Chapter 10. Caesarean birth
Introduction
The caesarean section rate in the UK has almost doubled in recent years, from 12% in 1990 to 21% in 2000. Between 2005 and 2006, 23.5% of births were by caesarean section, and more than half of these were emergency caesareans (The Information Centre 2007). With more than one-fifth of babies being born in this way, midwives can play a key role in making the experience a positive one for women and their families. This chapter describes care around the time of the birth; postoperative and postnatal care following caesarean section is discussed in volume 4 in this series.
Find out how caesarean section rates in the UK compare with those in other countries.
Find out about the aims and outcomes of the National Sentinel Caesarean Section Audit Report (Thomas & Paranjothy 2001).
Terminology
An elective or planned caesarean is one that is performed during pregnancy, before the onset of labour. An emergency caesarean is one that is performed during labour. However, these definitions seem inadequate when one considers the many permutations that can occur.
For example, a woman may be admitted to the labour ward from antenatal clinic for caesarean section following ultrasonography that suggests the fetus has stopped growing and requires prompt delivery – technically an ‘elective’ procedure. Alternatively, a woman might be in labour but not progressing and a decision made that the only option is caesarean, although neither she nor the baby is showing signs of compromise. Her ‘emergency caesarean’ takes place 2 hours later.
In order to provide a more precise definition of caesarean birth, a group of anaesthetists practising in the UK (Lucas et al 2000), developed and evaluated a classification system based on the use of four grades (Table 10.1). This classification was used in the Sentinel Audit (Thomas & Paranjothy 2001:49) and The House of Commons Health Committee (2003) recommended its continued use.
| (Lucas et al 2000, p. 349) | |
| Grade | Definition |
|---|---|
| (1) Emergency | Immediate threat to life of woman or fetus |
| (2) Urgent | Maternal or fetal compromise which is not immediately life threatening |
| (3) Scheduled | Needing early delivery but no maternal or fetal compromise |
| (4) Elective | At a time to suit the woman and maternity team |
Risk factors and indications for caesarean birth
In response to concerns about the rising caesarean birth rate in the United Kingdom, the National Sentinel Caesarean Birth Audit was undertaken by the Royal College of Obstetricians and Gynaecologists (Thomas & Paranjothy 2001). In addition to the collection of clinical data, women and obstetricians were surveyed about their views of childbirth, including their priorities for maternity care. One of the aims of the audit was to explore the determinants of caesarean birth. It concluded that the main primary indications for caesarean as reported by clinicians were: presumed fetal compromise (22%), failure to progress in labour (20%) and previous caesarean (14%). The caesarean birth rate was 88% for breech presentations and 59% for twin pregnancies.
Age
The National Sentinel Caesarean Birth Audit (Thomas & Paranjothy 2001) also found that women were more likely to have a caesarean birth with advancing maternal age: only 7% of women under 20 years old had a caesarean compared with 17% of women who were over 35 years old. Weaver et al (2001) argue that the perception that older women are more likely to experience complications during labour could give rise to ‘an increased willingness’ (p. 284) of both women and obstetricians to proceed to a caesarean.
Ethnicity
It has been reported (Tuck et al 1983) that black women (African and Caribbean) have a higher incidence of emergency caesarean birth compared with white women. Findings from the National Sentinel Caesarean Birth Audit concluded that the proportion of caesarean births was higher for women who were black African (31%) or black Caribbean (24%) compared with white women (21%). The indications for caesarean birth in these women were explored and were seen to relate to a higher proportion of maternal medical disease and fetal distress.
Primigravidae
Parity is also a significant factor in the incidence of caesarean birth. The results of the National Sentinel Audit showed that the primary caesarean birth rate in England was 24% for primigravid women and 10% for multiparous women. Of the women who had a previous caesarean the repeat caesarean rate was 67%.
Socio-economic status
Social class is also a predictor of caesarean birth. Using the index of multiple deprivation 2000, Barley et al (2004) found that women living in the most deprived areas of England had significantly reduced odds (0.86) of having an elective caesarean birth when compared with more affluent women. There were no differences for emergency caesarean. In a prospective longitudinal study involving a cohort of 22948 women, Hall et al (1989) found that women in social class I–IIIa (measured by the husband’s occupation) were significantly more likely to have had a caesarean for the birth of their first baby than other women.
Maternal request
Maternal request has often been cited as a reason for the increase in the caesarean birth rate (Devendra & Arulkumaran 2003, Singer 2004, Singh et al 2004). According to the clinicians in the National Sentinel Caesarean Birth Audit, it accounted for 7% of caesarean births (Thomas & Paranjothy 2001:17). However, results from the maternal survey revealed that 5.3% of women would prefer a caesarean birth, and these comprised mainly women who had already had a baby by this method (op. cit. p. 95).
Thus, women rarely request, and obstetricians rarely agree to, caesarean for non-medical reasons (McCourt et al 2007). Of those that do, fear for their baby or themselves is an influential factor (Weaver et al 2007). A systematic review of caesarean for non-medical reasons (Lavender et al 2006) found no trials that could provide evidence regarding the risks and benefits of caesarean where there was no medical indication. The authors concluded that alternative research methods are used to explore the outcomes associated with different modes of birth. The decision to undertake surgical delivery should only follow full discussion of the risks and benefits for the individual woman.
Summary of indications for caesarean birth
Emergency caesarean section
Caesarean during labour may be indicated if labour is obstructed, does not progress, if there is evidence of fetal compromise, cord prolapse, antepartum haemorrhage or evidence of scar dehiscence. Where it is becoming likely that labour might end in surgery, the woman should be informed of the possibility that she might need to go to theatre. She can begin to prepare herself for this eventuality, thus preventing the ultimate decision coming as a total shock.
Elective caesarean section
Indications vary depending on individual circumstances, but include: breech presentation, previous caesarean, placenta praevia, multiple pregnancy (three or more), intrauterine growth restriction, symphysis pubis dysfunction and antepartum haemorrhage. Occasionally, it is considered necessary to undertake an elective caesarean if the woman has had a previous traumatic experience or when a vaginal birth would almost certainly lead to psychological sequelae. Maternal request is not an indication for elective caesarean (NICE 2004).
Midwifery care
Involvement
When the situation does not go according to plan, it becomes particularly important that the woman’s hopes and wishes for the birth are heeded. There may be no reason, for example, why she cannot have skin-to-skin contact with the baby after the birth or why the father should not be the one to tell her the sex of the baby. Even in the most rushed of situations, the woman can still be involved in decisions about her care. Although the situation may be out of her control, she should not be made to feel that she is having things done to her without her knowledge or consent.
Preparation for theatre
The woman will need to be informed exactly why surgery is considered the most appropriate means of birthing the baby safely (RCOG 2006). Her verbal consent should be sought through discussion before she is asked to sign a consent form. If the woman is healthy it is not necessary to routinely take blood for ‘group and save’ (NICE 2004). If, however, the woman is unwell, then blood would be taken for cross-match and urgent full blood count (FBC).
It is essential that the urinary bladder is empty prior to surgery to avoid the risk of it being damaged during surgery (NICE 2004). A urinary catheter needs to be inserted, with every effort made to maintain privacy and dignity. If a regional anaesthetic needs to be administered and there is sufficient time, catheterization can be delayed until the anaesthetic has taken effect. Pubic hair needs shaving off, but not between the legs. If the woman is having elective surgery, she can do this shave herself. A clean gown is required if time permits. Jewellery should be removed and either given back to the woman’s partner or taken for safe keeping as per hospital policy. Wedding rings can be taped so that they do not form a point of contact for diathermy equipment. An intravenous infusion (IVI) would be sited.
Many maternity units have implemented guidelines for thromboprophylaxis, following the recommendations of an RCOG working party (1995), and ask all women who are likely to be immobile for some time to wear anti-embolic stockings. Thrombosis and thromboembolism account for 31% of all direct maternal deaths and are the major cause of death (Lewis 2007). If time allows, these stockings can be fitted prior to surgery, following appropriate leg measurement.
The woman should continue to be informed, and permission sought, before anything is done to her. She should understand why procedures are undertaken, and be introduced to anyone who comes into the room. Her birth partner should also be involved in all explanations and preparations.
In theatre
Anaesthesia for birth
Positive perceptions of caesarean section are associated with regional anaesthesia (Fawcett et al 1992, Reichert et al 1993). In the period 2005–2006, only 5% of elective and fewer than 10% of emergency caesareans were performed under general anaesthetic (The Information Centre 2007). Spinal anaesthesia accounts for 67% of elective and over 30% of emergency surgery, with a small but rising trend in combined epidural and spinal techniques (The Information Centre 2007).
Surgical techniques: incision and closure
