Cesarean Section

Definition

• A cesarean section is the delivery of a baby through an incision in the abdominal wall and uterus rather than through the pelvis and vagina.(1,2,3,4,5 ). General, spinal or epidural anesthesia may be used.(6)

• In a cesarean delivery, an incision is made through the lower abdominal wall and into the uterus.The incision may be vertical or transverse. However the type of incision is determined by condition of mother and the fetus.

TRANSVERSE INCISION

• It extends across the pubic hairline.

• It is used most often because it heals well and there is less bleeding.

• It also increase the chance for vaginal birth in future pregnancy.

VERTICAL INCISION

It extends from the navel to pubic hairline

REASONS FOR THE PROCEDURE

Some cesarean deliveries are planned and scheduled accordingly, while others may be performed as a result of complication that occur during labor.There are several conditions which may make a cesarean delivery more likely. These include, but are not limited to the following:

• Fetal distress indicated by abnormal fetal heart rate

• Abnormal position of the fetus during birth.

• Sluggish labor that fails to progress normally

• Baby is too large to be delivered vaginally

• Placental complications eg: placental previa

• Maternal medical condition such as diabetis, high blood pressure, HIV infection.

• Active herpes lesion in the mother’s vagina or cervix

• Twins or multiple fetus

• Previous cesarean delivery.(7)

PROCEDURE

PREOPERATIVE PREPARATION Informed written permission for the procedure,anesthesia and blood transfusion is obtained.

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

• Premedicative sedative must not be given.

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

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

• The stomach should be emptied , if necessary by a stomach tube.

• 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 about 3 minutes of preoxygenation in the theater.

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

• FHS should be checked once more at this stage.

• Neonatologist should be made available.

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

• Prophylactic antibiotics should be given (IV) before making skin incision.

IV cannula: Sited to administer fluids.

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

Anesthesia- May be spinal, epidural or general. However, choice of the patient and urgency of delivery are also considered.

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

Incision on the abdomen

Packing:The Doyen’s retractor is introduced.

Uterine incision

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.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 sucker.After the delivery of the shoulders, intravenous oxytocin 20 units or methergine 0.2 mg is to be administered.The rest of the body is delivered slowly and the baby is placed in a tray placed in between the mother’s thighs with the head tilted down for gravitational drainage.The cord is cut in between two clamps and the baby is handed over to the paediatrician.The Doyen’s retractor is reintroduced. The optimum interval between uterine incision and delivery should be lesd than 90 seconds.

Removal of the placenta and membranes:

By this time, the placenta is separated spontaneously.The placenta is 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 uterine wound.

Non closure of visceral and parietal peritoneum is preferred.

Concluding part: The mops placed inside are removed and the number is verified.Peritoneal toileting is done and blood clots are removed meticulously.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.(8)

POTENTIAL STRUCTURAL AND FUNCTIONAL IMPAIRMENTS

• Risk of pulmonary, gastrointestinal or vascular complication.

• Post surgical pain and discomfort.

• Development and adhesions at incision site.

• Faulty posture

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

• Abdominal weakness,diastasis recti

• General functional restrictions of 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 C section is deemed necessary. Therefore pelvic floor musculature and pudendal and levator ani nerves may still be compromised. Also pregnancy itself creates significant strain on pelvic floor musculature and other soft tissues.9

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 C section is a major abdominal surgery with all the complication of such surgeries and therefore the woman may also require general post surgical rehabilitation.

Physiotherapy Mangement after Cesarean Section

GOAL: Improve pulmonary function and decrease the risk of pneumonia

• Breathing instruction

• coughing and / or huffing

GOAL: Decrease incisional pain with coughing, movement or breast feeding

• Post operative TENS

• Support incision with pillow when coughing or breastfeeding Incisional support with pillow or hands with movement education regarding incisional care and risk of injury.

GOAL: Prevent post surgical vascular or gastrointestinal complications

• Active leg exercises

• Early ambulation

• Teach abdominal massage to peristalsis

GOAL: Enhance incisional circulation and healing; prevent adhesion formation

• Gentle abdominal exercise with incisional support.

• scar mobilisation

• friction massage

GOAL: Decrease post surgical discomfort from flatulence,itching or catheter

• Positioning instruction

• massage

• supportive exercises

GOAL: Correct posture

• Posture instruction, particularly regarding child care

GOAL: Prevent injury and reduce low back pain

• Instruction in incisional splinting

• positioning for ADLs

• Body mechanics instruction

GOAL: Prevent pelvic floor dysfunction

• Pelvic floor exercises

• Education regarding risk factors and types of pelvic floor dysfunction

GOAL: Develop abdominal strength

• Abdominal exercise progression,including corrective exercises for diastasis rectii.(6)

REFERENCES

1.Al-Ziraqi, I, et al: uterine rupture after previous caesarean section.BJOG 117(7):809-820,2010

2. Gilbert,E, and Harman, J;High risk pregnancy and delivery, ed.1.St Louis:CV Mosby,1986

3. Harrington,K, and Haskvitz, E:Managing a patient’s constipation with physical therapy.Phys Ther Nov 86:1511-1519;2006

4. Jamieson,D, and Steege, J:The prevalence of dysmenorrhea,dyspareunia, pelvic pain and irritable bowel syndrome in primary care practices.Obstet Gynecol 87(1):55-58,1996

5. Norwood,C:caesarean variations: Patients, facilities, or policies.Int J Childbirth Educ 1 :4,1986.

6. Carolyn Kisner, Lynn Allen Colby :Therapeutic Exercise Foundations and techniques 6 th edition:Pg 952

7. Pushpal K Mitra : Textbook of Physiotherapy in surgical conditions:Pg 235-238

8. Hiralal Konar:DC Dutta’s textbook of obstetrics 8 th edition:Pg 671