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31. Caesarean Delivery
31.1 Introduction
Caesarean section is delivery of the baby through the abdominal route by making an incision on the uterine wall. Many papers have been published stating that the ideal caesarean rate should be between 10% and 15%. Despite this, both developing and developed countries are witnessing a tremendous increase in caesarean rate. The increase in caesarean rate can be attributed to the reluctance of obstetricians towards VBAC and giving operative vaginal delivery a try. However, there is no denying that caesarean sections when indicated significantly reduce maternal and foetal morbidity and mortality. Caesarean section does expose a woman to additional surgical and anaesthesia risks as compared to the physiological normal delivery. So, every caesarean section should be indicated, and the risks and benefits should be carefully evaluated.
31.2 History
The extraction of Asclepius from the abdomen of his mother
31.3 Types of Caesarean Section
Traditional caesarean section: Midline vertical incision is taken over the abdomen. Once the skin is incised, the uterus is also incised vertically, and the baby is delivered.
Types of caesarean section
31.4 Preoperative Considerations
Consent: Obtaining informed consent is a process and not merely a medical record document. Indication, procedure and its complications and effect of caesarean delivery on future pregnancies must be discussed with the patient.
Nil by mouth for at least 8 h before the planned procedure.
Investigations: Complete blood count, blood grouping and crossmatching and antibody screening [1].
Preoperative shaving of the incision site is not required. If the pubic hair over the proposed incision site is thick, it can be clipped short, rather than shaved.
Antacid prophylaxis.
Antibiotic prophylaxis: Single dose of a first-generation cephalosporin or ampicillin is given for both elective and emergency caesarean sections intravenously. ACOG states that prophylaxis has to be administered within 60 min prior to the start of planned caesarean delivery or after baby is delivered and the cord is clamped [2].
The woman should be placed in a 15° left lateral tilt to avoid aorto-caval compression.
American College of Obstetricians and Gynecologists (2010) do not recommend continuous foetal heart monitoring before a scheduled caesarean section. That said, foetal heart sounds should be documented in the operating room prior to surgery.
31.5 Planned Caesarean Section
31.5.1 Planned Vaginal Delivery vs. Planned Caesarean Section
If we compare a planned caesarean section with a vaginal delivery in a woman with uncomplicated pregnancy, it can be stated that:
Perineal injury
Injury to the vagina
Early postpartum haemorrhage
Obstetric shock
Neonatal intensive care unit admission
Longer hospital stays
Risk of anaesthesia
Postoperative pain
31.5.2 Planning of Delivery
Risk and benefits should be discussed with the patient.
Informed consent should be taken after taking into consideration the clinical diagnosis, personal preferences and ethical issues.
Refusal is patient’s right and should be respected even when CS is clinically indicated.
Record of all the clinical factors and patient counselling should be properly taken.
31.5.3 Indications of Planned Caesarean Section [3]
- 1.
Breech presentation and transverse lie (Fig. 31.3)
- (a)
Singleton breech or transverse lie of more than 38 weeks
- (b)
Singleton breech or transverse lie with failed external cephalic version
- (c)
Term breech presentation or transverse lie for whom external cephalic version is contraindicated
- (a)
- 2.
Multiple pregnancy [4]
- (a)
If the first baby of the twin or triplet pregnancy is not cephalic, it is advisable to take for caesarean section
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- (a)
