Caesarean Section Flashcards
What is a Caesarean section?
The delivery of a baby through a surgical incision in the abdomen and uterus
What % of deliveries in England are by c-section?
25%
What is caesarean section regionally associated with?
Local deprivation and individual social class
What factors affect the likelihood of caesarean section?
- Place of birth
- Induction of labour beyond 41 weeks in uncomplicated pregnancy
- Consultant obstetrician involved in decision making
- Electronic fetal monitoring
How does place of birth affect likelihood of Caesarean section?
Planned home delivery or in a midwifery-led unit reduces likelihood
How does induction of labour beyond 41 weeks affect likelihood of Caesarean section?
Reduces the risk of perinatal mortality and therefore Caesarean section
How does the involvement of consultant obstetricians in decision making affect the likelihood of Caesarean section?
Reduces it
How does electronic fetal monitoring affect the likelihood of Caesarean section?
Increase it
How can the planning of Caesarean section be classified?
- Elective (planned)
or
- Emergency
How may categories of emergency Caesarean section are there?
4
Why are there different categories of emergency Caesarean section?
To ensure babies are delivered in a timely manner in accordance to their or their mothers needs
What is a category 1 emergency Caesarean section?
Where there is immediate threat to life to the woman or fetus and baby should be born within 30 minutes
What is a category 2 emergency Caesarean section?
Where there is maternal or fetal compromise that is not immediately life threatening and baby is usually born within 60-75 minutes
What is a category 3 emergency Caesarean section?
No maternal or fetal compromise but early delivery is needed
What is a category 4 emergency Caesarean section?
Where delivery is timed to suit the woman or staff
What are the indications for a category 1 emergency Caesarean section?
- Cord prolapse
- Fetal distress in the first stage
What are the possible indications for category 2 emergency Caesarean section?
- Failure to progress
- Transverse lie in labour
What are the most common reasons for emergency Caesarean section?
- Failure to progress
- Suspected/confirmed fetal compromise
What are the most common indications for elective (or emergency) Caesarean section?
- Breech presentation
- Other forms of malpresentation
- Twin pregnancy
- Maternal medical conditions
- Fetal compromise
- Transmissible disease
- Primary genital herpes in third trimester
- Placenta praevia
- Maternal diabetes
- Previous shoulder dystocia
- Previous 3rd/4th degree perineal tear
- Maternal request
What other malpresentations can be an indication for Caesarean section?
- Unstable lie
- Transverse lie
- Oblique lie
What is unstable lie?
A presentation that fluctuates between oblique/cephalic/breech/transverse etc.
When is twin pregnancy an indication for Caesarean section?
When the first twin is not cephalic presentation
When are maternal medical conditions an indication for Caesarean section?
When labour would be dangerous for the mother
When is fetal compromise an indication for Caesarean section?
- Early onset growth restriction
- Abnormal fetal Doppler
- When thought fetus would not cope with labour
What is an example of a transmissible disease that would be an indication for Caesarean section?
Poorly controlled HIV
Why is primary genital herpes in the third trimester an indication for Caesarean section?
There has been no time for development and transmission maternal antibodies to HSV to cross the placenta and protect the baby
When is maternal diabetes an indication for Caesarean section?
When baby is estimated to have fetal weight >4.5kg
When is a previous 3rd/4th degree perineal tear an indication for Caesarean section?
When the patient symptomatic and there is appropriate assessment
What does ‘maternal request’ mean ash indication for Caesarean section?
A variety of reasons from previous traumatic birth to ‘maternal choice’
What should be conducted before a Caesarean section on maternal request is decided on?
- MDT approach and counselling by a specialist midwife
What steps should be taken before a Caesarean section?
- FBC and G&S
- H2-receptor antagonist prescribed +/- metoclopramide
- Risk core for VTE
Give an example of a H2-receptor antagonist?
Ranitidine
What is metoclopramide?
An anti-emetic that increases gastric emptying
Why should women having caesarean section have ranitidine +/- metoclopramide?
They are at risk of Mendelson’s syndrome
What is Mendelson’s syndrome?
Aspiration of gastric contents into the lung
What can Mendelson’s syndrome lead to?
Chemical pneumonitis
Why are women having caesarean section at risk of Mendelson’s syndrome?
When they are lying flat there is pressure applied by the gravid uterus on the gastric contents
What can be prescribed as part of thromboprophylaxis in Caesarean section?
- TED stockings
- Low molecular weight heparin
What type of anaesthesia are most Caesarean sections performed under?
Regional anaesthesia
What types of regional anaesthesia are used in Caesarean section?
- ‘Topped up’ epidural
- Spinal anaesthetic
When might general anaesthetic be required in Caesarean section?
- Maternal contra-indication to regional anaesthetic
- Failure of regional anaesthetic to achieve required block
- Concerns about fetal wellbeing and need to expedite delivery as soon as possible often in the case of category 1 sections
How is the woman positioned during a Caesarean section?
With a left-lateral tilt of 15 degrees
Why is the woman positioned at a 15˚ angle in Caesarean section?
To reduce the risk of supine hypotension due to aorta-caval compression
What happens to the bladder in preparation for a Caesarean section?
Insert Foley’s catheter to drain the bladder
Why is it important to catheterise patients having Caesarean section?
To reduce the risk of bladder injury
What happens prior to ‘knife-to-skin’ incision?
- Skin prepped with anti-septic
- Antibiotics administered
What is the first step in a standard Caesarean section?
Create a skin incision (usually a transverse lower abdominal skin incision)
What is the second step in a standard Caesarean section?
Sharp or blunt direction into the abdomen
What layers must be dissected through to reveal the uterus in Caesarean section?
- Skin
- Camper’s fascia
- Scarpa’s fascia
- Rectus sheath
- Rectus muscle
- Abdominal peritoneum
What is Camper’s fascia?
Superficial fatty layer of subcutaneous tissue
What is Scarpa’s fascia?
Deep membranous layer of subcutaneous tissue
What forms the rectus sheath?
The anterior and posterior leaves laterally coming to merge medially
What is the third stage of a standard Caesarean section?
Incision is made in the visceral peritoneum covering the lower segment of the uterus and pushed down to reflect the bladder
What is the 4th step of a standard Caesarean section?
Uterine incision made on lower uterine segment beneath the line of peritoneal reflection
What is the 5th step of a standard Caesarean section?
Baby delivered cephalic/breech with fundal pressure from the assistant
What is the 6th step of a standard Caesarean section?
Oxytocin 5iu is given IV to aid delivery of the placenta by controlled cord traction by the surgeon
What is the 7th step of a standard Caesarean section?
Uterine cavity is ensured empty the closed, rectus sheath is closed and then the skin either with continuous/interrupted sutures or staples
What should be monitored post-Caesarean section?
- Observations on EWS
- Lochia (per vaginal blood loss post delivery)
What is important to improve recovery time in Caesarean section?
Early mobilisation, eating, drinking and catheter removal
What are the advantages of a primary Caesarean section?
Reduced risk of:
- Perineal trauma and tear
- Urinary and anal incontinence
- Utervovaginal prolapse
- Late stillbirth
- Early neonatal infections
What are the potential immediate complications in Caesarean section?
- Postpartum haemorrhage
- Wound haematoma
- Intra-abdominal haemorrhage
- Bladder/bowel trauma
- Neonatal complications
What amount of blood loss would be considered post-partum haemorrhage?
> 1000ml
What co-morbidities can increase the risk of wound haematoma post-Caesarean section?
- Large BMI
- Diabetes
- Immunocompromised
What are the potential immediate neonatal complications of Caesarean section?
- Transient tachypnoea of newborn
- Fetal lacerations
What is the risk of fetal laceration in Caesarean section?
1-2%
What can make the risk of fetal laceration higher in Caesarean section?
Previous membrane rupture
What are the potential intermediate complications of Caesarean section?
- Infection
- Venous thrombosis
What types of infection can result from Caesarean section?
- UTI
- Endometritis
- Respiratory tract infection
When is the risk of respiratory tract infection higher in Caesarean section?
When GA is used
What are the potential larger complications of Caesarean section?
- Urinary tract trauma (fistula)
- Subfertility
- Regret and other negative psychological sequelae
- Rupture/dehiscence of scar next labour
- Placenta praevia/accrete
- C-section scar ectopic pregnancy
