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Caesarean Section

Thank you for visiting this study website for the project entitled “The impact of a web-based educational tool on attitudes to and knowledge of Caesarean Delivery”. Your participation is appreciated. This website is intended for research purposes only for a study done for the Determinants of Community Health class at University of Toronto medical school. It was developed by Ms. Anjali Kulkarni, Ms. Emily Wright, Ms. Natasha Milligan, Dr. John Kingdom, Dr. Jackie Thomas, Dr. Prakeshkumar Shah.

 

Table of Contents

What is a Caesarean Delivery?

Reasons for a Caesarean Deilvery

Future Pregnancies

Complications of Caesarean Deilvery

Additional Resources on Caesarean Delivery


What is a Caesarean Delivery? 

• Delivery of a baby through surgical incisions made through the abdominal wall and uterine wall
• The incisions in the skin and uterus may be either horizontal or vertical
• The baby is delivered through the incisions, the umbilical cord will be cut, and then the placenta will be removed
• The stitches that close the uterus are dissolving, and stitches or staples will be used to close the skin 

There has been a gradual increase in the rates of Caesarean delivery in Canada, from 17.6% in 1993 to 26.3% in 2005 – this rate is continuing to rise. In Mount Sinai Hospital, 26% of first-time pregnancy women deliver by Caesarean section. Primary (first-time pregnant) Caesarean delivery is a safe and common major open abdominal surgery that carries low risks both during and after the procedure.

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Reasons for a Caesarean Delivery
In many cases, a woman and her doctor choose to deliver by a Planned Caesarean delivery, prior to the onset of labour. This can be due to a variety of medical reasons affecting the mother and baby, or can also be done in the absence of indications, due to patient choice. Such medical indications for Caesarean section include:

• Multiple pregnancy (twins, triplets, etc)
• Failure of labour to progress
• Concern for the baby (i.e. umbilical cord problems, abnormal fetal heart rate)
• Problems with placenta (i.e. placenta previa/accreta, as explained below)
• Large baby
• Breech presentation
• Maternal infections or medical conditions

Planned Caesarean delivery reduces the risk of:
• Injury to the perineal area (area around the vagina and anus) at delivery (3rd or 4th degree tear)
• Pain in the perineal area for 3 days postpartum
• Asphyxia (oxygen deprivation) of the baby during labour
• Injury of the head or shoulders of the baby during delivery

Planned Caesarean delivery increases the risk of:
• Abdominal pain from wound healing
• Medical visits for Caesarean wound infection after discharge
• Accidental skin incision of the infant at delivery
• Breathing problems (respiratory distress) in the infant at birth, requiring admission to a level 2 special care baby unit (NICU)

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Future Pregnancies
Having a Caesarean delivery in one pregnancy can affect delivery methods in subsequent pregnancies.

Background Information

VBAC (vaginal birth after Caesarean delivery) is the term given to attempts at vaginal delivery after having had one Caesarean delivery. This has a small, but increased risk of the womb opening at the site of the previous Caesarean section – this is termed uterine rupture. This complication may be serious for the mother, the baby, or both. Most physicians advise that VBAC should only be attempted in labour of natural onset, rather than being induced, because induction of labour increases the risk of uterine rupture. Therefore, women who desire an attempt at VBAC, but who do not get into early normal labour, may ultimately have to have a planned repeat Caesarean section. Overall, subsequent pregnancies following Caesarean section in a first pregnancy have a 70% chance of a repeat Caesarean delivery rate.

 With each subsequent Caesarean delivery, the risk of uterine rupture in VBAC increases. Therefore, after two Caesarean Deliveries, most women will have more pregnancies delivered by planned Caesarean delivery. 

Having a Caesarean delivery increases the risk of placenta previa, when the placenta covers the cervix, therefore blocking the birth canal. A woman who has placenta previa would likely deliver by a planned Caesarean delivery. This condition carries a high risk of blood transfusion, and a small risk of hysterectomy (removal of the uterus/womb at the same time as delivery of the baby, to stop bleeding).

The risk of a rare, but potentially serious condition, termed placenta accreta, is increased in women who conceive after a previous Caesarean section.  In such women, a low-lying placenta grows through the previous Caesarean section scars, and becomes firmly embedded in the wall of the uterus. This can lead to extensive bleeding when the placenta tries to separate from the uterus at delivery, so the standard treatment is to deliver the baby and remove the uterus (Caesarean hysterectomy) at the same time, so as to stop bleeding at delivery. The risk of placenta previa accreta is small (less than 1%) after one previous Caesarean section, but increases to 2% by a 3rd pregnancy after 2 previous Caesarean deliveries.

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Complications of Caesarean Delivery

During the Surgery
• Blood loss may be greater, or less than, at a vaginal delivery compared with a planned elective Caesarean section for a first pregnancy. Women who have an uncomplicated vaginal delivery have the lowest risk of blood transfusion. Women who have a primary (first pregnancy) planned Caesarean delivery have an intermediate risk, while women who either have a vaginal delivery after prolonged labour, a forceps delivery, failed forceps or vacuum delivery leading to an emergency Caesarean section, any type of Caesarean section during labour, or a planned repeat Caesarean section, have higher rates of blood loss requiring a blood transfusion. Overall, the risk of blood transfusion at a planned term Caesarean delivery in a first pregnancy is 1/200.
• Women may also experience negative reactions to anaesthesia for Caesarean section. They may:
          o Feel more pain during surgery if the anaesthetic is not working properly
          o Experience more nausea and/or vomiting from internal manipulation to perform a Caesarean section
• Bladder injury is an infrequent complication of Caesarean Deliveries and is rare in a first Caesarean section. However the risk increases with repeat Caesarean Deliveries. Bladder injury is extremely rare with vaginal deliveries.
• Bowel injuries occur in less than 0.1% of all Caesarean Deliveries, but cannot occur at a vaginal delivery, as the abdomen is not opened.


After the Surgery
• The recovery time for women after Caesarean delivery is longer than after a vaginal delivery, and can range from weeks to months due to pain at the site of incision. The length of hospital stay after a Caesarean delivery is currently 2-3 days, while the average hospital stay after a vaginal delivery is 1-2 days. While it is rare for women to need intensive care following delivery, it is more commonly required after a repeat Caesarean delivery, compared to a vaginal delivery.
• The risk of all types of infections, including wound infection after Caesarean delivery is approximately 17% (source CAESAR trial, UK). Amongst women delivering by Caesarean section, this risk is lowest for planned primary Caesarean delivery.
• Urinary tract infections (UTI) are more common in women delivering by Caesarean section than with a vaginal delivery. Women delivering by Caesarean section require a bladder catheter during surgery. This remains in place to drain the bladder for 12-24 hours post-operatively, and can be a source of infection.
• Caesarean Deliveries also increase the risk of developing deep vein thrombi, which are blood clots in the legs that could lead to blood clots in the lungs, known as pulmonary emboli, by 3-5-fold compared to vaginal delivery.

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Additional Resources on Caesarean Delivery  

National Institute for Health and Clinical Excellence Caesarean Section Guidelines:

• NICE Clinical Guidelines Webpage

• NICE Clinical Guidelines PDF

More information on placenta previa:
• US National Library of Medicine- placenta previa

Overview of Caesarean delivery:

 Caesarean Birth FAQ 

  E-medicine Caesarean Delivery

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