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, because life-threatening to the mother1

(1 to 2% of all deliveries)

– 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 low-resource contexts with difficult access to services and a high fertility rate, both the immediate and the medium and long term risks to the mother often outweigh the potential benefits to the infant.

6.4.2 Prerequisites for performing a caesarean

– 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 against 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 skin preparation.

– Foley catheter insertion.

– Routine antibiotic prophylaxis:
cefazolin slow IV1 : 2 g as a single dose (to be preferably administered 15 to 60 minutes prior to incision, otherwise, at incision)2, EXCEPT if prolonged rupture of membranes, maternal fever, frank chorioamnionitis, peritonitis, infected or prolonged uterine rupture or septic shock. In these cases, administer the appropriate antibiotic therapy2 .

– 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 maximum).

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:
Day 0 to Day 1, tramadol: 50 mg every 8 hours
Day 0 to Day 3, ibuprofen: 400 mg every 8 hours
Day 0 to Day 5, 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 the MSF handbook, Clinical guidelines.

• Respect the contra-indications; avoid non-steroidal anti-inflammatory drugs in situations where clotting and renal function may be compromised (sepsis, preeclampsia).

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

– Thromboprophylaxis:
Not done routinely for uncomplicated caesarean sections. Desirable, with a lowmolecular- weight heparin, 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:
• Day 0: 1 litre of 5% glucose and 1 litre of Ringer lactate over 24 hours.
• Day 1: 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 catheter removal on Day 1, unless:
• Blood-stained urine when catheter is removed.
• Urine output < 500 ml/24 hours.
• Peri/post-operative complication (wait to consult the surgeon and/or anaesthetist).

– Early mobilisation:
• Day 0: mobilisation at the edge of the bed beginning 6 hours post-operatively.
• Day 1: patient out of bed for the first time.

– Dressing and suture removal:
• If hygiene conditions are good: uncover wound on Day 1.
• Otherwise, remove dressing on Day 5 (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 Day 7.

– Cleaning:
Simple shower; no intravaginal cleansing.

– Breast-feeding:
• Begin breast-feeding as soon as possible.
• Monitor the infant (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.



Footnotes
Ref Notes
1 In patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory problems or oedema): clindamycin IV, 900 mg as a single dose.
2 Intrauterine foetal death, tinged or meconium-stained amniotic fluid and an initial attempt to extract vaginally are not indications for antibiotic therapy.