Caesareans Flashcards
What are the benefits of JC over pfannensteil
Less EBL Shorter delivery time Less operating time Less fever Less post op analgesia overall and less in the first 24 hours Reduction in total analgesia dose Increased time before needs analgesia Shorter post op stay
The overall risk of fetal injury at caesarean section is low. Nevertheless, there is potential for
fetal injury at caesarean section in certain circumstances. These injuries include:
- Skull fracture and/or intracranial haemorrhage following disimpaction where
the head is deep in the pelvis. - Brachial plexus palsy following difficult delivery of the shoulders in the
presence of fetal macrosomia - Cervical spine, spinal cord and/or vertebral artery injury following delivery of the after coming head of a breech presentation.
Consequences
Where delivery needs to be expedited with the presenting part deep in the pelvis, there are
added risks of caesarean section including increased risks of:
- Fetal Injury including skull fracture and/or intracranial haemorrhage.
- Maternal injury including:
• tears in the lower uterus;
• haemorrhage;
• urinary tract injury.
If second stage what are the 3 options for management?
Instrumental
LSCS
Wait and hope it comes down further
Before a fully LSCS what are the considerations that need to occur?
- A vaginal examination should be performed by the most senior obstetric doctor present
immediately prior to commencing the procedure. This is to:
Exclude the possibility of further head descent such that vaginal delivery would be more easily accomplished.
Apply steady firm upward pressure to assist with disimpaction of the fetal head and
assist with the abdominal delivery. There is some evidence that inflatable devices
might reduce the risk of uterine injury in these circumstances. Administration of a
tocolytic agent may be of benefit.
- An experienced obstetrician and paediatrician should be in attendance or readily
available where a technically difficult delivery is anticipated. - The anaesthetist should be appropriately prepared in anticipation of the need for acute
tocolysis and management of postpartum haemorrhage.
Intrapartum
how to help get the head out?
Elevating head Cupped hand vaginally to lift head - avoid 2 fingers Steady elevation hand in and lift Consider fetal pillow
Tocolysis to balance the retracted upper uterine segment that cannot accomodate the displaced fetus
If impossible then consider breech delivery - only if experience or if other attempts have failed
Post op considerations after second stage LSCS
Major PPH TXA Oxytocics blood products mechanical means
LSCS for the macrosomic fetus
What are the additional risks and methods to overcome these risks?
Caesarean section for the macrocosmic fetus may still result in shoulder dystocia and
brachial plexus palsy but with an incidence many times less than with vaginal birth
Delivery Principles
Where shoulder dystocia and fetal injury is anticipated, the abdominal wall and uterine
incisions should be sufficiently large to facilitate delivery. Where difficulties are encountered
during delivery, these may need to be extended:
1. To facilitate access for manoeuvres such as delivery of the posterior arm.
2. Converting the uterine incision into a ‘J’ or ‘T’ incision.
What are the risks of breech caesarean
- Cervical spine, spinal cord and/or vertebral artery injury may follow delivery of the
after coming head of a breech presentation. These injuries may follow hyperextension
of the cervical spine while trying to facilitate delivery of the fetal head through the
incision. It should be noted that:
These injuries may be more likely where the head is hyper-extended antenatally
producing anomalous development of the cervical spine, or when fetal muscular
tone is reduced through a neuromuscular disorder or fetal hypoxia.
Such injuries may also occur antenatally and are not necessarily the consequence of
the delivery itself.
- Maternal consequences of caesarean section can be considerable if the breech is
very deep in the pelvis such that vaginal breech delivery may be recommended.
Trials recommending caesarean section for breech presentation have not been
powered to examine the subgroup with full cervical dilatation and the breech deep
in the pelvis.
How to antenatally reduce breech LSCS complications?
Antenatal care that diagnosis brech and allows proper plans to be made eg ELLSCS or ECV
What is the intraoperative technique for delivery a breech?
Intra-operative technique
1. Where an emergency caesarean section is being undertaken for the breech
presentation in labour, a further vaginal examination should always be performed in
theatre immediately before embarking on the caesarean section in order to exclude
imminent vaginal delivery.
2. The key to successful delivery of the after coming head of any breech presentation
(whether abdominal or vaginal) is to maintain head flexion during delivery of the
limbs and torso. Head extension not only makes head diameters much greater but
also incurs the possibility of extension injuries.
3. The incision should be sufficiently large to allow access and the necessary
manipulations. Head flexion should be maintained during delivery of the limbs and
torso by the surgical assistant exerting pressure on the vertex in the appropriate
direction.
4. When delivery of the after coming head does not occur with simple downward
pressure on the uterine fundus, delivery of the after coming head should be effected
when the head is low in the uterus by either:
A modification of the Mauriceau-Smellie-Veit manoeuvre; or
Obstetric forceps.
5. Where the fetal head is not sufficiently low OR initial attempts at delivery are
unsuccessful, the accoucheur may consider:
Tocolysis administered by the anaesthetist may assist where there is a uterine
retraction ring around the fetal neck, most commonly accomplished with GTN,
salbutamol or terbutaline or deep general anaesthesia.
Extension of the uterine incision, most commonly upward in the midline in the form
of an “inverted T-incision”. Although undesirable for subsequent pregnancies, this
may avoid fetal injury (traumatic or asphyxial) in this technically difficult situation.
What are the neonatal consequences of El LSCS
Neonatal
Increase in neonatal respiratory morbidity
Between a 2-6.8X increase compared to VB or trial of VB
TTTS
Pulmonary hypertension
Surfactant deficiency
The reason is
Surfactant deficiency - that is stimulated from the corticosteroid surge in labour
Failure to clear lung fluid
NICU admissions 2X higher at planned term caesarean then planned VB
What is ASTECS
antenatal steroid for term LSCS
Steroids after 37 weeks reduces neonatal RDS
Inadequate long term data about the safety
What are maternal considerations for del timing for ELLSCS
Maternal considerations
10% if booked at 39 weeks will labour before their date
Therefore need an EMLSCS -
Increased risk of the procedure
Impact on resourcing
(depending on the indication this may be related to fetla risk – footling breech if ROM)
Risks of LSCS
Risks to mother
Maternal:
● emergency hysterectomy, seven to eight women in every 1000 (uncommon)
● need for further surgery at a later date, including curettage, five women in every 1000 (uncommon)
● admission to intensive care unit (highly dependent on reason for caesarean section), nine women in every 1000
(uncommon)
● thromboembolic disease, 4–16 women in every 10 000 (rare)
● bladder injury, one woman in every 1000 (rare)
● ureteric injury, three
women in every 10 000 (rare)
● death, approximately one
woman in every 12 000 (very rare).
● persistent wound and abdominal discomfort in the first few months after surgery, nine women in every 100
(common)
● increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies, one
woman in every four (very common)
● readmission to hospital, five women in every 100 (common)
● haemorrhage, five woman in every 1000 (uncommon)
● infection, six women in every 100 (common)
