Caesarean Section

1
Caesarean Section

• Max Brinsmead PhD FRANZCOG
• December 2011

2
Advances in Caesarean section

• Blood transfusion
• Spinal anaesthesia
• Joel Cohen-type incision
• Cord traction for the placenta
• Peritoneum not sutured
• Suture fat if gt2cm but do not drain
• Prophylactic antibiotics (before skin incision
  and not co-amoxiclav)
• Early oral fluids and ambulation
• Rectal NSAID for analgesia
• More Caesareans
• Quicker operations
• Sooner rather than later
• Confirmed by RCT

3
Yet to be tested...

• Role of the assistant
• Exteriorising the uterus (more pain)
• Single or dual layer closure uterus
• Mucosa-excluding suture
• When to drain (routinely not recommended)
• PPH prophylaxis (5 IU Syntocinon by slow IV)
• Thromboprophylaxis
• When CS is better than vaginal delivery
• Breech
• Previous Caesarean section
• Twins
• Midcavity arrest
• Symphysiotomy or CS
• All patients!!

4
So who needs a Caesarean section?

• I really dont know
• But many of my obstetric colleagues seem to know
• So 50 70 of Caesareans are now elective
  procedures
• And we should be aiming for 100 elective CS
• Because non elective CS is the worst of the 3
  options

5
Absolute indications for Caesarean

• Two or more previous CS
• Transverse lie
• Repeat APH unless placenta previa can be
  absolutely excluded
• Known contracted pelvis
• Complex twin presentations e.g. breech and
  transverse
• (Source Lawson, Harrison Bergstrom)

6
Risks of Caesarean Delivery

• Difficult to quantify because
• Most studies do not distinguish between elective
  and emergency operations
• The reason for the CS needs to be considered
• Some events are rare
• The question will only be resolved by
• A randomised trial
• With long term follow up

7
More likely with Caesarean birth

• Hospital stay 2-fold ?
• Intensive care 9-fold ?
• Maternal death 2-10 fold ?
• Bladder or ureter damage 30-fold ?
• Hysterectomy 40-fold ?
• Thromboembolism 4 16 fold ?
• Stillbirth in next pregnancy 2-fold ?
• Placenta previa in next pregnancy 2-fold ?
• Placenta accreta in future pregnancies

8
Same rate for vaginal and CS Birth

• Postpartum haemorrhage
• Endometritis
• Genital tract injury
• Faecal incontinence
• Postnatal depression
• Back pain
• Dyspareunia

9
More Likely with Vaginal Birth

• Perineal pain 2.5-fold ?
• Urinary incontinence 1.6-fold ?
• Uterovaginal prolapse 2-fold ?

10
More likely with Caesarean birth No Difference whether CS or Vaginal More likely with Vaginal Birth
Hospital stay 2-fold ? Postpartum haemorrhage Perineal pain 2.5-fold ?
Intensive care 9-fold ? Endometritis Urinary incontinence 1.6-fold ?
Death 2-10 fold ? Genital tract injury Uterovaginal prolapse 2-fold ?
Bladder or Ureter damage 30-fold ? Faecal incontinence
Hysterectomy 40-fold ? Postnatal depression
Thromboembolism 4 16 fold ? Back pain
Placenta previa in next pregnancy 2-fold ? Dyspareunia
Stillbirth in next pregnancy 2-fold ?
Placenta accreta Source NICE Guidelines
11
VBAC The Controversy

• Once a Caesarean always a Caesarean
• Edwin Cragin 1916
• In an era of classical CS
• Designed to prevent unnecessary primary CS
• For 60 years Trial of (lower segment) scar was
  standard British practice
• But repeat CS more common in the US
• Controversy broke out again in 2000
• And it was all about fetal risks

12
VBAC The Controversy

• Smith et al from Cambridge UK in JAMA 2002
• Reviewed 313, 238 singleton births, 37 - 43w,
  cephalic presentation in the Scottish Morbidity
  Register 1992 -1997 excluding congenital
  malformations and found
• Rate of perinatal death 11 times higher for VBAC
  compared to elective CS
• 2. This is 2 times higher than for multiparas
  having a vaginal birth

13
VBAC The Controversy

• Guise et al from Portland Oregan in BMJ July
  2004
• Reviewed 568 publications on VBAC vs elective
  CS but found only 71 had useful data
• Concluded that the additional risk of
  perinatal death from attempted VBAC was 1.4 per
  10,000 (95 percent confidence limits 0 - 9.8)
• In only 5 of uterine ruptures did the baby
  die
• This means that one has to perform 7142
  elective CS to prevent one baby death

14
Advantages of VBAC

• Greater maternal satisfaction
• But its not all about me
• Quicker recovery
• But not always
• Cheaper
• But not much cheaper than elective CS and can be
  much more costly
• Less RDS for babies
• But greater risk of death disability
• Less maternal morbidity and mortality
• But these are rare with elective CS

15
Advantages of VBAC - 2

• More vaginal births in the future
• But whats the point if theres only to be two
  kids!
• Less maternal depression
• But there is no evidence that this is so
• Breast feeding more likely to succeed
• Occurs in the delivery room
• Easier for mothers without wound pain
• Avoids risks unique to CS
• But these are rare

16
Advantages of Elective CS

• Certainty of timing
• Thats the modern way!
• Certainty of outcome
• If I have a 30 50 chance of CS just do one!
• Emergency CS more dangerous
• Its Pain-free
• More or less guaranteed!
• Often preferred by fathers obstetricians
• Thats a male thing

17
Advantages of Elective CS

• Protects the pelvic floor
• Controversial because
• Some risk arises from the pregnancy itself
• And CS may not be protective
• Safer for babies
• But the absolute risk of VBAC is small
• Avoids the risk of scar rupture
• But there is much uncertainty about the frequency
  of this
• and the maternal and fetal risks

18
VBAC Risk to the Fetus

• The rate of perinatal death is 11 x higher than
  for elective CS
• BUT
• This risk is equivalent to that of being a fetus
  to a Primigravida
• The absolute risk is only 4.5 per 10,000 births
• Confidence limits are wide
• In the 2002 UK publication all emergency CS were
  classified as attempted VBAC

19
Maternal Risk from VBAC

• Meta analysis of risk of death
• 2.8 per 10,000 with trial of scar
• 2.4 per 10,000 for elective CS
• No maternal death ever attributed to scar rupture
• Scar rupture
• Much confusion in the literature over the
  definition
• Rate of asymptomatic scar rupture the same
  whether VBAC or elect CS
• Overall rate approx. 0.5 or 1200
• Was 0.35 in the largest combined contemporary
  study
• Hysterectomy
• Additional risk from trial of scar is 3.4 per
  10,000
• Requires 2941 elective CS to prevent one
  hysterectomy

20
Patient selection for VBAC

• Type of previous CS
• 10 risk of rupture from classical and T
  incisions
• Myomectomy and Hysterotomy
• Indication for Previous CS
• But 50-75 of patients can VBAC after previous CS
  for CPD!
• Previous obstetric history
• VBAC success gt90 if there has been prior vaginal
  birth
• Dilatation at the time of previous CS
• Gestation at previous CS was there a lower
  segment?
• Number of previous CS
• Increasing risk with increasing number

21
Patient selection for VBAC -2

• Time since previous CS
• Risk of scar rupture is 2 3x greater if lt12m
• Maternal weight
• Miserable rates of VBAC for women gt135 Kg
• Lower uterine segment thickness
• No uterine ruptures if gt4.5 mm
• Maternal Age
• Clear evidence for declining uterine performance
  with age at first labour
• Family history of labour performance
• A field ripe for study

22
Patient selection for VBAC - 3

• Size of the mother and baby
• But we are very bad at estimating this
• Other pregnancy problems
• Should be assessed according to obstetric
  principles
• Engagement and cervical ripening
• Best assessed at the onset of labour
• Labour performance
• Thats why its called trial of scar
• Dilatation and descent
• Progress rather than arbitrary time limits
• Psychological Factors
• The patients willingness and drive
• The support provided

23
More than one previous CS?

• Tahseen Griffith BJOG Jan 2010 in a
  systematic analysis of available data and meta
  analysis concluded
• Overall success 71.1
• Risk of scar rupture 1.36 (this is 3x greater
  than for one CS)
• Perinatal risk is 0.09 (this is 3x greater than
  for one CS)
• The overall maternal morbidity was the same as
  that for elective CS
• Hysterectomy, transfusion, febrile morbidity etc

24
More than two previous CS?

• Cahill et al BJOG 2010 in a retrospective
  cohort study 89 women with gt2 previous CS
  concluded
• Overall success 79.8
• No cases of uterine rupture
• The overall maternal morbidity was the same as
  that for elective CS
• Hysterectomy, transfusion, febrile morbidity etc

25
Lower segment thickness and risk of scar rupture

• Rozenberg et al Lancet 1996 studied 642 women
  with ultrasound , measured the thinnest point of
  the lower segment against a filled bladder, then
  attempted VBAC
• gt4.5 mm - no ruptures or dehiscence (278)
• 3.6 - 4.5 mm 2 rate of scar rupture (177)
• 2.6 - 3.5 mm 10 rate of scar rupture (136)
• lt2.6 mm 16 rate of scar rupture (51)
• Can be technically difficult particularly in
  obese woman
• Vaginal and 3-dimensional measures promising

26
VBAC for the Obese?

• Carrel et al (Am J OG in 2003) studied 70 women
  gt200 lb, 70 who were 200-300 lb and 69 gt300 lb
• 81.8 success for those lt200 lb
• 57.1 success for those 200-300 lb
• 13.3 success for those gt300 lb
• Infection rate was
• 5.7 group 1
• 11.4 group 2
• 39 group 3
• (Very similar results published in 2001)

27
VBAC for Older Women?

• Byfield et al Am J OG in 2004 studied 659 women
  lt30 years age, 721 who were 30-35 years age and
  370 gt35 years age
• 72 success for those lt30
• 71 success for those 30-35
• 65 success for those gt35
• Scar rupture rate was
• 2.0 group 1
• 1.1 group 2
• 1.4 group 3

28
Pregnancy Interval and Risk of Scar Rupture

• Byfield et al Am J OG in 2002 studied 1527 women
  who attempted VBAC at lt12 to gt36 months after
  previous CS
• 4.8 ruptured for those lt12m
• 2.7 ruptured for those 13-24m
• 0.9 ruptured for those 25-36m
• 0.9 ruptured for those gt36m
• Also found 4-fold increased rate of rupture
  when the previous CS was a single layer closure
• (Similar finding published in 2000)

29
Induction of Labour for VBAC?

• Ravasia et al Am JOG 2000 studied 2119 women
  attempting VBAC between 1992 and 1998 of whom 27
  had an induction of labour
• Spontaneous labour 0.45 scar rupture rate
• Induced labour 1.4
• Cx ripening c PGs 2.9
• Cx ripening c Foley 0.7
• IOL not using PGs 0.7

30
Induction of Labour for VBAC -2?

• Lyndan-Rochelle et al NEJM 2001 studied all women
  attempting VBAC between 1987 and 1996 in
  Washington state
• Rate of Scar
  Rupture
• No labour 1.6 per 1000
• Spontaneous labour 5.2 " "
• Induced labour (not PGs) 7.7 " "
• Induced with PGs 24.5 " "
• However this study used ICD9 codes for
  identifying scar rupture and these are only 40
  accurate

31
Induction of Labour for VBAC -3?

• Lin Rayner Am JOG 2004 studied 3533 women
  attempting VBAC after one or more CS, 2523 in
  spontaneous labour, 438 by elective CS, 430
  induced with oxytocin and 142 induced with
  Misoprostol
• Rate of scar rupture was significantly higher
  when labour was induced.
• No significant difference between oxytocin
  (0.8) and Misoprostol (1.1)

32
Canadian College Surgeons Physicians Guidelines
1993 - 1

• Trial of labour should be recommended to all
  women who have had only one previous CS. Except
  for
• Previous classical, T or unknown uterine
  incision
• Previous hysterotomy or full thickness
  myomectomy
• Previous uterine rupture
• Any contraindication to labour in this pregnancy
  eg placenta previa, transverse lie etc.
• The wish of the patient is paramount
• (and the partner should ideally also be
  involved)

33
Canadian College Surgeons Physicians Guidelines
1993 - 2

• The patient should be made aware of the
  hospitals resources and any limitations
• The previous obstetric record should be
  consulted
• Consultation with a specialist obstetrician is
  not mandatory
• Induction of labour with oxytocin or Foley
  catheter is acceptable
• Augmentation with oxytocin is acceptable but
  caution required if arrest has occurred in the
  active phase of labour

34
Canadian College Surgeons Physicians Guidelines
1993 - 3

• Continuous EFM required only when when
  induction or augmentation of labour is used
• The problem of false positives
• No evidence that it is a specific indicator of
  scar rupture
• Epidural anaesthesia not contraindicated
• Twins not contraindicated
• Suspected fetal macrosomia diabetes not
  contraindicated

35
Caesarean Sections are Popular because

• Caesarean Section is Convenient
• Caesarean Section is Simple
• Caesarean Section is Safe
• Caesarean Section is better for babies
• When you have done a Caesarean you have done
  everything possible the medicolegal imperative

36
Caesarean Sections are Popular because

• Vaginal Birth is Painful
• Vaginal Birth is Unpredictable - If there is a
  13 or even a 15 chance of requiring a CS why
  not just do one?
• Vaginal Birth Ruins your Sex Life
• There is no evidence for this
• And the contrary may be true
• Vaginal Birth Destroys the Pelvic Floor
• Risk of urinary incontinence rises 1.6 fold
• But only exclusive CS will prevent that and...
• 40 of parous women will have incontinence in
  later life regardless of mode of delivery

37
Caesarean Sections are Popular because

• Once a Caesarean always a Caesarean
• The Term Breech Trial
• Loss of Obstetric Skills
• Pressures on Medical Resources

38
More Caesarean Sections occur when

• Fetal distress is diagnosed by CTG
• There is concern about transmission of an
  infection e.g. Herpes, Hep C, HIV
• There are medical problems and non obstetricians
  are involved e.g. diabetes, back pain, epilepsy
• Patients are privately insured
• GPs and midwives compete with specialists

39
Caesarean Sections are Popular because

• The Power of Choice
• Fathers have influence
• It is Fashionable
• Reduced Family Size

40
Caesarean Sections are increasing because

• There is an obesity epidemic
• Maternal age is increasing
• Epidurals sometimes fail
• Induction of labour sometimes fails
• An epidemic of sexual abuse?

41
Caesarean Sections are increasing because

• My mother and my sisters all had Caesareans
• This is an IVF baby
• Evolution of the species?