Caesarean Delivery

Definition | Indications | Types of Caesarean Delivery | Risk Factors | Complications | Management | References

Definition

Caesarean Delivery (also known as C-section) is a surgical procedure in which a baby is delivered through an incision made in the mother's abdomen and uterus. It is performed when vaginal delivery would put the mother or baby at risk.

Indications

Caesarean delivery may be planned (elective) or performed in an emergency, depending on maternal or fetal indications. Common indications include:

• Fetal Distress: Non-reassuring fetal heart rate patterns indicating potential fetal compromise.
• Placenta Previa: When the placenta covers the cervix, making vaginal delivery unsafe.
• Breech Presentation: Particularly if external cephalic version (ECV) is unsuccessful or contraindicated.
• Multiple Pregnancies: Especially in cases where the first twin is not in a cephalic presentation.
• Maternal Health Conditions: Such as preeclampsia, active genital herpes infection, or previous uterine surgery (e.g., myomectomy or previous caesarean section).
• Failure to Progress: Labour that does not progress despite adequate contractions, often due to cephalopelvic disproportion.

Types of Caesarean Delivery

Caesarean deliveries are classified based on timing and urgency:

• Elective Caesarean Section: Planned and scheduled caesarean delivery performed before the onset of labour, usually for specific indications.
• Emergency Caesarean Section: Performed when urgent delivery is needed to address maternal or fetal distress, often after labour has begun.
• Crash Caesarean Section: The most urgent form of emergency caesarean, performed when immediate delivery is required, typically within minutes, due to severe maternal or fetal compromise.

Risk Factors

• Previous caesarean delivery.
• Multiple pregnancies.
• Maternal obesity.
• Maternal age (especially over 35 years).
• Fetal macrosomia (large baby).
• Prolonged labour or labour dystocia.

Complications

While caesarean delivery is generally safe, it carries risks for both the mother and baby. Potential complications include:

• Maternal Complications:
  • Infection: Postoperative infections such as endometritis, wound infection, or urinary tract infection.
  • Haemorrhage: Increased risk of significant blood loss requiring transfusion.
  • Venous Thromboembolism: Increased risk of deep vein thrombosis (DVT) or pulmonary embolism (PE).
  • Adhesions: Scar tissue formation, which can lead to complications in future pregnancies or surgeries.
  • Uterine Rupture: In subsequent pregnancies, especially after multiple caesarean sections.
• Fetal Complications:
  • Respiratory Distress: Particularly in babies delivered before 39 weeks gestation, due to the absence of labour which helps to clear the lungs.
  • Injury: Rarely, the baby may be injured during the surgery, such as a skin cut from the surgical instrument.

Management

• Preoperative Management:
  • Patient Education: Discuss the indications, procedure, risks, and benefits of caesarean delivery with the woman and her family.
  • Consent: Obtain informed consent after discussing the risks, benefits, and alternatives to the procedure.
  • Preoperative Assessment: Includes blood tests (e.g., FBC, blood group and antibody screen), and assessment of the woman's medical history and any previous surgical history.
  • Antibiotic Prophylaxis: Administer antibiotics before the incision to reduce the risk of postoperative infection.
  • Venous Thromboembolism Prophylaxis: Consider the use of compression stockings and/or low molecular weight heparin (LMWH) to prevent DVT or PE.
• Intraoperative Management:
  • Anaesthesia: Most caesarean sections are performed under regional anaesthesia (spinal or epidural), allowing the mother to be awake and involved in the birth. General anaesthesia may be used in emergencies or if regional anaesthesia is contraindicated.
  • Surgical Technique: The procedure typically involves a lower segment transverse (bikini line) incision, which is associated with fewer complications and better healing compared to a vertical incision.
  • Fetal Delivery: Once the uterus is opened, the baby is delivered, the umbilical cord is clamped and cut, and the placenta is delivered.
  • Closure: The uterus, abdominal wall, and skin are closed in layers, with careful attention to haemostasis to prevent bleeding.
• Postoperative Management:
  • Monitoring: Monitor the mother's vital signs, pain level, and uterine tone closely in the immediate postoperative period.
  • Pain Management: Provide adequate analgesia, often including a combination of opioids and non-steroidal anti-inflammatory drugs (NSAIDs).
  • Early Mobilisation: Encourage early mobilisation to reduce the risk of venous thromboembolism and promote recovery.
  • Breastfeeding Support: Assist with initiating breastfeeding as soon as possible after delivery.
  • Wound Care: Educate the woman on how to care for her surgical wound and recognise signs of infection or complications.
  • Follow-Up: Arrange for a follow-up appointment to monitor recovery and address any concerns or complications.

References

1. NHS (2024) Caesarean Section. Available at: https://www.nhs.uk/conditions/caesarean-section/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Caesarean Birth. Available at: https://www.nice.org.uk/guidance/ng192 (Accessed: 24 June 2024).
3. Royal College of Obstetricians and Gynaecologists (2024) Green-top Guideline No. 45: Birth After Previous Caesarean Birth. Available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg45/ (Accessed: 24 June 2024).
4. Royal College of Obstetricians and Gynaecologists (2024) Green-top Guideline No. 45: Birth After Previous Caesarean Birth. Available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg45/ (Accessed: 24 June 2024).
5. World Health Organization (2024) WHO Recommendations on Non-Clinical Interventions to Reduce Unnecessary Caesarean Sections. Available at: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/caesarean-section-guideline/en/ (Accessed: 24 June 2024).
6. British Medical Journal (2024) The Risks and Benefits of Caesarean Delivery: A Global Perspective. Available at: https://www.bmj.com/content/367/bmj.l4372 (Accessed: 24 June 2024).

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