C-Section and PROM Flashcards
Classification of C-Sections?
- C-section is the delivery of a baby through a surgical incision in the abdomen and uterus.
- They are either elective or emergency.
- Emergency C-sections can then be sub-classified into 3 categories depending on their urgency.
- Emergency C-sections most commonly for failure to progress into labour or suspected/confirmed foetal compromise.
- Class 1 - Immediate threat to life of mother or foetus. (Should be born within 30 minutes)
- Class 2 - Maternal or foetal compromise that is not immediately life threatening. (Should be born within 60-75 minutes)
- Class 3 - No maternal or foetal compromise but needs early delivery.
Indications for elective C-Sections?
- Breech presentation
- Other malpresentations - transverse/oblique lie
- Twin pregnancies - first twin not cephalic
- Foetal compromise - early growth restriction/abnormal doppler
- Transmissible disease - poorly controlled HIV
- Maternal request
- Maternal diabetes - with baby >4.5kg EFW
- Maternal medical conditions - e.g. cardiomyopathy
- Placenta praevia - low lying placenta
- Primary genital herpes - HSV in 3rd trimester
- Previous 3rd/4th tear
- Previous major shoulder dystocia
Usually planned after 39 weeks to reduce respiratory distress in neonate (TTON), administration of corticosteroids to mother if delivery induced <39 weeks to stimulate surfactant development in foetal lungs.
Pre-op theatre procedure of C-sections brief:
- FBC and Group + Save should be taken (blood loss in C-sections can be excessive)
- H2 antagonists prescribed (Ranitidine +/- Metoclopromide) - pregnant women lying flat for C-section at risk of Mendelson’s syndrome (aspiration of gastric contents into lung causing chemical pneumonitis)
- Risk score for VTE - compression stockings and LMWH prescribed as appropriate.
Anaesthesia in C-sections?
- Usually performed under regional analgesia - ‘topped-up’ epidural or spinal anaesthetic
- Some times General is required - due to maternal CI to regional, failure of regional to achieve required block, or most commonly concerns about foetal wellbeing and the need to expedite delivery ASAP (often case for Cat 1 C-sections).
Operative procedure:
- Left lateral tilt of 15 degrees- reduce risk of supine hypotension due to aortacaval compression.
- Indwelling Foley’s catheter inserted when anaesthetic is ready - drain bladder and reduce risk of bladder injury during procedure.
- Skin prepared with antiseptic and antibiotics administered prior to incision.
- Traverse lower abdominal skin incision (Pfannelstiel/Joel-Cohen) > sharp/blunt dissection through several layers: skin, Camper’s + Scarpa’s fascias, rectus sheath + muscle, parietal peritoneum, revealing gravid uterus.
- Visceral peritoneum covering lower segment incised > pushed down and bladder retraced by Doyen retractor.
- Uterine incision made on lower uterine segment - baby delivered in cephalic/breech presentation with fundal pressure.
- Oxytocin 5iu given IV by anaesthetist to aid delivery of the placenta by controlled cord traction by surgeon.
- Uterine cavity ensured empty - closed with 2 layers, rectus sheath closed and then skin (with sutures/staples).
Post-OP:
- Observations recorded on early warning score chart, and loch (PV blood loss post delivery) monitored.
- Early mobilisation, earring and drinking, removal of catheter encouraged to enhance recovery.
Reduced risks of C-Section?
- Reduced risk: perineal trauma, pain, neonatal infection, incontinence, prolapse, late stillbirth.
- Has immediate, intermediate and late complications.
Immediate complications of C-section?
1) PPH
2) Wound haematoma (large BMI/diabetes/immunosuppressed)
3) Intra-abdominal haemorrhage
4) Bladder/bowel trauma (previous abdominal surgery)
5) Neonatal: TTON, foetal lacerations
Intermediate complications of C-Section?
1) Infection - UTI, respiratory, endometritis
2) VTE
Late complications of C-Section?
1) Fistulae (UT trauma)
2) Psychological
3) Subfertility
4) Rupture of scar at next labour
5) Placenta praviae/accrete
6) Caesarian scar ectopic pregnancy
What is PROM and P-PROM?
Two main classifications of premature membrane rupture:
1) PROM - Rupture of foetal membranes at least 1 hour prior to onset of labour at >37 weeks gestation - minimal risk (as advanced gestation).
2) P-PROM - Rupture of membranes occurring at <37weeks gestation - higher rates of maternal and foetal complications. (associated with 40% of pre-term deliveries.
Ax and PPx of PROM (+ P-PROM)?
- Foetal membranes consist of the chorion and amnion - strengthened by colleges and under normal circumstances they become weaker at term in preparation of labour.
- Weakening occurs due to apoptosis and collagen breakdown by enzymes.
- In PROM- and P-PROM, weakening and rupture occurs early: early activation of normal physiological process (higher levels of apoptotic markers and MMPs in amniotic fluid) and infection - inflammatory markers/cytokines contribute to weakening of membranes.
- 3 factors can lead to early weakening - early activation of normal physiology, infection, genetic predisposition.
Risk factors of PROM and P-PROM?
1) Smoking
2) Previous PROM/pre-term delivery
3) Vaginal bleeding during pregnancy
4) Lower genital tract infection
5) Polyhydramnios
6) Multiple pregnancies
7) Amniocentesis
8) Cervical insufficiency
Clinical features of PROM/P-PROM?
1) Hx of BROKEN WATERS - painless popping and gush of watery fluid leak from vagina.
2) Can be non-specific - gradual leakage of fluid from vagina/damp underwear pad/change in discharge consistency
3) Speculum exam - fluid drainage from cervix, pooling in posterior vaginal fornix
4) Lack of normal vaginal discharge ‘washed clean’ - suggestive of rupture of membranes
Tests: Ask woman to cough during examination- can cause dispelling of amniotic fluid.
AVOID performing digital vaginal examination until active labour in women with suspected PROM/P-PROM.
Ddx of PROM/P-PROM?
1) Urinary incontinence
2) Normal vaginal discharge during pregnancy
3) Increased sweat/moisture
4) Increased cervical discharge (infection)
5) Vesicovaginal discharge
6) Loss of mucus plug
