Cesarean Section

Original Editor - Mereena Baby Top Contributors - Mereena Baby, Lucinda hampton, Michelle Walsh, Kim Jackson, Nicole Hills, Victoria Geropoulos, Vidya Acharya, Regan Haley and Nupur Smit Shah

Definition

• A cesarean section can be defined as the procedure in which the delivery of a baby is through an incision in the abdominal wall and uterus rather than through the pelvis and vagina. General, spinal or epidural anesthesia is used.

• In a cesarean delivery, an incision is made in the lower abdominal wall and in the uterus.The incision can be vertical or transverse. However the condition of mother and the fetus determines which type of incision has to be used.

Transverse Incision

• Its extension lies across the pubic hairline.

• It is most commonly used because it heals faster and there is minimal bleeding.

• It also increases the chance for normal delivery in future pregnancies.

Vertical Incision

Its extension is from navel to pubic hairline.

Reasons for the Procedure:

Some cesarean deliveries are planned and scheduled , while others are performed as a result of complication that occurs during labor.There are several conditions in which cesarean delivery is more likely to occur. These include :

• Fetal distress which is indicated by abnormal fetal heart rate.

• Abnormal position of the fetus during birth like breech presentation etc.

• Slow moving labor that fails to progress normally.

• Size of a baby is too large to be delivered vaginally.

• Placental complications like placenta previa .

• Maternal medical conditions such as diabetes, high blood pressure, HIV infection etc

• Active herpes infection in the mother’s vagina or cervix.

• Twins or multiple fetus.

• Previous history of cesarean delivery.

Procedure

Preoperative Preparation

Informed written permission from the patient for the procedure,anesthesia and blood transfusion is obtained.

• Abdomen is scrubbed with soap and nonorganic iodide lotion.Hair is usually clipped.

• Premedicative sedative should not be given.

• Nonparticulate antacid (0.3 molar sodium citrate, 30 ml) is given orally before transferring the patient to the operation theatre.This is given to neutralize the existing gastric acid.

• Ranitidine 150 mg is usually given orally night before and it is repeated 1 hour before the surgery to raise the gastric pH.

• The stomach should be emptied , If needed,it can be emptied by a stomach tube also.

• Metoclopramide (10 mg) is given to increase the tone of the lower esophageal sphincter as well as to reduce the stomach contents.It is administered after 3 minutes of preoxygenation in the operation theater.

• Bladder has to be emptied by a Foley catheter which is kept in place in the perioperative period.

• Fetal heart sound should be evaluated again at this stage.

• Neonatologist should be available at this stage.

• Cross match blood when above average blood loss (placenta previa,prior multiple cesarean delivery ) is expected.

• Prophylactic antibiotics should be given (IV) before cesarean section.

Important Consideration:

IV cannula: Placed to administer fluids.

Procedure

Position of the patient : The patient should be placed in the dorsal position.In susceptible cases, to minimize any harmful effects of venacaval compression, a 15 degree tilt to her left using a wedge till delivery of the baby should be done.

Anesthesia- It can be spinal, epidural or general. However, choice of the patient and urgency of delivery is also considered.

Antiseptic painting-The abdomen should be painted with 7.5% providone-iodine solution or savlon lotion and should be properly draped with sterile towels.

Incision on the abdomen

Packing:The Doyen’s retractor is introduced in this stage.

Uterine incision

Delivery of head

The membranes are ruptured if it is still intact.The blood mixed amniotic fluid is sucked out by continuous suction.The Doyen’s retractor is removed.The head 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.The head is delivered by elevation and flexion using the palm to act as fulcrum.As the head is drawn to incision line,the assistant is to apply pressure on the fundus.If the 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 Wringley’s or Barton’s forceps. Delivery of the 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 suction machine.After the delivery of the shoulders, intravenous oxytocin 20 units or methergine 0.2 mg has to be administered.The rest of the body should be delivered slowly and the baby should be placed in a tray placed in between the mother’s thighs with the head tilted down for gravitational drainage.The cord should be cut in between two clamps and the baby should be handed over to the paediatrician.The Doyen’s retractor is reintroduced.The optimum interval between uterine incision and delivery should be less than 90 seconds.

Removal of the placenta and membranes:

By this time, the placenta is separated spontaneously.The placenta has to be extracted by traction on the cord with simultaneous pushing of the uterus towards the umbilicus per abdomen using the left hand(controlled cord traction).Routine manual removal should not be done.Dilation of internal os is not required.Exploration of the uterine cavity is desirable.

Suture of the uterine wound.

Non closure of visceral and parietal peritoneum is preferred .

Concluding Part:

The mops placed inside are removed and the number is checked.Peritoneal toileting should be done and blood clots are to be removed carefully and precisely.The tubes and ovaries are examined.Doyen’s retractor is removed.After being satisfied the uterus is well contracted, the abdomen is closed in layers.The vagina is cleansed of blood clots and a sterile vulval pad is placed.

Potential Structural and Functional Impairments:

• There is a risk of pulmonary, gastrointestinal or vascular complications.

• Post surgical pain and discomfort is common.

• Development and adhesions at incision site is seen.

• Faulty posture is commonly observed.

• Pelvic floor dysfunction which presents as:
  • Urinary or fecal incontinence
  • Organ prolapse
  • Hypertonus
  • Poor proprioceptive awareness and disuse atrophy

• Abdominal weakness,diastasis recti can occur.

• General functional restrictions is seen post delivery.

Significance to Physical Therapists

Pelvic Floor Rehabilitation

Women who have had a cesarean delivery may still require pelvic floor rehabilitation. Many women experience lengthy labor, including prolonged second stage ( pushing), before a cesarean section is considered necessary. Therefore pelvic floor musculature and pudendal and levator ani nerves function may still be compromised. Also pregnancy itself creates significant strain on pelvic floor musculature and other soft tissues.

Post Surgical Rehabilitation

Postpartum intervention for the woman who had a cesarean delivery is similar to that of the woman who has had a vaginal delivery. However, a cesarean section is a major abdominal surgery with all the complication of such surgeries and therefore the woman will also require general post surgical rehabilitation.

Physiotherapy Mangement after Cesarean Section

Goal: To improve pulmonary function and decrease the risk of pneumonia

• Breathing instructions should be given.

• Coughing and / or huffing technique should be taught.

Goal: To decrease incisional pain with coughing, movement or breast feeding.

• Post operative TENS can be given.

• Support incision site with pillow when coughing or breastfeeding.

• Incisional support with pillows or hands with movement ,education regarding incisional care and risk of injury.

Goal: To prevent post surgical vascular or gastrointestinal complications.

• Active leg exercises should be taught.

• Early ambulation should be encouraged.

• Abdominal massage to peristalsis can be taught.

Goal: To enhance incisional circulation and healing; prevent adhesion formation.

• Gentle abdominal exercise with incisional support should be taught ..

• scar mobilisation can be done.

• friction massage can be given.

Goal: To decrease post surgical discomfort from flatulence,itching or catheter.

• Instructions regarding positioning should be given.

• massage can be given.

• supportive exercises can be taught.

Goal: To correct posture.

• Posture instructions should be given, particularly regarding child care.

Goal: To prevent injury and reduce low back pain.

• Instructions regarding incisional splinting and positioning for ADLs should be given.

• Instructions regarding body mechanics should be given.

Goal: To prevent pelvic floor dysfunction

• Pelvic floor exercises should be taught.

• Education regarding risk factors and types of pelvic floor dysfunction should be given.

Goal: To develop abdominal strength

• Abdominal exercise progression , including corrective exercises for diastasis rectii should be taught.