Caesarean_Section_Flashcards
Why has the rate of caesarean section increased significantly in recent years?
Largely secondary to an increased fear of litigation.
What are the two main types of caesarean section?
Lower segment caesarean section (comprises 99% of cases) and classic caesarean section (longitudinal incision in the upper segment of the uterus).
What are some indications for a caesarean section?
Absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labour/prolapsed cord, failure of labour to progress, malpresentations (brow), placental abruption (if fetal distress), vaginal infection (active herpes), cervical cancer (disseminates cancer cells).
What is a Category 1 caesarean section?
An immediate threat to the life of the mother or baby (e.g., suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia). Delivery should occur within 30 minutes of making the decision.
What is a Category 2 caesarean section?
Maternal or fetal compromise which is not immediately life-threatening. Delivery should occur within 75 minutes of making the decision.
What is a Category 3 caesarean section?
Delivery is required, but mother and baby are stable.
What is a Category 4 caesarean section?
Elective caesarean.
What serious risks should clinicians make women aware of according to the RCOG?
Emergency hysterectomy, need for further surgery at a later date (including curettage for retained placental tissue), admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, death (1 in 12,000).
What future pregnancy risks are associated with a caesarean section?
Increased risk of uterine rupture during subsequent pregnancies/deliveries, increased risk of antepartum stillbirth, increased risk of placenta praevia and placenta accreta in subsequent pregnancies.
What frequent maternal risks are associated with a caesarean section?
Persistent wound and abdominal discomfort in the first few months after surgery, increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies, readmission to hospital, haemorrhage, infection (wound, endometritis, UTI).
What frequent fetal risks are associated with a caesarean section?
Lacerations (one to two babies in every 100).
What are other complications of a caesarean section not specifically mentioned in the RCOG document?
Prolonged ileus, subfertility due to postoperative adhesions.
What is the recommendation for Vaginal Birth After Caesarean (VBAC)?
Planned VBAC is appropriate for pregnant women at >= 37 weeks gestation with a single previous Caesarean delivery. Around 70-75% of women in this situation have a successful vaginal delivery. Contraindications include previous uterine rupture or classical caesarean scar.
Caesarean section
The rate of caesarean section has increased significantly in recent years, largely secondary to an increased fear of litigation
There are two main types of caesarean section:
lower segment caesarean section: now comprises 99% of cases
classic caesarean section: longitudinal incision in the upper segment of the uterus
Indications (apart from cephalopelvic disproportion/praevia, most are relative)
absolute cephalopelvic disproportion
placenta praevia grades 3/4
pre-eclampsia
post-maturity
IUGR
fetal distress in labour/prolapsed cord
failure of labour to progress
malpresentations: brow
placental abruption: only if fetal distress; if dead deliver vaginally
vaginal infection e.g. active herpes
cervical cancer (disseminates cancer cells)
Caesarean sections may be categorised by the urgency
Category 1
an immediate threat to the life of the mother or baby
examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia
delivery of the baby should occur within 30 minutes of making the decision
Category 2
maternal or fetal compromise which is not immediately life-threatening
delivery of the baby should occur within 75 minutes of making the decision
Category 3
delivery is required, but mother and baby are stable
Category 4
elective caesarean
The RCOG advise clinicians to make women aware of serious and frequent risks:
‘Serious’
Maternal:
emergency hysterectomy
need for further surgery at a later date, including curettage (retained placental tissue)
admission to intensive care unit
thromboembolic disease
bladder injury
ureteric injury
death (1 in 12,000)
Future pregnancies:
increased risk of uterine rupture during subsequent pregnancies/deliveries
increased risk of antepartum stillbirth
increased risk in subsequent pregnancies of placenta praevia and placenta accreta)
Frequent’
Maternal:
persistent wound and abdominal discomfort in the first few months after surgery
increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
readmission to hospital
haemorrhage
infection (wound, endometritis, UTI)
Fetal:
lacerations, one to two babies in every 100
Other complications which are recognised but not specificially mentioned in the RCOG document include;
prolonged ileus
subfertility: due to postoperative adhesions
Vaginal birth after Caesarean (VBAC)
planned VBAC is an appropriate method of delivery for pregnant women at >= 37 weeks gestation with a single previous Caesarean delivery
around 70-75% of women in this situation have a successful vaginal delivery
contraindications include previous uterine rupture or classical caesarean scar
A 39-year-old woman at 39 weeks gestation in the labour suite is having a cardiotocography (CTG) review.
Her waters broke 8 hours ago and she has been in labour for 4 hours. This is her second pregnancy, with her previous being delivered by normal vaginal delivery. This pregnancy has been uncomplicated so far. Her Bishop score is 7.
Her CTG findings are shown below:
Foetal heart rate 102 bpm (110 - 160)
Variability 16 bpm (5 - 25)
Decelerations Variable, with 30% of contractions (absent)
Contractions 4 per 10 minutes (3 - 4)
These findings have been consistent for 20 minutes.
What is the most appropriate management?
Commence syntocinon infusion
Increase frequency of CTG checks
Initiate tocolysis and offer a category 3 caesarean section
Perform foetal blood sampling
Prepare for category 2 caesarean section
Prepare for category 2 caesarean section
Category 2 caesarean sections are for maternal or fetal compromise that are not immediately life-threatening
This woman’s CTG findings are non-reassuring. Persistent foetal bradycardia of between 100-110 bpm represents non-reassuring findings, whereas under 100 bpm represents abnormal findings. The presence of variable decelerations, in under 50% of contractions, is also a non-reassuring finding, whereas variable decelerations in over 50% of contractions, or a prolonged deceleration would be an abnormal finding.
The management of non-reassuring CTG findings, which are persistent in nature, is to prepare for category 2 caesarean section. This category of caesarean is for a maternal or foetal compromise that is not immediately life-threatening. Examples of maternal compromise include minimal abruption or antepartum haemorrhage, failure to progress, maternal exhaustion or maternal request. Examples of foetal compromise include undiagnosed breech or non-reassuring CTG findings - abnormal CTG findings are indications for a category 1 caesarean section.
Commence syntocinon infusion is incorrect. There is no evidence that augmenting contractions would be beneficial. She is contracting at the appropriate rate, and it appears the labour is progressing well.
Increase frequency of CTG checks is incorrect. Whilst this will likely be done in any non-reassuring or abnormal CTG, it is not the single best action, as the definitive action needed is to plan delivery.
Initiate tocolysis and offer a category 3 caesarean section is incorrect. Tocolysis should not be performed at this stage of active labour - tocolytics are used in preterm labour. Additionally, a category 3 caesarean section does not resolve this issue quick enough - there is foetal compromise present and therefore this must be dealt with urgently.
Perform foetal blood sampling is incorrect. Foetal blood sampling is indicated for abnormal CTG findings, to determine the health of the foetus - it is not routinely performed for non-reassuring CTG findings.
