Dip Obs

1. Caesarean delivery
Themba Hospital DipObs Tutorials
By Dr N.E Manana

2. Intro
• All district hospitals should have staff and facilities for the
performance of a caesarean delivery 24 hours a day
• All hospitals should be able to perform an emergency caesarean
section within one hour of the decision to operate
• In general, the performance of a CD without a valid indication is
unacceptable practice.

3. Foetal maturity testing before elective
caesarean delivery
• If elective (non-urgent) caesarean delivery is planned for a woman at term,
and the gestational age is uncertain but apparently close to term, foetal
lung maturity testing may be helpful.
• After performing amniocentesis, amniotic fluid is sent to the laboratory to
assess surfactant content. The local laboratory will first need to be
consulted to ask what foetal lung maturity tests, if any, they perform.
• Alternatively, consider doing a foam test at the bedside:
• NB: If HIV positive, the patient needs to be virally suppressed. If Rhesus
negative, Anti-D needs to be administered.

4. Preparation and precautions before CD
• Obtain signed informed consent for surgery with the operation and its
indication clearly explained to the woman.
• Ensure that emergency blood for transfusion is available in the
hospital.
• Measure the woman’s Hb level.
• Ensure an experienced operator is available to do, or to assist at,
caesarean deliveries in the second stage of labour.
• Consider transfer to a specialist hospital if difficulties with surgery are
expected, e.g. placenta praevia, previous myomectomy, abruptio
placentae with a dead baby, transverse lie, morbid obesity and
serious co-existing medical or surgical conditions

5. Just before starting
• The adapted WHO surgical safety checklist has been commenced.
• Contraception such as IUCD and tubal ligation have been discussed, and
informed consent obtained if requested by the woman.
• The foetal presentation and position are known, and the fetal heart can be
heard.
• The indication for the CD is still valid.
• Broad-spectrum intravenous antibiotics have been given. These may be
either prophylactic or therapeutic antibiotics.
• If, the patient has evidence of intra-uterine sepsis, or there are factors
which put her at high- risk of post-operative sepsis, then intravenous
therapeutic antibiotics (e.g co-amoxyclav 1,2g) should be started pre-op
and continued post-op for five days, although intravenous antibiotics could
be changed to oral antibiotics after a few days depending on the patient’s
condition.

6. Haemorrhage during caesarean delivery
At CD, excessive bleeding and its complications can be prevented by:
• Having an experienced surgeon available or transferring to specialist care
pre-operatively if severe bleeding is anticipated, e.g. placenta praevia or
caesarean delivery in the second stage of labour
• Having blood for transfusion available if Hb <10 g/dL pre-operatively
• Routinely giving oxytocin 2.5 mg IV immediately after delivery of the baby
(anaesthetist) and repeating it if uterus does not contract
• Followed by routine oxytocin infusion which should be maintained in the
postnatal ward
• Delivery of the placenta by cord traction, not manual removal
• Good surgical technique
• Ensuring haemostasis

7. Manage bleeding
• Call for help.
• Remove excessive blood with suction or swabs.
• Inform the anaesthetist to administer tranexamic acid 1 gm by slow iv injection, additional
uterotonics, fluid resuscitation and blood replacement if needed.
• Determine whether blood loss is from an atonic uterus, placental site, or from bleeding incisions
or tears.
• Check bleeding is not from adhesions or intersecting blood vessels between the rectus sheath and
muscle beneath
• If blood loss is from an atonic uterus, proceed as for atonic uterus after vaginal delivery.
• If blood loss is from the placental site (e.g. placenta praevia): Place square sutures in the placental
bed
• Consider balloon tamponade in lower segment
• Consider a brace suture (e.g. B-Lynch suture), systematic devascularisation, or hysterectomy
• If hysterectomy is required but cannot be done, tie a Foley catheter tourniquet around the uterus
(to arrest bleeding) and await help or transfer to specialist care

8. Manage bleeding
if blood loss is from tears or extension of uterine incision:
• Define anatomy clearly
• Remove sutures if necessary to expose bleeding areas
• Arrest bleeding with figure-of-eight sutures
• Identify vertical tears and suture separately after securing apex, avoid placing sutures
near the ureters in the base of the broad ligament
• Consider mass uterine artery ligation where tears have extended laterally into the broad
ligament
• Consider systematic devascularisation or subtotal hysterectomy
• Consider other causes of bleeding, e.g. ruptured liver in pre-eclampsia, ruptured spleen
• With persistent bleeding from the uterus, tie a Foley catheter tightly around the uterine
lower segment including the broad ligaments and wait for help, or transfer to specialist
care for hysterectomy.
• Ensure that blood pressure and heart rate are stable before transfer, and consider use of
Non pneumatic Anti Shock Garment (NASG).

9. Postoperative orders
• Prescribe analgesia:
• Opiate, e.g. morphine 10 mgms intramuscularly with prochlorperazine 12.5 mg
intramuscularly four to six hourly when necessary for 24 hours
• Indomethacin 100 mg suppository 12 hourly, or ibuprofen 400 mg orally three
times daily (not in patients with asthma, peptic ulcer, pre-eclampisa, kidney
dysfunction or immune deficiency) for two or three days when necessary
• Paracetamol one gram orally four times daily when necessary
• Prescribe intravenous fluids: Ringer’s lactate one litre with 20 units oxytocin over
eight hours
• Give prophylaxis against thromboembolism for women at risk (sodium heparin 5
000 units subcutaneously 12-hourly or enoxaparin 40 mg SC daily while in
hospital).
• Risk factors to consider are advanced maternal age, obesity, HIV infection, pre-
eclampsia, immobility and co-existing illnesses.
• Encourage early oral intake and mobilization in women with uncomplicated CD

10. Haemorrhage after caesarean delivery
• PPH may occur after the operation in the theatre recovery area or in
the postnatal ward.
• Haemorrhage may be internal (intraperitoneal, extraperitoneal), or
external (vaginal).
• Internal bleeding can be difficult to diagnose clinically - be aware of a
post-CS patient with tachycardia and tender abdomen, as the Hb does
not drop immediately and the bleeding is concealed.

11. Haemorrhage after caesarean delivery
PPH after CD can be prevented by:
• All the steps above for preventing haemorrhage at caesarean section (above)
• Routinely checking all incisions and tubal ligation sites for bleeding before closing the
abdominal cavity
• By ensuring (with the anaesthetist) that the mother’s pulse rate is less than 100/minute,
systolic BP is greater than 100 mmHg and that the respiratory rate is less than 24 /minute
before closing the anterior abdominal wall.
• Any abnormality of the vital signs requires a call for help
• Routinely giving oxytocin 20 units in one litre Ringer’s lactate over the first eight hours
postoperatively
• Routinely rubbing the uterus and expelling clots immediately after completing the CD
• Regular postoperative observation of general condition, BP, heart rate and pad checks
• Intensive observation (in high care) of women who had excessive bleeding at CD or who
are at risk for further haemorrhage

12. Haemorrhage after caesarean delivery
Manage excessive bleeding after caesarean delivery as follows:
• Record general condition, heart rate, respiratory rate and BP
• Insert one or two large bore IV lines and resuscitate with Ringer’s lactate
• Insert a urinary catheter, determine the cause of bleeding:
• If the uterus is atonic, massage the uterus (this can be painful) and evacuate
clots, then give uterotonics and 1 gm tranexamic acid as for atonic uterus after
vaginal delivery
• If the uterus is well contracted, arrange a “re-look laparotomy” and proceed as
for haemorrhage at CD (as above)
• NB: Re-laparotomy may be life-saving. If at a district hospital the surgeon should
get advice from the specialist at the referral hospital and be able to perform
conservative surgical measures and apply uterine tourniquet to stabilize the
patient before referral after laparotomy.
• The doctor performing anaesthesia must be skilled in general anesthesia as well
as regional.

15. Insertion of uterine compression suture
Inserting a uterine compression suture:
• This may be done for PPH after normal delivery (Hayman) or after
caesarean section (B.Lynch).
• Put the woman in a modified Lloyd Davies position (thighs spread but not
flexed much), to allow surgery while observing for vaginal bleeding.
• Exteriorise the uterus and open the lower segment (if post CS) with a
transverse incision.
• Compress the uterus with the hands. If this stops the bleeding, a B-Lynch
brace suture or Hayman sutures) is likely to be successful
• Use a single 1 metre length of thick absorbable suture material (chromic or
polyglycolic 1 or 2) with a large needle.
• Ensure that the assistant compresses the uterus well while the suture is
tightened and tied.

18. Thank you