Caesarian Section
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A caesarian 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

References

Read more about our sources

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) currently works as a GP Registrar and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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