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MRCOG PART 2 SBAs and EMQs

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EMQ1502
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Essay 314 - CS

Posted by H H.

I will discuss with the patient the procedure of planned cesarean section(CS). I will tell her that it iclude delivery of her baby through her tummy. A transverse skin incision will be done just above her pubic hair line through which her womb is cut to deliver the baby. The benfit of this is to deliver her baby who is presenting by his/her hindpart,this would reduce the risk morbidity and mortality to baby (Term breech trial).
I will discuss frequent risks of CS ,including abdominal discomfort,and wound pain . Will discuss serious risks like injury to urinary bladder,and additional procedures need to repair including the application of urinary catheter post operatively, injury of ureter and how to repair, injury to bowel and might be need for colostomy and what this would invove. Will discuss possibility of bleeding,measures needed to stop bleeding blood transfusion and even the need for hystrectomy. Will discus risk of risk of venous thromboembolism and infection. Will discuss risk of maternal mortality in 1 of 12000 cases. Will discuss future risks of CS on next pregnancy (placenta previa, accreta, not having big family, reduced fertility from adhesions). Will discuss Fetal risks including, respiratory problems and possibility of fetal laceration 2%.
I will discuss type of anesthesia ,either general (GA) or regional. Will discuss risks of GA including difficult intubation and respiratory aspiration.Will tell her she will have the chance to discuss the type of anesthesia with the anesthetist.
I will discuss with her procedures that she would not like to have with out previous autherisation eg, blood transfusion and if she is a Jehovah wittness will allow her to sign a seperate consent.
I will discuss with her alternatives to planned CS, incuding external cephalic version ECV and subsequent cephalic vaginal delivery or vaginal beech delivery.Will discuss ECV ( 50% likely to succeed, risk of fetal bradycardia,compromise,risk of placental abruption,need for emergency CS, benfits of 50% of having vaginal delivery ,reducing CS rate,risk of increased operative vaginal delivery, benfits of ECV out weight risks)
Will discuss planned vaginal breech delivery , this can be done at areas of expertise are available, she can be referred to such places, will discuss term breech trial and that perinatal mortality and morbidity are increased 3 folds in vaginal beech delivery compared to planned CS.
I will give her written information of what I discussed and give her time to decide before signing. Will tell her that she can change her mind any time even after signing.




will discuss type of anesthesia with anesthetist,regional anesthesia associated with better post operatve recovery and relief of pain and allow better bonding with baby . Will take proper antiseptic measures ,personell and operation field to reduce risk of infection. Urinary bladder is catheterised to reduce risk of injury. Use tissue spliting maneuover (cohen technique) during opening the anterior abdominal wall will reduce bleeding and hematoma formation. Opening the visceral peritoneum and pushing the urinary bladder down to avoid its injury. Identification of injury of the bladder and subsequent repair after delivery of baby and repair of uterus .Urologist might be needed.
Care on opening the uterus to deliver the baby to avoid laceration of baby with scalple. Closure of uterus in two layers gives better results than single layer closure. Abdominal toilet for any collection of blood to avoid infection . Inspection of adnexae if there is any adnexal mass or ovarian cyst that should be dealt with to avoid post operative complications.
The peritoneum is not closed as this is associated with less formation of adhesions, shorter post operative recovery time,less pain and less ileus.
The abdomen is closed in layers taking care to close any dead space to avoid hematoma formation.The skin is closed by subcuticular stich to give better cosmotic results than interrupted stiches unless there is risk of wound bleeding or infection ,in which case interrupted stiches are preferred as they would allow for drainage.


Posted by SRABANI M.
SM
The woman should be informed about the benefits & risks for both current & future pregnancies of planned caesarean section versus planned vaginal delivery for breech presentation at term.She should be informed that planned caesarean section carries a decreased perinatal mortality & early neonatal morbidity for babies with breech at term compared to planned vaginal delivery.She should have all informations regarding the procedure including timing of caesarean section.Record all the factors influencing the decision & the most influential factor.She should be informed that intended benefit of section is to secure safest &/or quickest route of delivery in her situation. She should also be informed that there is no evidence that long term health of the baby with breech presentation is influenced by how the baby is born.She should also know that planned caesarean section is less costly than planned vaginal birth.Women with unfavourable clinical features should be specifically advised of increased risk to them & their babies of attempting vaginal delivery.She should know that routine radiological pelvimetry is not necessary.Woman should be advised that there is a small increase in serious immediate complications for them compared with planned vaginal delivery.She should also be informed that planned section for breech presentation does not carry any additional risk to long term health outside pregnancy. She should be advised that the long term effects of planned section for term breech presentation on future pregnancy outcome is uncertain.Before consenting, she should get information about proposed procedure & its intended benefits.Overall complication rate of caesarean section should be discussed.Also it should be mentioned that complication rate is higher when section is done during labour than it is done before labour.She should be informed about maternal risk factors like emergency hysterectomy( 7 per 1000),need for further surgery at a later date including curratage ( 5 in 1000), admission to ICU,thromboembolic disease, haemorrhage, bladder & ureteric injury & rarely death.There may be increased risk of uterine rupture in subsequent pregnancies, increased risk of antepartum stillbirth & increased risk of placenta praevia & accreta.There are some frequent risks like persistent wound and abdominal discomfort in the first few months after surgery (9%) . Increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies (25%), Readmission to hospital (5%), Infection (6%) and also fetal risk of laceration( 1%) . She should get all information regarding any extra procedure which may become necessary during section.Other procedures should be discussed & the lady’s wishes should be recorded. A record should be made of any source of information ( RCOG/ local) given to the woman before surgery.Anasthesia should be discussed.She must be aware of the form of anaesthesia & detail discussion is important with the anaesthetist before the surgery.Her BMI ( 24Kg /M2) should not pose major problem from anaesthetic point of view.Also it should be mentioned that caesarean section is associated with lower risk of perineal pain, urinary incontinence & uteovaginal prolapsed.Everything should be documented & consent should be signed before the surgery

b. The surgeon who will be conducting the operation should have appropriate training , skill ,experience & judgement for this clinical situation.The practioner supervising ( if needed) the procedure should have appropriate training which may include simulated training.The theatre staff should have proper training & equipment to deal with this procure ( incuding emergency situation or extra procedures related to this) .Good communication between the team members is important. She should have pre operative assessment including anaesthetic review.The safe delivery of this woman requires multidisciplinary teamwork including an experienced obstetrician, consultant anaesthetist, theatre staff and midwife.During surgery the skin should be cleaned properly taking extra care over umbilicus, skin folds & groin. The incision should allow adequate access which may help to reduce operating time.Transverse incision has got advantages over longitudinal incision in this lady for exposure, cosmetic effect,postoperative pain and possibility of postoperative adhesion or herniation.Use of diathermy during procedure is valuable for effective haemostasis and also reduce the incidence of wound infection( while using on the skin).Closing peritoneum does not have significant advantage.The rectus sheath should be preferably closed with a delayed absorption suture material like PDS ( Polydioxone or polygyconate).There is no evidence that subcutaneous drains reduce postoperative wound complications.She should receive intraoperative prophylactic antibiotic ( first generation cephalosporine or ampicillin, one dose).She shoud have assessment for thromboembolic risk before the procedure & ted stocking, early mobilisation, good hydration after procedure shold be offered.

Posted by Bindi J.
BJ:
A:
History of her parity and previous caesarean section including previous pelvic surgeries should be taken to assess the morbidity with caesarean section. The notes should be reviewed for placental location, placenta praevia and for operative or postoperative complications in case of previous caesarean section. The woman should be informed that caesarean section involves delivering the baby and placenta through a low transverse abdominal incision and transverse uterine incision. The woman should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for her baby compared with planned vaginal birth. However there is no evidence that the long term health of the baby is influenced by how the baby is born. The operative procedure generally takes 45 minutes in uncomplicated situations. The frequently occurring risks are- persistent wound and abdominal discomfort several months after the operation, increased risk of repeat caesarean section(25%) when vaginal delivery is attempted in future pregnancies. Infection and haemorrhage are common and there is 2% risk of fetal laceration. Seriously occurring risks are damage to the bladder and ureter. Emergency hysterectomy and thromboembolic disease are rare. There is increased risk of uterine rupture during subsequent pregnancies and an increased risk of antepartum still birth. She should be informed that extra procedures like blood transfusion, repair of bladder, bowel or blood vessels and hysterectomy may be performed if needed. The woman should be informed that sometimes forceps are used to deliver the head of the baby. The woman should be given the opportunity to discuss about regional and general anaesthesia. The woman should be told that the usual postoperative hospital stay is 3 days. The caesarean section will be booked for her after 39 weeks and the date will be informed to her. She should be provided with leaflet information and clear documentation of detailed discussion should be recorded in her notes. Another appointment may be made if she wishes. Consent may be taken in the clinic as per the unit protocol.
B:
The operation should be performed by an appropriately trained surgeon or by a trainee under supervision. Joel Cohen incision is the incision of choice. This is associated with reduced post operative febrile morbidity, less post operative pain and improved cosmetic effect. Use of blunt dissection for extension of uterine incision should be done as it reduces blood loss, incidence of post partum haemorrhage and the need for blood transfusion. Use of forceps is reserved for difficult delivery of the head of the baby. 5 I.U Syntocinon by slow intravenous injection should be used to encourage uterine contraction and to decrease blood loss. Removal of placenta should be by controlled cord traction as this reduces the risk of endometritis. Intraperitoneal repair of the uterus should be undertaken as exteriorisation of the uterus is associated with more pain and doesnot improve operative outcome. Uterine incision should be sutured in two layers. Neither visceral nor parietal peritoneoum should be sutured to decrease operative time and the need for postoperative analgesia. Routine use of wound drains and closure of subcutaneous tissue space should not be undertaken as it is not associated with a decrease in wound infection or wound haematoma. Intraoperative antibiotic prophylaxis should be offered to minimise the risk of post operative infection.
Posted by SYAMALRANJAN S.
SRS-IN
a) I will discuss the risks and benefits (according to evidence-based informations and respecting her wishes) of planned caesarean section (CS) compared with planned vaginal breech delivery. CS reduces perinatal mortality and early neonatal morbidity. No evidence about long-term health effects of baby by the mode of delivery(vaginal / CS). Small increase of serious immediate complications for the woman but does not carry any long term health complications for her outside pregnacy . Long term effects for future pregnancy outcomes are uncertain.
I will discuss the procedure of planned CS operation including risks and benefits along with alternatives( external cephalic version and vaginal delivery, also other options such as vaginal breech delivery and emergency CS if problems) .
Frequent risks and serious risks are to be discussed thoroughly.
Frequent risks includes persistent wound and lower abdominal discomfort for few months , readmission to hospital , infection ( around 5-10 / 100 cases). Others are haemorrhage (uncommon), repeat CS (very common). Possibility of fetal laceration(2/100).
Serious risks are rare such as emergency hysterectomy , admission to intensive care unit, thromboembolism, bladder/ ureteric injury, further surgery in later date like curettage . Very rarely (1/12,000) death may occur.
There are future increased pregnancy risk of uterine rupture(2-7/1000), placenta praevia / accreta(4-7/1000), antepartum stillbirth.
Extra procedure like hysterectomy , blood transfusion , repair of injuries of bladder,bowel,vessels may be required if any injuries. Other procedures like ovarian cystectomy, oophorectomy may be required and discussed. Woman’s wishes regarding these ( also about blood transfusion) should be respected and documented.
Through discussion about analgesia and anaesthesia ( may have from anaesthetist) and choices to be documented.
Information leaflet / tape to be given for further information.


b) I will give transverse abdominal incision because it has less post-operative pain and good cosmetic effects compaired with mid-line incision. Joel Cohen incision ( straight skin incision,3 cm above symphysis pubis, subsequent tissues are opened bluntly, if necessary extended using scissiors but not by knife) is the incision of choice because it reduces operative time , post-operative febrile morbidity.
If well-formed lower uterine segment , I will use blunt rather than sharp extension of lower segment because it will reduce blood loss and less incidence of post-parum haemorrhage and need for blood transfusion.
Oxytocin 5 IU slow intravenous injection during CS will enhance uterine contraction and reduce blood loss.
Placenta is to be removed by controlled cord traction but not manual removal because it decreases endometritis.
Intraperitoneal repair of uterus is preffered. Exteriorisation of uterus is not recommended ( more pain and does not improve operative outcomes like haemorrhage ,infection).
Uterine incision should repaired by two layers . Neither visceral nor parietal peritoneum is sutured because it reduces operative time , need less post-operative analgesics ,more maternal satisfaction.
Routine closure of subcutaneous fat should not be done(unless it is more than 2cm) because it does not reduce wound infection.
Superficial wound drains should not be used because it does not decrease haematoma , infection.
Prophylactic antibiotics like first generation cephalosporin or ampicillin will reduce post-operative infection(like endometritis , urinary tract , wound infection- which is around 8%)
Thromboprophylaxis (according to risk assessment like immobility, blood loss, infection) like adequate hydration , early mobilization , graduated elastic stickings, low molecular weight heparin ( following guidelines) should be offered
Posted by Chitra.s M.
The woman is offered evidence based information & support regarding Ceserean section (CS)taking her needs & belief into account.She is offered information about the indication for the procedure,the procedure itself,the maternal & fetal effects & alternatives to planned CS. she is informed that Cs involves delivery of the baby & placenta through a transverse cut in the lower abdomen.The benefit of Planned CS for breech presentation for the fetus is a lower short term neonatal mortality & morbidity when compared to vaginal breech delivery. she should be informed that elective caeserean has higher rates of neonatal respiratory morbidity though the absolute risk is small after 39 weeks.The woman is informed that the risk of fetal laceration during CS is about 2%.There is no evidence that the long term health of the baby is influenced by the mode of delivery.The maternal benefits of CS are a reduced perineal pain in short term & reduction in chance of urinary incontinence & uterovaginal prolapse long term.CS is associated with increased post op abdominal pain.The possibility of bladder /Ureter injury, need for further procedures(like laparotomy),hysterctomy, admission to intensive care unit is explained, though the absolute risks are small.CS also involves increased length of hospital stay.She is counselled that there is also an increased risk of thromboembolism & maternal death when compared to vaginal delivery.The effects on future pregnancy & delivery-like increased risk of placenta previa & accreta ,Scar dehiscence/rupture should be discussed.
She is informed that regional anaesthesia is preffered to general anesthesia as it is associated with reduced maternal & fetal morbidity.Referral to anesthetist is offerd for further discussions regarding the choice of anesthesia.
The other alternatives-external cephalic version & planned vaginal breech delivery are discussed.She is informed that ECV involves turning the baby to head first in the womb & reduces the need for CS.The success rates vary according to parity.It may be associated with fetal heart rate abnormalities,admission for labour induction,painless vaginal bleeding.Planned vaginal breech delivery is associated with increased short term neonatal mortality & morbidity.It is offerd when personnel trained in conducting vaginal breech deliveries are avilable.
The woman\'s choice should be recorded along with the factors influencing her decision. Information leaflets about CS,ECV & breech delivery are provided.Any specific concerns like those regarding blood transfusion(eg-Jehovah\'s witness)should be adressed.A follow up is arranged if further disussions are required.

B.Ceserean section (CS) should be performed using transverse skin incision as it is associated with less postop pain & improved cosmesis when compared to a vertical skin incision.Amongst the transverse incision Joel Cohen;s incision is preferred .The skin is transeversely incised 3cm above pubic symphysis& blunt opening of subsequent layers.It is associated with reduced post op pain & less operative time compared to Pfannensteil & Maylards incision.The uterine incision is extended bluntly when the lower segment is well formed.This reduces blood loss, need for blood transfusion & post partum haemorrhage.Placenta is removed by controlled cord traction .This results in reduced incidence of endometritis compared to routine manual removal.Uterotonics like 5units oxytocin iv is given to promote uterine contraction & minimise blood loss.Intraperitoneal repair of uterine incision is done as exteriorisation results in more pain with no benefit regarding blood loss.Parietal & visceral peritoneum are not closed.Non closure of peritoneum results in less post op pain & less febrile morbidity.Rectus sheath is closed with delayed absorbable sutures. Routine subcutaneous tissue closure is not done as it has no effect on wound infection.Subcutaneous tissue is closed if it is>2cm.Routine wound drains are not kept as they dont decrease wound hematoma or infections.Subcuticular sutures are used as thy are associated with better cosmetic results & reduced pain compared to staples.Perioperative antibiotics like intravenous cephalosporins or ampilcillinsingle dose is given as it reduces incidence of post operative infections.Thromboprophylaxis should be offerd, the choice(hydration ,early mobilisation,TED stocking & LMWH) depending on the risk & unit protocol
Posted by Chitra.s M.
The woman is offered evidence based information & support to make informed choice about the mode of delivery.Communication is provided taking her needs & belief into account.She is offered information about the indication for the procedure,the procedure itself,the maternal & fetal effects & alternatives to planned CS. she is informed that Cs involves delivery of the baby & placenta through a transverse cut in the lower abdomen.The benefit of Planned CS for breech presentation for the fetus is a lower short term neonatal mortality & morbidity when compared to vaginal breech delivery. she should be informed that elective caeserean has higher rates of neonatal respiratory morbidity though the absolute risk is small after 39 weeks.The woman is informed that the risk of fetal laceration during CS is about 2%.There is no evidence that the long term health of the baby is influenced by the mode of delivery.The maternal benefits of CS are a reduced perineal pain in short term & reduction in chance of urinary incontinence & uterovaginal prolapse long term.CS is associated with increased post op abdominal pain.The possibility of bladder /Ureter injury, need for further procedures(like laparotomy),hysterectomy, admission to intensive care unit is explained, though the absolute risks are small.CS also involves increased length of hospital stay.She is counselled that there is also an increased risk of thromboembolism & maternal death when compared to vaginal delivery.The effects on future pregnancy & delivery-like increased risk of placenta previa & accreta ,limitation of family size is discussed.The possibilty of Scar dehiscence/rupture during subsequent preganacies & labour should be discussed.
She is informed that regional anaesthesia is preffered to general anesthesia as it is associated with reduced maternal & fetal morbidity.Referral to anesthetist is offerd for further discussions regarding the choice of anesthesia.
The other options for present pregnancy & delivery-external cephalic version & planned vaginal breech delivery are discussed.She is informed that ECV involves turning the baby to head first in the womb & reduces the need for CS.The success rates vary according to parity.It may be associated with fetal heart rate abnormalities,admission for labour induction,painless vaginal bleeding.Planned vaginal breech delivery is associated with increased short term neonatal mortality & morbidity.It is offerd when personnel trained in conducting vaginal breech deliveries are avilable.
The woman\'s choice should be recorded along with the factors influencing her decision. Information leaflets about CS,ECV & breech delivery are provided.Any specific concerns like those regarding blood transfusion(eg-Jehovah\'s witness)should be discussed & documented.A follow up is arranged if further disussions are required.

B.Ceserean section (CS) should be performed using transverse skin incision as it is associated with less postop pain & improved cosmesis when compared to a vertical skin incision.Amongst the transverse incision Joel Cohen;s incision is preferred .The skin is transeversely incised 3cm above pubic symphysis& blunt opening of subsequent layers.It is associated with reduced post op pain & less operative time compared to Pfannensteil & Maylards incision.The uterine incision is extended bluntly when the lower segment is well formed.This reduces blood loss, need for blood transfusion & post partum haemorrhage.Placenta is removed by controlled cord traction .This results in reduced incidence of endometritis compared to routine manual removalof placenta.Uterotonics like 5units oxytocin iv is given to promote uterine contraction & minimise blood loss.Intraperitoneal repair of uterine incision is done as exteriorisation results in more pain with nodifferences in other outcomes like infection & haemorrhage.Parietal & visceral peritoneum are not closed.Non closure of peritoneum results in less post op pain & less febrile morbidity.Rectus sheath is closed with delayed absorbable sutures. Routine subcutaneous tissue closure is not done as it has no effect on wound infection.Subcutaneous tissue is closed if it is>2cm.Routine wound drains are not kept as they dont decrease wound hematoma or infections.Subcuticular sutures are used as thy are associated with better cosmetic results & reduced pain compared to staples.Perioperative antibiotics like intravenous cephalosporins or ampilcillinsingle dose is given as it reduces incidence of post operative infections.Thromboprophylaxis should be offerd, the choice(hydration ,early mobilisation,TED stocking & LMWH) depending on the risk & unit protocol
Posted by L S.
LS:
a) I would explain in non medical terms about the intended procedure which will involve delivery of the baby through the tummy, or abdomen. Step by step details of the procedure including site of incision and type of anesthetic (usually spinal, injection in the back) to be used informed. The duration of the procedure about 45 minutes informed. The intended benefit here is delivery of the baby. Serious and frequently occurring risk for caesarian section which can be divided into maternal risk, fetal risk and risk in future pregnancies discussed. Maternal risks include hysterectomy, the need for further surgery and injury to bladder or ureter. Fetal risk is mainly lacerations. In future pregnancies there are risk of uterine rupture, increased risk of placenta praevia and placenta accreta. Extra procedures which may become necessary during procedure like hysterectomy, blood transfusion and repair of injury to bowel, bladder or ureter informed. Statement of patient regarding procedures that should not be carried out without further discussion obtained and documented. Alternative to breech delivery either via vaginal breech delivery or via cephalic presentation after a procedure called external cephalic version informed. The risk and benefit of alternative procedure discussed. Information leaflet regarding caesarian section and alternative procedures given. Time taken for answering any questions and doubts that patient might have. At end of discussion patient should be able to explain all that is discussed prior to consenting. Once decision made timing, usually at 39 weeks informed and date of caesarian taken and booked. Decision on management if she goes into labour prior to operation date discussed and documented.

b) Appropriately trained surgeon for the procedure. Bladder should be catheterized and hemoglobin optimized prior to starting surgery. Her skin should be cleansed taking extra care over umbilicus and groin. The incision planned should have adequate access. Poor access prolongs operating time, makes retraction physically demanding. Transverse incision (Joel Cohens) has advantage of less postoperative pain allowing earlier mobilization and less chest infections. Diathermy is effective for hemostasis of skin incision to reduce incidence of wound infection. Use of oxytocin once baby delivered to reduce hemorrhage and encourage uterine contraction. Placenta delivered with controlled cord traction to reduce endometritis risk of manual removal. Effective hemostasis vital for safe surgery and reduces re laparotomy which carries significant added risk. Routine use of exteriorization of uterus to repair uterine incision especially if suspected angle tear although not evaluated adequately can help in ensuring hemostasis with better view during repair. Single layer uterine closure is as effective as double layer closure. Peritoneum does not need to be closed. Rectus sheath closed with delayed absorbable suture material like polydioxone. No evidence subcutaneous drain reduces post operative wound complication. Intraoperative prophylactic dose antibiotic to cover both gram negative and gram positive organism usually cefuroxime 1.5g stat dose used in our centre. Thromboembolic deterrent stockings and lifting woman’s feet during surgery and avoiding undue pressure over skin surfaces are essential for intraoperative thrombophylaxis.
Posted by Ulduz A.
a)All women with an uncomplicated breech presentation at 37 wks should be offered ECV.It should be explained that it increasing chance of vaginal delivery.
In order to obtain informed consent the procedure of CS will be explained to the women in lay terms.She has to know that CS decreases perinatal mortality and morbidity and neonatal death,but in long-term no difference by which mode baby was delivered.
CS is decreasing risk of perineal pain,urinary incontinence and uterovaginal prolapse.
Women should be aware that CS for breech presentation carries a small but serious immediate complications.
Maternal risks of CS includes infection,bleeding which may need blood transfusion,VTE,bladder,bowel,ureteric injures,Emergency hysterectomy,admission to ICU.Attidude of women to blood transfusion clarified and fixed in the notes.She should be informed about risk of maternal death which is 1/12 000.
The long-term risks for the mother,such as scar dehiscence in subsequent pregnancies,increased risk of repeated CS,placenta previa and accreta,decreased family size should be considered.
Women has to be informed that preferred method elective CS is a regional anastesia.It will give her chance to see her baby and will increase bonding.the details of anaestesia,risks and benefits will be explored when woman meets anaestethist.
At the end to make sure that woman has clear understanding of the events and consent signed by both.
Risk to the fetus includes TTN and fetal lacertations.
b)Good knowledge of anatomy,good surgical skills or surgery under senior supervision,prompt haemostasis and gentle handling of tissues are increasing chance of succesful surgery.
Prophylactic antibiotic as cephalosporins single dose given before abdominal incision to decrease wound infection and postpartum endometritis.
Abdominal incision done 3 cm above symphysis pubis as a straight line.It is cosmetically good with good healing results and less hernia formation.
Rectus sheath opened by the knife in the middle and extended by Mayo scissors.
Muscle opened by blunt separation to decrease blood loss.
Uterus opened by through lower segment transversly and extended by curved scissors as a smile to avoid uterine vessels to decrease bleeding and extension.
After delivery of the baby Syntocynon given to make uterus to contract and decrease blood loss.
Placenta delivered spontaneously,because manual removal increases blood loss and risk of infection.
Uterus closed in two layers.Peritoneal closure is not advised because it increases delayed healing,increased analgesia requirements,more adhesion formation.Rectus sheath better to close with delayed absorbable suture material as PDS.Subcutaneus fat not closed unlees it is more than 3 cm in thickness to prevent wound haematoma.Routine use of wound drains not recommended.Subcuticular stiches better because of better cosmetic appearences and less pain,no need to remove as skin steples.
Thromboprophylaxis in the form of TED stockings,sequential compression device or if appropriate LMWH after discussing with anaestethist should be considered to decrease risk of VTE.



Posted by Ulduz A.
a)All women with an uncomplicated breech presentation at 37 wks should be offered ECV.It should be explained that it increasing chance of vaginal delivery.
In order to obtain informed consent the procedure of CS will be explained to the women in lay terms.She has to know that CS decreases perinatal mortality and morbidity and neonatal death,but in long-term no difference by which mode baby was delivered.
CS is decreasing risk of perineal pain,urinary incontinence and uterovaginal prolapse.
Women should be aware that CS for breech presentation carries a small but serious immediate complications.
Maternal risks of CS includes infection,bleeding which may need blood transfusion,VTE,bladder,bowel,ureteric injures,Emergency hysterectomy,admission to ICU.Attidude of women to blood transfusion clarified and fixed in the notes.She should be informed about risk of maternal death which is 1/12 000.
The long-term risks for the mother,such as scar dehiscence in subsequent pregnancies,increased risk of repeated CS,placenta previa and accreta,decreased family size should be considered.
Women has to be informed that preferred method elective CS is a regional anastesia.It will give her chance to see her baby and will increase bonding.the details of anaestesia,risks and benefits will be explored when woman meets anaestethist.
At the end to make sure that woman has clear understanding of the events and consent signed by both.
Risk to the fetus includes TTN and fetal lacertations.
b)Good knowledge of anatomy,good surgical skills or surgery under senior supervision,prompt haemostasis and gentle handling of tissues are increasing chance of succesful surgery.
Prophylactic antibiotic as cephalosporins single dose given before abdominal incision to decrease wound infection and postpartum endometritis.
Abdominal incision done 3 cm above symphysis pubis as a straight line.It is cosmetically good with good healing results and less hernia formation.
Rectus sheath opened by the knife in the middle and extended by Mayo scissors.
Muscle opened by blunt separation to decrease blood loss.
Uterus opened by through lower segment transversly and extended by curved scissors as a smile to avoid uterine vessels to decrease bleeding and extension.
After delivery of the baby Syntocynon given to make uterus to contract and decrease blood loss.
Placenta delivered spontaneously,because manual removal increases blood loss and risk of infection.
Uterus closed in two layers.Peritoneal closure is not advised because it increases delayed healing,increased analgesia requirements,more adhesion formation.Rectus sheath better to close with delayed absorbable suture material as PDS.Subcutaneus fat not closed unlees it is more than 3 cm in thickness to prevent wound haematoma.Routine use of wound drains not recommended.Subcuticular stiches better because of better cosmetic appearences and less pain,no need to remove as skin steples.
Thromboprophylaxis in the form of TED stockings,sequential compression device or if appropriate LMWH after discussing with anaestethist should be considered to decrease risk of VTE.



Posted by Naheed M.

NM
The woman should be informed that elective caesarean section (C.S) reduce the risk of perinatal morbidity and mortality in breech presentation of a term baby .Vaginal delivery of the term breech is associated with risk of difficult and delayed delivery of baby’s head or stuck head after delivery of limbs and trunk causing higher perinatal morbidity and mortality. However there is no evidence of any effect of mode of delivery on the long term health of the baby. There is no proved benefit of x-ray pelvimetry suggesting the mode of delivery or the safety of vaginal delivery and also carries the risk of radiation. Emergency C.S doesn’t reduce the perinatal morbidity and mortality risk and the risk is equal to the vaginal delivery. Woman should be informed about the option of external cephalic version which reduces the incidence of caesarean delivery for breech presentation. Its success rate is 30-70% depends upon the expertise of the oprator. It is performed after 36 weeks in primigravida and 37 in multigravida.
The woman should be informed about the options of anaesthesia (general and regional). Regional anaesthesia carries the advantages of low blood loss, lower risk of venous thromboembolism, faster recovery from anaesthesia, and good postopertative pain control. The methods of anaesthesia should be informed to woman to help her making an informed decision. The occasional risks associated with anaesthesia should be informed such as headache. Elective C.S carries lower risk of maternal morbidity compared to emergency C.S however if compared to vaginal term breech delivery it carries higher risk of maternal short term morbidity i-e abdominal pain, constipation and hospital stay. In rare cases surgery may be associated with injuries and damage to the other organs such as bowel, bladder, ureter or blood vessels which may cause hemorrhage, need of blood transfusion or in extreme cases fertility sacrifying procedures such as hysterectomy. Woman should be reassured that these complication are rare.
She should be informed that neonatologist will attend the birth of the baby and will examine and manage the baby according to the need. She should be informed about her estimated total duration of hospital stay after an uncomplicated C.S.
B.
Preoperative prophylactic antibiotic reduces the risk of infection.
Elective C.S in a well facilitated unit (having multidisciplinary team help e.g senior( Sr)obstetrician,
Sr. anaesthetist, hematologist and radiologist) ensures the maximum reduction of the surgery related
Risks. The surgeon should be experienced or if not should perform under sr. obstetrician’s supervision. The surgeon should know the anatomy of human body well and the assistant and the whole operative room team should be efficient. All aseptic measures, instrumentation, lights and other necessities should be ensured before surgery. Selection of anaesthesia should be appropriate according to the clinical situation.
Communication between all involved health staff should be clear and efficient.
Lower segment transverse C.S carries benefit of cosmetic purpose and higher chance of vaginal delivery success in future pregnancy ( compared to the classical incision).
Hemostasis should be efficiently secured throughout surgery by pursuing blunt surgical methods through anatomical planes. Efficient hemostasis reduces risk of blood transfusion, blood-born infections, adhesion formation and postoperative anemia. Uterus should be carefully opened avoiding the risk of extension of
Incision angles and tissues handling should be gentle. In case of any surgical complication such as damage to other organs or uncontrolled bleeding, help from all possible sources (sr. obstetrician or other specilists: urologist, hematologist,radiologist) should never be delayed.
Baby’s delivery should be actively performed before the drainage of all of the amniotic fluid as this may cause difficult delivery and prolonged surgery time. After removing placenta uterus should be closed in 2 layers making sure no bleeding point left and uterus contracted well. Peritoneal layers shouldn’t be stitched as it may cause more adhesions and pain while rectus sheath should be effeiciently stitched with delayed absorbing suture like
polydiaxanone. It reduces the risk of postoperative hernia. Skin should be stitched with subcuticular suture (prolene) for cosmetic reason unless any specific indication for interrupted suturing (i
Wound hematoma). Postoperative early mobilization, adequate hydration, pain control and thromboprophylaxis (if needed) helps the fater postoperative recovery. Any evidence of infection should be promptly identified and treated with antibiotic, also Anti-D should be provided if woman is un-sensitised having Rh-negative blood group.
Posted by Bee N.
(Bee)
A healthy 26 year old woman attends the antenatal clinic at 37 weeks gestation. The fetus is in a breech presentation and she wishes to be delivered by planned caesarean section. Her BMI is 24 Kg/m2. (a) Logically outline the information you will discuss with the woman in order to obtain informed consent for caesarean section [12 marks]. (b) Discuss your operative interventions to minimise surgical morbidity during elective caesarean section [8 marks].

A) To Obtain an informed consent, I will discuss the pros and consalternatives she has to ceaserean section(CS) which will include External cephalic version and breech delivery. I will inform her the purpose of the operation is to reduce risk fetal morbidity and mortality but may increase morbidity to her. I will inform her that the operation will be done when she is 39 weeks gestation in theatre by a competent doctor. I will also let her know that this is done under a spinal anaesthesia. If this is not achieved or achievable, then she will get a general anaesthsia. The anaesthetist will go into more details about this. I will then inform her that the opration takes about 30 - 45 minutes except difficulties are encountered. She will be given a cut at the bikini line and a similar cut on her uterus. the baby will be delivered and then the placenta. The cavity of the uterus will be emptied and the utrus closed. Her ovaries and tubes will be checked and then the rectus sheath will be closed. Her skin will be closed with dissolvable stiches unless otherwise necessitated by the events during operation. I will inform her of the benefits of the operation which include delivery of baby,knowledge of time of delivery, avoidance of labour and perineal injuries. I will then inform her of the risks associated with the operation which include 2% risk of injury to the baby, less than 1% risk of bleeding which may require blood tranfusion and infection at the womb, urinary tract and skin around incision. I will inform of risk of injury to abdominal organs which is less than 1%. I will inform her that there is increased very small risk of transient respiratory problem with delivery by CS especially if delivered before 39 weeks.In subsequent pregnancies she is at increased risk of placenta accreta (abnormal attachment of placenta to walls of womb), low lying placenta and 5 in a thousand chance of uterine rupture if she labours in next pregnancy. I will inform her of that she will be in hospital for a few days after CS and it will take 4 - 6 weeks before she can go back to her usual duties or work if she wishes to do so. She will be informed of thromboprophylaxis with low molecular weight heparin.

B)Operative intenventions to reduce surgical morbidity during CS will include particular attention to asepsis to reduce infection and transverse incision to lower abdomen which reduces blood loss. I will ensure the use of prophylactic antibiotic to minimise infection. I will use as blunt incision as much as possible to minimise tissue trauma. The bladder will be catheterised before start of operation and reflected off the lower uterine segment to minimise risk of bladder injury. Incision on uterus will be with a new blade to reduce risk of trauma to uterus and infection.Incision will be at lower uterine segment which is less vascularised compared to higher segments of the uterus. Though it is adviced that the Uterus be closed in 2 layers, no randomised control trial has shown benefits over single layer closure. The peritoneum, visceral or parietal will not be closed to reduce adhesion formation and post operative pain. 5 units of oxytocin will be given after delivery of baby to help reduce blood loss. Subcuticular absorbable stitches will be used unless necessitated by events during operation in which case interuppted stitches may be used. Abdominal drains will be left when necessary and blood in the paracolic gutters cleaned out as they are potential soursec of infection and irritation to abdominal organs. All the above will be done with good operating table lightening so bleeding points can be stopped and all organs properly visualised.
Posted by hala H.
a• I will discuss the benefits and risks of C/S compared to vaginal delivery in the delivery of breech and I will document this discussion.•I will explain what the procedure is the opining at edge of pubic hair line and abdominal wall to deliver fetus from womb under GA,or epidural anesthesia ,and the benefits and risks of any available alternative as tril of vaginal delivery.or external cephalic version,and should discuss anticipated risks to mother and fetus during proceder and post caesarean section either seirous like heamorrage,bladder injury, ureteric injury, death,or frequent risk like Persistent wound and abdominal discomfort in the first few months after surgery ,infection,or Increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies. Shoud discuss any other procedures necessary durin C/S likeHysterectomyblood transfusion, repair of damage to bowel, bladder or blood vessels• Other procedures, which may be appropriate but not essential at the time, such as ovarian cystectomy should be discussed and the woman’s wishes recorded, the woman must be aware of the form of anaesthesia planned and should be given an opportunity to discuss this in detail with the anaesthetist before surgery.
b.the procedure should done by expertise person or under supervision ,should use a transverse lower abdominal incision ,should use blunt extention of the uterine incision in c shaped give oxytocin 5iu slowly intervenous injection,and use controlled cord traction for removal of the placenta to controlled, and not manual removal as this reduces therisk of endometritis.Intraperitoneal repair of the uterus at CS shouldbe undertaken. Exteriorisation of the uterus is notrecommended because it is associated with pain and does not improve operative outcomes suchas haemorrhage and infection.The effectiveness and safety of single layer closure of
the uterine incision is uncertain. the uterine incision should be sutured withtwo layers.
Neither the visceral nor the parietal peritoneum should be sutured at CS because this reduces operating time and the
need for postoperative analgesia,.In the a midline abdominal mass closure with slowly absorbable continuous sutures should be used because this results in fewer incisional hernias and less dehiscence.Routine closure of the subcutaneous tissue spaceshould not be used, unless the woman has more than2 cm subcutaneous fat, because it does not reduce the incidence of wound infection.Superficial wound drains should not be used at CS becausethey do not decrease the incidence of wound infection or wound haematoma Obstetricians should be aware that the effects of differentsuture materials or methods of skin closure at CS are not certain.
Posted by drvimaladkm@yah K.
I would inform the patient what is caesarean section in simple words in her own language ( or with the help of interpreter).It is a major operation done in the lower belly by cutting through the skin & muscles and the uterus. The baby & placenta is delivered out. The uterus, skin are stitched back. This operation is done in the interest of the baby & mother as caesarean delivery of a breech baby(in her case) would decrease the risk of(long bones & visceral injuries) morbidity & (death due to asphyxia) mortality to the baby compared to vaginal delivery. Maternal morbidity is also reduced as vaginal manipulations are not present. However there are some risks associated with the surgery like common & uncommon risks /or complications may arise. Complications increase if done as emergency & late in labour. I would provide information leaflets based on local sources.
Certain serious risks like emergency hysterectomy may be required uncommonly (7to8 in1000) in cases of nonresponding Atonic or traumatic massive postpartum haemorrhage. Blood transfusion may be required due to intraoperative haemorrhage. She may require admission to intensive care unit (depending on reason for caesarean.) (9in1000)may be due to obstetrical ,medical or anaesthetic complications like aspiration. There is increased risk( 4 to16 in every 10000 operations) of thromboembolic disease due to immobility following surgery. Viscera (bladder 0.1% & ureter 0.03%)or uterine vessels may get damaged( & may be repaired as required) more so with H/O previous caesareans or laparotomy. Death may also occur 1 in 12000 operations.
Common risks like increase in infections of the wound, pain (9%)& discomfort may persist for some months. There is more chances of readmission to the hospital(5 in 1000).Sometimes the fetus may also have cut injury about 2%.There is increased chances of uterine rupture in the subsequent deliveries (0.4%). Risks of Placenta praevia or accreta will increase(4 to 8 in 1000).There is increased chances of repeat caesarean sections in the subsequent pregnancies.
If any other associated surgery like ovarian cystectomy is planned, it has to be informed to the patient,documented & her wish to be considered. The tubectomy specific separate consent has to be taken priorhand (minimum of 7 days) to execute. If there is a need for classical caesarean section to be done as in shoulder presentation, it has to be informed to the patient. In this case after coming head in a breech delivery may require obstetric (Pipers) forceps which has to be informed to the patient.
Type of anaesthesia, mode of anaesthesia has to be discussed involving anaesthetist considering patient’s wishes though regional anaesthesia is preferred due to less anaesthetic complications.
Abdominal wall , uterine incision & exposure has to be adequate for easy manipulation & delivery of the baby.While extracting the baby by breech, the baby’s body has to be covered once delivered with a wrap so that baby does not breath prematurely to avoid aspiration &asphyxia. The assistant has to maintain the flexion of the head so that it facilitates the delivery of the head without extention preferably by modified Maurice smellie technique than Burns marshall technique as it is associated with tentorial tears or piper’s forceps is used. Placenta is delivered by controlled contraction technique after spontaneous separation so that excess haemorrhage is avoided compared to manual removal. Uterus is stitched in 2 layers with vicryl suture materials without exteriorizing the uterus(unless need to control haemorrhage) to decrease chances of sepsis. Uterovesical pouch & parietal peritoneum & Rectus muscles are not sutured to decrease adhesions. Post operative pain is also reduced. Complete hemostasis & gentle handling of the tissues reduces the risk of sepsis & adhesions.
VDKM
Posted by ASB -.
ASB
(a) I would inform the patient the operation is called caesarean section ( CS). It involve delivery of the baby and placenta through cuts in the abdomen and uterus and forceps may be used in delivery of the head of the fetus . It is the safest route of delivery of the baby as the alternative option ( vaginal breech delivery ) is associated with higher perinatal mortality and early neonatal morbidity compared with CS. General or regional anaesthesia can be used and appointment with anaesthetist can be arranged for the patient to discuss anaesthetic options . Serious risks include uncommonly need for hysterectomy , need for further surgery at later date , ICU admission ; rarely formation of blood clots and very rarely death . Future pregnancy is associated with increased risk of uterine rupture , antepartum stillbirth, and placenta praevia and placenta accreta. Frequent risks include commonly abdominal and scar pain , repeat CS in subsequent pregnancies, cuts in the baby skin and rarely infection and haemorrhage . Documentation of information given to the patient.

(b) I would perform Joel Cohen incision ( transverse straight incision 3 cm above symphysis pubis )as it has less postoperative pain and better cosmotic effect than midline incision .Transverse incision of the lower uterine segment followed by blunt extension of the uterine incision as it reduces blood loss and incidence of postpartum haemaorrhage compared to sharp extension .oxytocin 5 iu slowly iv increase uterine contractility and decrease blood loss .delivery of placenta by controlled cord traction as it is associated with lower risk of endometritis compared to manual removal of placenta .suturing the uterus inside the abdomen as exteriorisation is associated with more postoperative pain . suturing the uterine incision in 2 layers as the efficacy and safety of single layer closure is uncertain .I would leave the visceral and parietal peritoneum without suturing as this decreases operative time and need for postoperative analgesia .If midline incision is performed , mass closure is preffered to layered closure as it has lower incidence of dehiscence and hernia formation .
Posted by shmaila S.
SS

(a) I will discuss with her the risks associated with caesarean section. woman will have a bikini line incision. there is a risk of infection associated with operative delivery so prophylactic intravenous antibiotics will be given at the time of operation.woman should be informed about risk of bleeding and that sometimes bleeding could be more than expected and she might need blood transfusion, she should be enquired very clearly if she is ok to have blood and blood products if the need arise. there is a risk of injury to adjacent organs ( i.e bowel, bladder and blood vessels), if the injusy is identified at the time of surgery it will need a repair accordingly and the patient may require a bigger operation(laparotomy) with an up and down abdominal incision.having an operation increases the risk of thromboembilism and that she will need LMWH for 5 days after the operation and TEDS.there is a small risk of injury to the baby(small nick to skin).there are anesthetics risks involved but i will let my anesthetic colleague to explain this to the her. she will need a urinary catheter for 24 hrs post operation.i will give her the opportunity to ask any questions before signing the consent form.

(b) I will aim for aseptic technique to minimize infection. catheterize the patient to minimize injury to bladder,and make sure that TEDS are on to minimize thromboembolism. patient should be lying on the operative table with atleast a 30 degree tilt till the baby is delivered to ensure proper circulation . i will make sure that patient gets prophylactic intravenous antibiotics at the time of knife to skin to minimize risk of infection.i will reflect the bladder down to minimize blader injury.i will make sure that there is satisfactory haemostasis.and check if urine is clear.
Posted by Shamita S.
ANS

The woman should be given the option of external cephalic version and vaginal delivery explaining to her that a caesarean section is associated with increased risk of of bleeding ,infection and a chance of repeat c/s ,scar deheicence and placenta accreta in the next pregnancy. Hence a caesarean section should be considered only if external cephalic version fails. Breech presentation in itself is associated with increased complication whatever be the mode of delivery.She should be informed that a planned c/s is associated with reduced perinatal morbidity and early neonatal morbidity for breech presntation but no differnce in the long term health of the foetus. She should told that a c/s performed only after 39wks reduces the risk of transient tachypnoea of the new born if performed earlier.While taking consent she should be informed about the procedure involved i.e. the abdomen would be cut by a low tranverese incision and the uterus would also incised to deliver the baby .The risks associated with the procedure is to be explained which includes pain in the abdomen, infection and also more serious and rare complications like damge to bladder, bowel, increased risk of venous thromboembolism and even death (1/12,000cases) . There is risk of foetal laceration in 2% cases.She should be informed about the extra procedures needed like blood transfusion ,repair of bladder in case of inadvert injury.even hysteretomy if severe PPH (uncotrolled by other methods).She should be informed that she would have to stay in hospital for 3-4 days and the need for catherization till the effect of anaesthesia subsides.She should be made aware of the type of anaesthesia planned (regional or general )and should also have the chance to discuss this in details with the anaesthetist .The woman should be provided with information leaflets, a record of the same and the dissscussions to be kept.The womans specific decisions are to be noted and respected.

The operative interventions to reduce surgical morbidity would include a straight transvere skin incision above the symphysis pubis. It would be less painful post operatively and have improved cosmetic effect.The subsequent tissue layers are to be opened bluntly and if necessary with scissors not a knife as it is asociated with shorter operating time and reduced post- op febrile morbidity.The use of seperate knives for skin and deeper tisuse is not recommended .Uterine incision should be blunt if lower segment is formed as it reduces blood loss ,incidence of PPH and need for transfusion .The placenta should be removed using contolled cord traction not manual removal as this reduces the risk of endometritis .Intraperitoneal repair of uterus is to be done as exteriorisation is associated with pain and does not improve operative outcomes .The uterine incision should be closed in 2 layers as safety and effectiveness of single layer closure is uncertian .The visceral or parietal peritoneum should not be sutured as this does not reduce the incidence of wound infection. Superficial wound drains should not be used as it does not decrease the incidence of wound infection or haematoma .The effect of different suture materials or method of skin closure are not certain and the surgeons prefernce is apt.The surgeon should be well versed with the procedure and the staff should be well trained to reduce the surgical morbidity.



Posted by Seham S.
SESA

(a)All women with breech presentation at term should be offered external cephalic version. I would inform her that she has another option that is non surgical which is external cephalic version(ECV).It is a procedure that include gentle pressure on abdomen to turn baby from breech to head presentation and then she can be induced to deliver normaly. If patient decline the procedure or has a contraindication to it so, i would discuss operation with her .She should know that planned c/s for breech delivery is associated with reduced perinatal and early neonatal morbidity compared to planned vaginal delivery.However long term health for breech baby is not affected how the baby is born.she should also know that there is small increase in immediat complications for her compared to planned vaginal delivery.Description of procedure include incision which is transvers one above pubic line .Anaesthesia will be either regional or general. Discussion with anaesthetist will be arranged.Maternal risk is rare however it is serious and she should know about it.Risk of bowel or bladder injury,bleeding and need for blood trasfusion.Effect on future pregnancy and increase risk of placenta praevia ,placenta acreta and risk of scar dehiscence or rupure in future deliveries. On the other hand, Planned c/s have the advantage of reducing risk of urinery incontinence and uterovaginal prolapse compared to vaginal delivery. I would ask her if she understand my words or if she has any question to explain. In case patient agreed ,timing will be determined and confirmed in her notes at 39 w . If patient goes in labour before that time, discussion about managment should be documented. Counselling should be done in simple language and free from medical jargons. Information leaflet and contact detailed should be given .

(b) To minimise surgical morbidity during elective c/s ,operation should be done by experienced surgeon,proper preoperative preparation as bowel enema and catheterisation and antihistaminics .Risk assessment for thromboprophylaxis should also be done . Incision is transvers .It mieght be pfannensteil or more better is (cohen) as it is associated with less postoperative pain and more cosmotic.Blunt dissection of layers reduce bleeding .Blunt extention of uterin incision reduce bleeding and need for blood transfusion.Placenta should be left for spontaneous expulsion otherwise gentle controlled traction of cord is done as it reduce endometritis and uterin inversion and bleeding compared to manual removal of placenta. Active managment of third stage of labour should be done by syntocinon and methergin to reduce risk of intraoperative or postoperative bleeding.Non closure of peritoniem will reduce risk of post operative pain, ileus and febrile incidence. Good haemostasis should be secured and drain could be inserted if bleeding is suspected.Closure of rectus sheath by delayed absorbable suture.Subcutaneous tissue is closed if it is thick to close dead space .Skin closed in subcuticular suture as it has good healing and cosmotic appearance. Antibiotic prophylaxis could be given as broad spectrum (cephalosporin) pluse metronidazole for anaerobe.
Posted by tahira jabeen J.
tj
A)
patient will be given information that in caesarean section baby & placenta will be delivered by cut in lower part of tummy and opening womb.she needs to be hospitalized for 3-4 days.the benifit of this surgery is that delivering breech by caesarean will reduce the perinatal morbidity & mortality associated with vaginal breech delivery.i will inform the patient about risks ,the frequent risks associated with caesarean are pain and lower abdominal discomfort after several months of surgery,wound infection,she may need readmission ,can have haemorrhage during operation,there is risk of repeat caesarean section in subsequent pregnancy about one in 4 women. common fetal risk is baby may have skin cut about 1-2 in 100.baby may have slightly increased respiratory distress associated with this operation as compared to vaginal delivery.patient will be give iformation about rare but serious complications like hystrectomy,need for blood trans fusion.,bladder or ureteric injury,she may need admission in icu,may develop VTE.in future preg if she opts for VBAC may have risk of uterine rupture,placenta previa or accreta.
i will inform patient that in case of excessive hammorhage she may need hystrectomy to be performed as extra procedure,or if visceral injury needs repair of bowl or bladder or blood transfusion.
i will inform patient about other options like ECV which can turn breech presentation to cephalic about 60% & redeuce need for caesarean.or if wants & meets all criteria for vaginal breech delivery she may go for that but it is associated with increased perinatal morbidity& morta;ity.her wishes about procedure which may be appropriate but not necessary should be uder taken or no should be documented.patient should be give information leaflet,tape video about procedure.she will be given oppurtunity to see anesthetist To discuss type of anesthesia & risks associated with aesthesia.
B)
interventions take to reduce the surgical morbidity will be to cosider aseptic measures while preparing pt for surgery like povidone scrub,using sterlized techiques.to catheterize her to avoid bladder injury.by securing hemostasis properly.using sharp disection to disect bladder flap to avoid injury.opennig uterus by transverse incision ends directing upwards to avoid extention.
no blind sutures should be taken to secure hemostasis to avoid ureteric ligature or injury.uterus to be closed in 2 layers.non closure of parietal peritoneum as it will reduce pain,febrile illess & illeus.skin to be closed by subcuticular stiches .no hurry while performing surgery & early ivolvement of senior or specialist if required in case of complications.
Posted by Green K.
Green:

a) Offer option of external cephalic version(ECV) for breech if not contraindicated as it is associated with lower chance of having a Caesarean section. However if ECV is declined then an elective Caesarean section is associated with lower maternal morbidity and perinatal mortality and morbidity compared to vaginal breech delivery.
Procedure is be called Caesarean section. An incision would be made on the abdomen transversely across the pubic hairline through the layers into the womb. The baby and the afterbirth would be delivered via a transverse incision on the womb. Benefit of the procedure would be the safe delivery of the baby. Frequent risk includes admission to high dependency unit (9:1000), emergency hysterectomy (7-8:1000), need for surgery at a later date (5:1000), bladder injury (1:1000), blood clots in the legs (4-16:10,000), injury to the ureters (3:10,000) and risk of death (1:12,000). Implications to future pregnancies includes uterine rupture (2-7:1000), antepartum still birth (1-4:1000) and afterbirth covering the os and deeply adherent after-birth (4-8:1000). Increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies (1:4)
Frequent occurring risks includes persistent wound and abdominal discomfort in the first few months after surgery 9:100), readmission to hospital (5:100), hemorrhage (5:1000) and infection (6:100). Risk of fetal laceration is 1-2:100.
Extra procedures that may be needed during the procedure includes hysterectomy, blood transfusion and repair of damaged bowel, bladder or blood vessels. Patient\'s wishes on procedures which may be appropriate but not essential such as ovarian cystectomy/ oophorectomy would be documented.
Type of anesthesia planned (regional) as it is safer and associated with less maternal and neonatal morbidity compared to general anesthesia. Provide patient information leaflets on Caesarean section and its risks. Patientl\'s wishes woud be respected.

b) Intraoperative single dose antibiotics such as cephalosporin or ampicillin to reduce risk of postoperative infection. Proper scrubbing technique by surgeons and nurses to reduce risk of infection. Use of antiseptic solutions to clean wound site and ensure sterility of instruments to reduce infection risk. Catheterization of the bladder to reduce risk of bladder injury. Procedure done by trained operator or trainee under supervision to ensure proper surgical technique. Joel-Cohen incision used as it is associated with reduced postoperative febrile morbidity and shorter operating times. Blunt extension of uterine incision as opposed to sharp extension reduce blood loss and incidence of postpartum hemorrhage and need for transfusion. IV Oxytocin 5units used to encourage contraction of the uterus and decrease blood loss. Placenta removed via controlled cord traction as manual removal is associated with increased risk of endometritis. Intraperitoneal repair of of the uterus as exteriorisation is associated with more pain. Uterus closed in 2 layers as single layer closure as effectiveness and safety of single layer closure is uncertain. Parietal and visceral peritoneum not sutured to reduce operating time , reduce need for postoperative analgesia and improves maternal satisfaction. Routine closure of subcutaneous fat avoided unless more than 2cm thick as it does not reduce incidence of wound infection. Superficial wound drains avoided as it does not decrease incidence of wound infection or haematoma. Skin closure with subcutaneous absorbable sutures as it is associated with reduced postoperative pain and is provides good cosmetic effect. Postoperative thromboprophylaxis with low-molecular weight heparin and thrombolembolic deterrent stockings should be administered as per unit\'s protocol.
Posted by Im F.
A
previous obstetriric history shoild be reviewed parity previous mode of delivery and complication should be inquired.
options regarding mode of delivery ie vaginal breech, external cepalic version and section should be informed and documented.
she should be advised that planned ceaserean section reduces the risk of perinatal mortality and morbity as compared to vaginal
breech deliveries.


external cepalic version reduces the chance of breech presentation at delivery.it has low rate of complication.
it lowers chance of having c/s.succesful rate is 50% with a trained operator.it is done at 36 wks in primi and at 37
wks in multipara.it is associated with fetal tachycardia and non reactive CTG but no
evidence of increase neonatal morbidity and mortality.antepartum heamorrhage and uterine rupture are rare complications
.external cepalic version is associated with pain but severe pain is experienced by 5%.


planned caesarean section which is done at 39 wks to prvent respiratory morbidity in neonate.reginal ansethesia is

offered as its safer with less maternal and neonatal morbidity.perinael pain is reduced but increase in

inabdominal pain.injury to bladder ,ureteric injury is increased compared with vaginal delivery.the rate of further

surgery ,hysterctomy and admission to intensive care is increased. risk of thomboembolism is increased

.length of stay and re admission rate are also high. but there is no difference in risk of heamorhage infection

and genital tract injury.
long term effects of planned caesarean section include reduction in urinary incontince, utero vaginal prolapse
as compared to vaginal delivery and is associated with difficulty to concieve .rate of placenta previa,uterine rupture
and still birth increases.

.thereis no difference in feacal incontinence ,backache postnatal depression and dysparunia.



B
the section should be performed by an adequately trained staff.it should be done in a center where transfusion

facilities are avaiable.prophylactic antibiotics such ist genaeration cephalsporins should be gine as it reduces risk
of post op infections. thromboprophylaxis reduces the risk of deep venous thrombosis and pulmonary embolism..
antacids to reduce gastric volume and acidity thereby reducing risk of aspiration pneumonitis and antiemetics to
reduce nausea and vomiting. the incision should be transverse 3 cm above the symphysis pubis as lower than this
causes bleeding and discomfort.

subsequent layers to be opened bluntly as this reduces the operating time and postoperative febrile morbidity.
extention of incision on uterus should be blunt as it reduces the blood loss ,incidence of postpartum heamorrage

and transfusion.oxytocin 5 iu im to reduce bleeding .

removal of placenta by controlled cord traction as manual removal increses blood loss and rate of infection.peritoneal

closure should be avoided as it increase operative time.exteriorization of the uterus sholdbe avoided as its associated
with pain and does not improve operative outcome.subcutaneous fat should only be sutured if its more than 2 cm as
routine closure is does not reduce the incidence of infection.wound drians should be avoided as does not reduce
incidence of wound heamatoma and infection.
Posted by R S.
R S

a. The information given includes explanation of the procedure; it involves a transverse incision at bikini line to allow access to the abdominal cavity. Caesarean section for breach presentation is associated with reduce incidence of perinatal morbidity and mortality in comparison with planned vaginal delivery. Further more there will be less pelvic floor dysfunction particularly if the woman didn’t give vaginal delivery before. However, there is small increase in immediate serious risks like urinary tract injury, bowel injury or hemorrhage that require return to theater. Other frequent complications include urinary tract infection from catheterization, post operative pain or wound infection. We inform her that other procedures might be performed like blood transfusion, repair of urinary tract or bowel if injury had occurred.
Alternatively she might have a trial for vaginal breech delivery; it should be conducted in a hospital where trained personnel in vaginal breech delivery are present. However, it might end with emergency CS if vaginal delivery trial had failed. Other alternatives include external cephalic version. It involves rotating the fetus to the cephalic lie. It is successful in 30-80% of cases and can reduce the incidence of CS to the half. On the other hand, it might be associated with small increase in risks like abruption, fetal distress or fetomaternal hemorrhage which may need emergency CS in 0.5% of cases.
She will be offered the opportunity to discuss type of anesthesia with the anesthetist.

b. I will advice for emptying the bladder to reduce risk of ladder injury. Access to peritoneal cavity is preferably done cephalid to reduce bladder injury also. The bladder is reflected carefully from the lower uterine segment, this will help drawing the ureters away from the surgical field.
Uterine incision ends are preferably directed upward so if extension occurred; there will be less incidence of ureteric injury or broad ligament heamatoma. If adhesion present, careful blind dissection is preferred to sharp dissection.
If hemorrhage occurs, meticulous heamostasis should be done with avoidance of inserting blind sutures or stitched. Pressure with a swap is advisable.
Carefulness with the use of diathermy to avoid bowel injury.
If difficulty encountered, we should call for help of more experiences colleague, also for urologist or general surgeon if complication happened.
Drains will be needed when there is risk of accumulation of blood in the peritoneal cavity to allow drainage especially if the patient is planned to receive anticoagulant postoperatively.
Posted by S S.
(a)I would like to know as why she wants to go for cesarean section. Since cesarean section is an operative intervention and is associated with increased maternal morbidity as compared to vaginal delivery, external cephalic version (ECV) should be discussed with her as an option. The risks associated with cesarean section are haemorrhage, infection, injury to surrounding viscera like bowel and bladder, this more likely if there has been a previous pelvic surgery, trauma to the baby and delayed recovery as compared to vaginal delivery. The other procedures that may be done are repaire of injured structures like bowel, bladder, ureters and cesarean hysterctomy in case of massive post partum haemorrhage. She may also need blood transfusion and risks associated with it, though minimal. Cesarean is usually done under regional anaesthetic but general may be required in cases of failed regional or when regional is contraindicated. Complications associated with regional are risk of infection, post dural puncture headache and dural hematoma formation. The risks associated with general are difficult intubation, Mendelson\'s syndrome and haemorrhage due to uterine relaxation. The baby is also at increased risk of respiratory complications. The alternatives to cesarean are external cephalic version followed by vaginal delivery and vaginal breech delivery.
ECV can be offered to women with singleton breech, without history of previous cesarean section at 37 completed weeks. history of preeclampsia and antepartum haemorrhage in current pregnancy should be ruled out. Fetus should be of average size, unengaged, not in footling presentation and liquor volume should be adequate. The person performing ECV should have enough expertise and facilities for performing emergency cesarean section should be available. The complications during ECV are fetal bradycardia, placental abruption, cord compression, true knota and emergency cesarean section. It can be unsuccessful or in some cases fetus can revert back to breech and in such situation cesarean section is indicated.
Evidence from term breech trial suggest that cesarean section is a safer mode of delivery for fetus as compared to vaginal breech delivery which is associated with increased perinatal morbidity and mortality. Apart from this expertise for conducting vaginal breech delivery should also be available.
(b)The operative interventions to minimise complications are meticulous hemostasis to minimise risk of haemorrhage, like subcutaneous bleeders should be cauterised, uterus opened by blunt incision and closed in two layers, in case of excessive intra abdominal or subcutaneous bleeding drains should be put in to avoid hematoma formation and to give estimation of blood loss. Oxytocin or syntometrine should be given after delivery of the shoulders. Placenta should be removed completely and should be checked for completeness before uterine closure. Antibiotic prophylaxis after cord clamping to reduce post operative infective morbidity. High risk of suspicion of adhesions and meticulous technique to minimise risk of injury to surrounding viacera. Continuous bladder drainage to minimise risk of bladder injury. Intraoperative thromboprophylactic measures like pneumatic comperssion or use of graduated compression stockings to decrease the risk of deep vein thrombosis. Senior help should be sought sooner than later if difficulty is encountered at any step. Continous training and auditing should be done as part of assessment of competency and professional development.
Posted by Dr Dyslexia V.
X
a) I would inform her that caesarean section (LSCS) is a form of surgery requiring delivery of fetus via a vertical incision made on the supra pubic region. Based on current situation, she could attempt external cephalic version which is about 50% successful and would be able to allow her a normal vaginal delivery. If ECV failed or declined, she could still be counseled regarding vaginal breech delivery if all the prerequisites met such as fetus less than 3.8kg in facility and obstetrician able to conduct vaginal breech delivery.

However, planned LSCS is associated with less mobility. Serious risk include death which is 1 per 12,000, hysterectomy, bladder, ureter, bowel injury ranges from 3 to 10 per 10,000 deliveries. Other perioperative risks include infection and thromboembolic disease which also could occur but could be minimized with prophylactic antibiotic such as ampicillin and VTE reduced by low molecular weight heparin, early ambulation and good hydration. Other injury include, injury to fetus such as accidental laceration which ranges 1% of delivery.

I will also ask her wishes in regards to blood transfusion if required and of requiring any additional procedure such as accidental discovery of an ovarian cyst which might require cystectomy.

She will be informed that routinely that she will be offered spinal or epidural anesthesia which include post-op pain relief. The need for general anesthesia is based on circumstance such as failed spinal anesthesia and is associated with an higher risk.

Future pregnancy after 1 caesarean section should be informed as there is risk of uterine rapture in about 2 to 7 per thousand deliveries. Increase risk of antipartum and perinatal mobility and mortality of neonate is increased in subsequent pregnancy. Risk of placenta previa and acreta is increased in subsequent pregnancies.

b) The risk of operative mobility is reduced by performing a planned LSCS as suppose to an emergency LSCS. Intravenous access is cited while blood is taken for full blood count for hemoglobin status and group safe and hold if required a patient who might have uncorrected anemia. Adequate fasting of more than 6 hours, use of regional anesthesia, use of antiemetics and H2 antagonist given pre-op could reduce aspiration syndrome. The use of indwelling catheter is important as to reduce risk of bladder injury and useful to monitor urine output. Incision could be done via Cohen incision which is a horizontal incision placed above the pubis symphasis reduce post-op recovery mobility compared to a vertical incision. Uterine incision could be done bluntly after initial incision by sculptor as to reduce risk of uterine artery. Uterus should be close in 2 layers to reduce risk of dehiscence or bleeding post-op. Peritoneal closure not done to reduce post-op pain and adhesion. Preoperative antibiotics such as ampicillin should be given to reduce infection and endometritis. VTE prophylaxis given with low molecular weight heparin, adequate hydration and early post-op mobilization. The rectus sheet is closed with vicyl sutures to prevent incisional hernia. And the skin closed with subcuticular sutures for proper hemostasis and cosmetic affect.
Posted by Sarika N.
A healthy 26 year old woman attends the antenatal clinic at 37 weeks gestation. The fetus is in a breech presentation and she wishes to be delivered by planned caesarean section. Her BMI is 24 Kg/m2. (a) Logically outline the information you will discuss with the woman in order to obtain informed consent for caesarean section [12 marks].
A)Breech presentation has a high implication on increasing Caesarean section rates since Term Breech trail has been published and suggested that planned C/S reduce perinatal mortality and short term neonatal morbidity. The incidence of breech presentation is 4%. In absence of contra- indications for ECV as placenta previa, uterine abnormalities, previous caesarean section, SROM, fetal distress, IUGR, APH within last 7 days , it should be offered to the pateint as can reduce the risk of breech presentation in labour.
The patient should be counselled that spontaneous rotation is about 8% for nulliparious women after 36 weeks, the success rate of ECV is about 50%, but depend on parity, ethnicity, uterine tone, liquor volume. In nulliparious woman the success rate is 40%, for multiparious about 60% by trained operator with low complications rate.
The patient wishes are important and information regarding immediate and long term complications of Caesarian section should be given. Caesarean section is not risk free proceedure and immediate complications are bleeding, pain, ureteric, bladder injury, thromboembolic disease, in rare cases hysterectomyand ITU admission, long term complications include increased risk of placenta previa in future pregnancies, uterine rupture, SB in future pregnancies, roblems with fertility and neonatal respiratory morbiodity. Patient should be informed re steps of the proceedure and what it involves: benefits, risks, catheter, TED stockings, discussion with anaesthesist regarding the risks of the anaesthesia, incision, length of stay in the hospital for about 24 48hours if no complications, regular analgesia, recovery and explain signs and symptoms of endometritis, UTI, thromboembolism when discharged. Consent form should be signed and confirmed.
(b) Discuss your operative interventions to minimise surgical morbidity during elective caesarean section [8 marks].
Preoperatively haemoglobin should be checked to exclude anaemia as it can increase the risk for PPH. Assess risk of thromboembolic disease ( offer TED stockings, hydration, early mobilisation and LMWH).
In the theater site indwelling catheter, which reduce the risk of injury to the bladder. During surgery using Pfanensteil incision is associated with quicker recovery and more cosmetic appearance. Bladder should be reflected from the low segment to avoid injury.
Blunt extention of the uterine scar is associated to less trauma to the fetus and less haemorrage. Controlled cord traction should be used to remove placenta as will reduce the risc of trauma to the uterus and uterine inversion. To reduce bleeding Oxytocin 5IU by slow IV injection should be given after delivery of the baby.Closing the uterine incision with two layers provide better haemostatic effect, healing. One dose of IV antibiotics reduce the risc of infection.
It is important to avoid visceral or parietal peritoneum as it is incresing perioperative time and febrile postoperative morbidity, also avoid superficial wound drains as it can cause infection and delayed healing. Avoiding exteriorising the uterus as it can be traumatic to the surrounding tissues. After the operation patient should be monitored in recovery area with one-to -one observations until stable. In the ward half hourly observations for the first 2 hours are recommended. Good analgesia and support are important part of the postoperative care.
Posted by Bgk H.
;)

A. I will discuss in sensitive and non judgemental manner. Her decision need to be respected. However patient need t be given enough and correct information in order for her to make an informed decision.
She should be discussed about the procedure of caesarean section. This involve making about 10 cm low transverse skin incision, entering the abdomen and making a cut at the lower part of her womb to deliver the baby. The intended benefit is to deliver the fetus through abdominal route and reduce the risk of fetal and neonatal morbidity to compare with delivery vaginally.
The frequent occurring risk such as pain morbidity, bleeding, and infection should be informed. The serious risk of caesarean section like bowel, bladder, blood vessel injury and ureter should be informed. The risk of massive bleeding need to be informed and it may lead to hysterectomy and death.
The extra procedure that may be taken like blood transfusion should be informed if needed. And the additional need of visceral repair if noted to be injured during the procedure.
Her expectation post procedure such as pain relief, thromboprophylaxis injection, urinary catheter and wound care should be discussed.
She should be given the option of External Cephalic Version ECV if it is not contraindicated. Condition such as placenta praevia, ruptured membrane or recent antepartum haemorrhage are not suitable for trial of external cephalic version. However the success rate of the procedure in general and local institutional data needs to be informed. The entire procedure and the risk of ECV such as transient fetal bradycardia, placenta abruption, and pain need to be informed.
She should also be aware about the option of vaginal breech delivery in a suitable and properly selected patient. However this is associated with the risk of fetal and neonatal morbidity.
She should be discussed that it is recommended to perform the procedure at 39 weeks of gestation to reduce the risk of neonatal complication. However if she is in labour before the date of the operation, she must be aware that she might need to undergo emergency caesarean section.
She should be informed that there is possibility that the fetus may turn to cephalic presentation spontaneously and caesarean section is not warranted anymore. She should be informed that fetal presentation should be determined before the operation start.
The implication of her next pregnancy like risk of placenta praevia, uterine rupture and limited family size should be told.
The anaesthetic choice should be informed and appointment with the anaesthetic should be arranged.

b. She should be admitted as close as possible to day of surgery to reduce risk of hospital acquired infection and maternal anxiety. She should be given sodium citrate and antacid before the procedure to avoid mendelson syndrome.
She should be identified in theatre. The procedure should be done by experienced operator of trainee under supervision. The equipment must be well maintain and in good condition. Shaving is not recommended. Bladder should be catheterised
Procedure must be undertaken in aseptic technique. Preferably pfanensteil skin incision should be made as it reduce the pain morbidity and cosmetically more acceptable. Blunt technique of separating the peritoneum reduces the occurrence of bleeding and visceral injury.
Uterovesical fold should be carefully identified and incised. Bladder should be pushed downward away from the lower segment using wet gauze. Uterine incision can be made with the same blade as skin incision. Exteriorizing the uterus is not recommended. Manual removal of the placenta should be avoided. Os should be open up for drainage of blood and lochia.
Double closure of uterus has not been proven to reduce the morbidity, however single layer closure can only be taken place in research setting. Peritoeum layer should not be closed as it may prolonged the operative time and increase the usage of suture material.
Haemostasis should be secured before closing the abdomen. Minimal tissue handling should be practiced all the time. Routine usage of drain is not recommended.
Subcutaneous fat layer need to be approximated if more than 2 inch thickness.
Posted by G. K.
GSK
A)
If the present pregnancy is uncomplicated without any fetal compromise hsuch as APH, uterine abnormalities, previously scarred uterus and abnormal placentation, she should be offered the the option of external cephalic version. (ECV) if not offered before. she should be told that that it reduces the risk of C/sec and the asoociated risk.
If the ECV has failed or declined by the patient, she should be counselled about the procedure of C/sec.She should be told that it\'s an operative delivery which is usually done under regional anasthesia ,involving a cut in the lower part of the tummy above the bikini line and then a cut in the uterus to deliver the baby.She should be told that if the procedure is done under regional analgesia, she will be awake and will see her baby being born. Also her partner can accompany her if she wishes.During the procedure she may feel touch and presure but will not feel any pain.
She should be councelled about the risks of the procedure which include damage to bowel and bladder, ureteric injury, need for blood transfusion and the risk of laceration to the baby with scalpel during opening the uterus intraoperatively.Immedietly postoperatively, there\'s risk of abdominal pain,difficulty mobilizing due to pain,increased risk of thromboembolism, and difficulty with establishing breast feeding if she wishes to breast feed.Also her stay will be longer and recovery will be slower as compared to a vaginal delivery.She should be told that there\'s no increase risk of infection, genital tract injury, back ache, dyspareunia, fecal incontinence when compared to vaginal delivery. She should be told that there\'s increased risk of respiratory morbidity in the newborn as compared to vaginal delivery.
She should also be councelled about the long term implications of c/sec which include abnormal placentation (placenta previa and placenta accreta) in a subsequent pregnancy,the risk of emergency c/sec if she she wishes to deliver vaginally the next time,risk of uterine rupture, risk of adhesions making any further surgery more difficult.She should also be told that the risk of uterovaginal prolapse and urinary incontinene decrease with c/sec.
B)
To minimse surgical morbidity, the patient should be fasting overnight to reduce the risk of aspirations of gastric contents during the procedure. She should receive thromboprophylaxis and TEDS to reduce the risk of thromboembolism. She should be prescribed antibiotic prophylactically in the form of a single dose of ampicilin or cephalosporin to reduce the chances of infection.The procedure should be done under regional anasthesia to reduce the morbidity associated with general anasthetic.The patient should be catheterised to avoid risk of damage to the bladder.
The surgeon carrying out the procedure should scrub thoroughly and observe aseptic measures. He/she should be experienced or otherwise the procedure should be done under supervision of a senior obstetrician.
During the procedure , the abdomen shold be opened with pfennenstiel iincision 2cm above the symphysis pubis.During dissection of the bladder too much lateral disection should be avoided. uterus should be opened by making an incision in the lower uterine segment with corners of incisions going upwards so as to avoid lower extension of the scar into the vagina.The incision in the uterus should be extended bluntly with fingers.After deliver of the baby , oxytocin 5IU should be given IV. The placenta should be removed with controlled cord traction and manual removal should be avoided.The uterus should be closed in two layers. The closure of peritoneum should be avoided as it leads to increased posoperative pain and adhesion formation.The routine closure of fat layer should be avoided unless it is more than 2cm thick.After closing the skin, the wound should be cleaned and a sterile adhesive dressing should be applied.The patient should be continued on LMWH and IV fluids posoperatively. Early mobilzation should be encouraged.
Posted by Sarika N.
S/N
Her request of Elective LSCS will be respected as CS at term had been shown to reduce perinatal mortality, morbidity and short term neonatal morbidity without affecting maternal mortality rate according to term breech trial.

Other benefits of CS include; less perineal pain, lower risk of urinary incontinence and utero- vaginal prolapse. On the other hand risk of CS will be explained: abdominal pain, haemorrhage and need for blood transfusion, bladder injury 1/1000, bowel injury. Risk of venous thromboembolism 16/100 000 , as well as anaesthetic risk and maternal death 1/12000 .CS also associated with increase hospital stay ,febrile morbidity, increase need of analgesia ,increase rate of CS in her future pregnancy ,low lie placenta ,morbidly adherent placenta as well as not having more children.

Additional procedures during CS also will be discussed like blood transfusion and her acceptance to that, repair of any damage and rare possibility of hysterectomy and ITU admission.

Neonatal risks after elective CS include; neonatal respiratory morbidity especially if cs done before term, risk of foetal laceration during cs 1-2/100.

Alternative procedures will be discussed as External cephalic version has success rate of 50% and can reduce rate of breech presentation at term but carries risks of reversion ,Emergency cs for foetal distress and associated with abdominal discomfort and sometimes painful. .Other alternative is vaginal breech delivery but it carries risk of increased perinatal mortality and morbidity and necessitates a special expertise in breech delivery.
Information leaflet will be given and time to think if requested before making informed consent. All discussion points will be clearly documented in her notes and time for operation will be given between 39-40 weeks to avoid neonatal respiratory morbidity.

B) On admission she will be offered quick USS to confirm the presentation and avoid incidental version to cephalic presentation before operation. Indwelling Foley’s catheter will be inserted, preliminary FBC and group& save will be taken. After regional anaesthesia which is the preferred method in her case .Modified Joel Cohen incision is preferred as it has less bleeding and less operative time. Transverse lower uterine incision but with blunt uterine entry to avoid foetal laceration. skills in breech delivery is still very important and methods for delivering the shoulder like Lovset manoeuvre as well as methods to deliver after coming head including use of Forceps to avoid uterine laceration and unnecessary extension of uterine angles and /or extra vertical incision to deliver the head . Carful handling of breech and avoiding unnecessary force to avoid iatrogenic fracture of the femur or hip dislocation and abdominal visceral injury.

Placenta will be delivered by CCT as it shown to minimise blood loss. Oxytocin 5 Iu after delivery of the head to minimise blood loss due to atony as well as one dose of IV broad spectrum antibiotic to minimise risk of infection. Careful closure of uterus after ensuring empty uterine cavity and adequate haemostasis should be given. Non closure of visceral and parietal peritoneum carries less post operative febrile morbidity and pain plus less operative time .abdominal closure by absorbable suture material after ensuring complete swabs ,needles and instrumental count.
Patient will be offered good analgesia, hydration and thromboprophylaxsis after assessing her thrombosis risk in addition to TEDS stocking which should be applied at the beginning of the procedure until fully mobilised.
Clear documentation of all operative details including the neonatal assessment of baby after delivery given by attending nenatologist.
Posted by Jan I.
Jan

Given her breech presentation and decision for an elective Caesarean section (CS) it would be necessary to discuss alternatives including external cephalic version (ECV) and breech vaginal delivery. I would do this using terms & language that the patient understands. I would explain that ECV aims to turn the baby to \'head down\' by manipulating it through the abdomen. If successful the pregnancy can be allowed to continue without other intervention awaiting spontaneous labour. I would explain that the success of ECV depends on size of the baby, liquor volume, engagement of the breech and flexion status of the legs but it is approximately 50%. There is a very small risk of fetal distress (secondary to abruption or cord accident) that may necessitate emergency CS and a chance that the baby will return to a breech presentation even after successful version. I would explain that a breech vaginal delivery is an option though based on the findings of the Term Breech Trial there is increased perinatal morbidity and mortality associated with this. There is an increased risk of cord prolapse necessitating emergency CS (especially if a footling breech presentation) that carries risks to the baby. If she declines these and still wishes delivery by CS I would discuss the risks and benefits of the procedure. The benefits are that it avoids the risks associated with vaginal breech delivery and ECV. There is also a decreased incidence of pelvic organ prolapse compared to vaginal delivery. The risks are a risk of infection (usually of the wound or urinary tract), trauma to bladder, ureters or bowel that will necessitate subsequent repair & haemmorhage that may require blood transfusion. There is a risk of thromboembolic disease including deep vein thrombosis or a pulmonary embolus. The risks of these can be reduced by the use of TED stockings and low molecular weight heparin after delivery. There is a small risk of fetal laceration of 1-2%. There is also a risk of transient tachypnoea of the newborn which may require admission of the baby to the neonatal unit. Longer term consequences include a risk of uterine rupture if vaginal delivery is attempted in a subsequent pregnancy (approx. 3 in 1000) and an increased risk of emergency CS. There is an increased risk of placenta praevia and morbidly adherent placenta. There is also a reduction in fertility and the potential for adhesion formation which may complicate future abdominal/pelvic surgery. I would advise her that compared to vaginal delivery there is increased post delivery pain associated with CS. The details of this discussion should be entered into the patient\'s notes and a consent form should be signed.
The procedure should be done by an adequately trained surgeon (with support or supervision if appropriate). The CS should be done with regional anaesthesia as this avoids the risks of a general anaesthetic & intubation. The patient should have pubic hair shaved on the table as this reduces the incidence of superficial infection (compared to shaving in advance). Gastric acid reducing medication should be given preoperatively to reduce the risk of acid regurgitation during delivery and subsequent Mendelson\'s Syndrome. The bladder should be catheterised to reduce its volume and therefore reduce the likelihood that it gets damaged during the operation. Flowtron boots should be worn by the patient on table to reduce stasis of blood flow in the lower limbs which can predispose to deep vein thrombosis (DVT). Prophylactic antibiotics should be used intraoperatively to reduce the incidence of postoperative infection. The procedure should be performed through a transverse suprapubic incision as this heals faster with less post-operative pain and infection than a midline incision. Meticulous attention should be given to haemostasis during entry into the abdomen to reduce blood loss. The bladder should be reflected inferiorly to reduce the chance it is damaged; this will also move the ureters and reduce the likelihood of trauma to them during repair of the uterine incision. Care should be taken during the transverse lower segment incision to the uterus to avoid fetal laceration. This can be completed with a blunt instrument or with a finger to avoid the use of a scalpel. Delivery of the baby should be done with care to avoid extending the uterine incision angles with can increase blood loss and the incidence of ureteric injury. The cavity should be inspected and swabbed to confirm no placental tissue remains; this can predispose to post operative uterine infection. Sytocinon should be used to promote uterine tone and reduce blood loss. A two layer closure of the uterus should be performed as this reduces the risk of subsequent uterine rupture. A drain should be sited if there are concerns about potential ongoing surgical blood loss to reduce the incidence of a haematoma formation and to increase the chance that this is noticed sooner postoperatively. A fat stitch can be used if the subcutaneous fat layer is greater than 2cm as this reduces the likelihood of a wound haematoma. TED stockings and low heparin should be used postoperatively to reduce the incidence of DVT.
Posted by Atashi S.
( a ) As the patient decided to deliver the baby by caesarean section I will discuss the information to obtained informed consent including, explanation of the procedure, intended benefit of elective C/S than trial of vaginal birth at term breech and also inherit risk of this operative procedure. Baby is to be delivered per abdominaly through a low transverse incision above her bikini line. Planned C/S is associated with significant reduction in perinatal /neonatal mortality and serious morbidity and a significant reduction in the perinatal /neonatal death.Cesarean section associated with lower risk of perineal pain,urinary incontinence,utero vaginal prolapse. Planned C/S is associated with a small but significant increase in maternal morbidity.Serious maternal risk include emergency hysterectomy may be needed(7 to 8 per1000).Need for surgery at a later date, including curettage( 5 per 1000 ).Admission to intensive care unit ( highly dependent on reason for C/S;( 9 per 1000 ).Risk of thromboembolic disease( 4 to 16 per 1000 ).Haemorrhage( 5 per 1000 ).Risk bladder injury 1 per 1000,ureteric injury 3 per 10000.Risk of maternal death 1 per 12ooo.Frequent maternal risk include persistent wound and abdominal discomfort in the first few months after surgery( 9% ).Increase risk of repeat section when vaginal delivery is attempted in subsequent pregnancy(25%).Readmission to hospital (5% ).Risk of infection ( 6% ).There is 1 to 2 % risk of fetal lacerations. Risk in future pregnancy include uterine rupture in pregnancy / delivery( 2 to 7 per 1000).Increase risk of antepartum still birth (1 to 4 per 1000 ). Increase risk of placenta praevia and placenta accrete in subsequent pregnancy( 4 to 8 per 1000 ).Extra procedure which may become necessary during the procedure including hysterectomy , blood transfusion, repair of injury to damage bowl, bladder, blood vessels.Other procedure, which may be appropriate but not essential at the time, such as ovarian cystectomy/oophorectomy should be discussed . Procedure and plan of anesthesia and analgesia need to be discuss with her. I will provide her information leaflet.

( b ) To minimise surgical morbidity I will set the time of operation in that hour when a good surgical team including a paediatrician is available .I will open the abdomen by Joel cohen incision which is associated with less post operative pain, allow early mobility,less chest infection and allow better cosmetic result Proper haemostasis is to be achived by appropriate use of diathermy to avoid haematoma formation. Catheterization of bladder is to be done to minimize the risk of injury.Prophylactic broad spectrum antibiotic is to be given to minimize the risk of infection .Viseral peritoneum is to be opened and bladder is to be mobilize to avoid injury. Lower segment is to be identified properly and then incision is to be given. After removal of placenta uterine exploration is to be done to exclude retained product of conception. Closure of peritoeum is not to be done (both viseral and parietal ) as it is associated with reduce adhesion formation, shorter post operative recovery , less pain , less ileus. Adequate hydration need to be maintained by iv fluid during the procedure and TED stocking should be given to minimize thromboembolic manifestation.

Posted by Julia K.
Since this patient wants to go ahead with the option of elective caesarean section I am as medical professional obliged to provide her with accurate and evidence based information regarding the risks and benefits. I will inform her that caesarean section involves the delivery of the baby and placenta through the cut (usually transverse) on the abdomen and uterus. The benefit of the surgery is to provide a safer mode of delivery for the baby in this particular case. Since the term breech trial showed the reduced risk of stillbirth and perinatal morbidities for breech babies delivered via elective caesarean section versus vaginal route. The operation carries some risks that could be divided into two groups 1) frequent and 2) rare but serious. The first one includes abdominal pain and infection 4-8% (wound, endometritis and urinary), laceration to the baby (1-2%), haemorrhage 0.1%, readmission to the hospital 5%. Serious risks are: damage to the bladder (1 in 1000), bowel and ureters ( 1 in 10 000), thrombosis 4-16 in 10 000, admission to ITU , hysterectomy 7 in 1000, anaesthetics complication, risk of maternal death. 1 in 12 000
In the event of excessive blood loss she may require a blood transfusion. If visceral damage happens it would need to be repaired during the procedure. There could be potential effect on the future pregnancy. Previous caesarean section may increase a risk of maternal morbidity and mortality in future pregnancies and labour, risk of abnormal placentation in the future (praevia or accreat), scar rupture, stillbirth, antepartum haemorrhage and repeated caesarean section 1 in 4. I will tell her that anaesthetics aspects will be discussed with her separately by the anaesthetists, but in general we recommend to have regional anaesthesia since it is safer. I will support the information with a leaflet. I will write down the information on the consent form and ask patient to sign it after answering all her questions. I will explain that the elective caesarean section would be done at 39 week since the risk of respiratory problems in baby is much less after 39 weeks.
2) I will check the result of the full blood count that was hopefully done prior to the day of caesarean section to make sure that she is not anaemic. Patient would need to be catheterised before the surgery to reduce the risk of urinary retention (especially with regional anaesthesia) and damage to the bladder. A and opefter cleaning and draping the patient I will performing a transverse Cohen entry, since it reduces the risk of febrile complications and operative time. After reflecting the bladder, I will incise the uterus at the lower segment and extend the excision with my hand to reduce the risks of bleeding and blood transfusion. After delivery of the baby. I will deliver the placenta with cord controlled traction to reduce the risk of endometritis (in comparison with manual removal). I will close the uterus in two layers. No peritoneal closure is required since it reduces patient demand for analgesia and improves patient satisfaction. After closure of the sheath, I will close the skin with dis solvable subcutaneous stitch. I will make sure that during the surgery the patient has a dose of intravenous antibiotics (cefuroxime or amoxicillin) to reduve the risk of infection and a bolus of syntocinon (5 iu) in order to improve uterine contractions and decrease the risk of bleeding. After finishing surgery and cleaning and dressing the wound I will clean vagina and provide patient with the rectal pessary of painrelief in form of paracetamol or diclofenac. She would need to have some thromboprophylaxis in form of TEDs stockings and early mobilisation +/-LMWH depending on the local protocol.
Posted by SUNDAY A.
sos

I would give a detailed account of the procedure informing her of the type of the incision to be used- lower transverse abdominal incision, duration and complexity of the procedure should be discussed in case of possible uterine anomaly, low lying placenta or previous adverse reaction to anaesthesia. I would tell her the benefit of the procedure which is to deliver the baby in the safest possible way . I will inform her of the common risk which include bleeding, infection, fetal laceration, anaesthetic risk. The serious risk would include deep vein thrombosis and pulmonary embolism, damage to bladder/bowel/blood vessels while rare risk including need for hysterectomy and maternal death. Additional procedure which may be carried out would include repair to damaged viscera, hysterectomy and blood transfusion. The type of analgesia required would be discussed which would likely be a regional technique such as spinal except there is a contraindication or patient’s preference for general anaesthesia. Information leaflets would be given to reinforce understanding and patient allowed to ask questions after the date which should be around 39 weeks gestation and time of the operation have been confirmed. The patient should then be allowed to sign the consent form once her understanding has been checked and she is able to retain the information and ensuring her decision are entirely voluntary and her concerns has been answered.
b)The bladder should be catherised prior to skin incision to prevent inadvertent bladder injury. The skin should be cleaned properly with betadine or other antiseptic lotion as per what is available in the unit and standard aseptic technique used. The abdominal incision should be wide – not less than 10cm to create enough room for the breech to be delivered easily without causing more fetal morbidity. Careful dissection of the lower segment is mandatory to prevent fetal laceration which is common in breech deliveries. The surgeon should always ensure that the breech is in sacroanterior position throughout delivery with minimal handling of the fetal soft tissue. Delivery of the after coming head should be controlled and Morisseau-Smellie-Veit manoeuvre can be used or forceps can be applied to aid delivery. The placenta should be delivered by controlled cord traction to prevent uterine inversion or snapping of the cord necessitating manual removal. IV syntocinon 5units should be given as soon as possible after delivery and syntocinon infusion 40units in 500mls normal saline at 125mls/hr can be started to prevent uterine atony. Intraoperative antibiotics such as IV augmentin 1.2 gm start dose is recommended after cord clamping to reduce infection and surgical morbidity.
Posted by M E.
SAM
a) I would explain that the procedure for a caesarean section involves a transverse incision on the lower abdomen and uterus for delivery of the fetus. Owing to the breech presentation there is a higher risk of the use of forceps for the delivery of the head. She should be advised that the benefit of a caesarean section for a breech fetus, is that it reduces the perinatal mortality from birth asphyxia and trauma as compared to a vaginal delivery according to the term breech trial. There is also a reduction in early neonatal morbidity.

I will inform the patient about the frequent risks involved in a caesarean section such as persistent pain in the abdomen and incision site for a few month after surgery. There is the risk of haemorrhage in 5:1000, although uncommon at elective caesarean section it may require hysterectomy in rare instances. There is the risk of infection of 5:1000, however antibiotics are given during surgery to reduce this risk. There is also a 1:100 risk of laceration to the fetus during delivery.

She should be counselled of the impact of a caesarean section on her future pregnancies. There is 1 in 4 chance that she would require repeat caesarean section for future pregnancies when a vaginal delivery is attempted. There is also a small risk of 1 in 1000 pregnancies that uterine rupture can occur during subsequent pregnancies and delivery. There is also a higher incidence of placenta praevia and placenta accreta in future pregnancies.

Other rare but serious risks of caesarean section need to be discussed, such as visceral injury to bladder, ureters and blood vessels. If injury occurs, extra procedures to repair these structures are required and blood transfusion may be necessary with haemorrhage.

The type of anaesthesia require should be discussed. Patient should also be given written information about caesarean section

b)Preoperatively the patient should be catheterised to ensure that the bladder would not be in the surgical field.Aseptic procedure should be employed during scrubbing and cleaning of patients abdomen to reduce the risk of infection.

A transverse incision should be made to the abdominal wall, 2 cm above the pubis symphysis, since this is associated with less pain and better cosmatic appearance. Peritoneal fold should be open via sharp resection, and retacted to ensure that bladder remains away from surgical field. A transverse lower segment incision should be made on the uterus, since this area is less vascular than the upper segment of the uterus.

After the baby is delivered, intravenous syntocinon should be given to encourage uterine contaction and reduce intrapartum bleeding. Placenta should be removed via controlled cord traction and the uterus swabbed out to remove and membranes or placental tissue. This would reduce the incidence of endometritis or the need for further curettage.

The uterus should be closed in two layers with polyglactin, which maintains its tensile strength for 4 weeks and associated with less tissue reaction and adhesion formation. The viseral and parietal peritoneum should not be closed, this will reduce post operative pain.

Intravenous antibiotics, such as cephalosporin or ampicillin should be give intraoperatively, after delivery of the baby. This would reduce post operative wound infection and endometritis.

Inspection of the uterus, and muscles for adequate hemostasis prior to closure of the skin should be performed.

Post operatively patient should be started on LMWH for thromboprophylaxis and graduated tension stocking to reduce the risk of DVT. Early mobilization should be encouraged.