Classification ofUrgency of Caesarean Section Dr. Voon HY Dr. Chai CS Dr. Hong SC 16 March 2012
Introduction• Traditional classification ELECTIVE of C-section EMERGENCY (limited value for data collection and audit of outcomes)• In 2000, Lucas et al proposed a new classification, consisting of 4 categories, with a target DDI (Decision to delivery interval) for caesarean section for ‘fetal compromise’ of 30 minutes.
The purposes of the classification are:a)minimising communication difficulties relating to urgency of delivery, between and within teamsb)Identify specific cases requiring ‘immediate’ delivery (category 1)c) facilitate data collectiond)facilitate retrospective audit of outcomes
Result• Classification 4 has the best agreement among anaesthetists and obstetricians (86% agreement)• This agreement rose to 90% if grade II and III were combined.
Urgency of LSCSGrade DefinitionI : Emergency Immediate threat to life of woman or fetusII : Urgent Maternal or fetal compromise which is not immediately life- threateningIII : Scheduled Needing early delivery but no maternal or fetal compromiseIV : Elective At a time to suit the woman and maternity team
Examples - ICategory I - Immediate threat to life of woman orfetus- Acute fetal distress /Fetal bradycardia- Cord prolapse- Severe placenta abruptio-Bleeding placenta previa major with maternal hypovolaemia- Uterine rupture & scar dehiscence- Failed instrumental delivery with fetal distress
Examples IICategory II - Maternal or fetal compromise but not immediately life-threatening- Malpresentation in labour (eg. Brow presentation, face chin posterior)- Anterpartum haemorrhage without hypovolaemia- Failed IOL
Examples IIICategory III - Needing early delivery but no maternal or fetal compromise- Early labour in woman booked for elective LSCS- Macrosomic baby in early labour- Breech in early labour
Examples IVCategory IV - At a time to suit the woman and maternity team- Previous LSCS x 2- Refused TOS- Breech presentation- Multiple pregnancy (first fetus not cephalic)- HIV & HSV
Scenario IA 25 year old primiparous woman whose cervix has been 6 cm dilated for 8 hours despite maximal oxytocin. The CTG is entirely normal
Scenario IIA primiparous woman presents to labour ward at 5cm cervical dilatation with an undiagnosed breech presentation. The CTG shows a fetal heart rate of 180/min with no decelerations
Scenario III• A primiparous woman at 35 weeks’ gestation has pre-eclampsia. She is on a hydralazine infusion. Proteinuria > 3g/day. The fetus has severe IUGR and absent end-diastolic flows. On routine monitoring CTG is found to be abnormal.
Scenario IVThe CTG of a multiparous woman at 2cm cervical dilation shows persistent late decelerations on the CTG. The liquor is heavily stained with meconium
Scenario V• A primiparous woman in labour has a prolapsed cord. The CTG is entirely normal.
Scenario VIThe CTG of a multiparous woman shows a severe fetal bradycardia for 2mins
Scenario VII• A woman who speaks foreign language and who has not received any antenatal care presents to the labour ward with an antepartum haemorrhage. On examination, she is not tachycardic, has a BP of 120/70 mmHg and is estimated to be of 38 weeks gestation. The CTG is normal. Bleeding is continous.
Scenario VIIIThe CTG of a primiparous woman in labour shows variable decelerations. Fetal blood pH is 7.17 The cervix is 3cm dilated.
Scenario IX• A woman at 39 weeks’ gestation presents to labour ward with an abruptio. The CTG shows persistent late decelerations
Scenario X• A woman who is booked for elective caesarean section, having had a previous LSCS for cephalopelvic disproportion, presents in active labour. On examination her cervix is 4cm dilated and the CTG is normal.
PROFORMA ON DECISION TODELIVERY TIME FOR CATEGORY ICAESAREAN SECTION IN SGH
30 MINUTE RULE?30-minute mark is taken from the 5th edition ofACOG’s Guideline for Perinatal Care:Any hospital providing obstetric service should have the capability ofresponding to an obstetric emergency. No data correlate the timingof intervention with outcome, and there is little likelihood that anywill be obtained.However, in general, the consensus has been thathospitals should have the capability of beginning a cesarean sectionwithin 30 minutes of the decision to operate.
NICHD (Bloom et al 2006)More than 11000 cases analysed, 2800 CS performed
NICHD conclusion-DDI has no impact on maternal complications-an infant delivered <30 min for an emergency indicationwas more likely to be acidemic and require intubation-delivery <30 min does not guarantee that therewill be no adverse outcome-95% of infants delivered in >30 min did nothave compromise.
30 min DDIEfficiency of Unscheduled C-section improved36%59% (Huissoud et al 2009) A goal not a finite time