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Simulation

Cesarean Section

Module

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Objectives

By the end of this lesson, you should be able to:

  1. Describe indications for cesarean section
  2. Explain preoperative planning for cesarean section including options for anesthesia and patient preparation
  3. Demonstrate the steps of a cesarean section
  4. Describe possible perioperative complications

United States Cesarean Rate, 1970-2011

Cesarean rates between 1970 and 2011.
Sources:
  • Current: CDC, National Centers for Health Statistics
  • Historical: CDC. Rates of cesarean delivery, 1993. MMWR 1995;44:303-307.; Am J Public Health. 1987 August; 77(8): 955-959.

Indications for Cesarean Section

  • Non-reassuring fetal status
  • Cephalopelvic disproportion or failed labor
  • Previous cesarean section o classical section - absolute indication
  • Previa or accreta
  • Cord prolapse
  • Macrosomia
    • > 4500 g in diabetic patient
    • > 5000 g in non-diabetic patient
  • Non-vertex presentation
  • Infections
    • Active herpes simplex virus (HSV) genital lesion
    • 38-week scheduled C-section for HIV viral load > 1000
  • History of significant shoulder dystocia
  • Prior vaginal surgery or repair
  • Prior myomectomy entering uterine cavity
  • Abdominal cerclage
  • Certain fetal anomalies
    • Cervical teratoma
    • Thyroid mass
    • Sacrococcygeal teratoma
  • Worsening preeclampsia remote from delivery
  • Perimortem
  • Maternal request
  • Other

Cesarean Delivery Upon Maternal Request

  • Informed consent, including discussion
    • Early in prenatal care
    • Frequently throughout the pregnancy
  • Not before 39 weeks of gestation
  • Should not be performed due to lack of adequate pain control options in labor
  • Not recommended for women desiring several children because of increased risk of:
    • Placenta previa
    • Placenta accreta
    • Gravid hysterectomy

Indications for Cesarean Section

  • Labor arrest 34%
  • Nonreassuring fetal tracing 23%
  • Malpresentation 17%
  • Multiple gestation 7%
  • Maternal-fetal 5%
  • Other obstetric indications 4%
  • Macrosomia 4%
  • Maternal request 3%
  • Preeclampsia 3%

Preparation for Cesarean Section

  • Preoperative informed consent
    • Review risks, benefits and alternatives
  • Anesthesia
    • Spinal
    • Epidural
    • Combined spinal-epidural
    • General
  • Prophylactic measures:
    • Perioperative antibiotics
    • Antacid (ie, Bicitra)
    • Teds/SCDs
  • Preoperative labs
    • Complete blood count (CBC), type and screen
Preparation of anesthesia in a cesarean section.
Preparation of anesthesia in a cesarean section.
Images courtesy of U.S. Department of Health and Human Services.
  • Pre-op fetal monitoring
  • Determine fetal/placental position
  • Patient positioning
    • Dorsal supine, left tilt
  • Grounding pad
  • Hair clipping at surgical site
  • Foley catheter placement
  • Abdominal prep/vaginal prep/sterile draping
  • NICU/Peds aware
  • Perform time-out

External monitor in use during labor.

Steps of the Procedure Entry

Possible Perioperative Complications

  • Hemorrhage
    • Uterine atony (most common cause of hemorrhage)
    • Retained uterine products
    • Uterine Vessel Laceration
    • Extension of hysterotomy into cervix/vagina
    • Disseminated intravascular coagulation
  • Endomyometritis
  • Wound infection
  • Urinary retention
  • Vesicovaginal fistula
  • Bowel injury, ileus, or obstruction
  • Deep vein thrombosis (DVT)
  • Pulmonary embolus
  • Amniotic fluid embolus

References

  • Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at caesarean section. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD004737. DOI: 10.1002/14651858.CD004737.pub2.
  • Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol 2011;118:29-38.
  • Cromi A, Ghezzi F, Di Naro E, Siesto G, Loverro G, Bolis P. Blunt expansion of the low transverse uterine incision at cesarean delivery: a randomized comparison of 2 techniques. Am J Obstet Gynecol 2008;199:292.e1-6.
  • Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery: an updated systematic review. Am J Obstet Gynecol 2013;209:294-306. Fetal macrosomia. Practice Bulletin No. 173. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e195–209.
  • Figueroa D, Jauk VC, Szychowski JM, Garner R, Biggio JR, Andrews WW, et al. Surgical staples compared with subcuticular suture for skin closure after cesarean delivery: a randomized controlled trial [published erratum appears in Obstet Gynecol 2013;121:1113]. Obstet Gynecol 2013;121:33-8.
  • Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1- infected adults and adolescents. Department of health and human services. DHHS. Available at: https://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf. Retrieved July 2, 2015.
  • Siddiqui M, Goldszmidt E, Fallah S, Kingdom J, Windrim R, Carvalho JC. Complications of exteriorized compared with in situ uterine repair at cesarean delivery under spinal anesthesia: a randomized controlled trial. Obstet Gynecol 2007;110:570-5.
  • Walsh CA, Walsh SR. Extraabdominal vs intraabdominal uterine repair at cesarean delivery: a metaanalysis. Am J Obstet Gynecol 2009;200:625.e1-8.
  • Xu LL, Chau AM, Zuschmann A. Blunt vs. sharp uterine expansion at lower segment cesarean section delivery: a systematic review with metaanalysis. Am J Obstet Gynecol 2013;208:62.e1-8.