Caesarean Section

Question 1

What are types of C section? Advantages?

Answer 1

Lower uterine segment CS
Transverse incision in the lower segment is associated with reduced adhesion formation, lower blood loss and lower risk of scar dehiscence

Classical CS
Vertical incision on uterus 
If:
Very premature fetus
Fetus lies transverse with ruptured membranes
Structural abnormality
Fibroids making LSCS impossible

Question 2

What are some indications for CS?

Answer 2

Breech position, transverse lie
Repeat CS
Fetal compromise - fetal bradycardia, scalp pH <7.2, cord prolapse
Failure to progress in labour
Severe pre-eclampsia
IUGR with absent or reversed end-diastolic flow
Twin pregnancy when first twin is not a cephali presentation
Transmissible disease
Previous major shoulder dystocia
Placenta praevia
Maternal request

Question 3

What are the categories of CS?

Answer 3

1 - Immediate threat to life of woman or fetus.
Baby should be delivered within 30 minutes od devision
e.g. placental abruption, fetal bradycardia

2 - Maternal or fetal compromise that is not immediately life-threatening
(30-60min)
e.g. failure to progress

3 - semi-elective - no maternal or fetal compromise but needs early delivery
e.g. pre-eclapmsia or failed induction of labour

4 - elective
e.g. term singleton breech
Carried out after 39 weeks unless maternal or fetal indications arise

Question 4

When should category 4 CS be carried out? Why?

Answer 4

After 39 weeks
To reduce the incidence of transient tachypnoea of newborn

If deliver is planned for < 39 weeks, corticosteroids given for fetal lung maturity and surfactant development

Question 5

What should you do before an elective CS?

Answer 5

FBC
Group and Save - test blood loss is 500-1000ml

H2 receptor antagonist prescribed e.g. Ranitidine ± metoclopramide to increase gastric emptying
- Risk of Mendelson’s syndrome (aspiration of gastric connects into the lung causing chemical pneumonitis due to lying flat for CS)

VTE risk calculated
Antithromboembolic stockings ± LMWH

Question 6

What should you do before emergency CS

Answer 6

Explain and consent

Anaethestist, theatre staff, neonatologist, senior obstetrician

Neutralise gastric content with 20 ml of 0.3 molar sodium citrate and promote gastric emptying with metoclopramide IV (no time for H2 antagonist to work)

Blood group and save and/or crossmatch e.g. 2U for abruption, 6U for placenta praevia

Catheterise bladder

Offer prophylactic abx

Question 7

What is usually used for anaesthetic in CS?

Answer 7

Topped up epidural
or spinal

Sometimes general is required

Question 8

How are women on thromboprophylaxis managed?

Answer 8

Halve dose on day before planned CS

Omit dose on morning and give 3h post-op unless epidural used

Question 9

Describe the CS procedure

Answer 9

Left lateral tilt of 15 degrees to reduce risk of supine hypotension due to aortocaval compression
Foley catheter inserted
Prophylactic abx administered prior to incision

Skin
Superficial fatty later of subcutaneous tissue
Deep membranous later of subcutaneous tissue
Rectus sheath
Rectus muscle
Abdominal peritoneum
Uterus - lower segment beneath line of peritoneal reflection

Oxytocin given IV to aid deliver of the placenta by controlled cord traction

Question 10

What should you do post-operative after CS

Answer 10

Observations:
HR, RR, BBP and sedation levels
Lochia (PV blood loss post delivery) is monitored
Analgesia

Question 11

What are intraoperative complications of CS?

Answer 11

Intraoperative:
Blood loss > 1L
Uterine lacerations, extensions
Blood transfusion
Bladder laceration
Bowel injury
Uterus injury
Hysterectomy

Question 12

What are immediate post-operative complications of CS?

Answer 12

Post-partum haemorrhage > 1000ml
Wound haematoma (increased in patient with large BMI/diabetes/immunosuppressed)
Intra-abdominal haemorrhage
Bladder/bowel trauma
Neonatal: 
- transient tachypnoea of newborn
- fetal lacerations

Question 13

What are intermediate complications of CS?

Answer 13

Infection: UTI
Endometritis
Respiratory

VTE

Question 14

What are late complications of CS?

Answer 14

Urinary tract trauma - fistula
Subfertility
Regret and other negative psychological sequealae
Rupture/dehiscence of scar at next labour
Higher risk of Placenta praevia/accreta in following pregnancy
Caesarean scar ectopic pregnancy

Question 15

What are risks of vaginal birth after C-section?

Answer 15

Risk of uterine scar rupture
Increased risk of placenta praevia/accreta

• monitor fetal heart rate continuously

Question 16

What are the layers cut in CS?

Answer 16

Skin
Superficial fascia
Deep fascia
Anterior rectus sheath
Rectus abdominis (not cut - pushed laterally following lines alba incision)
Transversalis fascia
Extraperitoneal CT
Peritoneum
Uterus