10/11) Labour & Delivery - Caesarean Section (VBAC,NICE,Consent) Flashcards
Overall CS rate
25% (15% emergency, 10% elective)
Risk of uterine rupture with previous uterine rupture
5%
Risk of uterine rupture with previous classical CS
20%
Risk of placenta praaevia with increasing numbers of CS
Overall rate 1 in 200 No CS 1 in 400 1 CS 1 in 160 2 CS 1 in 60 3 CS 1 in 30 4 CS 1 in 10
Risk of placenta accreta with praaevia and increasing numbers of CS
1 CS: 12%
2 CS: 30%
3 CS: 50%
Advice re: VBAC with two previous CS
Risk of uterine rupture and chance of success similar
Success rate of VBAC
72-74% (84% if previous CS for malposition, 74% if previous for fetal distress, 64% if previous for shoulder dystocia)
Risk of scar rupture
0.5%
Risk of anal sphincter injury with VBAC
5%
Risk of instrumental delivery with VBAC
39%
Risk of maternal death with VBAC compared to ELCS
4/100,000 VBAC
13/100,000 ELCS
Risk of TTN with VBAC compared to ELCS
2-3% VBAC
4-5% ELCS (6% if ELCS at 38/40)
Risk of stillbirth beyond 39+0 whilst waiting for ELCS
0.1% (similar to primip)
Risk of HIE with VBAC compared to ELCS
0.08% VBAC
<0.01% ELCS
Risk of delivery related perinatal death with VBAC
0.04% (similar to primip)
When do uterine ruptures most commonly occur?
> 90% occur during labour with peak incidence 4-5cm.
18% occur in second stage, 8% diagnosed following vaginal delivery.
Risk of uterine rupture in unscarred uterus
0.02%
Risks of induction/augmentation in VBAC
2-3 x increased risk uterine rupture
1.5 x increased risk EMCS
Indications to offer CS to women with HIV
- Consider either CS or NVD in women on antiretroviral therapy with viral load 50-400 copies/mL
- Offer CS to women with HIV who are (a) not on antiretroviral therapy or (b) on antiretrovirals and viral load > 400 copies/mL or (c) co-existent HIV and hepatitis C
When to offer CS to women with HSV?
Primary HSV in 3rd trimester
Overall complication rate with CS (ELCS and EMCS)
ELCS: 16%
EMCS: 24% (0-1cm 17%, 9-10cm 33%)
Risks associated with CS
Persistent discomfort: 9/100 Bleeding: 5 in 1000 Infection: 6 in 100 VTE: 1 in 1000 Damage to bladder: 1 in 1000 Damage to ureters: 3 in 10,000 Cut to baby: 1 in 100
Risks to future pregnancies: Repeat CS: 1 in 4 Antepartum stillbirth: 1-4 in 1000 Uterine rupture: 2-7 in 1000 Praevia/accreta: 4-8 per 1000
Return to hospital 5 in 100 Return to theatre 5 in 1000 Emergency hysterectomy 8 in 1000 ICU admission 9 in 1000 Death 1 in 12000
When should a Cat 1 and Cat 2 CS be performed?
Cat 1: 30 minutes
Cat 2: 75 minutes
What reduces the likelihood of CS in labour?
- Continuous support in labour
- IOL beyond 41w if uncomplicated pregnancy
- Partogram with 4h action line
- Consultant obstetricians involved in decision for CS
When should obs be done after recovery?
Every 30 minutes for 2h and then hourly thereafter.
- If spinal opioids then 12h for diamorphine, 24h morphine
Epidural opioids/PCA - hourly monitoring throughout treatment and at least 6h afterwards.
When to remove dressing after CS?
24 hours
When to remove catheter?
Once mobile and >12h after epidural top up
Incidence of PPH at CS (not from the consent guidance)
5%
Overall risk of surgical site infection
9.6%
What percentage of asymptomatic patients will have an abdominal wall or abdominal cavity fluid collection D4 post CS?
48%
When do most bladder injuries occur?
At primary CS - during peritoneal entry.
At repeat CS - during dissection of bladder from lower segment.
Incidence of post-op ileus after CS
12% (may be reduced to 5% by chewing gum!)
