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