Caesarean Section

Question 1

What is a Caesarean Section (CS)?

Answer 1

It is a surgical technique whereby the fetus is delivered through an incision in the uterus

Question 2

How common is caesarean section?

Answer 2

It is the mode of birth in 30% of births

Question 3

What is the two main reasons why caesarean sections have been rising over the last 50 years?

Answer 3

1. Increasing incidence of conditions which are more likely to lead to CS such as advanced maternal age and increasing maternal obesity
2. More risk averse population

Question 4

What is the most common reason for women having a CS now?

Answer 4

PHx of CS – women who have had one CS for whatever reason, will have another.

Question 5

What is the difference between an elective and emergency CS?

Answer 5

An elective CS would have been planned in the antenatal period and performed before the onset of labour. An emergency CS is performed in labour or unplanned in the antenatal period.

Question 6

What anatomical location do 99% of all CS nowadays take place? Why is this incision used?

Answer 6

Lower Uterine Segment. Old skool practices of having a vertical incision in the upper uterine segment are 20 times more likely to rupture in the next pregnancy.

Question 7

If a woman decides to have one CS what is the risk of uterine rupture if you try to vaginally deliver for the next baby? What is the risk of perinatal death?

Answer 7

1/200 will have uterine rupture. 1/5 of these women will die.

Question 8

What are 4 indications for CS? (There are 9)

Answer 8

Uterine Scar
Obstructed Labour
Inadequate progress in labour and/or fetal compromise
Malpresentation – transverse or oblique lie. Breech can be delivered vaginally.
Antepartum Haemorrhage – related to placenta praevia and how far from the os the placenta lies.
Severe pre-eclampsia and eclampsia – in extreme preterm, cervix is unripe if delivery needs to happen. So CS is necessary
Multiple Pregnancy – If there is malpresentation of the first twin then CS is indicated.
Probable cephalopelvic disproportion
Maternal Request – need to be well informed

Question 9

What are the reasons that a planned vaginal birth is the way to go?

Answer 9

Psychological
Neonatal Respiratory Distress Syndrome
Maternal Risks in this Pregnancy
Maternal Risks in Subsequent Pregnancies

Question 10

At what gestation is a CS usually booked in?

Answer 10

CS at 39 weeks

Question 11

What is important in the preparation of a woman for a CS? Think normal surgical prep procedure

Answer 11

Consent
Fasting
Blood Tests – FBE, cross match, group and hold
Gastric acidity reduction
Regional Analgesia – spinal block
IV infusion – need to be weary of potential blood loss
ABx at time of CS – reduces risk of endometriosis and wound infection

Question 12

What are the adverse effects of a CS? (Immediately, Early post-op, late sequalae)

Answer 12

Immediate – anaesthetic reactions (OD, hypoxia, apnoea), operation complications, exacerbation of mother’s pre-existing condition

Early post-op – Infection, Thromboembolism, haemorrhage, ileus, wound dehisecence

Late sequelae (relate to subsequent pregs) – Uterine rupture, placenta praevia, placenta accrete (both of the last two increase with each subsequent pregs)

Question 13

What are the risks if a woman decides to have a Trial of Labour after CS?

Answer 13

Uterine Rupture

Perinatal Mortality and Morbidity – higher than for a elective CS

Question 14

What is the main reasons for and against Vaginal Birth after CS (VBAC)?

Answer 14

Increased risk of placenta praevia and placenta accreta. With each subsequent CS there is an exponentially increased risk of placenta praevia (0.5 – 1 – 2 – 4 – 10) and placenta accreta of those with praevia (2 – 10 – 30 – 50 -70).