A literature review of Cesarean Section

in StemSocial5 months ago

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With all the stigma in Nigeria towards women who give birth through this surgical means, in Nigeria and probably in Africa, it is important that people understand the full scope the birthing solution that is Cesarean section.

Cesarean section or CS for short, is a delivery of a baby via open incision of the abdomen known as laparotomy and uterine incision known as hysterotomy. The very first documented cesarean was done in 1020 AD, and since then, the operational technique has progressed and changed significantly. To read more of that check here

It is the most common type of surgery performed in the United States. Despite ongoing efforts to lower the number of cesarean sections, doctors do not expect a major reduction for at least another one or two decades. Check that out here

Cesarean delivery can be the safest or even the only way for some women to deliver a healthy infant, despite the dangers of both immediate and long-term complications of the procedure.

ANATOMY AND PHYSIOLOGY OF CESAREAN SECTION

To achieve a cesarean delivery, the surgeon has to cut through all the layers that separate him or her from the fetus; the skin, subcutaneous tissue, the fascia, the abdominal muscles and then the peritoneum covering the uterus.

The uterus is made up of three layers: the serosal outer layer called the perimetrium, the second layer made up of muscle called the myometrium, and the mucosal inner layer called the endometrium. The uterine incision, also known as a hysterotomy, is made by cutting through all three of these layers.

INDICATIONS OF CESAREAN SECTION

A fetus cannot or should not be delivered vaginally for a variety of reasons. In some clinical settings, a vaginal birth might be risky, hence some of these indications are rigid.

There has been a focus on reducing the number of first-time cesareans, because many mothers who have one cesarean delivery will have to have subsequent deliveries via cesarean section. She may opt for another cesarean for a variety of reasons, or she may not be a good candidate for a vaginal birth in the future.

Authors reviewed the most widely recorded indications for first-time cesarean deliveries are difficult labor, irregular fetal heart rate pattern, malpresentation of the fetus, multiple gestations, and suspected fetal macrosomia (large fetus).

Maternal Indications for Cesarean includes; prior cesarean delivery, maternal request, cephalopelvic disproportion, previous perineal trauma, herpes simplex or HIV infection, cardiac or pulmonary disease etc.

Uterine/Anatomic Indications for Cesarean includes; abnormal placentation, placental abruption, prior classical hysterotomy, history of uterine incision dehiscence, invasive cervical cancer etc.

Fetal Indications for Cesarean includes; abnormal fetal heart tracing, umbilical cord prolapse, failed operative vaginal delivery, malpresentation, macrosomia etc.

In a 2007 study, researchers looked at how much increased fetal risk a woman or her caregiver thought was acceptable in order to accomplish a vaginal delivery and avoid a cesarean section.

CONTRAINDICATIONS

Even though there are ideal conditions for cesarean section, like the availability of anesthesia & antibiotic medications and even the necessary Instruments needed, the lack of these factors is not a contraindication if indeed cesarean section is clinically indicated.

A cesarean section is unethical if the pregnant woman declines. Informed consent requires that the patient gets adequate information and counseling about the procedure. However, if she refuses to have surgery performed on her, she has the right to refuse as an autonomous patient.

There are several clinical situations where a cesarean delivery is not the best option. These relative contraindications could be considered such as; fetal demise or severe fetal malformation with the possibility of vaginal delivery, patient with severe thrombocoagulopathy.

Procedure

Preparation: Prenatal care should include informing women and their spouses about the risk of cesarean delivery, according to enhanced recovery guidelines.Before, during, and after the surgery, the patient should be informed on what to expect.

Mothers with conditions such as anemia, diabetes, hypertension, obesity should be optimized before the surgery.
It is normal to ask a stable patient who is having an elective cesarean to fast for 6 hours.

Patients should be encouraged to drink clear liquids until two hours before surgery, and solid meals should be avoided for six hours prior to surgery, according to new enhanced recovery guidelines, because there's a risk of aspiration pneumonitis with cesarean section, antacids (sodium citrate) and a histamine H2 antagonist can be administered to prevent low gastric pH before the surgery.In an emergency, fetal or maternal indications usually takes priority over the fasting state of the pregnant woman before the surgery.

Other pre-op steps that are taken include;
Pre-op Analgesic for improved pain control after surgery.However, due to the likelihood of reduced psychomotor function after birth, as well as fetal concerns (thermogenesis difficulties, poor Apgar scores, and "floppy baby syndrome"), preoperative sedation should not be used.

The cesarean section, like any other procedure, carries the risk of infection. The most important risk factor for a woman having an infection in the postpartum period is a cesarean section. A cesarean delivery puts a woman 20 times more at risk of infection than a vaginal delivery.

Antibiotic prophylaxis can significantly reduce the risk of infection following a cesarean surgery by 60% to 70%. Antibiotics should be given prior to surgery rather than after the umbilical cord has been clamped.

The antibiotic used is determined by the clinical situation and whether the patient has any allergies.
Technique: The cesarean section is a difficult procedure to do. For wound healing and scar tissue formation reduction; proper tissue handling, appropriate bleeding control, and preventing infection are crucial.

A surgeon's technique choice are influenced by a variety of reasons. It is advised, as with any area of medical practice, that those choices be based on evidence.

Various Cesarean Delivery Techniques include;
Pfannenstiel-Kerr method
Joel-Cohen method
Misgav-Ladach method
Modified Misgav-Ladach method

Surgery Team: the following people are needed for a cesarean section:
The surgeon
The surgeon’s assistant
The anesthesiologist or anesthetist
A scrub nurse or technician
Pediatrician.

Complications

The following are some of the potential complications of cesarean deliveries:

Hemorrhage; there is a risk of severe bleeding during and after a cesarean section, as there is with any delivery and surgery in general.

Risk of infection; Other usual problems after a cesarean section include wound infection and endometritis, in addition to postpartum bleeding.

Risk of fetal trauma
Injury to nearby structures
Adhesion formation and difficulty with subsequent deliveries

References:

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This is so good to read and something I can totally relate to. I just wonder why CS is quite common with private hospitals and some government hospitals. At some point, I started thinking it’s a way of generating revenue and I might not be far from the truth.

Well. Like I wrote, there are indications for a CS that are expected. Anything outside of those indications are usually frowned upon by the medical community.

Nowadays, CS is recommended for the slightest of things. Ask around.

I'll ask around, You might be right. But that's not standard practice.

Lost the first love of my life to Cs complications. Still gives me ptsd till today.

My condolences. Safe deliveries are a goal for every nation.

Its sad how we are so far away from this.

May God save us. Our health sector is a death trap

A big one.

The facilities available are not up to standard, the compensation for work is terrible, the people incharge are nothing to write home about.

Its angry Nigerians against angry doctors.

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