Caesarean Section
The guidelines recommend management of common obstetric conditions at primary and referral level, based on local experience and evidence-based practice. They are not intended as strict protocols nor as standard operating procedures, but rather as a guide to safe effective management of common obstetric problems. The guidelines should be most useful to interns, medical officers and registrars.
Pre-operative testing before Caesarean section
Requests by women for Caesarean section
Women who refuse Caesarean section
Surgical techniques vary according to the circumstances, and experience of the operator. The Joel-Cohen transverse abdominal approach is preferred
NOTES ON CAESAREAN SECTION
- Give sodium citrate 30 mL orally 30 minutes before the expected start of the operation, not necessarily at the time of booking
- Give metoclopramide 10 mg IM 30 minutes before the start of the operation
- Just before starting the operation, ensure that:
- Tubal ligation has been considered with the necessary consent signed if that is the woman’s choice
- The fetal heart can still be heard
- The indication for operation is still valid, & known to the woman
- The fetal presentation & position are known
- Give a broad spectrum antibiotic as a single dose, eg Cefazolin 1 g IV, 30 - 60 minutes before the procedure, irrespective of whether the operation is elective or emergency
- Consider a vertical skin incision with previous vertical incision, or risk of intra-operative haemorrhage (antepartum haemorrhage, severe pre-eclampsia), difficult delivery (transverse lie, prolonged second stage), or postoperative infection (prolonged labour or rupture of membranes, offensive liquor)
- Consider a vertical uterine incision (classical, but usually down into the lower segment) for extensive lower segment adhesions, lower uterine leiomyomas, transverse lie, poorly formed lower segment (especially with preterm breech presentation) and cervical cancer (high vertical incision)
- Ensure that oxytocin 2.5 units is given IV slowly after delivery of the baby, to be repeated after 3 minutes if the uterus does not contract adequately
- Take special care in caesarean delivery where the head is deeply engaged. Ask for help in pushing the baby up from below, or consider a ‘reverse breech’ method. Get senior help if inexperienced with such situations
- For persistent excessive bleeding, inform the anaesthetist and get senior help. Identify and control bleeding points, also manage as for persistent postpartum haemorrhage including uterotonics and tranexamic acid
- Immediate postoperative IV fluids are usually Ringer-Lactate 1 L with 40 units oxytocin over 8 hours (5 units/hour), followed by 1 L of Plasmalyte over 8 hours (125 mL/hour)
- Start postoperative mobilisation and feeding as soon as the woman feels strong enough and hungry
- Prescribe postoperative intravenous broad-spectrum antibiotics (e.g. Co-amoxyclav 1.2 g IV 8 hourly) for women where there has been offensive liquor (chorio-amnionitis) during labour
- Prescribe postoperative analgesia: Morphine 0.1 mg/kg IM 6 hourly with metoclopramide 10 mg IM 6 hourly for 24 hours.
- Add ibuprofen 400 mg 8 hourly orally & paracetamol 1 g 6 hourly orally.
- Avoid ibuprofen in patients with renal dysfunction, severe pre-eclampsia, asthma, or a history of peptic ulcers. Give tramadol 100 mg orally 6 hourly
- Discharge the woman from hospital on the third postoperative day if she is feeling well, is apyrexial, & has a heart rate <100/min. Discharge on the second day is permissible if there are no specific risks of problems. Advise on contraception, & refer to local clinic for follow-up & removal of sutures.
PRE-OPERATIVE TESTING BEFORE CAESAREAN SECTION
Recommended testing for various situations:
- Healthy women with no medical problems: Hb, Platelets, Creatinine
- Mild pre-eclampsia & gestational hypertension: Hb, Platelets, Urea, Creatinine
- Severe pre-eclampsia: FBC, U&E, AST, INR if platelet count <100x109/L
- Abruptio placentae: U&E, FBC, INR
- Cardiac disease: electrocardiogram (ECG), echo, FBC, INR on warfarin
- Women with AIDS, or systemic infections: U&E, FBC
Further points
- Spinal block is acceptable if platelet count ≥75x109/L provided there is no other evidence of coagulopathy
- For an operative procedure, platelet count should be ≥50x109/L
- It may be inappropriate to wait for results in an emergency
- Encourage good communication between obstetrician and anaesthetist
- Request detailed pre-anaesthetic assessment for high risk patients
REQUESTS BY WOMEN FOR CAESAREAN SECTION
Caesarean section is associated with an increased risk of maternal infection, haemorrhage, thromboembolism, adhesions, and placenta accreta or uterine rupture in a subsequent pregnancy. Women who ask for caesarean section and have a relative indication, e.g. poor obstetric history or previous caesarean section, may be scheduled for elective caesarean section. It is policy in public hospitals not to perform caesarean section for the sole reason that a woman is HIV infected, or upon her request.
Inform women who request caesarean section with no indication about the possible risks and benefits of the procedure. In public hospitals, performing caesarean section without a clinical indication is unacceptable practice.
WOMEN WHO REFUSE CAESAREAN SECTION
Some women refuse caesarean section and put the lives of themselves and their babies at risk. No person can be physically forced to undergo surgery. The following stepwise procedure may help such a patient to agree to the operation:
- Listen carefully to the reasons for refusal and take these into account
- Give a full explanation in the language best understood by the woman
- Call the most senior doctor and nurse available to explain the situation
- Call the closest relatives to explain the need for surgery
- Call the hospital clinical director or ethics committee to ask for further advice