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Caesarean Section
An operative procedure to deliver a viable foetus or more (i.e. after 28 weeks or 20 weeks according to the ACOG) through an abdominal and uterine incisions.
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Incidence
* Increased from 5% in 1970 to 25% in 1990 due to: * Procedures as high forceps and difficult mid forceps are abandoned in favour of Caesarean Section (C.S.) * Increased C.S delivery in breech presentation. * Destructive operations are abandoned in favour of C.S. * Decreased morbidity and mortality due to C.S encourages its use. * Increased repeated C.S due to increased primary C.S.
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Indications
Maternal indications: 1. Contracted pelvis and cephalopelvic disproportion (see before). 2.Pelvic tumours especially if impacted in the pelvis or cancer cervix. 3. Antepartum haemorrhage (see before). 4.Hypertensive disorders with pregnancy (see before). 5. Abnormal uterine action (see before). 6.Previous uterine scar as hysterotomy or metroplasty. 7. Previous successful repair of vesico-vaginal fistula.
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Indications
8.Previous caesarean section if, a. the cause of the previous section is permanent e.g. contracted pelvis. b. previous section was upper segment. c.suspected weak scar as evidenced by: > History of puerperal infection after the previous section. > Hysterosalpingography or hysteroscopy done after the previous section reveals a defect in the scar. > Vaginal bleeding during current labour. > Marked tenderness over the scar during current labour. >Associated conditions as antepartumhaemorrhage or malpresentations.
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Indications
Foetal indications: 1. Malpresentations and malposition (see before). 2.Prolapsed pulsating cord or foetal distress before full cervical dilatation. 3.Diabetes mellitus 4.Bad obstetric history as recurrent intrauterine foetal death in last weeks of pregnancy or repeated intranatal foetal death. 5.Post-mortem C.S. done within 10 minutes of maternal death to save a living baby.
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Contraindications
1.Dead foetus: except in; a. Extreme degree of pelvic contraction. b.Neglected shoulder. c.Severe accidental haemorrhage. 2. Disseminated intravascular coagulation: to minimise blood loss. 3.Extensive scar or pyogenic infection in the abdominal wall e.g. in burns.
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Caesarean Hysterectomy
Hysterectomy is carried out after caesarean section in the same sitting for one of the following reasons: * Uncontrollable postpartum haemorrhage. * Unrepairable rupture uterus. * Operable cancer cervix. * Couvelaire uterus. * Placenta accreta cannot be separated. * Severe uterine infection particularly that caused by Cl. welchii. *Multiple uterine myomas in a woman not desiring future pregnancy although it is preferred to do it 3 months later.
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Caesarean Sterilisation
Tubal sterilisation is usually advised during the fourth caesarean section.
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