1. OPERATIVE DELIVERY Dr Jacqueline Woodman Consultant Obstetrician & Gynaecologist

2. Caesarean Section A Caesarean section is a surgical procedure in which an incisions is made in the uterus to deliver one or more babies The first modern Caesarean section was performed by German gynaecologist Ferdinand Adolf Kehrer in 1881.

3. Indications for Caesarean Section 1.Placenta praevia 2.Transverse lie 3.Previous classical Caesarean section 4.Obstructed labour e.g. cephalo-pelvic disproportion, failure to progress 5.Breech presentation 6.Abruptio placenta 7.Previous repeated Caesarean section 8.Fetal indications:  Congenital abnormality e.g. severe hydrocehalus  Multiple pregnancy e.g. first twin breech, triplets  Cord prolapse  Severe preterm IUGR 9.Maternal request e.g. tokophobia

4. Planned Caesarean section will increase the following risks: Maternal: – Longer hospital stay – Bleeding that requires a hysterectomy – Heart attack Neonatal: – ICU admission http://www.nice.org.uk/nicemedia/live/13620/57166/57166.pdf

5. Risks of Caesarean section Maternal: – Haemorrhage: 5 per 1000 Hysterectomy: 8 per 1000 – Infection: 6 per 100 – Thrombosis: 4-16 per 10 000 – Visceral and / or vascular injury Bladder injury: 1 per 1000 – Anaesthetic risks – Death: 1 per 12 000 – Future pregnancy: antepartum stillbirth: 1-4 per 1 000 Uterine rupture: 2-7 per 1000 Placenta accreta: 4-8 per 1000 Neonatal: – Tansient tachypnoea of the newborn (TTN) – Injury to baby: 1-2 per 100 http://www.rcog.org.uk/guidelines

6. Caesarean section: the procedure Skin incision and entry? – Joel Cohen vs Phannelstiel: a 65% reduction in reported postoperative morbidity with the Joel-Cohen incision. Incision of uterus: – transverse lower segment vs Classical Closure of the uterus: – 1 vs 2 layer Closure of the abdomen: – peritoneum, sheath, subcutaneous, skin http://apps.who.int/rhl/reviews/CD004453.pdf

7. Classification of urgency of Caesarean section Maternal or fetal compromise: 1. Immediate threat to life 2. No immediate threat to moterh or baby 3. Requires early delivery No maternal or fetal compromise 4. At a time convenient to all

8. Operative Vaginal Delivery Ventouse Forceps

9. Indications for ventouse / forceps Failure to progress in second stage Fetal distress in second stage Maternal exhaustion Maternal conditions e.g. Heart conditions

10. Conditions for a ventouse / forceps Fully dilated Maternal consent Station and position of fetal head known Bladder empty Lithotomy Analgesia

11. Thank you

12. References NICE CEMACH RCOG