Maternal or fetal compromise, not immediately life threatening (e.g. pre-eclampsia, severe fetal growth restriction)
Timed delivery (e.g. previous CS with fibroids; breech presentation at term)
Elective (e.g. maternal request)
Sub-acute (e.g. failure to progress)
1. Immediate threat to the life of the woman or fetus (immediate)
2. Maternal or fetal compromise which is not immediately life threatening (urgent)
3. No maternal or fetal compromise but needs early delivery (scheduled)
4. Delivery to suit the woman or staff (elective)
For quality assessment and (inter)national comparison, one may also use the so-called ten-group classification (Table 10.2) [3]. In a comparison between nine institutional cohorts it was found that overall CS rates correlate strongly with CS rates in singleton cephalic nullipara (r = 0.99). So, if you consider your CS rate too high, then review the indications in this subgroup. CS rates in induced labour were found to be similar to spontaneous labours and greatest institutional variation was found in spontaneously labouring multipara (6.7-fold difference) and nulliparas (3.7-fold difference). The World Health Organization (WHO) proposes this classification system as a global standard for assessing, monitoring and comparing CS rates within healthcare facilities over time, and between facilities [4].
| Group | Classification |
|---|---|
| 1 | Nulliparous, single cephalic, ≥37 weeks, in spontaneous labour |
| 2 | Nulliparous, single cephalic, ≥37 weeks induced (including prelabour CS) |
| 3 | Multiparous (excluding previous CS), single cephalic, ≥37 weeks, in spontaneous labour |
| 4 | Multiparous (excluding previous CS), single cephalic, ≥37 weeks, induced (including prelabour CS) |
| 5 | Previous CS, single cephalic, ≥37 weeks |
| 6 | All nulliparous breeches |
| 7 | All multiparous breeches (including previous CS) |
| 8 | All multiple pregnancies (including previous CS) |
| 9 | All transverse/oblique lies (including previous CS) |
| 10 | All preterm single cephalic, <37 weeks, including previous CS |
Indications for CS
A CS is performed when it is perceived to be a safer method of delivery for the mother and/or baby than delivery by the vaginal route. However, when considering a CS the future reproductive career of the woman should also be taken into account. For instance, a CS in case of breech presentation is likely to reduce perinatal mortality [5,6], but the risk of uterine rupture and/or placenta accreta/increta in a subsequent pregnancy may hamper some of this advantage. This is illustrated by case reports of maternal death due to and following a pregnancy ending in a CS because of breech presentation [7]. Caesarean section for twins has become standard in many countries, but in a recent large randomized controlled trial no improved outcome was found in women randomized to CS [8].
There are numerous indications for CS. A not-exhaustive list is shown in Box 10.1.
1. Prelabour – maternal
Surgical Scarred uterus following previous myomectomy. Previous classical CS, more than two previous lower segment CSs. In case of one previous lower segment incision there is an estimated 0.5% risk of scar rupture and maternal preference should influence the mode of delivery. Previous anal sphincter damage with symptoms, or abnormal endoanal ultrasound or manometry may worsen during a subsequent vaginal delivery and these women should be given the option of an elective CS.
Ovarian cyst/myoma Allows surgical removal of the cyst, and in cases in which they obstruct the pelvis.
Medical Certain maternal diseases may necessitate a CS, such as Marfan syndrome with a dilated aortic root.
Psychological The reasons why a woman wishes to have a CS ‘on maternal request’ should be explored. Counselling, starting preferably early in pregnancy, might be indicated should they describe fear of childbirth. The risks and benefits of the procedure should be explained in order to ensure the woman has made a fully informed decision. A clinician has the right to refuse to perform a CS on the grounds of maternal request alone [8] but all efforts should be directed towards a consensus between patient and doctor.
2. Prelabour – fetal
Mechanical Transverse lie, certain congenital malformations, breech presentation. In case of breech presentation, external cephalic version should be offered. The benefits of a CS for the current pregnancy outcome should be discussed in relation to future reproductive wishes and associated complications (placenta accreta, uterine rupture, etc.).
Fetal compromise/severe IUGR In case of antenatal fetal heart rate (FHR) abnormalities indicative of hypoxaemia or anaemia, a CS should be performed. The same holds for early IUGR with severe fetal Doppler abnormalities. At present there are no data to suggest that a term small-for-gestational-age fetus is better off by being delivered by CS.
Vasa praevia This may be detected antenatally by ultrasound and Doppler. Elective CS is indicated to avoid rapid exsanguination that is associated with tearing of the fetal vessels.
3. Prelabour–feto-maternal
Placental abruption, placenta praevia and eclampsia may be put in this category. In case of maternal eclampsia, (blood pressure) stabilization is indicated before CS.
4. Intrapartum fetal distress
Emergency CS is indicated in acute causes of fetal distress, like cord prolapse, uterine rupture, abruptio placentae or ruptured vasa praevia. In other cases of abnormal CTG patterns adjunct technologies like fetal scalp blood sampling or scalp stimulation may prevent unnecessary CSs and the same holds for therapeutic measures such as amnioinfusion and reduction of excessive (induced) contractions. Acute tocolysis with either beta-mimetic drugs or oxytocin receptor blockers may also improve the fetal condition while awaiting a CS [9,10].
5. Intrapartum feto-maternal
Failure to progress and cephalo-pelvic disproportion/malpresentation are the most frequent reasons for intrapartum CS. In case of failure to progress in the absence of obvious disproportion or malpresentation, rupture of the membranes and oxytocin administration should be considered.
The Incidence of CS
CS rates have dramatically increased during the last few decades, without evidence of substantial improvements in outcome [11]. Factors related to this increase are summarized in Figure 10.1, starting with electronic fetal monitoring introduced in the early 1970s, to medico-legal issues, financial incentives to attending physicians and traffic jams preventing the doctor arriving in time from a private office to the hospital (see [11]).
Schematic representation of factors that (may) have contributed to an increase in CS rate with time.
Nowadays, CS rates vary considerably, from less than 20% in the north of Europe to 50% in the south of Europe and China and to even higher rates in South America [11]. This large range indicates that CS rates have nothing to do with evidence-based medicine. It is more likely due to a loss of practical skills, erroneous interpretation of fetal electronic monitoring tracings, an increase in inductions of labour (without giving it a proper try), the loss of care during labour, financial incentives, outpatient clinics far away from the birthing centre and – last but not least – medico-legal issues. In 2015, the WHO issued a revised statement on CS rates [3]. They conducted two studies: a systematic review of available studies that had sought to find the ideal CS rate within a given country or population, and a worldwide country-level analysis using the latest available data. Based on these available data, and using internationally accepted methods to assess the evidence with the most appropriate analytical techniques, the WHO concluded: ‘1) That CSs are effective in saving maternal and infant lives, but only when they are required for medically indicated reasons, and 2) That at population level, CS rates higher than 10% are not associated with reductions in maternal and newborn mortality rates’ [4].
Attempts to reduce CS rates have not been effective thus far, maybe with the exception of the north of Portugal. In 2011 a project started that included: (a) a uniform classification of CS; (b) dissemination of knowledge; (c) publication of CS rates per hospital; (d) equal doctor’s fee for CS and vaginal delivery; (e) financing of hospitals based on CS rate (a lower amount in cases of high rates); and (f) implementation of STAN technology for fetal surveillance. Since then the CS rate not only was reduced in the north of Portugal, but in the whole country, from about 36% to 33% [12].
Techniques
Discussions concerning the technique of CS mostly concentrate on the more classical approach, cutting all layers, as compared to a more digital approach, the so-called Joel-Cohen method, and to the closure of the uterus in one or two layers.
The modified Joel-Cohen method is associated with a lower duration of the operation, less blood loss, lower rate of need for postoperative analgesia and lower febrile morbidity as compared to the Pfannenstiel method [13,14,15] and is, therefore, the current method of first choice, despite the fact it initially looks a more barbaric method used by doctors who do not seem to know the correct surgical procedures. The procedure is summarized – and recommended and referenced – in the latest NICE guidelines [2], and is shown in Box 10.2.
Abdominal wall incision CS should be performed using a transverse abdominal incision because this is associated with less postoperative pain and an improved cosmetic effect compared with a midline incision. The transverse incision of choice should be the Joel-Cohen incision (a straight skin incision, 3 cm above the symphysis pubis; subsequent tissue layers are opened bluntly and, if necessary, extended with scissors and not a knife), because it is associated with shorter operating times and reduced postoperative febrile morbidity.
Instruments for skin incision The use of separate surgical knives to incise the skin and the deeper tissues at CS is not recommended because it does not decrease wound infection.
Extension of the uterine incision When there is a well-formed lower uterine segment, blunt rather than sharp extension of the uterine incision should be used because it reduces blood loss, incidence of postpartum haemorrhage and the need for transfusion at CS.
Fetal laceration Women who are having a CS should be informed that the risk of fetal laceration is about 2%.
Use of forceps Forceps should only be used at CS if there is difficulty delivering the baby’s head. The effect on neonatal morbidity of the routine use of forceps at CS remains uncertain.
Use of uterotonics Oxytocin 5 IU by slow intravenous injection should be used at CS to encourage contraction of the uterus and to decrease blood loss.
Method of placental removal At CS, the placenta should be removed using controlled cord traction and not manual removal as this reduces the risk of endometritis.
Exteriorization of the uterus Intraperitoneal repair of the uterus at CS should be undertaken. Exteriorization of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes such as haemorrhage and infection.
Closure of the uterus The effectiveness and safety of single-layer closure of the uterine incision is uncertain. Except within a research context, the uterine incision should be sutured with two layers.
Closure of the peritoneum Neither the visceral nor the parietal peritoneum should be sutured at CS because this reduces operating time and the need for postoperative analgesia, and improves maternal satisfaction.
Closure of the abdominal wall In the rare circumstances that a midline abdominal incision is used at CS, mass closure with slowly absorbable continuous sutures should be used because this results in fewer incisional hernias and less dehiscence than layered closure.
Closure of subcutaneous tissue Routine closure of the subcutaneous tissue space should not be used, unless the woman has more than 2 cm subcutaneous fat, because it does not reduce the incidence of wound infection.
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