C section

Question 1

planned C section may reduce what risks

Answer 1

perineal and abdominal pain during birth and 3 days postpartum

injury to vagina

early postpartum haemorrhage

obstetric shock.

Question 2

planned C section may increase what risk in babies

Answer 2

neonatal ICU admission

Question 3

planned C section ay increase what risks

Answer 3

longer hospital stay

hysterectomy caused by postpartum haemorrhage

cardiac arrest.

Question 4

why might C section may be offered

Answer 4

Breech presentation (at term)

Other malpresentations – e.g. unstable lie (a presentation that fluctuates from oblique, cephalic, transverse etc.), transverse lie or oblique lie.

Twin pregnancy – when the first twin is not a cephalic presentation.

Maternal medical conditions (e.g. cardiomyopathy) – where labour would be dangerous for the mother.

Fetal compromise (such as early onset growth restriction and/or abnormal fetal Dopplers) – where it is thought the fetus would not cope with labour.

Transmissible disease (e.g. poorly controlled HIV).

Primary genital herpes (herpes simplex virus) in the third trimester – as there has been no time for the development and transmission of maternal antibodies to HSV to cross the placenta and protect the baby.

Placenta praevia – ‘Low-lying placenta’ where the placenta covers, or reaches the internal os of the cervix.

Maternal diabetes with a baby estimated to have a fetal weight >4.5 kg.

Previous major shoulder dystocia.

Previous 3rd/4th perineal tear where the patient is symptomatic – after discussion with the patient and appropriate assessment.

Maternal request – this covers a variety of reasons from previous traumatic birth to ‘maternal choice’. This decision is after a multidisciplinary approach including counselling by a specialist midwife

Question 5

when to offer women with HIV CS

Answer 5

are not receiving any anti-retroviral therapy or

are receiving any anti-retroviral therapy and have a viral load of 400 copies per ml or more.

Question 6

what weeks can a planned CS be arranged

Answer 6

after 39 weeks

Question 7

classification for emergency C section

Answer 7

1. immediate threat to the life of the woman or fetus
2. maternal or fetal compromise which is not immediately life-threatening

perform 1 and 2 ASAP

3. no maternal or fetal compromise but needs early delivery
4. delivery timed to suit woman or staff.

Question 8

what should be done before a CS

Answer 8

FBC and a Group and Save

H2-receptor antagonist should be prescribed – e.g. Ranitidine +/- metoclopramide (an anti-emetic that increases gastric emptying).

risk score for VTE

Question 9

when should preoptesting should not occur in CS

Answer 9

grouping and saving of serum

cross-matching of blood

a clotting screen

preoperative ultrasound for localisation of the placenta, because this does not improve CS morbidity outcomes (such as blood loss of more than 1000 ml, injury of the infant, and injury to the cord or to other adjacent structures)

Question 10

if women has regional anaesthesia will they need a catheter

Answer 10

YAS

indwelling urinary catheter to prevent over-distension of the bladder

Question 11

why is elective C section only advised after 39 weeks

Answer 11

reduce respiratory distress in the neonate – known as Transient Tachypnoea of the Newborn.

Question 12

however if c section has to occur before 39 weeks what do u administer

Answer 12

corticosteroids

stimulates development of surfactant in the fetal lungs.

Question 13

why is H2 receptor antagonist prescribed prior to C section

Answer 13

Pregnant women lying flat for a Caesarean section are at risk of Mendelson’s syndrome (aspiration of gastric contents into the lung), leading to a chemical pneumonitis. This is because of pressure applied by the gravid uterus on the gastric contents.

Question 14

what may be given to reduce VTE

Answer 14

Anti-thromboembolic stockings +/- low molecular weight heparin should be prescribed as appropriate.

Question 15

most common analgesia used in C section

unplanned c section

Answer 15

regional anaesthetic – this is usually an ‘topped-up’ epidural or a spinal anaesthetic.

preoxygenation, cricoid pressure and rapid sequence induction to reduce the risk of aspiration

Question 16

how is the woman positioned for a C section and why

Answer 16

left lateral tilt of 15° – to reduce the risk of supine hypotension due to aortocaval compression.

Question 17

standard technique

Answer 17

skin incision - is usually with either a Pfannenstiel or Joel-Cohen – these are both transverse lower abdominal skin incisions.

Sharp or blunt dissection into abdomen

The visceral peritoneum covering the lower segment of the uterus is then incised and pushed down to reflect the bladder, which is retracted by the Doyen retractor.

Uterine incision is made on the lower uterine segment beneath the line of peritoneal reflection. This is a transverse curvilinear incision which is digitally extended. The baby is then delivered cephalic/breech with fundal pressure from the assistant.
- De Lee’s incision (lower vertical) may be required if the lower uterine incision is poorly formed (rare).

Oxytocin 5iu is given intravenously by the anaesthetist to aid delivery of the placenta by controlled cord traction by the surgeon.

The uterine cavity is ensured empty, then closed with two layers. The rectus sheath is then closed and then the skin (either with continuous/interrupted sutures or staples).

Question 18

name the different layers that need to be cut in a c section

Answer 18

Superficial fascia
Deep fascia
Anterior rectus sheath
Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba)
Transversalis fascia
Extraperitoneal connective tissue
Peritoneum
Uterus

The skin,

Camper’s fascia (superficial fatty layer of subcutaneous tissue)

Scarpa’s fascia, (deep membranous layer of subcutaneous tissue)

Rectus sheath, (anterior and posterior leaves laterally, that merge medially)

Rectus muscle

Abdominal peritoneum (parietal)

this reveals the gravid uterus.

Question 19

post op of c section what occurs

Answer 19

After the Caesarean section, observations are recorded on an early warning score chart, and lochia (per vaginal blood loss post delivery) is monitored.

Early mobilisation, eating and drinking and removal of catheter is encouraged to enhance recovery.

Question 20

risks of vaginal birth after C section

Answer 20

• 1 in 200 risk of uterine scar rupture.
• The risk of perinatal death is low and comparable to the risk of women laboring with their first child.
• There is a small increased risk of placenta praevia +/- accreta in future pregnancies, and of pelvic adhesions.
• The success rate of planned VBAC is 72–75%, however this is as high as 85-90% in women who have had a previous vaginal delivery.
• All women undergoing VBAC should have continuous CTG in labour as a change in fetal heart rate can be the first sign of impending scar rupture.
• Risks of scar rupture is higher in labours that are augmented or induced with prostaglandins or oxytocin.

Question 21

are prophylatic ABx given to C section before procedure

Answer 21

yasss

Question 22

complications at the immediate stage

Answer 22

MOTHER

• Postpartum haemorrhage (>1000ml)
• Wound haematoma (increased in patient with large BMI/diabetes/immunosupressed)
• Intra-abdominal haemorrhage
• Bladder/bowel trauma (more common in patients who have had previous abdominal surgery)

NEONATAL:

• transient tachypnoea of the newborn
• fetal lacerations (1-2% risk, higher with previous membrane rupture)

Question 23

complications at the intermediate stage of c section

Answer 23

Infection:

• urinary tract infection
• endometritis
• respiratory (higher risk if general aneasthetic used)

Venous thromboembolism

Question 24

complications at the late stage of c section

Answer 24

• Urinary tract trauma (fistula)
• Subfertility (there is a delay in conceiving compared to women who have had vaginal deliveries)
• Regret and other negative psychological sequelae
• Rupture/dehiscence of scar at next labour (VBAC)
• Placenta praevia/accrete
• Caesarean scar ectopic pregnancy

Question 25

indications of C section

Answer 25

absolute cephalopelvic disproportion
placenta praevia grades 3/4
pre-eclampsia
post-maturity
IUGR
fetal distress in labour/prolapsed cord
failure of labour to progress
malpresentations: brow
placental abruption: only if fetal distress; if dead deliver vaginally
vaginal infection e.g. active herpes
cervical cancer (disseminates cancer cells)

Question 26

serious maternal risks of C section

Answer 26

emergency hysterectomy
need for further surgery at a later date, including curettage (retained placental tissue)
admission to intensive care unit
thromboembolic disease
bladder injury
ureteric injury
death (1 in 12,000)

Question 27

Frequent materanla risks of c section

Answer 27

persistent wound and abdominal discomfort in the first few months after surgery
increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
readmission to hospital
haemorrhage
infection (wound, endometritis, UTI)