Operative delivery

Published on 09/03/2015 by admin

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Last modified 09/03/2015

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Chapter 40 Operative delivery

Caesarean section

Caesarean section births constitute approximately one-quarter of births in many countries. Although now a relatively safe procedure, emergency caesarean section carries an increased risk of maternal mortality and morbidity.

Risk of uterine rupture with labour after caesarean section

Classical caesarean section

The overall risk of rupture after a classical caesarean section is about 6%, with 2% scar dehiscence before labour.

Lower segment caesarean section

There is a 0.3% risk of dehiscence overall, increasing to 0.7% with labour and 0.1% at elective caesarean section.

Trial of vaginal delivery after lower segment caesarean section

Up to 40% of women undergo a repeat caesarean section after one lower segment caesarean section for a non-recurring cause. The risks and benefits of repeat caesarean section and trial of vaginal delivery require consideration when deciding on the mode of delivery.

Risks of caesarean section

Maternal risks

• higher overall maternal mortality rate compared with vaginal delivery, although comparable rates with elective caesarean section

• higher febrile morbidity

• increased blood loss

• anaesthetic risks

• increased risk of deep venous thrombosis

Neonatal risks

• increased risk of respiratory distress secondary to retained lung fluid

• birth trauma

Factors to consider in deciding the mode of delivery

• Number of previous lower segment caesarean sections: only small numbers have been reported regarding trial of vaginal delivery after two caesarean sections.

• Indications for the first caesarean section: the vaginal delivery rates are lowest when the initial indication was for failure to progress.

• Previous vaginal delivery: if the woman has had a previous vaginal delivery, there is a greater likelihood of delivering vaginally again.

• Vaginal delivery can be achieved in up to 75% of trials of labour. There is a tendency for higher vaginal delivery rates if oxytocin is used for augmentation and longer labour is allowed. The use of oxytocin remains controversial.

Symptoms and signs of uterine rupture

• acute continuous abdominal pain

• acute fetal distress

• reduction in contractions

• vaginal bleeding

Complications of caesarean section

Haemorrhage

• Haemorrhage accounts for 6% of maternal deaths associated with caesarean section.

• There are higher risks with placenta praevia, placental abruption, atonic uterus, multiparity and prolonged labour.

Urinary tract

• The risk of bladder injury at caesarean section is lower than 1%.

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