Classification

Caesarean sections can be classified into elective or emergency:

• Category 1 – immediate (“crash”): these are performed when there is an

immediate threat to the life of the woman or fetus. Delivery should take
place as soon as possible. The Royal College of Obstetricians and
Gynaecologists recommends that a category 1 section should be performed
within 30 minutes of making the decision for caesarean delivery.
• Category 2 – urgent: these are indicated when there is maternal or fetal
compromise, which is not immediately life-threatening. To be performed as
soon as possible, and within 75 minutes of decision for delivery.
• Category 3 – scheduled: this category of C-section is indicated where there
is no maternal or fetal compromise, but early delivery is required.
• Category 4 – elective: the timing of this delivery is planned to suit the
woman and staff.

Indications
Indications for a category 1 (crash) caesarean section include:

• Cord prolapse
• Sustained fetal bradycardia
• Fetal hypoxia (scalp pH < 7.20)
 • Placental abruption
• Uterine rupture

Indications for a category 2 (urgent) caesarean section include:

• Failure to progress in labour with pathological CTG

Indications for a category 3 (scheduled) caesarean section include:

• Intrauterine growth restriction with poor fetal function tests

• Failed induction of labour
• Breech in labour

Indications for a category 4 (elective) caesarean section include:

• Previous caesarean section

• Breech presentation
• Other malpresentations
• Twin pregnancy where the first twin is not a cephalic presentation
• Placenta praevia
• Maternal HIV
• Primary genital herpes in the third trimester
• Previous hysterotomy or “classical” caesarean section
• Maternal diabetes with an estimated fetal weight >4.5kg in cases where
vaginal delivery is unlikely to be successful
• Maternal request

Elective caesarean sections are normally planned around 39 weeks gestation. This
is to reduce the risk of the neonate developing respiratory distress in neonates
born at earlier gestations, known as transient tachypnoea of the newborn.

Procedure
Peri-operative and anaesthetic concerns

Before a caesarean section, there are several steps and investigations that should
be performed to reduce morbidity associated with the procedure:
 • Pre-operative haemoglobin check and correction of anaemia. A group &
save should also be taken.
• H2-receptor antagonists or proton pump inhibitors (currently off license) +/-
anti-emetics like metoclopramide. Metoclopramide is a prokinetic anti-
emetic agent, and this can help reduce the risk of aspiration of gastric
contents.
• Women should be risk-assessed and appropriate thrombo-prophylaxis
should be prescribed. This includes compression stockings, hydration, early
mobilisation and low-molecular-weight heparin as appropriate.
• Prophylactic antibiotics should be given immediately prior to the skin
incision.
• In cases of ruptured membranes, an iodine-based vaginal wash is
recommended pre-operatively to reduce the risk of endometritis.

An indwelling urinary catheter should be inserted for the duration of the

procedure to prevent over-distension. This reduces the risk of damage to the
bladder during the surgery. The catheter can be removed once the woman is
mobile after regional anaesthesia, but no sooner than 12 hours after the last “top-
up” dose of anaesthetic.

Regional anaesthesia is preferred to general anaesthesia. Most caesarean sections

are performed under a spinal or “topped-up” epidural anaesthesia.

Caesarean section under general anaesthesia is reserved for cases where there is a
maternal contraindication for regional anaesthesia, where spinal or epidural
anaesthesia fails to achieve an adequate block or more commonly for category 1
sections where there is an immediate concern for fetal wellbeing.

General anaesthesia for an emergency caesarean section should include pre-

oxygenation, cricoid pressure and rapid sequence induction to reduce the risk of
aspiration of gastric contents.

All types of anaesthetic require a left lateral tilt of up to 15 degrees for uterine
displacement to prevent maternal hypotension (e.g. via insertion of a wedge
cushion).

Types of caesarean section

Lower uterine segment incision

There are two types of skin incisions for this type of caesarean section: the
Pfannenstiel incision and a Joel-Cohen incision.

NICE recommends a Joel-Cohen incision, defined as a straight horizontal incision

above the symphysis pubis. Subsequent layers are opened bluntly. This allows for a
shorter operating time and reduces the incidence of postoperative febrile illness.

Abdominal wall layers

The layers of the abdominal cavity opened and closed during a caesarean section
include:

• Skin
• Subcutaneous tissue (including Scarpa’s fascia)
• Rectus sheath
• Rectus muscle
 • Parietal peritoneum
• Uterus including visceral peritoneum

Classical caesarean section

This procedure is rarely performed as it involves a vertical incision into the upper
uterine segment.

A classical caesarean section may be indicated in the following cases:

• Structural abnormality of the uterus

• Difficult access to the lower uterine segment due to adhesions or fibroids
• Where hysterectomy will follow caesarean delivery (e.g. in cases of morbidly
adherent placenta)
• Post-mortem caesarean section where the fetus is viable
• Cervical cancer
• Anterior placenta previa with abnormally vascular lower uterine segment
• Transverse lie with ruptured membranes
• Very preterm fetus where the lower uterine segment is poorly formed

Classical caesarean sections are associated with greater rates of adhesions and
infections compared to lower uterine segment incisions.

The closure of a classical caesarean section is more complicated and takes longer
to complete. Following dissection of the abdominal and uterine walls, and delivery
of the fetus, five units of oxytocin are given to the woman to aid the delivery of the
placenta by controlled cord traction. Once the uterine cavity has been emptied,
the uterus is closed with two layers. The rectus sheath and skin are closed either
with continuous or interrupted sutures or staples.
Complications
When compared to vaginal delivery, caesarean section has lower rates of perineal
trauma and pain. However, primary caesarean section has a higher incidence of
abdominal pain, venous thromboembolism, bladder or ureteric injury and
hysterectomy.

Complications of caesarean section can further be divided into intraoperative and

postoperative complications.

Intraoperative complications

Intraoperative complications occur in 12-15% of caesarean sections and are more

common in women undergoing an emergency caesarean section. These may
include:4

• Anaesthetic side effects (e.g. hypotension, nausea)

• Haemorrhage sometimes requiring blood transfusion and, rarely,
hysterectomy (7-8/1000)
• Uterine or uterocervical lacerations
• Bladder or bowel lacerations +/- repair
• Ureteral injury

The risk of haemorrhage is increased in women with a high BMI, placenta praevia
or placental abruption or in cases of very high or low birthweight.

Postoperative complications

Postoperative complications can occur in up to one-third of women. These include:

• Pain: opioid analgesia is used first-line +/- laxatives. This is stepped down to
paracetamol and non-steroidal anti-inflammatory drugs (NSAID) use once
pain is adequately controlled.
• Infection: endometritis, wound infection and urinary tract infections. Occurs
in approximately 8% of women undergoing caesarean section. Where the
woman’s body mass index is greater than 35, negative pressure dressings
may be considered to decrease the risk of wound infection.
• Venous thromboembolism
• Pulmonary atelectasis
 • Return to theatre for another procedure
• Longer hospital stay compared to vaginal delivery

Complications affecting future pregnancies may include:

• Abnormal placentation (e.g. accreta spectrum/praevia)

• Uterine rupture
• Repeat caesarean section

For women who have had a previous caesarean section, the risk of placenta
praevia and placenta accreta increases in subsequent pregnancies. There is also a
higher risk of antepartum stillbirth in subsequent pregnancies and this risk
increases with each successive caesarean section performed.5

Fetal/neonatal complications may include:

• Fetal laceration risk of 2%

• Transient tachypnoea of the newborn
• Admission to a neonatal unit

Vaginal birth after caesarean section (VBAC)

Vaginal birth after caesarean section is an appropriate option and may be offered
to women who have a singleton pregnancy with a cephalic presentation at 37
weeks who had a single lower uterine segment caesarean section in the past, with
or without previous vaginal deliveries.6

VBAC is contraindicated in women who have had a previous uterine rupture or

classical caesarean section, or for women where vaginal delivery is contraindicated
irrespective of the presence of a scar (e.g. in major placenta praevia).

A planned VBAC is associated with a 0.05% risk of uterine rupture.

The success rate of planned VBAC is 72-75%, however, may be as high as 90% in
women who have had a previous successful vaginal delivery, which is the greatest
predictor of a successful VBAC.

Continuous fetal monitoring should be utilised during the delivery as a change in

fetal heart rate can be an early sign of impending uterine scar rupture.
Women should be counselled that the risk of uterine rupture increases two to
three-fold with the use of uterotonic agents or prostaglandins in induced or
augmented labour.