Caesarean section

risk-of-infection-may-be-high-in-c-section

 

Definition

Cesarean delivery — also known as a C-section — is a surgical procedure used to deliver a baby through incisions in the mother’s abdomen and uterus.

A C-section might be planned ahead of time if you develop pregnancy complications or you’ve had a previous C-section and aren’t considering vaginal birth after cesarean (VBAC). Often, however, the need for a first-time C-section doesn’t become obvious until labor is underway.

If you’re pregnant, knowing what to expect during a C-section — both during the procedure and afterward — can help you prepare.

Uses

A 7-week old Caesarean section scar  and linea nigra  visible on a 31-year-old mother.

Caesarean section is recommended when vaginal  delivery might pose a risk to the mother or baby. C-sections are also carried out for personal and social reasons. Systematic reviews have found no strong evidence about the impact of caesareans for non-medical reasons. Recommendations encourage counseling to identify the reasons for the request, addressing anxieties and information, and encouraging vaginal birth. Elective caesareans at 38 weeks showed increased health complications in the newborn. For this reason, planned caesarean section  (also known as elective caesarean sections) should not be scheduled before 39 weeks gestational age unless there is very good medical reason to do so.

Medical uses

Some medical indications are below. Not all of the listed conditions represent a mandatory indication, and in many cases the obstetrician must use discretion to decide whether a Caesarean is necessary. This decision is a complex one and many factors need to be taken into account.

Complications of labor and factors increasing the risk associated with vaginal delivery, such as:

  • abnormal presentation (breech or transverse positions)
  • prolonged labour or a failure to progress (dystocia)
  • Fetal distress
  • Cord prolapse.
  • Uterine rupture or an elevated risk thereof
  • increased blood pressure (hypertension) in the mother or baby after amniotic rupture  (the waters breaking)
  • increased heart rate (tachycardia) in the mother or baby after amniotic rupture (the waters breaking)
  • Placental problems
  • failed labour induction
  • failed instrumental delivery (by forceps  or ventouse  (Sometimes a trial of forceps/ventouse delivery is attempted, and if unsuccessful, the baby will need to be born by caesarean section.)
  • large baby weighing >4000g (macrosomia)
  • umbilical cord abnormalities (vasa previa,  multilobate including bilobate and succenturiate-lobed placentas, velamentous insertion)

Other complications of pregnancy, pre-existing conditions and concomitant disease, such as:

  • Pre-eclampsia.
  • previous (high risk) fetus
  • HIV infection of the mother with a high viral load (HIV with a low maternal viral load is not necessarily an indication for caesarean section)
  • Sexually transmitted diseases, such as a first outbreak of genital herpes very recently before the onset of labour (which can cause infection in the baby if the baby is born vaginally)
  • previous classical (longitudinal) Caesarean section
  • previous uterine rupture
  • prior problems with the healing of the perineum  (from previous childbirth or Crohn’s disease)
  • Bicornuate uterus.
  • Rare cases of posthumous birth  after the death of the mother

Other

  • Decreasing experience of accoucheurs with management of the breech presentation — since the publication of the Term Breech Trial it is clear that planned caesarean section in women presenting at term in their first pregnancy with a breech presentation has a lower risk of infant death than planned vaginal breech delivery.Although obstetricians and midwives are extensively trained in proper procedures for such deliveries using simulation mannequins, there is decreasing experience with actual vaginal breech delivery which may increase the risk further.)

Prevention

It is generally agreed that the prevalence of caesarean section is higher than needed in many countries and physicians are encouraged to actively lower the rate. Some of these efforts include: emphasizing that a long latent phase  of labor is not abnormal and thus not a justification for C-section a new definition of the start of active labor from a cervical dilatation of 4 cm to a dilatation of 6 cm; and allowing at least 2 hours of pushing for women who have previously given birth and 3 hours of pushing for women who have not previously given birth before laborm arrest  is considered. Physical exercise during pregnancy also decreases the risk.

Risks

Recovery from a C-section takes longer than does recovery from a vaginal birth. And like other types of major surgery, C-sections also carry risks.

Risks to your baby include:

  • Breathing problems.Babies born by scheduled C-section are more likely to develop transient tachypnea — a breathing problem marked by abnormally fast breathing during the first few days after birth. C-sections done before 39 weeks of pregnancy or without proof of the baby’s lung maturity might increase the risk of other breathing problems, including respiratory distress syndrome — a condition that makes it difficult for the baby to breathe.
  • Surgical injury.Although rare, accidental nicks to the baby’s skin can occur during surgery.

Risks to you include:

  • Inflammation and infection of the membrane lining the uterus.This condition — known as endometritis — can cause fever, foul-smelling vaginal discharge and uterine pain.
  • Increased bleeding.You’re likely to lose more blood with a C-section than with a vaginal birth. However, transfusions are rarely needed.
  • Reactions to anesthesia.Adverse reactions to any type of anesthesia are possible. After a spinal block or combined epidural-spinal anesthesia — common types of anesthesia for C-sections — it’s rare, but possible, to experience a severe headache when you’re upright in the days after delivery.
  • Blood clots.The risk of developing a blood clot inside a vein — especially in the legs or pelvic organs — is greater after a C-section than after a vaginal delivery. If a blood clot travels to your lungs (pulmonary embolism), the damage can be life-threatening. Your health care team will take steps to prevent blood clots. You can help, too, by walking frequently soon after surgery.
  • Wound infection.Infections are more common with C-sections compared to vaginal deliveries. C-section infections are generally found around the incision site or within the uterus.
  • Surgical injury.Although rare, surgical injuries to nearby organs — such as the bladder — can occur during a C-section. Surgical injuries are more common if you have multiple C-sections. If there is a surgical injury during your C-section additional surgery might be needed.
  • Increased risks during future pregnancies.After a C-section, you face a higher risk of potentially serious complications in a subsequent pregnancy — including problems with the placenta — than you would after a vaginal delivery. The risk of uterine rupture, when the uterus tears open along the scar line from a prior C-section, is also higher if you attempt vaginal birth after C-section (VBAC).

Classification

Caesarean sections have been classified in various ways by different perspectives. One way to discuss all classification systems is to group them by their focus either on the urgency of the procedure, characteristics of the mother, or as a group based on other, less commonly discussed factors.

It is most common to classify caesarean sections by the urgency of performing them.

By urgency

Conventionally, caesarean sections are classified as being either an elective surgery  or an emergency  operation. Classification is used to help communication between the obstetric, midwifery and anaesthetic team for discussion of the most appropriate method of anaesthesia. The decision whether to perform general anesthesia  or regional anesthesia (spinal or epidural anaesthetic) is important and is based on many indications, including how urgent the delivery needs to be as well as the medical and obstetric history of the woman.Regional anaesthetic is almost always safer for the woman and the baby but sometimes general anaesthetic is safer for one or both, and the classification of urgency of the delivery is an important issue affecting this decision.

A planned caesarean (or elective/scheduled caesarean), arranged ahead of time, is most commonly arranged for medical indications which have developed before or during the pregnancy, and ideally after 39 weeks of gestation. In the UK this is classified as a ‘grade 4’ section (delivery timed to suit the needs of the service) since there is no rush in these situations. Emergency caesarean sections (those where vaginal delivery has been planned beforehand, and the indication for section has developed since this plan was agreed, usually after assessment by a healthcare professional) are classified in the UK as grade 3(delivery within 4 hours of the decision, no maternal or fetal compromise), grade 2 (delivery required within 90 minutes of the decision but no immediate threat to the life of the woman or the fetus) or grade 1 (delivery required within 30 minutes of the decision: immediate threat to the life of the mother or the baby)

Elective caesarean sections may be performed on the basis of an obstetrical or medical indication, or because of a medically non-indicated maternal request.Among women in the United Kingdom, Sweden and Australian about 7% preferred caesarean section as a method of delivery. In cases without medical indications the American Congress of Obstetricians and Gynecologists and the UK Royal College of Obstetricians and Gynaecologists recommend a planned vaginal delivery. The National Institute for Health and Care Excellence recommends that if after a women has been provided information on the risk of a planned caesarean section and she still insists on the procedure it should be provided. If provided this should be done at 39 weeks of gestation or later.

By characteristics of the mother

Caesarean delivery on maternal request

Caesarean delivery on maternal request (CDMR) is a medically unnecessary caesarean section, where the conduct of a childbirth via a caesarean section is requested by the pregnant  patient even though there is not a medical indicationto have the surgery.

After previous Caesarean

Mothers who have previously had a caesarean section are more likely to have a caesarean section for future pregnancies than mothers who have never had a caesarean section. There is discussion about the circumstances under which women should have a vaginal birth after a previous caesarean.

Vaginal birth after caesarean (VBAC) is the practice of  birthing a baby  vaginally after a previous baby has been delivered by caesarean section (surgically). According to The American Congress of Obstetricians and Gynecologists (ACOG), successful VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies. According to the American Pregnancy Association, 90% of women who have undergone caesarean deliveries are candidates for VBAC. Approximately 60-80% of women opting for VBAC will successfully give birth vaginally, which is comparable to the overall vaginal delivery rate in the United States in 2010.

Twins

For otherwise healthy twin pregnancies where both twins are head down a trial of vaginal delivery is recommended at between 37 and 38 weeks. Vaginal delivery in this case does not worsen the outcome for either infant as compared with caesarean section. There is controversy on the best method of delivery where the first twin is head first and the second is not. When the first twin is not head down at the point of labour starting, a caesarean section should be recommended. Although the second twin typically has a higher frequency of problems, it is not known if a planned caesarean section affects this. It is estimated that 75% of twin pregnancies in the United States were delivered by caesarean section in 2008.

Breech birth

A breech birth is the birth  of a baby from a breech presentation,  in which the baby exits the pelvis with thebuttocks or feet  first as opposed to the normal head-first presentation. In breech presentation, fetal heart sounds are heard just above the umbilicus.

The bottom-down position presents some hazards to the baby during the process of birth, and the mode of delivery (vaginal versus caesarean) is controversial in the fields of obstetrics  and midwifery.

Though vaginal birth is possible for the breech baby, certain fetal and maternal factors influence the safety of vaginal breech birth. The majority of breech babies born in the United States and the UK are delivered by caesarean section as studies have shown increased risks of morbidity and mortality for vaginal breech delivery, and most obstetricians counsel against planned vaginal breech birth for this reason. As a result of reduced numbers of actual vaginal breech deliveries, obstetricians and midwives are at risk of de-skilling in this important skill. All those involved in delivery of obstetric and midwifery care in the UK undergo mandatory training in conducting breech deliveries in the simulation environment (using dummy pelvises and mannequins to allow practice of this important skill) and this training is carried out regularly to keep skills up to date.

Resuscitative hysterotomy

A resuscitative hysterotomy, also known as a peri-mortem caesarean delivery, is an emergency caesarean delivery carried out where maternal cardiac arrest has occurred, to assist in resuscitation of the mother by removing the aortocaval compression generated by the gravid uterus. Unlike other forms of caesarean section, the welfare of the fetus is a secondary priority only, and the procedure may be performed even prior to the limit of fetal viability   if it is judged to be of benefit to the mother.

Other ways, including by surgery technique

There are several types of caesarean section (CS). An important distinction lies in the type of incision (longitudinal or transverse) made on the uterus, apart from the incision on the skin: the vast majority of skin incisions are a transverse suprapubic approach known as a Pfannenstiel incision but there is no way of knowing from the skin scar which way the uterine incision was conducted.

  • The classical caesarean section involves a midline incision on the uteruslongitudinal incision which allows a larger space to deliver the baby. It is performed at very early gestations where the lower segment of the uterus is unformed as it is safer in this situation for the baby: but it is rarely performed other than at these early gestations, as the operation is more prone to complications than a low transverse uterine incision. Any woman who has had a classical section will be recommended to have an elective repeat section in subsequent pregnancies as the vertical incision is much more likely to rupture in labour than the transverse incision.
  • Thelower uterine segment section is the procedure most commonly used today; it involves a  transverse cut  just above the edge of the bladder.  It results in less blood loos  and has fewer early and late complications for the mother, as well as allowing her to consider a vaginal birth in the next pregnancy.
  • A caesareanhysterectomy  consists of a caesarean section followed by the removal of the uterus.  This may be done in cases of intractable bleeding or when the placenta  cannot be separated from the uterus.

The EXIT procedure  is a specialized surgical delivery procedure used to deliver babies who have airway compression.

The Misgav Ladach method is a modified caesarean section which has been used nearly all over the world since the 1990s. It was described by Michael Stark, the president of the New European Surgical Academy, at the time he was the director of Misgav ladach , a general hospital in Jerusalem. The method was presented during a FIGO conference in Montréal in 1994 and then distributed by the University of Uppsala, Sweden, in more than 100 countries. This method is based on minimalistic principles. He examined all steps in caesarean sections in use, analyzed them for their necessity and, if found necessary, for their optimal way of performance. For the abdominal incision he used the modified Joel Cohen incision and compared the longitudinal abdominal structures to strings on musical instruments. As blood vessels and muscles have lateral sway, it is possible to stretch rather than cut them. The peritoneum is opened by repeat stretching, no abdominal swabs are used, the uterus is closed in one layer with a big needle to reduce the amount of foreign body as much as possible, the peritoneal layers remain unsutured and the abdomen is closed with two layers only. Women undergoing this operation recover quickly and can look after the newborns soon after surgery. There are many publications showing the advantages over traditional caesarean section methods. However, there is an increased risk of abruptio placenta and uterine rupture in subsequent pregnancies for women who underwent this method in prior deliveries.

What you can expect

During the procedure

While the process can vary, depending on why the procedure is being done, most C-sections involve these steps:

  • At home.While research suggests the benefit is unclear, you might be asked to bathe with an antiseptic soap before your C-section to reduce the risk of infection. Don’t shave your pubic hair. This can increase the risk of surgical site infection. If your pubic hair needs to be removed, it will be trimmed just before surgery.
  • At the hospital.Before your C-section, your abdomen will be cleansed. A tube (catheter) will likely be placed into your bladder to collect urine. Intravenous (IV) lines will be placed in a vein in your hand or arm to provide fluid and medication. You might be given an antacid to reduce the risk of an upset stomach during the procedure.
  • Most C-sections are done under regional anesthesia, which numbs only the lower part of your body — allowing you to remain awake during the procedure. A common choice is a spinal block, in which pain medication is injected directly into the sac surrounding your spinal cord. In an emergency, general anesthesia is sometimes needed. With general anesthesia, you won’t be able to see, feel or hear anything during the birth.
  • Abdominal incision.The doctor will make an incision through your abdominal wall. It’s usually done horizontally near the pubic hairline (bikini incision). If a large incision is needed or your baby must be delivered very quickly, the doctor might make a vertical incision from just below the navel to just above the pubic bone. Your doctor will then make incisions – layer by layer – through your fatty tissue and connective tissue and separate the abdominal muscle to access your abdominal cavity.
  • Uterine incision.The uterine incision is then made — usually horizontally across the lower part of the uterus (low transverse incision). Other types of uterine incisions might be used depending on the baby’s position within your uterus and whether you have complications, such as placenta previa — when the placenta partially or completely blocks the uterus.
  • The baby will be delivered through the incisions. The doctor will clear your baby’s mouth and nose of fluids, then clamp and cut the umbilical cord. The placenta will be removed from your uterus, and the incisions will be closed with sutures.

If you have regional anesthesia, you’ll be able to hear and see the baby right after delivery.

After the procedure

After a C-section, most mothers and babies stay in the hospital for two to three days. To control pain as the anesthesia wears off, you might use a pump that allows you to adjust the dose of intravenous (IV) pain medication.

Soon after your C-section, you’ll be encouraged to get up and walk. Moving around can speed your recovery and help prevent constipation and potentially dangerous blood clots.

While you’re in the hospital, your health care team will monitor your incision for signs of infection. They’ll also monitor your movement, how much fluid you’re drinking, and bladder and bowel function.

You will be able to start breast-feeding as soon as you feel up to it. Ask your nurse or a lactation consultant to teach you how to position yourself and support your baby so that you’re comfortable. Your health care team will select medications for your post-surgical pain with breast-feeding in mind. Continuing to take the medication shouldn’t interfere with breast-feeding. Pain control is important since pain interferes with the release of oxytocin, a hormone that helps your milk flow.

Before you leave the hospital, talk with your health care provider about any preventive care you might need, including vaccinations. Making sure your vaccinations are current can help protect your health and your baby’s health.

When you go home

While you’re recovering:

  • Take it easy.Rest when possible. Try to keep everything that you and your baby might need within reach. For the first few weeks, avoid lifting from a squatting position or lifting anything heavier than your baby.
  • Support your abdomen.Use pillows for extra support while breast-feeding. A pregnancy belt might provide additional support.
  • Drink plenty of fluids.Drinking water and other fluids can help replace the fluid lost during delivery and breast-feeding, as well as prevent constipation.
  • Take medication as needed.Your health care provider might recommend acetaminophen (Tylenol, others) or other medications to relieve pain. Most pain relief medications are safe for women who are breast-feeding.
  • Avoid sex.Don’t have sex until your health care provider gives you the green light — often four to six weeks after surgery. You don’t have to give up on intimacy in the meantime, though. Spend time with your partner, even if it’s just a few minutes in the morning or after the baby goes to sleep at night.

Contact your health care provider if you experience:

  • Any signs of infection — such as a fever higher than 100.4 F (38 C), severe pain in your abdomen, or redness, swelling and discharge at your incision site
  • Breast pain accompanied by redness or fever
  • Foul-smelling vaginal discharge
  • Painful urination
  • Heavy bleeding that soaks a sanitary napkin within an hour or bleeding that continues longer than eight weeks after delivery

Postpartum depression — which can cause severe mood swings, loss of appetite, overwhelming fatigue and lack of joy in life — is sometimes a concern as well. Contact your health care provider if you suspect that you’re depressed. It’s especially important to seek help if your signs and symptoms don’t fade on their own, you have trouble caring for your baby or completing daily tasks, or you have thoughts of harming yourself or your baby.

Recovery

Abdominal, wound and back pain can continue for months after a caesarean section, with some evidence that non-steroidal anti inflammatory drugsare helpful. Women who have had a caesarean are more likely to experience pain that interferes with their usual activities than women who have vaginal births, although by six months there is generally no longer a difference. However, pain during sexual intercourse is less likely than after vaginal birth, although again, by six months there is no difference.

There may be a somewhat higher incidence of postnatal depression in the first weeks after childbirth for women who have caesarean sections, but this difference does not persist. Some women who have had caesarean sections, especially emergency caesareans, experience post traumatic stress disorder.

Trying To Avoid A Cesarean

Key Factors In Considering Cesarean Birth:

Several key factors can influence the choice of a cesarean vs. vaginal delivery.

These factors include:

  • Choice of health care provider and their philosophy regarding cesarean birth
  • Birth setting
  • Access to labor support
  • Medical interventions during labor

Steps For Avoiding Cesarean Birth:

  • Find a health care provider and birth setting with low rates of intervention
  • Ask the health care provider about their philosophy on cesareans and their cesarean rate (rates vary between 10-50%nationally)
  • Create a flexible  birth plan  and discuss the plan with your health care provider
  • Become more educated about birth by taking child birth classes, reading books, and asking lots of questions.
  • Arrange for continuous labor support from a professional, like a doula. (Studies show that women with continuous labor support are 26% less likely to have a cesarean2).
  • Explore options for coping with pain
  • Ask your health care provider about how long you can delay going to the hospital once labor begins. A common reason forces are and is prolonged labor   at the hospital.
  • Avoid continuous electric fetal monitoring during labor. Studies show that EFM can increase the chance of cesarean by up to one-third.
  • Avoid  epidural analgesia  if possible.
  • Ask for recommendations on turning a breech baby, and actively attempt these if necessary.
  • Avoid induction if possible.
  • When in labor, find laboring and pushing positions that work for you to help labor progress.

Reference:

http://www.mayoclinic.org/tests-procedures/c-section/basics/definition/prc-20014571

https://en.wikipedia.org/wiki/Caesarean_section

http://www.mayoclinic.org/tests-procedures/c-section/basics/risks/prc-20014571

https://en.wikipedia.org/wiki/Caesarean_section

http://www.mayoclinic.org/tests-procedures/c-section/basics/what-you-can-expect/prc-20014571

https://en.wikipedia.org/wiki/Caesarean_section

http://americanpregnancy.org/labor-and-birth/avoid-cesarean/

 

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