10/11) Labour & Delivery - Caesarean Section (VBAC,NICE,Consent)

Question 1

Overall CS rate

Answer 1

25% (15% emergency, 10% elective)

Question 2

Risk of uterine rupture with previous uterine rupture

Answer 2

5%

Question 3

Risk of uterine rupture with previous classical CS

Answer 3

20%

Question 4

Risk of placenta praaevia with increasing numbers of CS

Answer 4

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

Question 5

Risk of placenta accreta with praaevia and increasing numbers of CS

Answer 5

1 CS: 12%
2 CS: 30%
3 CS: 50%

Question 6

Advice re: VBAC with two previous CS

Answer 6

Risk of uterine rupture and chance of success similar

Question 7

Success rate of VBAC

Answer 7

72-74% (84% if previous CS for malposition, 74% if previous for fetal distress, 64% if previous for shoulder dystocia)

Question 8

Risk of scar rupture

Answer 8

0.5%

Question 9

Risk of anal sphincter injury with VBAC

Answer 9

5%

Question 10

Risk of instrumental delivery with VBAC

Answer 10

39%

Question 11

Risk of maternal death with VBAC compared to ELCS

Answer 11

4/100,000 VBAC

13/100,000 ELCS

Question 12

Risk of TTN with VBAC compared to ELCS

Answer 12

2-3% VBAC

4-5% ELCS (6% if ELCS at 38/40)

Question 13

Risk of stillbirth beyond 39+0 whilst waiting for ELCS

Answer 13

0.1% (similar to primip)

Question 14

Risk of HIE with VBAC compared to ELCS

Answer 14

0.08% VBAC

<0.01% ELCS

Question 15

Risk of delivery related perinatal death with VBAC

Answer 15

0.04% (similar to primip)

Question 16

When do uterine ruptures most commonly occur?

Answer 16

> 90% occur during labour with peak incidence 4-5cm.

18% occur in second stage, 8% diagnosed following vaginal delivery.

Question 17

Risk of uterine rupture in unscarred uterus

Answer 17

0.02%

Question 18

Risks of induction/augmentation in VBAC

Answer 18

2-3 x increased risk uterine rupture

1.5 x increased risk EMCS

Question 19

Indications to offer CS to women with HIV

Answer 19

• 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

Question 20

When to offer CS to women with HSV?

Answer 20

Primary HSV in 3rd trimester

Question 21

Overall complication rate with CS (ELCS and EMCS)

Answer 21

ELCS: 16%
EMCS: 24% (0-1cm 17%, 9-10cm 33%)

Question 22

Risks associated with CS

Answer 22

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

Question 23

When should a Cat 1 and Cat 2 CS be performed?

Answer 23

Cat 1: 30 minutes

Cat 2: 75 minutes

Question 24

What reduces the likelihood of CS in labour?

Answer 24

• Continuous support in labour
• IOL beyond 41w if uncomplicated pregnancy
• Partogram with 4h action line
• Consultant obstetricians involved in decision for CS

Question 25

When should obs be done after recovery?

Answer 25

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.

Question 26

When to remove dressing after CS?

Answer 26

24 hours

Question 27

When to remove catheter?

Answer 27

Once mobile and >12h after epidural top up

Question 28

Incidence of PPH at CS (not from the consent guidance)

Answer 28

5%

Question 29

Overall risk of surgical site infection

Answer 29

9.6%

Question 30

What percentage of asymptomatic patients will have an abdominal wall or abdominal cavity fluid collection D4 post CS?

Answer 30

48%

Question 31

When do most bladder injuries occur?

Answer 31

At primary CS - during peritoneal entry.

At repeat CS - during dissection of bladder from lower segment.

Question 32

Incidence of post-op ileus after CS

Answer 32

12% (may be reduced to 5% by chewing gum!)