Guidelines for Obstetrics

1. Classification
of
Urgency of Caesarean
Section
Dr. Voon HY
Dr. Chai CS
Dr. Hong SC
16 March 2012

2. 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.

3. The purposes of the classification are:
a)minimising communication difficulties relating to
urgency of delivery, between and within teams
b)Identify specific cases requiring ‘immediate’
delivery (category 1)
c) facilitate data collection
d)facilitate retrospective audit of outcomes

6. 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.

7. Urgency of LSCS
Grade Definition
I : Emergency Immediate threat to life of
woman or fetus
II : Urgent Maternal or fetal compromise
which is not immediately life-
threatening
III : Scheduled Needing early delivery but no
maternal or fetal compromise
IV : Elective At a time to suit the woman
and maternity team

8. RCOG Good Practice Guideline

9. Examples - I
Category I - Immediate threat to life of woman or
fetus
- 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

10. Examples II
Category 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

11. Examples III
Category 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

12. Examples IV
Category 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

13. Scenario I
A 25 year old primiparous woman whose
cervix has been 6 cm dilated for 8 hours
despite maximal oxytocin. The CTG is
entirely normal

14. Scenario II
A 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

15. 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.

16. Scenario IV
The CTG of a multiparous woman at 2cm
cervical dilation shows persistent late
decelerations on the CTG. The liquor is
heavily stained with meconium

17. Scenario V
• A primiparous woman in labour has a
prolapsed cord. The CTG is entirely normal.

18. Scenario VI
The CTG of a multiparous woman shows a
severe fetal bradycardia for 2mins

19. 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.

20. Scenario VIII
The CTG of a primiparous woman in labour
shows variable decelerations. Fetal blood pH
is 7.17 The cervix is 3cm dilated.

21. Scenario IX
• A woman at 39 weeks’ gestation presents to
labour ward with an abruptio. The CTG shows
persistent late decelerations

22. 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.

23. PROFORMA ON DECISION TO
DELIVERY TIME FOR CATEGORY I
CAESAREAN SECTION IN SGH

24. 30 MINUTE RULE?
30-minute mark is taken from the 5th edition of
ACOG’s Guideline for Perinatal Care:
Any hospital providing obstetric service should have the capability of
responding to an obstetric emergency. No data correlate the timing
of intervention with outcome, and there is little likelihood that any
will be obtained.
However, in general, the consensus has been that
hospitals should have the capability of beginning a cesarean section
within 30 minutes of the decision to operate.

25. NICHD (Bloom et al 2006)
More than 11000 cases analysed, 2800 CS performed

26. NICHD conclusion
-DDI has no impact on maternal complications
-an infant delivered <30 min for an emergency indication
was more likely to be acidemic and require intubation
-delivery <30 min does not guarantee that there
will be no adverse outcome
-95% of infants delivered in >30 min did not
have compromise.

27. 30 min DDI
Efficiency of Unscheduled C-section improved
36%59% (Huissoud et al 2009)
A goal not a finite time