Cesarean section - Indications and Complications

This is part of the Gynsurgery guidelines used in an educational setting for residents in Ob-Gyn.

Indications

1. Repeat Elective
2. Active phase labor arrest
3. Abnormal fetal heart rate tracing
4. Primary Cesarean section for maternal indication
5. Primary Cesarean Section for fetal indication (not abnormal FHR)

Complications of Cesarean Section

1. Injury to the newborn
   1. Laceration
   2. Hip dislocation – breech presentation
   3. Neck injury – breech presentation
   4. Failure to deliver in a timely manner
2. Hemorrhage
   1. Uterine atony
   2. Placental problems: previa, accreta, percreta
   3. Lacerations, of cervix, of vagina
   4. Hysterotomy bleeding
3. Resultant hysterectomy
4. Endometritis
5. Bladder injury
6. Bowel injury
7. Bowel illeus
8. Ureter injury
9. Risks in subsequent pregnancies
   1. Uterine rupture
   2. Excessive adhesions – close abdominal peritoneum
   3. Misplacentation

Prevention of Complications

1. Injury to the newborn
   1. Laceration
      1. Ensure good exposure of site, and consider blunt probing with scalpel handle or hemostat to enter uterus
      2. Avoid holding scalpel like a pencil
      3. Do not incise uterus in haste
   2. Hip dislocation – breech presentation
      1. Allow baby to deliver to the level of umbilicus
      2. Hold at infant pelvis, not legs or soft tissues of abdomen
      3. Avoid excessive rotary motion when delivering arms
   3. Neck injury – breech presentation
      1. Avoid hyperextension of the head when delivering breech
   4. Extremity fracture –breech and versions
      1. Avoid excessive force on legs and arms
   5. Failure to deliver in a timely manner
      1. Confirm for position and presentation before rupture of membranes
      2. Avoid excessive fundal pressure to prevent stimulating contractions
      3. Ensure adequate room in fascial incision and rectus separation
      4. Anticipate need for vaginal elevation of the head in arrested descent labor cases
2. Hemorrhage
   1. Uterine atony
      1. Avoid manual extraction of the placenta
      2. Start pitocin after delivery of infant, before delivery of placenta
      3. Consider routine uterotonic be used (methergine or misoprostol ) in patients at high risk for atony (prolonged labor, hyperdistension of the uterus from polyhydramnios, twins), fibroids, uterine anomalies and recent tocolytics
   2. Placental problems: previa, accreta, percreta
      1. Be familiar with uterine tourniquet techniques
   3. Lacerations, of cervix, of vagina
      1. Complete uterine incision by tearing lateral instead of cutting if possible for LTCS
      2. When tearing hysterotomy, curve in an upward direction laterally
      3. Do not use the lower uterine segment as a fulcrum for your delivery hand with a well-descended head
   4. Hysterotomy bleeding
      1. Close uterine incision with continuous locking suture
      2. Identify the uterine vessels laterally before beginning to suture the hysterotomy incision
3. Resultant hysterectomy
   1. Be aware of uterine vessel and hypogastric artery ligation techniques
4. Endometritis
   1. Prophylactic antibiotics, up to 60 minutes before CS
   2. Avoid use of sponges in the uterus
   3. Express placenta rather than manually removing it
   4. If manually dilating cervix, avoid contaminating rest of field
   5. Consider preoperative vaginal betadine prep or intravaginal metronidazole gel
5. Bladder injury
   1. Create bladder flap by dissecting visceral peritoneum down off the lower uterine segment if head has descended deep into the pelvis
   2. Enter abdominal peritoneum as cephalad to the fascial incision as possible
6. Bowel injury
   1. At initial peritoneal cavity entry, check for bowel or omental adhesions to the uterus, tubes, ovaries or peritoneum
7. Bowel illeus
   1. Avoid packing bowel with dry sponges/lap packs
8. Ureter injury
   1. When suturing near the uterine vessels, palpate to make sure ureter is not in area of intended suture
9. Risks in subsequent pregnancies
   1. Uterine rupture
      1. Avoid active segment laceration or intentional incisions
      2. Use a rapidly absorbable suture on uterine incision (not delayed absorbable)
      3. Use a two layer closure of the uterine incision
      4. Advise appropriate interval for subsequent pregnancy (2 years)
   2. Excessive adhesions – close abdominal peritoneum
   3. Misplacentation