The document provides detailed information on cesarean births, including definitions, incidence factors, classifications, and surgical techniques. It outlines different categories of cesarean sections based on urgency, recommendations for incision methods, and strategies to reduce complications such as infections and postoperative issues. Additionally, it discusses patient care post-surgery, including activity resumption and mental health considerations.

1. Cesarean Birth
BY:
Mohamed El Sayed Salama
Assistant Lecturer of OBS&GYNE
Al-azhar University

2. Cesarean section:
 Delivery of the baby by an abdominal and
uterine incision after 28 weeks of pregnancy.
 It is called hysterotomy, if removal is done
before 28 weeks of pregnancy.

3.  Incidence:

4. Factores contribute to an increase in
the rate of caesarean section:
 Inaccurate dating of the pregnany.
 Fetal monitoring.
 Macrosomia .
 Maternal request.
 Advancing maternal age.
 Socioeconomic factors.
 Reduced parity.

5.  Improvements in surgical techniques .
 Decreased morbidity and motality.
 Type of health insurance, whether the hospital
is private or public .
 Choose the time and day of delivery.

6. Classification of cesarean birth:
 Based on the timing of CS at the time of decision making, the indications are
grouped under one of four categories.

7. Category 1 or emergency cs:
 There is an immediate threat to the mother or the
fetus.
 Ideally the CS should be done within the next 30
min
 Some examples are: abruption, cord prolapse,
scar rupture,scalp blood pH <7.20 and prolonged
FHR deceleration < 80 beats/min.

8. Category 2 or urgent CS :
 There is maternal or fetal compromise but was
not immediately life threatening.
 Here the delivery should be completed within
60-75 min and cases with FHR abnormalities
are those of concern.

9. Category 3 or scheduled CS:
 The mother needed early delivery but there was
no maternal or fetal compromise.
 There may be concern that continuation of
pregnancy is likely to affect the mother or fetus
in hours or days to come.
 e.g.: case of iatrogenic preterm delivery where
need to give a course of steroid for lung maturity.

10. Category 4 , elective or planned CS :The
delivery is timed to suit the mother and staff.

20. Factors affecting the likelihood of
emergency caesarean birth during
intrapartum care:

29. Abdominal wall incision:
 1.4.28 Perform caesarean birth using a low, transverse,
straight skin incision with subsequent tissue layers
opened bluntly and, if necessary, extended using sharp
dissection.
 This may need to be modified with a higher incision for
women and pregnant people with class 3 obesity (BMI 40
kg/m2 or more).
 A vertical midline incision may be required for some
clinical indications. [2004, amended 2023]

30. Instruments for skin incision:
Do not use separate surgical knives to incise the skin and the deeper
tissues in caesarean birth, as it does not decrease wound infection. {2004}
Extension of the uterine incision:
When there is a well-formed lower uterine segment, use blunt rather than
sharp extension of the uterine incision to reduce blood loss, incidences of
postpartum hemorrhage and the need for transfusion during caesarean
birth. [2004]
Fetal laceration
Inform women who are having a caesarean birth that the risk of fetal
lacerations
is about 2%. [2004]

31. Use of forceps:
Only use forceps in caesarean birth if there is difficulty delivering the baby's
head. The effect on neonatal morbidity of the routine use of forceps at
caesarean
birth remains uncertain. [2004]
Use of uterotonics:
Use oxytocin 5 IU by slow intravenous injection in caesarean birth to
encourage
contraction of the uterus and decrease blood loss. [2004]
Method of placental removal:
Remove the placenta in caesarean birth using controlled cord traction and
not
manual removal to reduce the risk of endometritis. [2004]

32. Exteriorisation of the uterus:
Perform intraperitoneal repair of the uterus for caesarean birth.
Routine
exteriorisation of the uterus is not recommended because it is
associated with
more pain and does not improve operative outcomes such as
haemorrhage and infection. [2004, amended 2021]
Closure of the uterus:
Use single layer or double layer uterine closure in caesarean
birth, depending on
the clinical circumstances. Note that single layer closure does
not increase the
risk of postoperative bleeding or uterine rupture in a subsequent
pregnancy.[2021]

33. Closure of the peritoneum:
Do not suture the visceral or the parietal peritoneum in
caesarean birth to reduce
operating time and the need for postoperative analgesia, and
improve maternal
satisfaction. [2004]
Closure of the abdominal wall:
If a midline abdominal incision is used in caesarean birth, use
mass closure with
slowly absorbable continuous sutures as this results in fewer
incisional hernias
and less dehiscence than layered closure. [2004]

34. Closure of subcutaneous tissue:
Do not routinely close the subcutaneous tissue space in caesarean birth
unless the woman has more than 2 cm subcutaneous fat, as it does not
reduce the incidence of wound infection. [2004]
Use of superficial wound drains:
Do not routinely use superficial wound drains in caesarean birth as they do
not decrease the incidence of wound infection or wound haematoma
on the use of negative pressure wound therapy. [2004,amended 2021]
Closure of the skin:
Consider using sutures rather than staples to close the skin after
caesarean birthto reduce the risk of superficial wound dehiscence.

35. Timing of antibiotic administration:
Offer women prophylactic antibiotics before skin incision for
caesarean birth, choosing antibiotics that are effective
against endometritis, urinary tract and wound infections.
[2011, amended 2021]
Inform women that: endometritis, urinary tract and wound
infections occur in about 8% of women Caesarean birth
(NG192)
using prophylactic antibiotics before skin incision reduces
the risk of maternal infection more than prophylactic
antibiotics given after skin incision, and that there is no
known effect on the baby. [2011, amended 2021]

36. 
Thromboprophylaxis for caesarean birth:
Offer thromboprophylaxis to women having
a caesarean birth.
Take into account the risk of thromboembolic
disease when choosing the method of prophylaxis
(for example, graduated stockings, hydration, early
mobilisation, low molecular weight heparin).
[2011]

42.  Resuming activities and discharge home:
 Inform women who have had a caesarean birth that they can resume
activities
such as driving a vehicle, carrying heavy items, formal exercise and sexual
intercourse when they feel they have fully recovered from the caesarean
birth
(including any physical restrictions or pain). [2004, amended 2021]
 When caring for women who have had a caesarean birth, discuss that after a
caesarean birth they are not at increased risk of depression, post-traumatic
stress symptoms, pain on sexual intercourse, faecal incontinence or
difficultieswith breastfeeding. [2004, amended 2021]
 While women are in hospital after having an emergency or unplanned
caesarean birth, give them the opportunity to discuss with healthcare
professionals the reasons for the caesarean birth, and provide both verbal
and printed information about birth options for any future pregnancies. If the
woman prefers, provide this at a later date. [2011, amended 2021]

43.  References:
NICE guideline
Published: 31 March 2021
Last updated: 30 January 2024
www.nice.org.uk/guidance/ng192