Caesarean sections Flashcards
Discuss caesarean sections in NZ and Australia
-Rates in Australia
-Rates in NZ
-Elective repeat CS rate
- Aus rates - 33% 2015
- NZ rates 25% 2015
- Elective rates = 14% of all CS
What are the success rates for VBAC for the following
-VBAC following single previous CS
-VBAC after 2 previous CS
-VBAC with previous VB
-VBAC if no previous VB, Previous CS for FTP, Requiring IOL, BMI >30
-VBAC if BMI >40
-Preterm VBAC
-Twin VBAC
- VBAC following single previous CS - 75% (varied in the literature)
- VBAC after 2 previous CS - 65-75%
(No difference in success rates for 1 or 2 CS) - VBAC with previous VB - 85-95%
- VBAC if no previous VB, BMI >30, Previous CS for FTP, Requiring IOL = 40%
- VBAC if BMI > 40 = 39% (> double risk of uterine rupture)
- Preterm VBAC - same success rate as term VBAC (Less rupture)
- Twin VBAC - same as success rate as singleton VBAC
What are the factors which favour a successful VBAC (4)
-Previous safe VB
-Previous successful VBAC
-Spontaneous onset of labour
-Uncomplicated pregnancy without other risk factors
What are the factors which reduce success of a VBAC (11)
-Previous CS for dystocia
-IOL
-Co-existing fetal, placental or maternal conditions
-Maternal BMI >30
-Fetal macrosomia >4kg
-Advance maternal age
-Short stature
-More than one previous CS
-Risk factors associated with increase risk of scar rupture
-Gestation >41 weeks
-Fetal malpresentation
What are the contraindications to VBAC (5)
- Previous classical section
- Previous T or J extension
- Congenital uterine anomalies
- Inability to perform an EMCS
- Contraindications to VB
What are the risk and benefits of VBAC
-Neonate risks (5)
-Neonate benefits (2)
- Neonate risks
-Increased uterine rupture 1:200 with 1:7 chance of death or brain injury
-Increased perinatal mortality 0.4-0.7:1000 (Low and comparable to nullips)
-Fetal acidosis <7.0pH 1.5:1000
-Increased HIE 0.4: 1000
-Increased Intracranial injury 1:1900
-Increased birth injury - Neonatal benefits
-Reduced neonatal distress 2-3%
-Higher breastfeeding rates
What are the maternal risks and benefits of VBAC
-Risks (6)
-Benefits (4)
- Maternal risks
-Increased risk of emergency CS 1:4
-Increased serious CS complication rate compared with ELCS 13% vs 7%
-Increased risk uterine rupture 1:200
-Increased womb infection 29:1000
-Increased need for blood transfusion 2:1000
-Hysterectomy 0.8:1000
-Pelvic floor trauma - 5% 3rd and 4th
-Instrumental delivery 39% - Benefits
-Avoid major surgery
-Earlier mobilisation and DC from hospital
-Reduce future pregnancy complication
-Increase chance of future successful VBAC
- What are the neonatal risks and benefits for ELCS
-Risks (3)
-Benefits (4)
- Risks
-Chance of EMCS prior to ELCS 118:1000
-Increased neonatal respiratory distress 4-5% (No difference after 40/40)
-Lower rates of breast feeding - Benefits
-Decreased uterine rupture <0.2:1000
-Reduced perinatal mortality 1:100,000
-Reduced HIE 0:1000
-Reduced intracranial injury 1:2750
What are the maternal risks and benefits of ELCS
-Risks (2)
-Benefits (5)
- Risks
-Increased surgical complications
-Increased risk of complications in future pregnancies - Benefits
-Decreased womb infection 15:1000
-Decreased need for blood transfusion 10:1000
-Decreased uterine rupture <0.2:1000
-Avoid pelvic floor trauma
-Can plan time for birth
-Avoid EMCS with increased complications (13 vs 7%)
What are the risk factors for uterine scar rupture (8)
-Very rare if unscarred uterus 0.5-2:10 000
-Multiparity
-Previous classical 90:1000
-Inverted T or J incision 19:1000
-Low vertical incision 20:1000
-IOL and augmentation esp with prostaglandins
-Pregnancy interval <18 months 2-3x risk
-Risk of recurrent rupture = >5%
-Previous uterine surgery with breech of cavity
What are the signs of uterine rupture (9)
-Abnormal CTG (65-75%)
-Haematuria 25%
-Loss of station
-Concave abdomen
-Shoulder tip pain or diaphragm irritation
-Constant pain persists between contraction 8%
-Blood stained liquor 4%
-Cessation of effective uterine activity
-Maternal tachycardia or hypotension
Discuss VBAC and induction of labour
-Risk of repeat CS
-Chance of successful VBAC
-Risk of rupture (5)
- Risk of repeat CS - 33% with IOL cf 18% if Spont labour
- Chance of successful VBAC = 65%
- Risk of rupture
-2-3 times higher with IOL
-Risk 10:1000 (Double spontaneous labour)
-Risk increased 4 times with use of oxytocin (2:100)
-Combined PG with oxy has highest risk
Discuss augmentation and VBAC
-Chance of VBAC success
-Risk of uterine rupture
- Chance of VBAC success 75%
- Chance of uterine rupture 8-9:1000
Discuss VBAC after >1 previous CS
-Success rate of VBAC
-Rupture rate
-Advice for VBAC after 3 CS
- Success rate for VBAC 70%
- Rate of rupture 1.6% (Note less than with oxy IOL)
- Advice for VBAC after 3 CS - don’t!!
Discuss evidence based CS technique
-Which techniques have high level evidence (5)
-Which techniques are not supported by the evidence (3)
- -Pre-skin incision antibiotics reduce maternal infection RR0.5
-Blunt extension of the uterotomy in cephalad-caudad direction reduces blood loss and lateral extensions
-Spontaneous removal of the placenta reduces infection and blood loss cf MROP.
-Single layer closure in women who have completed their families
-Suture closure of adipose tissue if more than 2cm RR 052 for haematoma / seroma formation - Techniques not supported
-Manual cervical dilation
-Subcut drains
-Supplemental oxygen
Discuss pre-operative steps for evidence based CS
-Antibiotics (3)
-IDC (3)
-Skin prep (1)
-Vaginal cleansing (2)
- Antibiotics
-15-60 mins before skin incision.
-First generation cephalosporin
-Reduction in infection RR 0.5 compared to after skin incision
-Avoid augmentin - Indwelling catheter
-Evidence is poor
-NICE recommend
-Catheterisation associated with increased UTI and no increase in bladder injury. Poor evidence - Skin preparation
-Chlorhexidine associated with reduced surgical site infection cf iodine (RR 0.7) - Vaginal cleansing
-Perform with providine iodine
-Reduces post-CS endometritis esp. if in labour (RR 0.41) 7.1% vs 3.1%
Discuss incision type
-Pfannenstiel
-Joel-Cohen
- Pfannenstiel incision
-2-3cm above superior aspect of SP slightly curved - Joel-Cohen
-Straight incision 3cm below the line that transects the ASIS. Blunt entry through into the peritoneum.
-Joel-Cohen associated with less blood loss, faster operation time, less analgesia requirement, shorted post-op hospital stay cf pfannenstiel
Discuss evidence based CS
-Management of the fascial layer (3)
-Management of the bladder flap
-Hysterotomy method
- Management of the fascial layer
-Insufficient evidence to dissect off rectus muscles
-Low level evidence suggests not to dissect the lower rectus fascia
-Sharp entry to fascia with blunt extension recommended - Management of the bladder flap
-Omission of a bladder flap reduces time to delivery 1.27 mins
-No difference in bladder injury, blood loss.
-Consider in repeat CS, CS at fully, Prelabour CS - Hysterotomy method
-J incision preferable to inverted T if extension required
-Blunt extension of hysterotomy cephalo-caudal recommended - less blood loss, less angle extension cf sharp
Discuss evidence base CS
-PPH prophylaxis (4)
-Placental delivery (3)
-Uterine exteriorisation (3)
-Hysterotomy closure (4)
- PPH prophylaxis
-5IU oxy with delivery of anterior shoulder
-Routine oxy infusion
-Misoprostol confers no advantage over oxy
-TXA associated with reduced EBL >1000 and further use of uterotonics - Placental delivery
-Delivery spontaneously with CCT
-Avoid manual removal - increased blood loss, endometritis, Rh sensitisation
-Only do intra-uterine wiping if placental membranes seen - 1 x small RCT - Uterine exteriorisation
-New evidence suggests exteriorisation reduces blood loss
-Surgeon’s preference
-May be associated with increased discomfort. - Hysterotomy closure
-No difference in single or double layer closure for scar rupture / dehiscence / accreta / praevia
-Single layer faster operation time and maybe less blood loss
-Continuous and unlocked
-No evidence for suture type
Discuss evidence based CS
-Management of peritoneum (3)
-Intraperitoneal drain use (2)
-Sheath closure (1)
-Subcut closure (3)
-Skin closure (2)
- Management of peritoneum
-Closure associated with increased post op pain
-May be associated with reduced adhesions
-Insufficient evidence to support closure - Intraperitoneal drains
-Consider if anticoagulated
-Use large bore non suction - Sheath closure
-Continuous closure with absorbable suture - Sub cut closure
-Perform subcut irrigation - 1 x RCT
-Close if >2cm of adipose
-Reduction in haematoma/seroma formation RR 0.52
-No difference for wound infection - Skin closure
-Subcut stitches
-Stables associated with increased wound separation and no difference in wound infection
-Use absorbable monofilament
Discuss RANZCOG categories for CS urgency classification (4 categories)
- Category one: urgent threat to the life or health of mother or baby
- Category two: Fetal or maternal compromise but not immediately life threatening
- Category three: Requiring earlier than planned delivery but without current evidence of fetal compromise
- Category four: CS at a time that is acceptable to the woman and team
Discuss the RANZCOG recommendations for classifying CS urgency (5)
-Supports a nuanced approach to determine urgency
-Recommends no specific time interval attached to categories
-Urgency must be re-evaluated and this communicated with team
-Centers with >4000 should have own obstetric OT
-Clear communication important to reduce decision to delivery interval
Discuss classical caesarean section
-Indications (8)
-Technique (2)
-Risks (2)
- Indications
-Poorly formed lower segment
-Large uterine fibroids in lower segment
-Transverse lie and PPROM esp if back down
-Placenta praevia with large vessels in LUS
-Severe adhesions limiting access to LUS
-Planned CS hysterectomy
-Morbidly adherent placenta
-Perimortem CS - Technique
-Close in 3 layers
-Use monfilament for third layer to reduce adhesions - Risks
-PPH
-Increased risk of uterine rupture 9:1000
What are the risks associated with CS at fully / impacted fetal head
-Risks to baby (2)
-Risks to mother (6)
- Risks to baby
-Skull fracture
-Intracranial haemorrhage - Risks to mother
-Angle extensions into lower segment / vagina
-Bladder injury
-Ureteric injury
-Haemorrhage
-Blood transfusion
-Need for ICU
Discuss delivery principles for impacted fetal head / CS at fully
-Pre-operative considerations (4)
-Intra-operative considerations
-Post delivery considerations
- Pre-operative considerations
-Assess whether Vaginal or CS safest
-Apply upward pressure to assist disimpaction
-Consider fetal pillow (RR 0.23 for angle extension - Intra-operative considerations
-Perform hysterotomy higher to avoid going through vagina
-Stand on step
-Trendelenburg tilt
-Relax uterus - between contraction/tocolysis
-Turn to OT position
-Try to disimpact head with opposite hand
-Consider experienced assistant for vaginal disimpaction
-Extend incision
-Deliver breech - Post delivery considerations
-PPH prophylaxis
-Examine bladder carefully
-Examine carefully for hysterotomy extensions
Discuss CS delivery of breech baby
-Risks to fetus (6)
-Delivery method (8)
- Risk to baby
-Overall risk lower cf vaginal delivery
-Dislocation of hip, shoulder
-Cervical spine injury
-Spinal cord injury
-Vertebral artery injury
-Brachial plexus injury - Delivery method
-Extend uterotomy cephalo-caudal
-Elevate breech to hysterotomy
-Delivery legs with Pinards manoeuvres
-Delivery Shoulders with Lovsett’s manouevres
-Delivery Head maintaining fundal pressure to keep head flexed.
-If head not spontaneously delivered perform MSV manouvre
-If head still not delivered use obstetric forceps
-If head still not delivered consider tocolysis and inverted T incision
Discuss emergency peripartum hysterectomy
-Definition (1)
-Incidence (2)
-Causative factors (4)
-Risk factors (6)
- Definition
Hysterectomy performed immediately following or within 24hrs of delivery - Incidence
-0.2-5:1000
-95% follow CS delivery - Causative factors
-Morbidly adherent placenta (55%)
-Placenta praevia (20%)
-Uterine atony
-Uterine scar rupture - Risk factors
-Previous CS (9% risk if >6)
-Previous uterine surgery
-Advance maternal age
-Placenta praevia
-Multiparity
-Multiple pregnancy
Discuss emergency peripartum hysterectomy
-Considerations pre-hysterectomy(3)
-Surgical difficulties (5)
-Surgical considerations (3)
- Considerations
-If Hysterectomy is inevitable then don’t delay
-Should be decided on by senior clinician. Better if 2 SMO’s
-Can do aortic compression to buy time for decision and senior help - Difficulties
-Distended cervix - hard to identify external os
-Engorged and dilated pelvic blood vessels
-Friable and oedematous tissue
-Large bulky uterus
-Unstable patient - Surgical considerations
-Reflect bladder to minimise injury and displace ureters distally
-Use extra clamps on vessels to ensure haemostasis
-Consider subtotal hysterectomy as faster, safer.
Discuss PPH at CS
-Incidence (2)
-Maternal risk factors (6)
-Fetal risk factors (1)
-Situational risk factors (2)
- Incidence
-7% of EMCS
-5% of ELCS - Maternal risk factors
-Obstructed labour
-APH
-Placenta praevia/ morbidly adherent placenta
-Prolonged labour
-Obesity
-Uterine fibroids - Fetal risk factors
-Macrosomia - Situational risk factors
-EMCS
-GA
Discuss PPH at CS
-Causes (4 categories)
-Prevention (4)
- Causes
Uterine atony
Tissue trauma
-Angle extensions
-Cervicovaginal injury
-Bladder injury
-Muscle and adhesion bleeding
Placental
-Placenta praevia
-Morbidly adherent placenta
Coagulopathy - Prevention
-Meticulous surgical technique (JCM best)
-Correction of dextrose-rotation
-Correct placement of hysterotomy incision
-Delivery of placenta by CCT
Discuss management of PPH in CS (6)
1.Direct treatment at cause
2.Consider TXA for all causes
3.Manage atony with ecbolics, B-Lynch
4.Manage trauma with prompt surgical repair
-Secure angles
-Haemostatic sutures or uterine artery ligation
5. Bleeding from placental bed
-Figure of 8 sutures into placental bed
-Bakri balloon
Discuss rates of CS
-Incidence in NZ and Australia
-Reasons for increased CS rates (9)
-Evidence based ways to reduce CS rates (6)
- Incidence
-31% Australia
-27% NZ - Reasons for increased CS rates
-Increasing maternal BMI
-Increasing maternal advanced age
-Increasing multiple pregnancy
-Reduction in rotational instrumental deliveries
-Increase in CS for breech
-Increase in placenta praevia and morbidly adherent placenta
-Increase rates of neonatal survival at earlier gestation
-Increased maternal co-morbidities
-Increased anxiety regarding litigation - Means to reduce CS rates
-One to on continuous care
-IOL after 41/40
-Partogram with 4 hr action line
-Consultant obstetrician to make decision
-Fetal blood sampling
-Increase VBAC and ECV
Discuss vaginal seeding
-Definition (1)
-Reasons for doing (4)
-Benefits
-Risks
-What to do if mother is requesting
- Definition
-Innoculating a cotton swab with vaginal flora and exposing mouth, nose and skin of neonate - Reasons for doing
-Microbiome determined by mode of delivery.
-CS delivered infant have microbiome of maternal skin not vaginal mucosa
-Thought these differences may influence atopy and autoimmune diseases
-Children born by CS have increased rates of obesity, diabetes asthma and autoimmune disease. - Benefits
-AS yet unproven - Risks
-GBS, Chlamydia, HSV, Gonorrhoea - What to do if requested
-Risk of harm not justified without evidence of benefit
-If women wants to perform herself then consider testing for vaginal pathogens
-Make sure woman is well informed
-Ensure paeds and MW are aware
Discuss elective caesarean sections
-Indications for CS (9)
-When should a CS not be offered
-What are the increased risks of ELCS cf planned VB (7)
- Indications for CS
-Malpresentation: Breech / transverse
-Twins: MCMA or leading twin breech
-Placenta praevia
-Previous CS: declining VBAC, previous classical, J or T incision
-High HIV viral load >400 copies/mL
-Primary genital herpes
-HIV with concurrent Hep C
-Maternal diabetes with EFW >4.5kg
-EFW >5kg without maternal diabetes - When should ELCS not be offered
-Preterm birth - effect of ELCS unknown
-SGA - Effect of ELCS unknown
-Hep B or Hep C - unnecessary - Increase in ELCS risks cf planned VB
-Maternal death 5 times risk
-Peripartum hysterectomy 2 x risk
-Wound infection 3 x risk
-Endometritis 12% increase
-Less urinary and prolapse issues with ELCS
-Pain same between groups at 4 months
-Increased Neonatal mortality, asthma, GI infections, respiratory infections
Discuss approach of ELCS for maternal request (5 points)
- No RCT to help guide evidence
- Explore reasons why requested
- Discuss risks and benefits of VB vs CS
- Offer support / intervention depending on reason for request
- As per RANZCOG can either:
-Agree to provide once satisfied woman is well informed of choice
-If declines to provide must refer to another obstetrician for second opinion
Discuss timing of ELCS
-When should it be performed (5)
-Risk of pre-CS labour
-Should steroids be given for ELCS (4)
- Timing
-39 weeks of after to avoid: increase in neonatal respiratory disorders, behavioural and neurodevelopmental issues associated with birth before 39/40
Increased metabolic disorders, increased adult mental illness
-Small increase risk in still birth related to increase of SB with increasing gestation - Risk of labour pre-CS
-10% if booked at 39 weeks - Should steroids be given for ELCS
-RCOG recommend steroids until 38+6 for ELCS
-C Steroid study aimed to answer this question
-ASTECS non-blinded RCT found Babies who had steroids from 37 weeks for ELCS had less SCBU admissions but very high NNT as admissions were rare
-RANZCOG say consider giving if you can’t defer CS until after 39/40
Discuss complications of CS
-Incidence of complications at EMCS and ELCS (2)
-Factors that increase risk of complications (6)
- Incidence of complications
-ELCS - 7%
-EMCS 16% - Factors that increase complication risk
-Obesity
-Cat 1 CS
-Previous surgery
-Pre-existing medical conditions
-Dilation 9-10cm 33:100
-EMCS
Discuss risks of CS complications
-Maternal (11)
-Fetal (3)
- Maternal risks
-ICU admission 9:1000
-Emergency hysterectomy 8:1000
-Return to OT 5:1000
-Bladder injury 1:1000
-Ureteric injury 3:10 000
-Bowel injury - Rare
-Death 1: 12 000
-Repeat CS 1:4
-Wound infection 10:100
-Endometritis 18:100
-Ileus 10% - Fetal Risks
-IVH 1:900
-Fetal laceration 2:100
-Increased TTN, Pulmonary HTN, surfactant def (2-7 times increase)
-Still birth in future pregnancies 1-4:1000
How do CS impact future pregnancies (10)
-Delayed conception
-Increased ectopic pregnancy
-Uterine rupture
-Placenta praevia
-Placenta accreta
-Adhesions complicating future pregnancies
-Unexplained still birth >34 weeks
-IUGR
-PTB
-Unexplained still birth
Discuss Ogilvie syndrome
-Definition
-Pathophysiology
-Management
- Definition
-Acute large bowel obstruction without mechanical cause - Pathophysiology
-Imbalance in the autonomic innervation of the colon leading to atony and proximal dilation
-May occur due to PNS during CS
-Caecum becomes dilated leading to ischemia, perforation and peritonitis - Management
-If Caecum <10cm consider conservative management. Avoid lactulose and opiates
If Caecum >10-12cm
-Consider neostigmine
-Urgent colonic decompression with rectal flatus tube
-If perforation urgent laparotomy
Discuss RANZCOG recommendations for managing VBAC in labour (6)
- In a site with neonatal and OT access
- Continuous fetal monitoring
- IV access
- Clear fluids only
- VE at least every 4 hrs until 7cm then every 2 hours
- Epidural is not contra-indicated
In what circumstances is the risk of fetal injury at CS increased (3)
-Deep impaction of fetal head in pelvis - skull fracture, ICH
-Fetal macrosomia -brachial plexus injury
-Breech presentation - cervical spine, spinal cord and vertebral injury
Discuss recommendations (RANZCOG) for delivery of an impacted fetal head in second stage
-Pre-operative delivery (4)
-Intra-operative (3)
-Post-operative (1)
- Pre-operative
-A vaginal examination should be done by a senior doctor prior to CS commencing to exclude whether a VB is safer and easier
-Steady pressure to the fetal head to assist disimpaction should be applied (Hand or fetal pillow)
-Have experiences OB and paeds in the room
-Alter anaesthetics about need for acute tocolysis and PPH - Intra-operative
-Elevate the head into the abdomen by either - upward pressure from below or elevation of the fetal fetal by the accoucheur by passing the hand over the head and elevating
-Consider a tocolytic GTN
-Delivery by breech extraction - Post-operative
-Prepare for PPH secondary to atony, trauma, infection
How should shoulder dystocia in a CS be managed (3)
- Anticipate macrosomia and make a larger incision. Extend as required
- Consider delivery of the posterior arm
- Consider a J or T incision
Discuss the ASTECS trial
-Aim (1)
-Study methodology
-Primary outcomes
-Secondary outcomes
- Aim
-To see if steroids reduce respiratory distress in babies born by ELCS - Study design
-Pragmatic RCT
-10 maternity units
-2 x IM doses of 12mg betamethasone 48hrs before delivery
-Included women >37/40
-Not blinded - Primary outcome
-NICU admission for respiratory distress - Secondary outcomes
-Level of respiratory distress
-Level of care required
Discuss ASTECS trial
-Number included in the study (1)
-Results of the primary outcome (2)
-Results of the secondary outcome (3)
-Recommendations
- Number included in the study
n = 950 - Primary outcome results
RR of respiratory distress if treated with steroids 0.46 (SS)
-Reduction in respiratory distress in ELCS from 1.1 to 0.2% - Secondary outcome results
-Severity of respiratory distress was similar in both groups
-Babies in the control group required higher level of care
-Increased need for NICU associated with earlier gestation in both groups but more pronounced in control group in all categories - Recommendations
-Give steroids for ELCS
-Try to avoid ELCS before 39/40
