6.4 Caesarean section

Performing a caesarean section requires technical expertise and good obstetric knowledge for determining appropriate indications. There can be difficulties (haemorrhage, difficulty extracting the foetus, etc.) and complications (bladder injury, uterine tear, foetal trauma, etc.). Compared to vaginal delivery, caesarean section is associated with higher maternal mortality and an increased risk of complications for future pregnancies, regardless of the setting in which it is performed.

6.4.1 Indications

Absolute

These situations threaten directly the life of the mother (1 to 2% of all deliveries) [1] Citation 1. UON Network. Tackling Unmet Need for Major Obstetric Interventions. Concepts, General Principles and International Network, 2018.
http://www.uonn.org/wp-content/uploads/2018/09/guide1.pdf :

• Severe, uncontrolled ante-partum bleeding (tachycardia and hypotension).
• Malpresentation that cannot be turned (shoulder, brow or chin-posterior face).
• Absolute foeto-pelvic disproportion (partograph showing a failure to progress in the active phase of labour despite good uterine dynamics) and no possibility of instrumental extraction.
• Uterine rupture.
• History of 3 or more caesarean sections.

Relative

The decision to perform caesarean section should consider the risk/benefit for the mother and the infant in the given context: access to services and the availability and level of neonatal care.
The risks to the mother should be evaluated in the short term (death, infection, thrombo-embolism, etc.) and the medium/long term (future uterine rupture, placenta praevia or accreta during another pregnancy, etc.). In contexts with difficult access to services and a high fertility rate, the risks to the mother often outweigh the potential benefits to the infant. In any case, information about alternatives to caesarean section with corresponding risks and benefits should be shared with the woman, enabling her to make a choice.

Note: when a caesarean is planned, it should be done at 39 weeks LMP or later. Before 39 weeks LMP, caesarean births without labour – even when not premature (37-38 weeks LMP) – are associated with a high risk of neonatal respiratory distress. That risk exists regardless of the estimated foetal weight. If the due date is uncertain and there is a very high risk of uterine rupture (e.g., history of severe uterine rupture or more than 3 prior caesarean sections), consider caesarean section prior to onset of labour, during the ninth month, with preparation for managing neonatal respiratory distress. In other indications, it is better to wait until the woman goes into labour to do the caesarean section. Under those circumstances, if the patient lives far away, suggest that she move near the facility where she will deliver during her ninth month, either with family or at a residential facility (maternity waiting home).

6.4.2 Prerequisites for performing a caesarean section

• Skilled human resources for determining whether surgery is indicated, administering the anaesthesia and performing the surgery.
• Appropriate facilities (operating room, sterilisation, post-operative recovery room and blood transfusion).
• Appropriate equipment.
• Appropriate care and monitoring.

6.4.3 Pre-operative care

• Patient’s consent.
• Anaesthesia evaluation.
• Routine prophylaxis of gastric acid aspiration:

cimetidine PO (effervescent tablet): 200 mg in 30 ml of water, 20 minutes prior to surgery

6.4.4 Peri-operative care

• Standard surgical skin preparation.
• Foley catheter insertion.
• Routine antibiotic prophylaxis: cefazolin slow IV a Citation a. In patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory problems or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose. : 2 g single dose (to be preferably administered 60 minutes prior to incision) [2] Citation 2. Sullivan SA, Smith T, Chang E, et al. Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized, controlled trial. Am J Obstet Gynecol 2007; 196; 455.e1-455.e5. .
• Administer the appropriate antibiotherapy in case of b Citation b. Intrauterine foetal death, tinged or meconium-stained amniotic fluid and an initial attempt to extract vaginally are not indications for antibiotherapy. :
  • prolonged rupture of membranes or intra-uterine infection (Chapter 4, Section 4.9); 
  • peritonitis, infected or prolonged uterine rupture, septic shock.
• Administration of oxytocin:
  • 10 IU by slow IV injection routinely after clamping the cord, then,
  • 20 IU in 1 litre of Ringer lactate administered over 2 hours at a rate of 160 drops per minute (in the event of persistent haemorrhage, up to 60 IU max.).

6.4.5 Post-operative care

• Close initial monitoring:
  • Vital signs, bleeding, analgesia, etc. in the recovery room.
  • Transfer to inpatient unit after consulting anaesthetist.

• Analgesics (by oral route whenever possible):
  • Routine analgesics on a fixed schedule:
    • D0 to D1, tramadol: 50 mg every 8 hours
    • D0 to D3, ibuprofen: 400 mg every 8 hours
    • D0 to D5, paracetamol: 1 g every 6 hours
• Adjust according to the pain self-assessment. If necessary, add morphine: 10 mg every 4 hours.
  • Routine, regular pain self-assessment (self-assessment scale): see Clinical guidelines, MSF.
  • Respect the contra-indications; avoid non-steroidal anti-inflammatory drugs in situations where clotting and renal function may be compromised (sepsis, pre-eclampsia).

The surgeon may infiltrate the wound at the end of the procedure with levobupivacaine 0.5% (150 mg or 2 mg/kg, max. 30 ml); this provides increased pain relief in the first 4 to 8 hours after surgery.

• Thromboprophylaxis (low molecular-weight heparin):
  • Not done routinely for uncomplicated caesarean sections.
  • Desirable in the event of:
    • Caesarean section with hysterectomy.
    • History of deep vein thrombosis.
    • Two risk factors for thromboembolism (infection, prolonged labour, pre-eclampsia, severe bleeding or sickle cell disease).

• Infusion and IV catheter:

If uncomplicated caesarean section:

• D0: one litre of 5% glucose and one litre of Ringer lactate over 24 hours.
• D1: remove the IV catheter.

• Feeding:
  • Spinal anaesthesia: fluids may be resumed 2 hours post-operatively.
  • General anaesthesia: fluids may be resumed 4 hours post-operatively.
  • Uncomplicated caesarean section (no hysterectomy or pelvic peritonitis): light meal may be given 6 hours post-operatively. It is not necessary to wait until the patient passes gas.

• Urinary catheter:

Routine removal on D1, unless:

• Blood-stained urine when catheter is removed.
• Urine output < 500 ml per 24 hours.
• Peri/post-operative complication (wait to consult the surgeon and/or anaesthetist).

• Early mobilisation:
  • D0: mobilisation at the edge of the bed beginning 6 hours post-operatively.
  • D1: patient out of bed for the first time.

• Dressing and suture removal:
  • If hygiene conditions are good: uncover wound on D1.
  • Otherwise, remove dressing on D5 (or at discharge if stay less than 5 days). There is no need to change the dressing every day.
  • Remove skin sutures (if not absorbable) on D7.

• Cleaning:

Simple shower; no intravaginal cleansing.

• Breastfeeding:
  • Begin breastfeeding as soon as possible.
  • Monitor the neonate (risk of drowsiness if the mother receives tramadol or morphine).

• Documentation:
  • Operative report.
  • On discharge: give patient a document specifying the reason for the caesarean section and the type of hysterotomy performed (classical/low transverse), to aid in deciding the route of delivery for a subsequent pregnancy.