Caesarean delivery

Question 1

Evidenced based CS:

• Antibiotics?

Answer 1

Prior to skin incision

Cephazolin 2g (consider increased dose in obesity)

Effect:
- Less endometritis, wound infections, fever and other infections (e.g. UTI)
- Data:
–Elective: 60% less endometritis, 25% less
wound infections
–Emergency: 65% less infections

Question 2

Evidenced based CS:

• Thromboprophylaxis?

Answer 2

• TEDs and SCDs

- Consider clexane in women with additional risk factors/in women with emergency CS

Question 3

Evidenced based CS:

• Vaginal prep?

Answer 3

• Cochrane review looking at Vaginal preparation preoperatively with povidone-iodine solution
• Endometritis rates were significantly reduced (5.2% versus 9.4%)
• The reduction being particularly significant for women with ruptured membranes (1.4% versus 15.4%, RR 0.13)

Question 4

Evidenced based CS:

• IDC?

Answer 4

Some evidence to suggest lower UTI rates with removal of IDC but not sufficiently powered to comment on risk of urological injury

Question 5

Evidenced based CS:

• Skin prep/shaving?

Answer 5

Clipping hair rather than shaving has lower wound infection rates

Question 6

Evidenced based CS:

• Abdominal entry

Answer 6

Joel cohen vs Pfannanstiel:

less fever, pain and analgesic requirements, reduced blood loss and operative time and a shorter hospital stay

The Joel-Cohen technique involves making a straight transverse incision 3cm below the level of the anterior superior iliac spines, with the subcutaneous tissues opened only in the middle 3cm and the rectus sheath incised transversely in the midline.27 The subcutaneous tissue and rectus sheath is then extended laterally with blunt dissection, which is also used to separate the rectus muscles vertically and laterally and open the peritoneum

Question 7

Evidenced based CS:

• Uterine incision

Answer 7

• Blunt incision has less blood loss/risk of transfusion

- Cephalad-caudad vs transverse carries lower risk of extension and reduced blood loss

Question 8

Evidenced based CS:

• Delivery of the placenta

Answer 8

• Evidence supports spontaneous delivery (with CCT and fundal massage) over manual removal
• Less blood loss/endometritis/shorter hospital stay
• Evidence to support use of synto infusion to reduce the risk of PPH

Question 9

Evidenced based CS:

• Closure of the uterus

Answer 9

• Shorter operating time with single layer- may be considered if no further pregnancies desired
• Locking and single layer- increased rate of thinner residual myometrial thickness and may increase dehiscence

Question 10

Evidenced based CS:

• Closure of the peritoneum

Answer 10

Not closing peritoneum associated with: less postoperative fever, shorter operating times and reduced hospital stays.

Closure of the visceral peritoneum is also associated with increased urinary frequency, urgency and stress incontinence in the short term.

There are some long-term data that do suggest reduced intraabdominal adhesion formation when peritoneal closure is performed; however, the evidence regarding this remains limited and inconsistent at present

Question 11

Evidenced based CS:

• Closure of subcut tissue

Answer 11

• Close when >2cm subcut fat

Question 12

Evidenced based CS:

• Skin closure

Answer 12

Possible decreased rates of dehiscence and infection with continuous sutures rather than staples (but study looked at staples removed after D4)

Question 13

Measures to improve breastfeeding

Answer 13

• Early skin to skin

- Establish breast feeding as soon as possible