Caesarian Section

Original article by Tom Leach | Last updated on 28/6/2014
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C-section is major surgery, with real risks, and the decision to perform such an operation should not be taken lightly!
 

Epidemiology

  • Incidence in increasing, mainly due to the increased diagnoses of fetal distress, as diagnosed by CTG monitoring. Also increasing used for non-longitudinal lies (e.g. breech, transverse)
  • WHO recommends not >15% of deliveries should be via c-section
  • In the UK, the rate is about 25% (in the USA, about 30%)
  • The NHS does NOT offer elective c-section without a medical reason – in some very rare cases, if it is thought the mother has a psychological fear of pregnancy, then elective c-section may be offered
  • 9% of c-sections are performed before the onset of labour
  • Reasons for c-section:
    • First pregnancy
      • 25% - failure to progress
      • 28% - fetal distress
      • 14% - breech
    • Subsequent Pregnancies
      • 45% - previous c-section
 

Indications

Indications for elective c-section
  • Placenta praevia
  • Breech presentation
    • Usually eversion is offered at 36 weeks if the mother declines, or eversion is unsuccessful, offer elective c-section
    • Other malpresentations may also be considered
  • Twins where the first twin is not cephalic
  • Previous vaginal surgery (e.g. fistula repair)
  • Maternal infection (e.g. HIV, active herpes in 3rd trimester)
  • Pregnancy >41 weeks
    • These women are not routinely offered c-section, if there are no complications with the pregnancy. Instead, induction of labour is usually performed at 41 weeks
  • Surgery usually planned for 39 weeks
    • 10% of patients will go into labour before this time, and require emergency c-section
    • Performing elective c-section at this time reduces the risk of neonatal respiratory problems
      • 7x greater risk for c-section at 37 weeks
      • 3x greater risk for c-section at 38 weeks
      • Equal with vaginal risk at 39 weeks
 
Indications for Emergency C-section
  • Cord prolpase
  • Failure to progress
  • Fetal distress during the first stage of labour
  • Antepartum haeomorrhage (abruption or placenta praevia)
  • Transverse lie during labour
 

Procedure

Usually performed under spinal or edipural block – not general anaesthetic
  • Halothane cannot be used – as it increases uterine contractions
  • Light anaesthesia – has in the past been used, to prevent anaesthesia of the baby – but it can result in a state of paralysed awareness for the mother!
  • Only about 8% of c-sections are performed under general anaesthetic
  • Prophylactic antibiotics do reduce the risk of infection. Typical regimen:
    • 2g cefradine IV at induction, plus
    • 1g at 6 hr
    • 1g at 12h post-op
    • Use antibiotic prophylaxis for both elective and emergency c-section
  • There are two types of inscision that can be made:
    • Vertical Incision – less commonly used in modern times. From umbilicus to pubic bone.
    • Lower uterine segment incision –a smaller incision, made horizontally just above the pubic bone.
    • Fetal laceration occurs in 2% of cases
    • Reduces risk of infection
    • Reduces risk of complications
    • Better cosmetic appearance
    • Reduces risk of uterine tear
 

Thromboprophylaxis and C-section

  • Ongoing prophylaxis regimen
    • Halve the dose on the day before planned c-section
    • On the day of c-section, omit the usual dose
    • Then give usual prophylaxis 3 hours after surgery, unless – epidural used
    • 2% of women will have a haematoma at the wound site
  • Those not with ongoing prophylaxis
  • Risk factors:
    • Age >35
    • Obesity (>80Kg)
    • Para 4+
    • Pre-eclampsia
    • Emergency c-section
    • Varicose veins
    • Ongoing infection
    • > 4 days immobility
    • Major current illness
  • o   Low risk
    • If no risk factors are present, then all that is required is good hydration, and early mobilisation
  • o   Medium Risk
    • Labour >12 hours
    • Give heparin prophylaxis and / or mechanical methods (e.g. Stockings)
  • o   High risk
    • Give 5 days heparin post op, or until fully mobilised, whichever is longer. Also use stockings
    • Any woman with >3 above RF’s
    • Any woman with extended abdominal surgery – eg. Hysterectomy
    • FH or personal Hx of thromboembolism or thrombophilia
    • Lower limb paralysis
  • Women with thromboembolism in pregnancy
    • Require prophylaxis for 6 weeks post partum
 
Removal of the placenta at C-section
Manual removal can cause endometritis, and thus gentre traction should be applied to the cord, to aid natural removal of the placenta.
 

After surgery

  • 1:1 care on recovery unit
  • Measurements every ½ hour for first 2 hours
  • Mobilise as soon as possible
  • Appropriate analgesia
  • Typical hospital stay is 3-4 days
    • In normal vaginal deliveries, hospital stay is 6-72 hours
 

Complications

  • Aspiration – depending on anaesthesia / intubation use
  • PE
  • PPH
  • Infection
  • Longer hospital stay – which can cause bonding issues between family / mother / baby