Caesarean Birth

Categories of Urgency

| Category | Definition | Decision-to-Delivery Interval | |----------|-----------|-------------------------------| | 1 | Immediate threat to life of woman or fetus | ASAP — ideally <30 min | | 2 | Maternal or fetal compromise not immediately life-threatening | Most within 75 minutes | | 3 | No maternal/fetal compromise but early delivery needed | Usually within 24 hours | | 4 | Elective — delivery timed to suit woman and staff | At scheduled time |

Indications for Planned Caesarean

• Placenta praevia (major — covering internal os)
• Malpresentation (breech after failed/declined ECV, transverse lie)
• Multiple pregnancy (monoamniotic twins, triplets)
• HIV (if viral load >400 copies/ml at 36 weeks)
• Primary genital herpes in third trimester
• Previous classical caesarean section or other full-thickness uterine surgery
• Some fetal conditions (e.g. gastroschisis)
• Maternal request (after discussion of risks and benefits — should be respected)

Maternal Request Caesarean

• A woman's request for caesarean section should be respected and not refused
• Explore reasons and ensure informed decision-making
• If clinician is unwilling to perform maternal request CS, refer to a colleague who will
• Planned CS for maternal request should not be performed before 39+0 weeks

Informed Consent

• Discuss: risks of CS vs vaginal delivery, implications for future pregnancies
• CS risks: haemorrhage (reported rates 1-5%), infection (wound, endometritis), VTE, injury to bladder/ureter/bowel (<1%), anaesthetic complications, longer recovery
• Future pregnancy risks: VBAC considerations, increased risk of placenta praevia and accreta with each CS, uterine rupture risk
• Benefits: avoidance of labour-related risks, planned timing, reduced risk of pelvic floor injury

Anaesthetic Considerations

• Regional anaesthesia (spinal or epidural): preferred for all categories (1-4)
• General anaesthesia: reserved for category 1 when speed is essential, failed regional, patient refusal/contraindication to regional
• GA risks: failed intubation (higher in obstetric population), aspiration (Mendelson's syndrome), awareness
• Antacid prophylaxis: ranitidine (H2 blocker) + sodium citrate (antacid) — to reduce gastric acidity
• Aortocaval compression: left lateral tilt (15 degrees) or wedge under right hip

Surgical Technique

• Skin incision: transverse (Joel-Cohen or Pfannenstiel) preferred over midline
• Uterine incision: lower-segment transverse preferred
• Blunt extension of uterine incision: associated with less blood loss
• Closure: uterine closure in two layers (reduces rupture risk in subsequent pregnancy); single-layer closure acceptable
• Intra-abdominal peritoneal closure: not recommended (no benefit, increases operative time)
• Skin closure: subcuticular sutures preferred over staples (lower wound infection rate)

Enhanced Recovery

• Early oral fluids and diet (within hours)
• Early mobilisation (same day)
• Early removal of urinary catheter (within 12 hours)
• Thromboprophylaxis: TED stockings + LMWH (start 6-12 hours post-operatively, continue for minimum 10 days)
• Wound care: remove dressing at 24 hours, daily inspection

VTE Prophylaxis Post-Caesarean

• All women post-CS should receive thromboprophylaxis
• LMWH for minimum 10 days (or longer if additional risk factors)
• TED stockings from admission until fully mobile
• Early mobilisation is encouraged

Important Facts for MRCOG

• Category 1: immediate threat, deliver ASAP (target <30 min)
• Category 2: maternal/fetal compromise, target within 75 minutes
• Regional anaesthesia preferred for all categories
• Maternal request for CS: should be respected and offered (≥39 weeks)
• Left lateral tilt to prevent aortocaval compression
• Joel-Cohen incision: preferred transverse skin incision
• Lower segment transverse uterine incision: standard
• Post-CS: minimum 10 days LMWH thromboprophylaxis
• Each additional CS increases placenta praevia and accreta risk

Source: NICE CG132 / NG192 (2021)

Read the original on nice.org.uk

Clinically reviewed by NHS obstetricians and gynaecologists · Source last updated 2021

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