OPERATIVE DELIVERY

Dr Jacqueline WoodmanConsultant Obstetrician & Gynaecologist

Caesarean Section

• A Caesarean section is a surgical procedure in which an incisions is made in the uterus to deliver one or more babies

• The first modern Caesarean section was performed by German gynaecologist Ferdinand Adolf Kehrer in 1881.

Indications for Caesarean Section

1. Placenta praevia2. Transverse lie3. Previous classical Caesarean section4. Obstructed labour

e.g. cephalo-pelvic disproportion, failure to progress

5. Breech presentation6. Abruptio placenta7. Previous repeated Caesarean section8. Fetal indications:

Congenital abnormality e.g. severe hydrocehalus Multiple pregnancy e.g. first twin breech, triplets Cord prolapse Severe preterm IUGR

9. Maternal request e.g. tokophobia

Planned Caesarean section will increase the following risks:

• Maternal: – Longer hospital stay– Bleeding that requires a hysterectomy– Heart attack

• Neonatal:– ICU admission

http://www.nice.org.uk/nicemedia/live/13620/57166/57166.pdf

Risks of Caesarean section

• Maternal: – Haemorrhage: 5 per 1000

• Hysterectomy: 8 per 1000– Infection: 6 per 100– Thrombosis: 4-16 per 10 000– Visceral and / or vascular injury

• Bladder injury: 1 per 1000– Anaesthetic risks– Death: 1 per 12 000– Future pregnancy:

• antepartum stillbirth: 1-4 per 1 000• Uterine rupture: 2-7 per 1000• Placenta accreta: 4-8 per 1000

• Neonatal:– Tansient tachypnoea of the newborn (TTN)– Injury to baby: 1-2 per 100

http://www.rcog.org.uk/guidelines

Caesarean section: the procedure

• Skin incision and entry?– Joel Cohen vs Phannelstiel: a 65% reduction in reported

postoperative morbidity with the Joel-Cohen incision.• Incision of uterus:

– transverse lower segment vs Classical• Closure of the uterus:

– 1 vs 2 layer• Closure of the abdomen:

– peritoneum, sheath, subcutaneous, skin

http://apps.who.int/rhl/reviews/CD004453.pdf

Classification of urgency of Caesarean section

Maternal or fetal compromise:1. Immediate threat to life2. No immediate threat to moterh or baby 3. Requires early delivery

No maternal or fetal compromise4. At a time convenient to all

Operative Vaginal Delivery

• Ventouse• Forceps

Indications for ventouse / forceps

• Failure to progress in second stage• Fetal distress in second stage• Maternal exhaustion• Maternal conditions e.g. Heart conditions

Conditions for a ventouse / forceps

• Fully dilated• Maternal consent• Station and position of fetal head known• Bladder empty• Lithotomy• Analgesia

Thank you

References

• NICE• CEMACH• RCOG