Caesarean Section A caesarean section (AE cesarean section), or c-section, is a form of childbirth in which a surgical incision is made through

a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies. Types:

The classical caesarean section involves a midline longitudinal incision which allows a larger space to deliver the baby. However, it is rarely performed today as it is more prone to complications. The lower uterine segment section is the procedure most commonly used today; it involves a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair. An emergency caesarean section is a caesarean performed once labour has commenced. A crash caesarean section is a caesarean performed in an obstetrical emergency, where complications of pregnancy onset suddenly during the process of labor, and swift action is required to prevent the deaths of mother, child(ren) or both. A caesarean hysterectomy consists of a caesarean section followed by the removal of the uterus. This may be done in cases of intractable bleeding or when the placenta cannot be separated from the uterus. Traditionally other forms of CS have been used, such as extraperitoneal CS or Porro CS. a repeat caesarean section is done when a patient had a previous section. Typically it is performed through the old scar.

Indications: precious (High Risk) Fetus prolonged labour or a failure to progress (dystocia) apparent fetal distress apparent maternal distress complications (pre-eclampsia, active herpes) catastrophes such as cord prolapse or uterine rupture multiple births abnormal presentation (breech or transverse positions) failed induction of labour failed instrumental delivery (by forceps or ventouse. Sometimes a 'trial of forceps/ventouse' is tried out - This means a forceps/ventouse delivery is attempted, and if the forceps/ventouse delivery is unsuccessful, it will be switched to a caesarean section. This takes place in the operating theatre. the baby is too large (macrosomia) placental problems (placenta praevia, placental abruption or placenta accreta) umbilical cord abnormalities (vasa previa, multi-lobate including bi-lobate and succenturiate-lobed placentas, velamentous insertion) contracted pelvis Sexually transmitted infections such as genital herpes (which can be passed on to the baby if the baby is born vaginally, but can usually be treated in with medication and do not require a csection) previous caesarean section (though this is controversial see discussion below) prior problems with the healing of the perineum (from previous childbirth or Crohn's Disease)

Anaesthesia: The mother has the option of receiving regional anaesthesia (spinal or epidural) or general anaesthesia for caesarean section. Regional anaesthesia has the advantage of allowing her to remain awake for the delivery and avoids sedation of the newborn. Pain relief after the caesarean is also improved. General anaesthesia for caesarean section is becoming less common as scientific research has now clearly established the benefits of regional anaesthesia for both the mother and baby. General anaesthesia tends to be reserved for emergencies where the mother or baby's life is immediately threatened or other high-risk cases. The risks of general anaesthesia for mother and baby are still extremely small overall. Risks: Statistics from the 1990s suggest that less than one woman in 2,500 who has a caesarean section will die, compared to a rate of one in 10,000 for a vaginal delivery. A caesarean section is a major operation, with all that it entails, including the risk of post-operative adhesions. Pain at the incision can be intense, and full recovery of mobility can take several weeks or more. A prior caesarean section increases the risk of uterine rupture during subsequent labour. If a caesarean is performed under emergency situations, the risk of the surgery may be increased due to a number of factors. The patient's stomach may not be empty, increasing the anesthesia risk. Incidence: The World Health Organisation estimates the rate of caesarean sections at between 10% and 15% of all births in developed countries. In the public health network, the rate reaches 35%, while in private hospitals the rate approaches 80%. Studies have shown that continuity of care with a known carer may significantly decrease the rate of caesarean delivery[18] but that there is also research that appears to show that there is no significant difference in caesarean rates when comparing midwife continuity care to conventional fragmented care.

INTERVENTIONS AND PRACTICES CONSIDERED Making the Decision for Caesarean Section (CS) 1. 2. 3. Providing information on risks and benefits of CS to the pregnant woman in an accessible form Offering planned CS to women based on maternal and neonatal risk Reducing likelihood of CS by offering external cephalic version to women with uncomplicated singleton breech pregnancy, offering women continuous support during labour, offering induction of labour beyond 41 weeks, monitoring progress of labour, involving a consultant obstetrician in decision for CS, and using fetal blood sampling for suspected acidosis Requesting and obtaining consent for CS Timing of planned CS (after 39 weeks' gestation) Documenting urgency of CS Performing emergency CS as soon as possible

4. 5. 6. 7.

Procedural Aspects of CS

1.

Preoperative assessment Hemoglobin check Prescription of antibiotics Assessment of risk for thromboembolic disease Use of indwelling bladder catheter Note: Grouping and saving of serum, cross-matching of blood, clotting screen, and preoperative ultrasound to localize the placenta are not recommended for healthy women with an uncomplicated pregnancy.

2.

Anesthetic care Discussion of post-CS anesthesia Offering antacids and H2 receptor antagonists Offering antiemetics Offering regional anesthesia Reducing risk of hypotension by using Intravenous ephedrine or phenylephrine infusion Volume preloading with crystalloid or colloid Lateral lift of 15 degrees Preoxygenation and rapid sequence induction during general anesthesia for emergency CS Maternity unit drills for failed intubation Surgical techniques Use of double gloves in women who are human immunodeficiency virus (HIV) positive Use of transverse lower abdominal incision Use of blunt extension of the uterine incision Use of oxytocin Use of controlled cord traction for removal of the placenta Closure of incision with two suture layers Checking of umbilical artery pH Considering woman's preference for birth environment and facilitating skin-to-skin contact for mother and baby Note: The following interventions and procedures are not recommended: closure of the subcutaneous space (unless >2 cm fat); use of superficial wound drains; use of separate surgical knives for skin and deeper tissues; use of forceps routinely to deliver baby's head; suturing either the visceral or the parietal peritoneum; exteriorising the uterus; manual removal of the placenta

3.

4. 5. 6. 7. 8.

Postoperative monitoring, including monitoring of cardiorespiratory stability, degree of sedation, and pain control The resuscitation of the newborn at CS with a general anaesthetic or with presumed fetal compromise Care of women and baby after CS, including support for breastfeeding, supplemental analgesia, wound care, discharge options Monitoring of recovery following CS, including wound care and maintaining vigilance for complications Discussion of implications for future vaginal births