Caesarian section

Question 1

What is a caesarean section?

Answer 1

Delivery of baby through incision in abdominal wall and uterus, normally through lower section (LSCS)

Question 2

How many women in the UK delivery by caesarean?

Answer 2

25%

Question 3

What is the most common predictor for a woman needing a CS in her pregnancy?

Answer 3

Previous CS

Question 4

What is a classical CS?

Answer 4

Vertical incision in operation, rarely used

Question 5

What are the indications for classical CS?

Answer 5

Very premature foetus, lower segment poorly formed
Transverse lie with ruptured membranes
Structural abnormality making lower segment unusable
Fibroids
Anterior placenta praevia with abnormally vascular lower segment
Maternal cardiac arrest

Question 6

What are classical CS’s associated with?

Answer 6

More adhesion formation
Infection
Contraindication to subsequent vaginal delivery

Question 7

What is an LSCS?

Answer 7

Joel Cohen skin (transverse suprapubic cut 3cm above pubis symphysis) with blunt dissection after (to minimise blood loss)

Question 8

Why is LSCS preferred to classical CS?

Answer 8

Reduced adhesions
Reduced blood loss
Lower risk of scar dehiscence in subsequent pregnancies
Note the risk of foetal laceration 1-2%

Question 9

What are common indications for CS?

Answer 9

Repeat CS
Foetal compromise (bradycardia, low pH, cord prolapse)
Failure to progress/failed IOL
Malpresentation
Severe pre-eclampsia with IOL unlikely to succeed
IUGR with absent/reversed end diastolic flow
Twin pregnancy with non-cephalic twin
Placenta praevia

Question 10

What are the indications for an emergency section?

Answer 10

Prolonged first stage

Foetal distress

Question 11

What are the indications for an elective section?

Answer 11

Absolute indications 
-placenta praevia
-severe antenatal foetal compromise
-uncorrectable foetal lie
-previous vertical CS
-gross pelvic deformity
Relative indications
-breech presentation
-IUGR (severe)
-twin pregnancy
-DM
-previous CS
-older nulliparous
Delivery before 34w

Question 12

What are the categories of CS?

Answer 12

Category 1 (emergency/crash)
- foetus needs delivery within 30mins of decision being made e.g. abruption, bradycardia
Category 2 (urgent)
- maternal/foetal compromise, but can wait 30-60mins e.g. failure to progress
Category 3 (scheduled)
- semi-elective e.g. pre-eclampsia, failed IOL
Category 4 (elective)
- e.g. singleton breech; should be carried out after 39w unless complications arise (if <39w, give prophylactic steroids)

Question 13

What are the common intraoperative complications of CS?

Answer 13

Blood loss >1L (more likely with placenta praevia, abruption, extremes of birth weight, maternal obesity)
Uterine laceration/extensions beyond uterine incision
Blood transfusion (2-3%)
Rare
-Bladder, bowel, ureteric laceration
Hysterectomy

Question 14

What postoperative complications are associated with CS?

Answer 14

Wound infection
Endometritis
UTI
VTE (prescribe 7d prophylactic LMWH)

Question 15

What should be checked before any CS?

Answer 15

Placental site to exclude placenta praevia, accreta or percreta

Question 16

What should be performed before an emergency section?

Answer 16

Explain to mother, gain consent
Activate theatre staff, anaesthetist
Get senior help
Neutralise gastric contents
G&S, crossmatch
Take to theatre, set up IVI
Catheterise, tilt 15 degrees to left
Neonatologist present
Prophylactic abx offered

Question 17

How are gastric contents neutralised before an emergency section?

Answer 17

20ml of 0.3 molar sodium citrate and promote gastric emptying with metoclopramide 10mg IV (no time for H2 agonists to work - ranitidine reserved for elective sections e.g. 150mg PO 2hrs before surgery)
Routinely empty stomach to prevent post-op aspiration

Question 18

What should be performed in women already on thromboprophylaxis before emergency section?

Answer 18

If on high dose/75% weight adjusted therapeutic dose prophylaxis, halve to same dose/24hrs as was previously being given/12hrs, on the day before planned CS.
For all on prophylaxis omit dose on morning of CS and give 3hr postop unless epidural used
2% of women have wound haematoma

Question 19

What should be done after CS?

Answer 19

Skin-to-skin
Check obs (half hrly for first 2hrs, hourly for 24hrs and until 2hrs after epidural/PCA discontinued
Use NEWS (MEOWS)
After GA, give extra midwife support to help establish breastfeeding
Mobilise early
Remove wound dressing at 24hrs
Give analgesia
Average hospital stay 2-3d, but recovery 6-8w
Discuss reasons for CS, birth options in future and contraception

Question 20

What long term effects are associated with CS?

Answer 20

Higher incidence of placenta praevia/accreta
Uterine rupture risk increased with SRM
Doubled risk of antepartum stillbirth in subsequent pregnancy
Surgical risks increase with each subsequent CS