Caesarean Section

Clinical Guideline 13
RCOG APRIL 2004.

Caesarean Section
Doctor, I Would like a Caesarean
Section!
Making the Decision
Caesarean Section
Carrying Out the Procedure
How we can Decrease Morbidity
Regional Anaesthesia
Antibiotic Cover
Thromboprophylaxis
Anti-emetics
Timing-at 39 weeks





Caesarean Section
Reducing the likelihood of C Section
ECV-except in labour, ut scar , abn, foetal
compromise, ROM, blding, med condn.
Support During Labour
IOL AT 41 weeks
Partogram
Consultant involvement
EFM and FBS
Caesarean Section
INCIDENCE: 1 IN 5!

Common Indications
PRIMARY SECTION

Failure to progress 25%
Presumed foetal compromise 28%
Breech 14%

Caesarean Section
REPEAT SECTIONS
Previous Section 44%
Maternal request 12%
Failure to progress 10%
Presumed foetal Compromise 9%
Breech 3%
Caesarean Section
Provision of Information
EVIDENCE BASED
Indication
What the procedure involves.
Associated risks and benefits
Implications for future pregnancy
and birth after CS.

Caesarean Section
CONSENT

Risks v/s Benefits
Right to Refuse
Record Indication in order of Influencing
Factor
Caesarean Section
EMERGENCY LSCSHOW URGENT
Immediate threat to life of mother/foetus.
Maternal/foetal compromise-not
immediately life threatening
No maternal/foetal compromise but needs
early delivery.
Delivery timed to suit woman and staff.
Caesarean Section
PLANNED CS
1. Breech- ECV Failed OR CI
2. Multiple pregnancy-1 AND 2 TW.
3. Preterm birth- Not routinely
4. Small for Gestational Age- Not routinely
5. Placenta praevia Gr 3,4.
6. Predicting CS for CPD in labour -NO
7. Mother to Child Transmission- HIV,HepB
Hep C, HSV
Caesarean Section
Maternal Request
NOT an indication on its own.
Discuss Risks v/s Benefits
Is she afraid of childbirth-counsel.
Clinician has a right to refuse.
Respect her decision and offer referral.
Caesarean Section
Factors which DONT affect CS Rates
Walking
Position during labour
Epidural
Food and drink
Water Birthing
Caesarean Section
TIMING OF CAESAREAN SECTION

39 WEEKS

30 MINUTES FROM DECISION-TO-
DELIVERY
Caesarean Section
NECESSARY

HB (blood loss >1 litre
occurs in 4-8%)
NOT NECESSARY

ADVANCE BB3
CROSSMATCH
CLOTTING PROFILE
USG FOR PLACENTA
Caesarean Section
Anaesthesia
Regional-safer even in placenta praevia.
Rapid Sequence Induction
Antacid, H2 receptor antag, PPI
Antiemetic
Table tilt
Caesarean Section
SURGICAL TECHNIQUES
Double Glove for HIV
Joel Cohen- LESSPAIN, BETTER COSMETIC.
FASTER, LESS FEBRILE MORB.
Blunt extension of uterine incision-LESS BLD
LOSS
Placenta CCT
Dont exteriorize IT ONLY PAINS
Dont close peritoneum.-QUICK, LESS
ANALGESIA


Caesarean section
Suture in 2 layers (Bujold 2002, 3%v/s
0.5% risk of rupture with single layer)
Subcutaneous stitch only if >2cm.
Effects of suture materials unclear.
Antibiotics,prophylactic
Thromboprophylaxis


Caesarean Section
Care of the Baby
Paediatrician
Temperature maintenance
Skin to skin contact
BF support
Caesarean Section
Care of the woman
Monitoring-Half hourly for 2 hrs, then hrly.
Opioids- pca, intrathecal,NSAIDS
Food and Drink
Bladder care
Opportunity to Discuss
Hospital Stay
Caesarean Section
RECOVERY
Pain Relief
Wound care- DRESSING,S/O INFECTION
UTI
SUI (4%)
UT Injury (1 in 1000)
Resume activities
Caesarean Section
VBAC
Maternal Preferences and Priorities
Risks and Benefits
Risk of Rupture
Risk of perinatal and maternal Mortality
and Morbidity.
Caesarean Section
Pregnancy and Childbirth following C S
Rupture
Planned CS 12 /10000
Planned VBAC 35 /10000
Induced-non PG 80/ 10000
Induced-PG 240/10000
Caesarean Section
Pregnancy and Childbirth following C S

Risk of Foetal Intrapartum Death
VBAC 10 /10000
ERCS -- 1/10000

Caesarean Section
VBAC

Continuous EFM
Immediate access to CS
Immediate access to blood transfusion.
Better success if prior vaginal delivery
reduced
CAESAREAN VAGINAL
Perineal pain 2% 5%
U Incontinence
At 3 months
4.5% 7.3%
Prolapse Overall----------- 5%
Increased
CAESAREAN VAGINAL
Abdominal pain 9% 5%
Bladder Injury 0.1% 0.003%
Ureteric Injury 0.03% 0.001%
Further surgery 0.5% 0.03%
Hysterectomy 0.8% 0.01%
ICU Care 0.9% 0.1%
Thrombo-e Overall 0.04 --- To 0.16%
Increased
CAESAREAN VAGINAL
Hospital Stay 3-4 days 1-2 days
Readmission 5.3% 2.2%
Maternal Death 82.3/million 16.9/million
No more childrn 42% 29%
Placenta previa 0.7% 0.5%
Future rupture 0.4% 0.01%
Future SB 0.4% 0.2%
Resp morbidity 3.5% 0.5%
Not DIFFERENT
CAESAREAN VAGINAL
Haemorrhage 0.5% 0.7%
Infection 6.4% 4.9%
Gen tr Injury 0.6% 0.8%
Faecal Incont 0.8% 1.5%
Back Pain 11.3% 12.2%
No Difference
CAESAREAN VAGINAL
PND 10.1% 10.8%
Dyspareunia 17% 18.7%
Neonatal MORT 0.1% 0.1%
ICH 0.04% 0.03%
Br Plexus Injury Overall----------- 0.05%
CPalsy Overall----------- 0.02%