Caesarean Delivery

Clinical description

Caesarean delivery is delivery of the infant through a uterine incision.

Indications include:

• obstructed labour
• cephalopelvic disproportion
• abnormal lie
• malposition or malpresentation
• placenta praevia
• fetal distress
• cord prolapse with pulsating cord
• abruptio placenta with fetal distress
• previous myomectomy
• two or more previous caesarean deliveries
• high HIV viral load (> 1000 copies)
• extensive/obstructive vulvovaginal warts
• primary active HSV
• cervical dystocia
• failed IOL where urgent delivery is indicated, e.g., severe pre-eclamspsia or eclampsia, multiple pregnancy

with malpresentation of the leading fetus.

Signs and symptoms

History/Exam/Investigations Indication for caesarean delivery should be clearly documented in the file

Treatment

Pre-operative care

• Elective caesarean deliveries should be done during the weekday whenever possible
• Informed consent must be signed by patient
• IV access
• Send blood for Hb, group and save and X-match if indicated (i.e. previous scar, APH)
• Catheterize patient
• Medications:Prophylactic antibiotics 30-60 minutes prior to skin incision in theatre at time of induction of

anesthesia. Options include:

• Cefazolin 1-2g IV x 1
• Ampicillin 2 g IV x 1
• X-Penicillin IV 3 million units x 1
• Ceftriaxone 1 g IV (use only if other antibiotics above are unavailable)

Procedure

• Transverse skin incision (i.e., Cohen, Pfannenstiel) preferred
• Low transverse incision (i.e., Kerr) preferred for uterine incision
• Classical incision (vertical incision above the insertion of the round ligaments) indicated for poorly formed

lower segment (i.e., extreme prematurity), transverse lie with fetal back down, conjoined twins, inaccessible lower segment (i.e. dense adhesions, large leiomyoma) or cancer of cervix Post-operative care

• Monitor vitals (BP, TPR) and check for bleeding every 30 min for 2 hrs, every 1 hr for 4 hrs, then every 4-6

hrs until discharge. See Perioperative Management and other recovery room protocols.

• First 24 hrs post caesarean delivery
• Adequate IV fluids: [5% dextrose 1 L + RL 1 L + NS 1 L] or [NS 2 L + RL 1L] over 24 hrs
• Adequate analgesia: pethidine 50-100 mg IM every 6 hrs for 4 doses; diclofenac 100 mg PR BD,

Clinical description

Paracetamol 1000 mg every 6 hours PO

• Early ambulation
• Consider thromboprophylaxis if at high risk for DVT
• If catheterized, then remove catheter within 24 hrs unless otherwise indicated
• Diet
• Fluids PO when fully awake
• Light meal once fully awake and when they feel hungry, for uncomplicated caesarean sections OR

when fully recovered from regional anaesthesia

• If surgery was complicated, eat or drink as per instruction from the clinician.

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• Continue antibiotics:
• If preoperative antibiotics were not given, or patient hadchorioamnionitis, contaminated cesarean

section, immunocompromised status, prolonged or obstructed labor, or prolonged ROM (>18 hours), intrapartum fever of unknown origin  First 24 hrs:

• First line: Ampicillin 1 g q6h plus Gentamicin 160 mg x 1
• Second line: Ceftriaxone 1gram IV plus Flagyl 400 mg TDS PO

 Following 4 days: Amoxicillin 1 g TDS PO, plus Flagyl 400 mg TDS PO

• Post-op day 3: consider discharge if in stable condition and ambulatory
• Permanent suture removal: transverse skin incision on post-op day 5 or midline skin incision on post-op

day 7