C-section

Question 1

What is a caesarean section?

Answer 1

• surgical operation to deliver the baby via an incision in the abdomen and uterus
• can be planned (elective caesarean) or an emergency

Question 2

WHat is an elective caesarean and when is it usually performed?

Answer 2

• planned date for a c-section usually performed under spinal anaesthetic
• usually planned after 39 weeks gestation

Question 3

What are indications for an elective caesarean?

Answer 3

• prev c section
• prev symptomatic perineal tear
• placenta praevia
• vasa praevia
• breech presentation
• multiple pregnancy
• uncontrolled HIV infection
• cervical cancer

Question 4

What are the four categories of an emergency c-section?

Answer 4

• cat 1: immediate threat to life of mother or baby -> done within 30 mins
• cat 2: compromise to mother or baby but not imminent threat to life -> done within 75 mins
• cat 3: c-section required but mother and baby stable
• cat 4: elective c section

Question 5

What is the most commonly used skin incision in c sections?

Answer 5

-transverse lower uterine segment incision with scalpel

Question 6

What are the possible tranverse incisions in c sections?

Answer 6

• pfannenstiel incision - curved and 2 fingers width above pubic symphysis
• joel-cohen incision - straight incision that is slighlty higher (recommended)

Question 7

When might a vertical incision be used?

Answer 7

• rarely used

- may be used in very premature deliveries and anterior placenta praevia

Question 8

What is used after the initial incision?

Answer 8

• blunt dissection is used after to separate the remaining layers of the abdominal wall and uterus
• involves using fingers, blunt instruments, and traction to tear the tissues apart, rarther than cut them with sharp tools like a scalpel
• this results in less bleeding and less risk of injury to baby

Question 9

What are the layers of the abdomen that are dissected in a c-section

Answer 9

• skin
• subcut tissue
• fasia/rectus sheath
• rectus abdominal muscles (seperated vertically)
• peritoneum
• vesicouterine peritoneum (and bladder separated from uterus with bladder flap)
• uterus
• amniotic sac

Question 10

How is the baby delivered after the cuts are made?

Answer 10

-delivered by hand with help from pressure on the fundus (forceps may be used if necessary)

Question 11

How is are the cuts then closed after delivery?

Answer 11

• uterus closed using two layers of sutures
• exteriorisation (removing uterus) is avoided if possible
• abdomen and skin are then sutured and closed

Question 12

What anesthetic is used during a c-section?

Answer 12

• spinal anesthetic such as lidocaine is most commoly used as it is safer and has a faster recovery then general
• though with spinal the patient remains awake and some pts might not tolerate this well and prefer to be asleep so general will be used
• spinal also takes longer to initiate then general

Question 13

What are the risks associated with anaesthetic use in c-section?

Answer 13

• 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)

Question 14

Why do emergency c-sections have higher risks for complications than electives?

Answer 14

-usually performed in less controlled settings and for more acute indications (fetal distress)

Question 15

What are the possible complications of c-sections?

Answer 15

• general surgical risks: bleeding,infection, pain, VTE
• postpartum complications: PPH, wound infection/dehiscence, endometritis
• damage to local structures; ureter, bladder, bowel, blood vessels
• ileus/adhesions/hernias

Question 16

How can c-sections affect risk on future pregnancies?

Answer 16

• increased risk of repeat caeserean
• increased risk of uterine rupture
• increased risk of placenta praevia
• increased risk of stillbirth

Question 17

How can c-sections affect risk on babies?

Answer 17

• risk of lacerations (2%)

- increase incidence of transient tachypnoea of the newborn

Question 18

Is it possible to have a vaginal birth after a caesarean?

Answer 18

• yes provided the cause of caeserean is unlikely to recur

- assesment of likelihood of success should be made in each case

Question 19

What is the success rate of VBAC?

Answer 19

• around 75%

- uterine rupture risk in VBAC is about 0.5%

Question 20

What contraindicates having a VBAC?

Answer 20

• prev uterine rupture
• classical caeserean scar (vertical incision)
• other usual contraindications to vaginal delivery such as placenta praevia