Caesarian section Flashcards
Indications for elective Caesarian section
- Previous caesarean
- Symptomatic after a previous significant perineal tear
- Placenta praevia
- Vasa praevia
- Breech presentation
- Multiple pregnancy
- Uncontrolled HIV infection
- Cervical cancer
There are 4 categories of emergency Caesarian section:
- Category 1: There is an immediate threat to the life of the mother or baby. Decision to delivery time is 30 minutes.
- Category 2: There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is 75 minutes.
- Category 3: Delivery is required, but mother and baby are stable.
- Category 4: This is an elective caesarean, as described above.
The most commonly used skin incision is a transverse lower uterine segment incision. There are two possible incisions:
- Pfannenstiel incision is a curved incision two fingers width above the pubic symphysis
- Joel-cohen incision is a straight incision that is slightly higher (this is the recommended incision)
When would a vertical incision down the middle of the abdomen be used?
For very premature deliveries and anterior placenta praevia
What are the layers of the abdomen that need to be dissected in a Caesarian section?
- Skin
- Subcutaneous tissue
- Fascia / rectus sheath (the aponeurosis of the transversus abdominis and external and internal oblique muscles)
- Rectus abdominis muscles (separated vertically)
- Peritoneum
- Vesicouterine peritoneum (and bladder) – the bladder is separated from the uterus with a bladder flap
- Uterus (perimetrium, myometrium and endometrium)
- Amniotic sac
Risks associated with having an anaesthetic:
- Allergic reactions or anaphylaxis
- Hypotension
- Headache
- Urinary retention
- Nerve damage (spinal anaesthetic)
- Haematoma (spinal anaesthetic)
- Sore throat (general anaesthetic)
- Damage to the teeth or mouth (general anaesthetic)
Measures taken to reduce the risk of a Caesarian section:
- H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) before the procedure
- Prophylactic antibiotics during the procedure to reduce the risk of infection
- Oxytocin during the procedure to reduce the risk of postpartum haemorrhage
- Venous thromboembolism (VTE) prophylaxis with low molecular weight heparin
Generic surgical risks:
- Bleeding
- Infection
- Pain
- Venous thromboembolism
Complications in the postpartum period following Caesarian section:
- Postpartum haemorrhage
- Wound infection
- Wound dehiscence
- Endometritis
Damage to local structures during Caesarian section:
- Ureter
- Bladder
- Bowel
- Blood vessels
Potential effects of Caesarian section on the abdominal organs:
- Ileus
- Adhesions
- Hernias
Effects of caesarian section on future pregnancies:
- Increased risk of repeat caesarean
- Increased risk of uterine rupture
- Increased risk of placenta praevia
- Increased risk of stillbirth
Potential effects of caesarian section on the baby:
- Risk of lacerations (about 2%)
- Increased incidence of transient tachypnoea of the newborn
Is it possible to have a vaginal birth after a caesarian section?
What is the success rate of a vaginal birth after caesarian section (VBAC)?
What is the risk of uterine rupture in VBAC?
It is possible to have a vaginal birth after a previous caesarean section, provided the cause of the caesarean is unlikely to recur.
Success rate of VBAC is around 75%.
Uterine rupture risk in VBAC is about 0.5%.
What are the contraindications to a vaginal birth after caesarian?
- Previous uterine rupture
- Classical caesarean scar (a vertical incision)
- Other usual contraindications to vaginal delivery (e.g. placenta praevia)
