Caesarean section

Chapter 17 Caesarean section



David T Y. Liu, Mentor: Alexander Omu



CHAPTER CONTANTS


Indications for caesarean section 145

Preoperative care 146

Postoperative care 146

Types of incision 146
Abdominal incisions 146
Subumbilical midline incision 146

Transverse (Pfannenstiel’s) incision 147

Uterine incisions 147
Lower segment caesarean section 147

Classical caesarean section 147

Krönig–Gellhorn–Beck incision 147

Other situations 148

Operative steps for caesarean section 148

Caesarean section: specific issues 148
Communication 148

Vaginal birth after caesarean section 148

Signs of uterine scar rupture 149
Management for uterine rupture 150

Caesarean section after intrauterine fetal death 150

Difficulty with delivery of the fetal head 151

Caesarean hysterectomy 151

Classical caesarean section 152

Holding stitch 152

Bleeding lower segment uterine angles 152

Sterilisation 152

Caesarean section describes the surgical procedure for delivery of the fetus by incisions through the abdomen and uterus. The attendant risk of a surgical procedure must be considered. In the UK direct deaths following all caesarean sections is 82.3 per 1 000 000. For elective procedures this is 38.5 per 1 000 000. Death rate following vaginal delivery is 16.9 per 1 000 000 maternities (Department of Health (DoH) 2001). Pulmonary embolism, hypertension haemorrhage and sepsis continue to be salient causes of mortality. Inappropriate delegation, inadequate facilities and poor communication contribute to substandard care and necessitate improvement.


Sequelae of vaginal birth such as rectal and urinary incontinence, the question of choice, increased safety for caesarean section, more older women having babies and ready redress to litigation for complications with operative vaginal deliveries are factors leading to an increase in the rates of caesarean sections.



INDICATIONS FOR CAESAREAN SECTION


Caesarean sections can be subdivided into elective, scheduled or planned of varying emergency, unplanned emergency and peri-mortem and post-mortem categories to facilitate audit. Clearly complications and mortality attributed to the surgical procedure must be distinguished from contributions by obstetric complications and maternal medical problems.


Caesarean sections are performed to:


• overcome cephalo-pelvic disproportion and abnormal uterine activity

• expedite delivery for maternal or fetal reasons

• reduce fetal trauma (for example the small pre-term breech) and fetal infection (for example risk of transmitting herpetic infection or the human immunodeficiency virus (HIV))

• reduce maternal risk (for example certain cardiac disorders, intracranial lesions or cervical malignancy)

• allow women to exercise their informed choice.


PREOPERATIVE CARE



• Ensure reasons for surgery are valid. There should be input by senior colleagues and clear discussion with the woman and her partner. Document clearly for medicolegal reasons.

• Past obstetric and medical history must be reviewed. Check gestation (usually not before 39 weeks if elective surgery).

• Discuss mode of anaesthesia with the anaesthetist and the woman. Ideally, mode of anaesthesia or analgesia should be discussed in advance at a joint clinic with the anaesthetist. Regional anaesthesia is safer for the woman and the baby.

• Inform the paediatrician in good time.

• Check that cross-matched blood is available. Most labour wards now reserve 2 units of 0 Rhesus negative blood for emergencies. Cross-match 4 or more units if increased bleeding is likely, e.g. placenta praevia. Use cell saver for heavy loss or women refusing blood transfusion.

• Give an antacid (see Chapter 9).

• Obtain written consent. This includes discussion of need and procedure, risks, inadvertent damage to bladder and fetus.

• Introduce indwelling catheter.

• Administer prophylactic antibiotics. This is particularly relevant in emergency caesarean sections. Assess need for prophylaxis against thromboembolism following recommendations from the Royal College of Obstetricians and Gynaecologists’ Working Party Report (Department of Health 1995). Women with three or more moderate risk factors such as age more than 35, obesity of more than 80 kg, para 4, gross varicose veins, concurrent infection, pre-eclampsia, 4 days immobility prior to surgery, labour over 12 hours, major medical disease, extended pelvic surgery, personal or family history of venous thrombosis or pulmonary embolism (thrombophilia) and presence of antiphospholipid antibody will need heparin prophylaxis and leg stockings.


POSTOPERATIVE CARE


Presence of obstetric or medical complications mean some women will need close observation following caesarean section. The labour ward can serve as an area for recovery and care. Intensive or high dependency care facilities must be readily available in the same hospital. General care for all women includes:


• Assess vital signs at regular intervals (15 minutes). Make sure condition is stable.

• Watch fundal height, any bleeding from wound and amount of lochia. This is particularly important if the labour is prolonged, when the uterus has been distended by polyhydramnios or multiple pregnancies and where there is a threat of coagulation defects, for example, after antepartum haemorrhage and pre-eclamptic toxaemia. Infuse oxytocin for 4–6 hours.

• Maintain fluid balance.

• Ensure adequate analgesia. Continued use of epidural analgesia is particularly useful.

• Address specific requirements which prompt indication for caesarean section, e.g. medical conditions such as diabetes.

• Early physiotherapy and ambulation if there is no contraindication.

• Remember thrombo-prophylaxis. Early ambulation and attention to hydration suffice for low risk women with uncomplicated pregnancies and no risk factors. Avoid use of dextran 70. Subcutaneous heparin or mechanical methods are required where risk is considered moderate. Where risk of thromboembolism is high, heparin and leg stockings should be used for 5 days following surgery or until full mobilisation. For past histories of venous thromboembolism in pregnancy or the puerperium thrombo-prophylaxis should be continued for 6 weeks post partum.

• Before discharge an opportunity should be made available to examine events and address questions.

• Schedule an opportunity for postnatal review to ensure complete recovery, to discuss subsequent pregnancies and ensure follow-up care for medical conditions.


TYPES OF INCISION



Abdominal incisions


Essentially these are the subumbilical midline and transverse lower abdominal incisions (Figure 17.1).


image

Figure 17.1 Abdominal incisions: (a) subumbilical midline and (b) transverse ‘Pfannenstiel’s’.



Subumbilical midline incision


This incision is easy and quick. Access is good with minimal bleeding. It is useful when access to the lower segment is difficult, for example severe kyphoscoliosis or anterior lower segment fibroid. The scar however, is unsightly, there is more postoperative discomfort and dehiscence is more likely compared with transverse incisions.


Where extension upwards into the abdomen is likely a left or right paramedian incision can be performed.



Transverse (Pfannenstiel’s) incision


This is the current incision of choice. It is cosmetically pleasing, is less likely to dehisce and being less uncomfortable, allows better postoperative mobility. The incision can be technically more difficult especially in repeat surgery. It can be associated with greater blood loss and poorer access.


Variations include the Joel Cohen incision (placed higher up the abdomen) and Misgav Ladach (emphasises preservation of anatomical structures).



Uterine incisions


Entry into the uterus can be through a midline or a transverse lower segment incision (Figure 17.2).


image

Figure 17.2 Uterine incisions: (a) lower segment (b) classical and (c) Krönig–Gellhorn–Beck.



Lower segment caesarean section (Figure 17.2a)


This is the most common approach. The transverse incision is placed in the lower segment of the gravid uterus behind the uterovesicle peritoneum. Advantages include:


• The site is less vascular hence less blood loss.

• It contains spread of infection into abdominal cavity.

• It is in the less contractile part of the uterus hence scar rupture in subsequent pregnancies is less likely.

• Healing is better with fewer postoperative complications such as adhesions.

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  4. Assisted vaginal delivery and shoulder dystocia

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Mar 16, 2017 | Posted by in NURSING | Comments Off on Caesarean section

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