor is removed and the baby is delivered by
hooking the head with the fingers which are carefully
insinuated between the lower uterine flap and the head until
the palm is placed below the head. As the head is drawn to
the incision line the assistant has to apply pressure on the
fundus. If head is jammed, an assistant may push up the head
by sterile gloved fingers introduced into the vagina. The head
can also be delivered using either Wrigley’s or Barton’s
DELIVERY OF TRUNK
As soon as the head is delivered, the mucus from the mouth,
pharynx and nostrils is sucked out using rubber catheter attached
to an electric sucker and the delivery of shoulder is done.
Intravenous oxytocin 20 units or 0.2mg methergin is administered.
The rest of the body is delivered slowly and baby is placed in a tray
between mother’s legs with the head tilted down for gravitional
drainage. The umbilical cord is cut in between two clamps and the
baby is handed over to the nurse. The Doyen’s retractor is re
REMOVAL OF PLACENTA AND MEMBRANES:-
By this time (10-15 minutes) the placenta is likely to be separated
and it is extracted by traction on the cord with simultaneous
pushing the uterus towards the umbilicus per abdomen using the
left hand controlled cord traction. The membranes are scrapped
off using uterine curette. The removed placenta is taken in a tray
for an inspection. Introduce light warm normal saline to wash the
SUTURES OF UTERINE & ABDOMINAL LAYERS
The margins are picked up by Allis forcep or Green armytage. All the layers are
sutured seperatively using running continuous sutures in the deeper layers and
interrupted or interlock continuous sutures in the superficial layers.
POST OPERATIVE CARE
• The patient is observed for at least 4-6 hours with periodic checkup of pulse
and uterine contractions.
• Fluid replacement of about 2-2.5 litres should be done within an hour.
• On first day oral feeding in the form of plain or electrolyte water or raw tea
may be given. Active bowel sounds are observed by the end of the day.
• Light solid diet of patient’s choice is given on day 2.
• 3-4 teaspoons of lactulose may be given at bed time if bowels don’t move
• The abdominal stitches are to be removed on day 5(in transverse), or day
6(in longitudinal) incisions.
TRAY ONE TRAY SECOND
• Towel clip (Backhaus) Cord clamp
• Wrigley’s obstetric forcep Cord cutting scissor
• Curved artery forcep Sponge holding forcep st.
• Green armytage Suction catheter
• Allis tissue forcep Artery forcep small
• Sponge holding forcep Bull suction
• BP handle Bowl with NS & distil water
• Doyen’s retractor Gauze packs
• Morris retractor
• Mayo’s scissor
• Spencer scissor
• Little wood tissue forcep
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