Procedures Flashcards
What is a Caesarean section?
A caesarean section involves a surgical operation to deliver the baby via an incision in the abdomen and uterus.
How common are caesarean births?
Around 1 in 4 pregnant women in the UK has a caesarean birth.
What are the indications for an elective caesarean?
- Previous caesarean
- Symptomatic after a previous significant perineal tear
- Placenta praevia
- Vasa praevia
- Breech presentation
- Multiple pregnancy
- Uncontrolled HIV infection
- Cervical cancer
When would an emergency caesarian section be done?
- Performed in labour
- Prolonged first stage
- Not all criteria for instrumental delivery are met
- Inefficient uterine action
- Malposition
- Malpresentation
- Pelvic abnormalities
- Cephalopelvic disproportion
- Fetal distress
What are the categories of Caesarean 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.
What are the most common used skin incisions?
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)
What is vertical incision?
A vertical incision down the middle of the abdomen is also possible, but this is rarely used. It may be used in certain circumstances, such as very premature deliveries and anterior placenta praevia.
What is blunt dissection and what layers need to be dissected?
Blunt dissection is used, after the initial incision with a scalpel, to separate the remaining layers of the abdominal wall and uterus. Blunt dissection involves using fingers, blunt instruments and traction to tear the tissues apart, rather than to cut them with sharp tools such as a scalpel. This results in less bleeding, shorter operating times and less risk of injury to the baby.
The layers of the abdomen that need to be dissected during a caesarean are:
- 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
How is the baby delivered in a c-section, what needs to be stitched after?
The baby is delivered by hand with the assistance of pressure on the fundus. Forceps may be used if necessary.
The uterus is closed inside the abdomen using two layers of sutures. Exteriorisation (taking the uterus out of the abdomen) is avoided if possible. The abdomen and skin are then closed.
What are the risks of 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)
What measure do we use to reduce the risks during c-sections?
Measures to reduce the risks during caesarean section are:
- 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
There is a risk of aspiration pneumonitis during caesarean section, caused by acid reflux and aspiration during the prolonged period lying flat. H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) are given before the procedure to reduce the risk of this happening.
What are the maternal risks of having a c-section?
Generic surgical risks:
- Bleeding
- Infection
- Pain
- Venous thromboembolism
Complications in the postpartum period:
- Postpartum haemorrhage
- Wound infection
- Wound dehiscence
- Endometritis
Damage to local structures:
- Ureter
- Bladder
- Bowel
- Blood vessels
Effects on the abdominal organs:
- Ileus
- Adhesions
- Hernias
What are the fetal risks of a c-section?
- Risk of lacerations (about 2%)
- Increased incidence of transient tachypnoea of the newborn
What are the risks for future pregnancies after a c-section?
- Increased risk of repeat caesarean
- Increased risk of uterine rupture
- Increased risk of placenta praevia
- Increased risk of stillbirth
What is an episiotomy?
An episiotomy is where the obstetrician or midwife cuts the perineum before the baby is delivered. This is done in anticipation of needing additional room for delivery of the baby (e.g. before forceps delivery). It is performed under local anaesthetic. A cut is made at around 45 degrees diagonally, from the opening of the vagina downwards and laterally, to avoid damaging the anal sphincter. This is called a mediolateral episiotomy. The cut is sutured after delivery.
