case study: Lower Segment Caesarean Section

INSTITUT LATIHAN KEMENTERIAN KESIHATAN MALAYSIA KOTA KINABALU KURSUS DIPLOMA PEMBANTU PERUBATAN

CASE STUDY

TITLE LOWER SEGMENT CAESAREAN SECTION (LSCS)

 NAME

:

ALIAS BIN SABLE

IDENTITY CARD NO

:

940106-12-6227

MATRICS CARD NO

:

BPP2015-3721

YEAR INTAKE

:

JULY 2015

SEMESTER

:

FIVE (5)

PLACEMENT UNIT

:

OPERATING THEATRE HOSPITAL KOTA BELUD 1

CONTENT

NO.

TITLE

PAGE

1

Introduction

3

2

Literature Review

4

3

Discussion

5

4

Conclusion

8

5

References

9

2

INTRODUCTION

A lower (uterine) segment Caesarean section (LSCS), also called the Kerr incision is the most commonly used type of Caesarean section. It includes a transverse cut 1-2 centimetres above the attachment of the urinary bladder to the uterus, in the lower segment. This type of incision results in less blood loss and is easier to repair than other types of Caesarean sections. It also defined as the delivery of a fetus through surgical incisions made through the abdominal wall (laparotomy) and the uterine wall (hysterotomy). There is a myth which states that the word "Caesarean" originates from "Caesar", the Roman ruler, who according to the legend, was delivered by Caesarean section. But this is doubtful as his mother, Aurelia Cotta, lived for many years afterwards. At that ancient time, Caesarean section was performed when the mother was dead or dying, as an attempt to save the baby. Caesarean section at that time was not intended to preserve the life of the mother. It will only  perform when the mother is dying to save the baby. Development of surgical techniques and anaesthesia, later improves the procedure results in low morbidity and mortality. The first successful Caesarean section was done in 1882. However, there were complications due to poor facilities . The LSCS rate in Malaysian public hospitals has increased to 15.7% from 10.5% in the year 2000. There are inter-state variations in the rate ranging from a high of 25.4% in Melaka to 10.9% in Sabah. The West Coast states generally had a higher caesarean section rate than the East Coast states as well as East Malaysia. Most bleeding takes place from the angles of the incision, and forceps can be applied to control it. Green Armytage forceps are specifically designed for this purpose. Although the incision is made using a sharp scalpel, care must be taken not to injure the foetus, especially if the membranes are ruptured, or in emergencies like abruption. The incision can be extended to either sides using a scissor or by blunt dissection using hands. While using the scissors, the surgeon should ensure that a finger is placed underneath the uterus so that the foetus in protected from unintentional injury. If blunt dissection is done, intra-operative blood loss can be minimized. In cases where Kerr incision cannot be done (such as large  baby), Kronig incision (low vertical incision), classical, J or T incisions may be used to incise the uterus.

3

LITERARTURE REVIEWS

One of the great advances in operative was the development of the Lower Segment Caesarean Section, which was better than the classical upper segment vertical variety with its risk of subsequent rupture (Powell, John L. MD, FACOG, FACS, 2001)

The number of caesarean sections has increased over the last two decades, especially in the developed countries. Hence, it has increasingly become a greater challenge to provide care for the parturient, but this has given obstetric anaesthetists a greater opportunity to contribute to obstetric services. While caesarean deliveries were historically performed using general anaesthesia, there is a recent significant move towards regional anaesthesia. (Dr. Sean Yeoh, 2010)

The classical operation is performed in 1 – 2% of Caesarean sections usually for transverse lie, failure of development of the lower segment (prematurity 5 breech presentation), dense adhesions, large veins over the lower segment (placenta praevia), constriction ring and invasive carcinoma of the cervix. The classical operation is likely to be performed more often than formerly because more very premature infants (26 – 32 weeks' gestation) are being delivered by Caesarean section. (Lourdes St George and K. B. Kuah, 1987)

Caesarean section surgery has become one of the most common obstetric operations worldwide, accounting for over 27% of total deliveries over 2004/05 and 2007/08. The basic  procedure has been modified over the years and improved through its extensive practice. (Dr Z Shi, 2010) The caesarean delivery rate is increasing worldwide. Several studies have shown that one caesarean section implies a high risk for caesarean section in the next pregnancy. Caesarean section, especially repeat caesarean section, is associated with an increased risk for uterine rupture, abnormal placental implantation, placental abruption and uterine scar dehiscence in subsequent pregnancies. (O Vikhareva Osser and L Valentin, 2010)

4

DISCUSSION

Out of the reported Caesarean deliveries, 50% are planned (Elective Caesarean) and another 50% are Emergency Caesarean. Throughout my clinical attachment here at Operating Theatre Hospital Kota Belud, most of the caesarean deliveries are Emergency Caesarean. The Elective Caesarean is conducted or planned when the mother has complications such as multiple pregnancies, baby in breech which the buttocks or feet of the baby is the first anatomy that comes out from mother vagina or baby in transverse position, placenta praevia (placenta obstructs the birth canal), mother having a severe high blood pressure and previous history of birth complications. While Emergency Caesarean carried out to avoid fetal distress or when cervix does not open sufficiently or mother in labour with baby positions unfavourable for vaginal delivery. Before the LSCS is performed, the preoperative management has to be done. Guidelines recommend a minimum preoperative fasting time of at least 2 hours from clear liquids, 6 hours from a light meal, and 8 hours from a regular meal. However, patients are usually asked not to eat anything for 12 hours prior to the procedure. a. The following are also included in preoperative management: ➢

Placement of an intravenous (IV) line

➢

Infusion of IV fluids (eg, lactated Ringer solution or saline wit h 5% dextrose)

➢

Placement of a Foley catheter (to drain the bladder and to monitor urine output)

➢

Placement of an external fetal monitor and monitors for the patient’s blood  pressure, pulse, and oxygen saturation

➢

Preoperative antibiotic prophylaxis (decreases risk of endometritis after elective cesarean delivery by 76%, regardless of the type of cesarean delivery [emergent or elective])

➢

Evaluation by the surgeon and the anaesthesiologist

➢

Laboratory testing

 b. The following laboratory studies may be obtained prior to cesarean deliver y: ➢

Complete blood count

➢

Blood type and screen, cross-match

➢

Screening tests for human immunodeficiency virus, hepatitis B, syphilis 5

➢

Coagulation studies (eg, prothrombin and activated partial thromboplastin times, fibrinogen level)

➢

Imaging studies

In labor and delivery, document fetal position and estimated fetal weight. Although ultrasonography is commonly used to estimate fetal weight, a prospective study reported the sensitivity of clinical and ultrasonographic prediction of macrosomia, respectively, as 68% and 58%. The first step of caesarean delivery is to open the mother's abdomen through a lower midline incision. A transverse skin incision is associated with reduced postoperative pain and is more aesthetically acceptable to patients compared with a vertical incision (classic). The Pfannenstiel incision is slightly curved and made 2 to 3 cm above the symphysis pubis. The incision should allow for at least 15 cm of exposure. The skin and subcutaneous fat is incised with electrocautery. After the incision of abdomen, the anterior rectus sheath is incised transversely. The rectus muscles are separated in the midline. The parietal peritoneum is opened. The loose  peritoneum over the lower uterine segment is held and incised transversely, for about 10 cm in a semilunar fashion with its edges directed upwards. The bladder is dissected downward and is retained behind a Doyen's retractor placed over the symphysis. Membranes are ruptured by toothed or Kocher’s forceps. The head is delivered by introducing the right hand gently below it and lifting it up helped by fundal pressure done by the assistant, using one blade of the forceps or, using Wrigley’s forceps. If the head is deep in the pelvis it can be pushed up vaginally by an assistant. The Doyen’s retractor is removed after the hand or forceps blade is applied and before head extraction. Suction for the foetus is carried out before delivery of the head. In breech or transverse lie the foetus is extracted as breech. Once the umbilical cord is clamped and cut, it is time to deliver the placenta via spontaneous extraction. Gentle traction is placed on the cord and oxytocin is used to enhance uterine contractions. The placenta is checked to make sure it is complete and the uterus is explored with one hand to remove any remaining membranes or placental tissue. The uterus is than massaged to promote contraction. Oxytocin is given to promote uterine contraction and involution.

6

Closure of the uterine incision is done in 3 layers. The first is a continuous locking suture taking most of the myometrium but not passing through the decidua to guard against endometriosis and weakness of the scar. The second is a continuous or interrupted one inverting the first layer. The third is a continuous or interrupted layer to close the visceral  peritoneum of the uterus. Similarly, the rectus muscles are not surgically reapproximated. The fascial tissue is carefully closed to provide good wound strength and the skin is closed with a subcuticular suture. The last is to closing the incision. Abdomen is then closed in layers. After the LSCS is performed, postoperative management has to be done by the nurses. The management are including: ➢

Routine postoperative assessment

➢

Monitoring of vital signs, urine output, and amount of vaginal bleeding

➢

Palpation of the fundus

➢

IV fluids; advance to oral diet as appropriate, early feeding has been shown to shorten hospital stay

➢

IV or intramuscular (IM) analgesia if patient did not receive a long-acting analgesic or had general anesthesia; analgesia is usually not needed if patient received regional anesthesia, with/without a long-acting analgesic

➢

Ambulation on postoperative day 1; advance as tolerated

➢

If patient plans to breastfeed, initiate within a few hours after delivery; if patient plans to bottle feed, she may use a tight bra or breast binder in the postoperative period

➢

Discharge on postoperative day 2 to 4, if no complications

➢

Discuss contraception as well as refraining from intercourse for 4-6 weeks  postpartum, unless the patient had LARC placed at the time of the procedure

7

CONCLUSION

The birth experience with a LSCS is very different from that of a vaginal delivery. For one thing, the whole operation ordinarily takes no more than an hour, and depending on the circumstances, you may not experience any labour at all. Another important difference is the need to use medication that affects the mother and may affect the baby. If given a choice of anaesthetics, most women prefer to have a regional anaesthesia, an injection in the back that  blocks pain by numbing the spinal nerves such as an epidural or a spinal. Administration of a regional anaesthesia numbs the body from the waist down, has relatively few side effects, and allows you to witness the delivery. But sometimes, especially for an emergency LCSC, a general anaesthetic must be used, in which case you are not conscious at all. Your obstetrician and the anaesthesiologist in attendance will advise you which approach they think is best, based on the medical circumstances at the time.

8

REFERENCES

BOOKS i. ii. iii.

C. McIntosh Marshall (1939). Caesarean Section: Lower Segment Operation Eric Jauniaux, William Grobman (2016). Caesarean Section Helen Churchill, Wendy Savage (2010). Vaginal Birth After Caesarean

ONLINE ARTICLES i.

Radhae Raghavan, Pallavi Arya, Prathibha Arya, Susnata (2014). Abdominal incisions

and

sutures

in

obstetrics

and

gynaecology.

Retrieved

from

http://onlinelibrary.wiley.com/doi/10.1111/tog.12063/full

ii.

Arwinder Singh (2014). Undergoing a planned lower segment caesarean section. Retrieved from http://www.magonlinelibrary.com/doi/abs/10.12968/jodp.2014.2.2.79

iii.

Caroline De Costa (2005). Vaginal birth after classical Caesarean section. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1479-828X.2005.00387.x/full

iv.

Philip F. Williams (2006). Caesarean Section, Lower Segment Operation. Retrieved from http://www.ajog.org/article/S0002-9378(15)31478-2/abstract

v.

Hedwige

Saint

Louis

(2017).

Cesarean

Delivery.

http://emedicine.medscape.com/article/263424-overview

9

Retrieved

from