Anaesthesia for emergency caesarean section

The Report on Confidential Enquiries into Maternal Deaths in England and Wales 1982-84 (Department of Health 1989) recommends early involvement of the anaesthetist in women having emergency caesarean sections and the use of epidural anaesthesia in preference to general anaesthesia. In an observational prospective study the need for emergency abdominal delivery could be anticipated in 87% of 360 consecutive emergency caesarean sections. Early establishment of epidural analgesia allowed extension, to an appropriate level for the surgery, in 70%. The duty anaesthetist accompanying the obstetric team on three wardrounds a day could be forewarned of anticipated problems in most women who are eventually delivered abdominally.     

Anaesthesia for caesarean section

Quality and choice in anaesthesia for caesarean section have significantly improved over the last two decades. During this time, general anaesthesia usage has decreased to the point where, in some centres, it is an occasionally used technique for severe fetal distress. This change in practice may have been responsible for the fall in anaesthetic deaths in pregnant women that has occurred over the same period. The boom in regional anaesthesia has improved the aesthetics of childbirth by caesarean section, women's peri-operative comfort, and post-operative analgesia. It has, however, introduced new problems, such as delays in inducing anaesthesia in emergency situations, post-operative immobility and urinary retention. The increase in anaesthetic choices has led to inconsistencies in practice between individual anaesthetists, and between regions and nations. It is therefore impossible for obstetricians to make assumptions about the impact of anaesthesia on their patients. Where possible, anaesthetic protocols and guidelines should exist in every centre, with obstetricians clearly informed of relevant features. Such an approach will prevent inconsistent advice being given to patients and dangerous mistakes occurring. With every aspect of maternity care, a multidisciplinary team approach is in patients' best interests, and anaesthesia for caesarean section is no exception.     

Risk factors for emergency caesarean section in planned vaginal breech delivery

Purpose

To identify risk factors for emergency caesarean section in women attempting a vaginal breech delivery at term.

Methods

Data from 1092 breech deliveries performed between 1998 and 2013 at a Swiss cantonal hospital were extracted from an electronic database. Of the 866 women with a singleton, full term pregnancy, 464 planned a vaginal breech delivery. Fifty-seven percent (265/464) were successful in delivering vaginally. Multivariate regression analyses of risk factors were performed, and neonatal and maternal complications were compared.

Results

Risk factors for failed vaginal delivery were peridural anaesthesia (OR 2.05; 95 % CI 1.09–3.84; p = 0.025), nulliparity (OR 2.82; 95 % CI 1.87–4.25; p < 0.001), high birth weight (OR 1.17; 95 % CI 1.04–1.30; p = 0.006) and induction of labour (OR 1.56; 95 % CI 1.003–2.44; p = 0.048). Maternal age, height and weight; gestational age; or newborn length and head circumference were not associated with an unplanned caesarean section. The rate of successful vaginal delivery in the low risk sub-group (multiparous women without induction of labour) was 58–83 %, depending on birth weight category. The likelihood of success for the high risk sub-group (nulliparous women with induction of labour) fell below a third at neonatal birth weights >3250 g. Complication rates were low in the cohort.

Conclusions

Use of peridural anaesthesia, nulliparity, high birth weight and induction of labour were risk factors for unsuccessful vaginal breech delivery requiring an unplanned caesarean section. Awareness of these risk factors is useful when counselling women who are considering a vaginal breech delivery.

     

Indications for caesarean section

Caesarean section rates are rising. Caesarean section confers an increase in maternal mortality and morbidity as well as having considerable financial implications. Caesarean section is usually justified by the assumed benefit for the fetus. These benefits are often unquantified and based on scanty evidence. The changing trends in the rates of caesarean section for various indications may be explained partly by improved anaesthetic and neonatal techniques. Cultural changes and expectations in the general population and obstetricians' fear of litigation may have made the changing rate and indications for caesarean section seem more acceptable. There is little research evidence in this area. The evidence that caesarean section is the optimal mode of delivery for various major indications is critically examined. The obstetrician is under an obligation to share the evidence that caesarean section is the optimum mode of delivery with the pregnant woman and her birth attendants to allow the woman to make wise decisions about her management.     

Predicting psychological well-being after emergency caesarean section: A preliminary study

The experience of emergency caesarean section (EmCS) is traumatic for many women. Up to now, a possible relationship between psychological variables before and after EmCS has not been studied. Therefore, the present study was designed, to examine whether the women's psychological condition during pregnancy correlates with their psychological well-being after EmCS. Questionnaires were administered in gestation week 32, a few days and one month after EmCS. A consecutive sample of pregnant women (N = 1981) completed questionnaires (the predictors) at Time 1. Predictors were operationalized by means of the Wijma-Delivery Expectancy/Experience Questionnaire (W-DEQ vers. A), the Spielberger Trait Anxiety Inventory (STAI) and the Stress Coping Inventory (SCI). Of those women who had an EmCS (N = 97), a selection (N = 40) completed questionnaires (the criterion variables) at Times 2 and 3. The criterion variables were operationalized by means of the W-DEQ vers. B, the Impact of Event Scale (IES), and the Symptom Checklist (SCL). Fear of childbirth (W-DEQ vers. A) was the best overall predictor of the three criterion variables, whereas general anxiety (STAI) was the best predictor of mental distress (SCL) after EmCS. In conclusion, according to the results of this study, particularly fear of childbirth during late pregnancy, but also general anxiety, is associated with mental distress after a subsequent EmCS. Maternal follow-up after a complicated delivery should perhaps be directed especially to women with a history of serious fear of childbirth and/or other anxiety difficulties during gestation.     

Techniques for performing caesarean section

In many countries caesarean section has become the mode of delivery in over a quarter of all births. Safety of the mother and cost are the two main areas of concern. Various studies on the techniques of performing a caesarean section have focused on reducing the operating time, blood loss, wound infection and cost. Given the fact that caesarean section is the most commonly performed operation in obstetrics, it is important that trainers and trainees are familiar with the basic surgical techniques and that best practice is followed. At the same time surgeons should take necessary precautions to reduce their risk of exposure to Hepatitis B and HIV.The skin incision and entry into abdominal cavity is best achieved by the modified Cohen's incision. The lower segment transverse uterine incision has stood the test of time over a period of 75 years and remains the best way to enter the uterus. Closure of the uterus in single layer appears to be acceptable, whenever technically possible. Placental delivery should be by controlled cord traction after spontaneous expulsion. Closure of the visceral and parietal layers of the peritoneum no longer seems to be necessary. Obliteration of space in the subcutaneous layer, either by suture or by suction, seems to reduce wound disruption. These issues are being considered in the CAESAR randomized controlled trial of surgical techniques currently underway in England.Prophylactic antibiotics are mandatory in preventing post-operative morbidity. Many of the above mentioned steps have been tested in randomized trials. Further studies are needed to examine a wide range of questions arising from this review, e.g. best position of the patient, the value of exteriorization of the uterus whilst repairing the uterus, and the use of agents to relax the uterus in difficult deliveries.     

Preterm caesarean section

Summary. A retrospective study of 1921 caesarean sections at Rutherglen Maternity Hospital in Glasgow during the years 1979–1983, inclusive, showed that 229 (12%) were performed at less than 37 weeks gestation. Of these 229 preterm caesarean sections 41% were elective, 21% were for antepartum haemorrhage and 38% took place during labour. Of the 254 babies born 18 (7%) died in the neonatal period. These deaths comprised 31% of all neonatal deaths during the study period in this hospital. The neonatal death rate was 70% for babies weighing <1000 g (7 of 10) and 23% for babies weighing 1000–1500 g (6 of 26), but only 3% for babies heavier than this (7 of 217). Of the 75 women with a subsequent pregnancy after the preterm caesarean section 56% were again delivered by caesarean section. In view of the maternal morbidity associated with caesarean section and the poor neonatal outcome at birthweights of <1500g, the use of operative delivery for very low birthweight infants deserves further scrutiny.     

Preterm caesarean section

A retrospective study of 1921 caesarean sections at Rutherglen Maternity Hospital in Glasgow during the years 1979-1983, inclusive, showed that 229 (12%) were performed at less than 37 weeks gestation. Of these 229 preterm caesarean sections 41% were elective, 21% were for antepartum haemorrhage and 38% took place during labour. Of the 254 babies born 18 (7%) died in the neonatal period. These deaths comprised 31% of all neonatal deaths during the study period in this hospital. The neonatal death rate was 70% for babies weighing less than 1000 g (7 of 10) and 23% for babies weighing 1000-1500 g (6 of 26), but only 3% for babies heavier than this (7 of 217). Of the 75 women with a subsequent pregnancy after the preterm caesarean section 56% were again delivered by caesarean section. In view of the maternal morbidity associated with caesarean section and the poor neonatal outcome at birthweights of less than 1500 g, the use of operative delivery for very low birthweight infants deserves further scrutiny.     

Sense of coherence and symptoms of post-traumatic stress after emergency caesarean section

BACKGROUND: In this study of women who had undergone an emergency caesarean section (EmCS), the aim was to examine the associations between, on the one hand, the new mother's sense of coherence (SOC) and obstetric and demographic variables a few days postpartum, and on the other hand, post-traumatic stress symptoms 3 months' postpartum. METHODS: In a prospective study, 122 Swedish- or English-speaking new mothers completed 2 self-assessment questionnaires, at 2 days and 3 months after an EmCS. To measure SOC, we used the Sense of Coherence Scale (SOC-13), and to measure reactions to traumatic events, the Impact of Event Scale (IES-15). RESULTS: Independent risk factors associated with post-traumatic stress symptoms were: imminent fetal asphyxia as an indication for the operation, and low SOC in the woman. The group of women with low SOC were those with an intense fear of childbirth during pregnancy, immigrants, and socially underprivileged women. CONCLUSIONS: Symptoms of post-traumatic stress following EmCS are associated both with the new mother's personal coping style and with the circumstances of the event. We recommend that women who belong to groups who more often report a low SOC or who had imminent asphyxia as an indication for the operation should be offered support and follow-up.     

Elective caesarean section

As a part of the ongoing debate surrounding the steady increase in the rate of caesarean sections in general, the issue of elective caesarean section - following a complication-free pregnancy and in the absence of clear medical evidence actively suggesting a caesarean section - has likewise been addressed in greater depth. The progressive decline in mortality attending a well-planned caesarean section along with the reduction in morbidity brought about by improvements in caesarean section techniques have served to direct the attention towards the less apparent maternal and fetal risks of vaginal delivery. At the same time, the growing importance attached to the patient's input has made a clear definition of the concept of 'indication' more difficult. However, the distinction between medical indications and the freedom of choice of the patient is, in the predominant number of cases, an artificial one - in the ideal scenario, obstetrician and patient arrive at a joint decision after carefully considering the advantages and disadvantages of all relevant alternatives. Hence the term 'caesarean section on demand' needs to be recognized as prejudicial and needs to be replaced with the more accurate 'elective caesarean section'. Not only is ethical dilemma avoided in the process, but medical insurance agencies are left with no reasonable grounds to refuse support to such a procedure.     

Hysterectomy after caesarean section

OBJECTIVES: The indications for hysterectomy after caesarean section, postoperative period, and pathological examination of women. In whom hysterectomy hampered operated delivery, are being hereby analysed. MATERIALS AND METHODS: The study group consisted of 15 patients who gave birth in I Clinic Medical Academy in Warsaw in 1995-2001. RESULTS: In 7 with 15 women (46.7%) the supravaginal amputation was carried on at the rest in 8 (53.3%), the corpus and cervix of uterine was resected. In pathomorphological examination a trophoblast growth into uterine muscle was found. In 8 women (53.3%). In 5 (33.3%) in histological examination empty vessels were recognized. In one patient (6.7%) carcinoma praeinvasivum of uterine cervix and in one (6.7%) carcinoma of ovary were found. CONCLUSIONS: Uterine atonia and abnormalities of placentae were the main indications for hysterectomy after delivery.     

前置胎盘剖宫产子宫切口选择的临床研究

目的比较前置胎盘剖宫产子宫下段横切口和子宫下段纵切口对产时并发症、产后出血量及围产期结局的影响。方法以行子宫下段横切口剖宫产者为对照组(117例),以子宫下段纵切口剖宫产术为研究组(142例),分别记录两组研究对象剖宫产术时并发症、产时和产后24小时累计出血量、产后出血发生率及围产期结局。结果年龄、孕产次、孕周及前置胎盘类型和胎盘附着位置等有关因素比较无显著性(P＞0.05)。两组间的术时出血量、产后出血发生率、子宫切口撕裂发生率、宫腔填纱条和子宫切除率、围产期结局的比较差异十分显著(P＜0.01)。结论前置胎盘行子宫下段纵切口剖宫产术不仅可以减少术中出血量、产后出血率,而且避免子宫切口撕裂、宫腔填纱条和剖宫产术时子宫切除率也明显减少,是前置胎盘剖宫产结束妊娠的首选切口。     

Target decision to delivery intervals for emergency caesarean section based on neonatal outcomes and three year follow-up

Objective

To investigate current target decision to delivery intervals (DDIs) for ‘emergency’ caesarean section.

Study design

Prospective observational cohort study in a teaching hospital providing district and tertiary maternity services delivering 6000 babies per annum.

Results

68% Category 1 deliveries were achieved within 30 min and 66% Category 2 within 75 min (26% for antepartum Category 2 deliveries). Category 1 deliveries were quicker using general rather than regional anaesthesia (21 vs. 29 min, odds ratio [OR] for delivery <30 min 4.2, 95%CI 1.3–14.2). 8% Category 1 and 4% Category 2 neonates were acidotic or asphyxiated. The risk of acidosis was not reduced by delivery within 30 min for Category 1 (OR 0.56; 0.11–2.81), or within 75 min for Category 2 (OR 2.72; 0.6–25.1). Three babies were registered with developmental impairment by three years of age; none were Category 1 deliveries.

Conclusions

Our data suggest that clinical triage is effective, with the more compromised fetus delivered more rapidly using general anaesthesia. For Category 1 deliveries a 30 min target DDI is appropriate, although those born after longer DDI did not show developmental impairment. For Category 2 caesarean sections performed for acute fetal distress or concerns, failed instrumental delivery, failure to progress or placental bleeding, a 75 min DDI may be an appropriate target but did not protect against acidosis, asphyxia or developmental impairment. Longer DDIs did not result in unfavourable outcomes for other Category 2 indications.