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!

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 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 3^rd 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

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

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.

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

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