Caesarean section (aka C-section, C/s) is where surgical incision(s) are made through a mother's abdomen (laparotomy) and uterus (hysterotomy), to deliver newborn(s).
Patient information
The C section. What is it? Is it a cross section ?
Not really. It's where we make a surgical cut into mom's tummy, and womb, to deliver bub.
Has the C section got anything to do with Julius Caesar?
Yes. It was often said that Julius Caesar was born by C section, but we're not sure about this, since his mother lived on, and back in the day, there was very high risk for mom with the C section.
Method
Preparation options include:
Emergency C section (aka Code 1 Caesar, crash caesar, ELSCS) is when it is not planned before labor begins. In emergencies, usually general anesthesia is used, but when time is available, it is preferable to use regional anesthesia. Code 1's are performed when the complications of pregnancy onset suddenly during the process of labor, and swift action is required to prevent the death of the mother and/or child
Elective C section (aka planned Caesar, scheduled Caesar) is when it is arranged of time, most commonly arranged for medical reasons, ideally as close to the due date as possible. This allows it to be performed at a time when hospital resources are optimal, such as at daytime. They can also be elected on a non-indicated maternal request, preferably 39 weeks gestation or later. Also, the woman should be provided with information on the risk of a planned C section if she insists on the procedure
Abx prophylaxis used before an incision. Incisions include:
Lower uterine segment C-section (LSCS), the most commonly used. It involves a TRANSVERSE cut just above the edge of the bladder, and results in less blood loss, and easier repair
Classical C-section, involving a midline LONGITUDINAL incision, allowing a large space to deliver the baby, but is rarely performed as it is more prone to complications
Uterus is incised, and the incision is extended w/ blunt pressure
Placenta is delivered
Placenta is then removed
Single layer uterine closure is used if the mother doesn't want a future pregnancy. A single suture preferred over a double layer sutured, because it reduces blood loss
Closure of the peritoneum, although there is debate whether this is required
If subcutaneous tissue is >2cm, surgical suture is used
The partner is often encouraged to attend the surgery and support the mother. The anesthetist will usually lower the drape teporarily as the child is delievered so the parents can see their newborn
Discouraged practices include:
Manual cervical dilation
Any subcutaneous drain
Supplemental oxygen therapy w/ intent to prevent infection
Indications
Performed when vaginal delivery would put the baby or mother's life or health at risk
Medical indications, generally requires use of discretion to decide if C section is necessary, and may require taking into account many factors
Complications of labor, and risks associated with vaginal delivery, include:
Abnormal presentation (breech or transverse positions)
Prolonged labor or failure to progress (dystocia)
Fetal distress
Cord prolapse
Uterine rupture or an elevated risk thereof
HTN (increased BP) in the mother or baby after amniotic rupture (waters breaking)
Tachycardia (incrased HR) in the mother or baby after amniotic rupture (waters breaking)
Failed instrumental delivery (by forceps or ventouse, which may be trialled, and if unsuccessful, is delivered by C section)
Macrosomia (large baby >4kg)
Umbilical cord abnormalities (vasa previa, multilobate including bilobate and succenturiate-lobed placentas, velamentous insertions)
Complications of pregnancy, pre-existing conditions and concomitant disease, including:
Pre-eclampsia
Previous high risk fetus
HIV infection of the mother, with a high viral load
STD, e.g. 1st outbreak of genital herpes very recently before the onset of labor, which can cause infection in the baby if the baby is born vaginally
Previous classical/longitudinal C section
Previous uterine urpture
Prior problems with healing of the perineum, from previous childbirth or Crohn's disease
Bicornuate uterus
Rare cases of posthumous birth after the death of the mother
Can be performed upon request (and is requested more frequently than necessary) and is a practice health authorities would like to reduce
It should NOT be performed before 39 weeks [as this is considered full term for child development] without medical indication to perform surgery
Patient information
When would you surgically deliver bub, rather than by normal vaginal birth?
When vaginal delivery would put mom or bub's life at risk. We can do it on request of mom, but we like to avoid this. We try to avoid C section before 39 weeks, which is considered full term, unless there is a medical indication.
When is surgical delivery medically indicated?
If there's a complication with the pregnancy, or with delivering bub. Or anything else that would put mom or bub's life at risk.
Tx
Recovery, depends on pain tolerance and inflammation. It is recommended to:
Abstain from strenuous work (e.g. lifting objects >4.5kg, running, walking up stairs, or athletics) for up to 16 weeks
Waiting ~18 months before attempting to conceive another child
Planning, of the next pregnancy, regarding whether delivery after previous C section will be:
VBAC (vaginal birth after C section) → although beware that emergency C section may result
What happens post-C section?
Remember it's major surgery. And there's a big cut across the tummy. So avoid strenuous work. And wait for around 1.5 years before attempting to have another baby. And when you do decide to have a baby, you'll have to decide whether you want ot try to deliver vaginally, or repeat the C section.
Complications
Risks to the mother:
Psychological, including postnatal depression, birth-related PTSD
Less likely to become pregnant or give birth again (compared with women who've only had vaginal delivery)
Both a VBAC (vaginal birth after C section) andERCS (elective repeat C section) will be more likely to be complicated
Placenta accreta (i.e. all/part of the placenta attaches abnormally to the myometrium muscular layer of the uterine wall), in a subsequent pregnancy
Hysterectomy
Abdominal surgery risks, including:
Postoperative adhesions
Incisional hernias (which may require surigcal correction)
Wound infections
Wound hematoma
General surgical risks, including:
Cardiac arrest
Severe blood loss → may require blood transfusion
Postdural-puncture spinal headaches
Emergency Caesar risks, including:
Increased anesthesia risk, as the Pt's stomach may not be empty
Risks to the baby:
Elective childbirth before full term is associated with:
Higher infant mortality
Developmental problems
Wet lung
Patient information
What bad things can happen, as a result of surgially delivering bub?
There are general surgery risks, like sudden heart failure, severe blood loss, anesthetic risk. There are abdominal surgery risks, like adhesions, hernias, infection. Also, if you do the surgery without planning, what we call Emergency C section, there is increased anesthetic risk.
OK, those things are pretty general. Anything specific to surgically delivering bub?
It increases risk of psychological problems. You're less like to give birth again. Later vaginal or C section birth, is more likely to be complicated. The placenta can abnormally attach in a subsequent pregnancy. And you might need to take everything out, called a hysterectomy.
Any risks to bub?
Only if you deliver them before term, and it's the usual risks of preterm birth.
Prognosis
Increases bad outcomes in low risk pregnancies
The poor outcomes that occur with C sections are different from those that occur with vaginal delivery
The risk of death is 13 per 100k, as supposed to 3.5 per 100k for vaginal birth, in the developed world, and amongst those at low risk; or more than 3 times the risk
More likely to have problems wiht later pregnancies, so women who want large families should not seek an elective Caesar
Epidemiology
23m C sections are done globaly each year
In some countries, C section procedures are used more frequently than is necessary, and consequently governments and health organizations promote programs to reduce the use of C section in favor of vaginal delivery
The ideal for C section rate is 10-155. Some evidence supports a higher rate of 19% for better outcomes
60% of C sections are planned
More emergency Caesars (66%) are performed during the day rather than during the night
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