Notre Dame University

College of Health Sciences

Cotabato City

A CASE STUDY ON REPEAT

LOW TRANSVERSE CESAREAN
SECTION

Submitted by
Jerianne Mae M. Goopio and
Nicko Frederick I. Guanzon
(A8 and A5)

Submitted to:
Prof. Agnes D. Jakosalem, RN, LPT, MN
 INTRODUCTION

A repeat lower transverse cesarean section, a common surgical procedure in obstetrics,

presents epidemiological trends and various risk factors influencing its occurrence. Globally,

cesarean section rates have risen, with a significant proportion comprising repeat cesarean

deliveries (Gibbons et al., 2018). The prevalence varies across regions, influenced by healthcare

practices, maternal demographics, and medical indications. Risk factors for requiring a repeat

lower transverse cesarean section include a history of previous cesarean delivery, especially with

a low transverse uterine incision, which increases the likelihood due to scar integrity concerns

(American College of Obstetricians and Gynecologists, 2019). Additionally, the number of prior

cesarean deliveries exacerbates the risks, with each successive cesarean heightening complexities

(ACOG, 2020)

In fact, most cases of low tranverse cesarean section are mostly repeated as planned

cesarean of the patient and advised of the obgyne , thus history significantly influences the

decision-making process for subsequent pregnancies, as the integrity of the uterine scar from the

previous cesarean section is a key consideration. Studies have shown that women with a prior

low transverse cesarean section are more likely to undergo a repeat cesarean delivery compared

to those with different types of uterine scars due to concerns about uterine rupture and other

complications (Guise et al., 2010). However, repeat low transverse cesarean section may be

influenced by multiple factors, including the absence of prior labor experience in the patient, a

history of previous cesarean section, the due date of her pregnancy, and the possibility of

meconium staining in the amniotic fluid. Firstly, the lack of prior labor experience in the patient.

Research suggests that women with no prior vaginal delivery may face increased risks of

complications during a trial of labor after cesarean (TOLAC), including a higher risk of uterine

rupture. Additionally, if the patient's due date is approaching and there are concerns about the

progression of the pregnancy or fetal well-being, a repeat cesarean section may be recommended

to ensure a timely and safe delivery. Furthermore, the presence of meconium staining in the

amniotic fluid, indicating fetal distress, could prompt healthcare providers to expedite delivery,

often through cesarean section, to reduce the risk of meconium aspiration syndrome in the
newborn. These factors, along with considerations such as maternal age, medical history, and

provider preferences, contribute to the decision-making process surrounding the mode of

delivery for women who require a repeat low transverse cesarean section.
 HISTORY OF PRESENT ILLNESS

Patients’ Profile

Patient X is a 35 year old female, a filipino citizen married. Her religion

was Roman Catholic. She has no History of Hypertension, Diabetes Mellitus, or

Cardiovascular Disease Last February 2024, admitted to the Cotabato Regional and

Medical Center due planned Cesarean section.

1 Month Prior to Admission, the patient had prenatal check up with her

private physician and was advised by the institution for possible repeat Cesarean

section. The patient had previous Cesarean section (2018, CRMC), is G2 P1 (1001)

Pregnancy Uterine with 38 3/7 weeks Age of Gestation. it is noted that the patient

has no prior labor experience and has previously undergone a cesarean section. She

is currently seeking medical attention due to her pregnancy nearing its due date.
 ANATOMY AND PHYSIOLOGY

The female reproductive system includes parts of the

female body that are involved in fertility, reproduction and

sex. It includes organs such as the uterus, ovaries, fallopian

tubes, cervix and vagina. The menstrual cycle prepares the

body for a possible pregnancy, The female reproductive

system is made up of the internal and external sex organs

that function in the reproduction of new offspring. The

human female reproductive system is immature at birth and

develops to maturity at puberty to be able to produce

gametes, and to carry a fetus to full term.

OVARIES The ovaries are a

pair of oval structures about

1.5 inches (4 cm) long on

either side of the uterus in the

pelvic cavity. The ovarian

ligament extends from the

medial side of an ovary to the

uterine wall, and the broad

ligament is a fold of the peri

toneum that covers the ovaries. These ligaments help keep the ovaries in place.

Within an ovary are several hundred thousand primary follicles, which are present

at birth. During a woman’s childbearing years, only 300 to 400 of these follicles

will produce mature ova. As with sperm production in men, the supply of potential

gametes far exceeds what is actually needed, but this helps ensure the continuation

of the human species. Each primary ovarian follicle contains an oocyte, a potential

ovum or egg cell. Surrounding the oocyte are the follicle cells, which secrete
estrogen. Maturation of a follicle, requiring FSH and estrogen, was described

previously in the section on oogenesis. A mature follicle may also be called a

graafian follicle, and the hormone LH from the anterior pituitary gland causes

ovulation, that is, rupture of the mature follicle with release of the ovum. At this

time, other developing follicles begin to deteriorate; these are called atretic follicles

and have no further purpose. Under the influence of LH, the ruptured follicle

becomes the corpus luteum and begins to secrete progesterone as well as estrogen.

Hormones produced in smaller amounts by the corpus luteum are inhibin and

relaxin.

FALLOPIAN TUBES There are two fallopian tubes

(also called uterine tubes or oviducts); each is about 4 inches
(10 cm) long. The lateral end of a fallopian tube encloses an
ovary, and the medial end opens into the uterus. The end of
the tube that encloses the ovary has fimbriae, fringelike
projections that create currents in the fluid surrounding the
ovary to pull the ovum into the fallopian tube. Because the
ovum has no means of self-locomotion (as do sperm), the
structure of the fallopian tube ensures that the ovum will be
kept moving toward the uterus. The smooth muscle layer of the tube contracts
in peristaltic waves that help propel the ovum (or
zygote, as you will see in a moment).

The uterus is shaped like an upside-down pear, about 3 inches long by 2 inches wide by

1 inch deep (7.5 cm by 5 cm by 2.5 cm), superior to the urinary bladder and between the two

ovaries in the pelvic cavity The broad ligament also covers the uterus During pregnancy the

uterus increases greatly in size, contains the placenta to nourish the embryo-fetus, and expels the

baby at the end of gestation. The parts and layers of the uterus . The fundus is the upper portion

above the entry of the fallopian tubes, and the body is the large central portion. The narrow,

lower end of the uterus is the cervix, which opens into the vagina. The outermost layer of the

uterus, the serosa or epimetrium, is a fold of the peritoneum. The myometrium is the smooth

muscle layer; during pregnancy these cells increase in size to accommodate the growing fetus

and contract for labor and delivery at the end of pregnancy. The lining of the uterus is the

endometrium, which itself consists of two layers. The basilar layer, adjacent to the myometrium,

is vascular but very thin and is a permanent layer. The functional layer is regenerated and lost
during each menstrual cycle. Under the influence of estrogen and progesterone from the ovaries,

the growth of blood vessels thickens the functional layer in preparation for a possible embryo. If

fertilization does not occur, the functional layer sloughs off in menstruation. During pregnancy,

the endometrium forms the maternal portion of the placenta.

The vagina is a muscular tube about 4 inches (10 cm) long that extends from the cervix

to the vaginal orifice in the perineum (pelvic floor). It is posterior to the urethra and anterior to

the rectum (. The vaginal opening is usually partially covered by a thin membrane called the

hymen, which is ruptured by the first sexual intercourse or by the use of tampons during the

menstrual period. The functions of the vagina are to receive sperm from the penis during sexual

intercourse, to provide the exit for menstrual blood flow, and to become the birth canal at the end

of pregnancy. The vaginal mucosa after puberty is stratified squamous epithelium, which is

relatively resistant to pathogens.

The uterus is the primary reproductive organ involved in pregnancy and childbirth.

During a low transverse cesarean section, an incision is made horizontally across the lower

segment of the uterus. This type of incision is preferred due to its lower risk of uterine rupture in

subsequent pregnancies compared to other types of uterine incisions. Abdominal Wall of surgical

incision for a low transverse cesarean section is typically made in the lower abdomen, just above

the pubic hairline. This incision provides access to the uterus for delivery of the baby. The fetal

position within the uterus is assessed before the cesarean section to determine the optimal

approach for delivery. The baby's head is usually positioned downward, but variations in fetal

presentation may require adjustments during the procedure.

 PATHOPHYSIOLOGY

REPEAT CESAREAN SECTION

-Surgical procedure performed a vaginal delivery is not possible or safe, or when the health of
the mother on the baby is at stake.

Predigering Factors:

Over 30 years old

Precipitating Factors:

● Previous Cesarean Section

● Fetal Suffering
● Cephalopelvis disproportion

Due to the possibility of complications during pregnancy, complications that affect the baby,
labor and birth may lead to:

COMPLICATIONS

INFECTION-

SIGNS AND SYMPTOMS:

Fever, chills and sweets, redkiess sresor evelling in any sis including nagical wounds and porta

POSTPARTUM HEMORRHAGE-

SIGNS AND SYMPTOMS:

Heavy bleeding hypotension natasa, pale akin, swelling and paun around the vagina or perineum.

DEEP VEIN THROMBOSIS-

SIGNS AND SYMPTOMS:

Throbbing or cramping pain in I leg prelling in i leg wem skin tround the painful an red or
daricened in around the painful area, srollen veins that we hard or are when you touch them.

DIAGNOSTICS

Infection- Immunologic test

PPH- blood tests, pelvic exam, physical exam, ultrasound

DVT- Duplex ultrasonography

Repeat low transverse cesarean sections are often necessitated by obstetric factors that render
vaginal delivery unsafe or impractical. These factors may include maternal age over 30 and a
history of previous cesarean sections, which can increase the risk of complications during labor
and delivery. Complications such as cephalopelvic disproportion, fetal distress, or a history of
difficult deliveries may also contribute to the decision for a repeat cesarean section.
 BIBLIOGRAPHY

Hiramatsu, Yuji. “Lower-Segment Transverse Cesarean Section.” The Surgery Journal, vol. 6, no.

Suppl 2, June 2020, pp. S72–80. PubMed Central, https://doi.org/10.1055/s-0040-1708060.

Repeat Cesarean Section - an Overview | ScienceDirect Topics.

https://www.sciencedirect.com/topics/medicine-and-dentistry/repeat-cesarean-section. Accessed

22 Feb. 2024.

UpToDate. https://www.uptodate.com/contents/c-section-cesarean-delivery-beyond-the-basics/print.

Accessed 22 Feb. 2024.

Cesarean Delivery: Overview, Preparation, Technique. Dec. 2023. eMedicine,

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

Mascarello, Keila Cristina, et al. “Repeat Cesarean Section in Subsequent Gestation of Women from a

Birth Cohort in Brazil.” Reproductive Health, vol. 14, no. 1, Aug. 2017, p. 102. BioMed Central,

https://doi.org/10.1186/s12978-017-0356-8.

https://applications.emro.who.int/imemrf/Professional_Med_J_Q/Professional_Med_J_Q_2013_20_6

_916_923.pdf

Repeat Cesarean Delivery with History of Low Transverse Cesarean Section - AHA Coding Clinic®

for ICD-10-CM and ICD-10-PCS (ICD-9). https://www.findacode.com/newsletters/aha-coding-

clinic/icd/repeat-cesarean-delivery-history-low-I053033.html. Accessed 22 Feb. 2024.

“Female Body Diagrams.” Verywell Health, https://www.verywellhealth.com/female-body-diagram-

5209032. Accessed 22 Feb. 2024.

Methylergometrine: Indication, Dosage, Side Effect, Precaution | MIMS Philippines.

https://www.mims.com/philippines/drug/info/methylergometrine?mtype=generic. Accessed 22

Feb. 2024.

“Pathophysiology: Cesarean Section | PDF | Childbirth | Caesarean Section.” Scribd,

https://www.scribd.com/document/530789178/PATHOPHYSIOLOGY-CS. Accessed 22 Feb.

2024.