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cesarean section (C-section)

surgical procedure used to deliver an unborn fetus Indications: - *high risk vaginal delivery - prior C-section Contraindications: - prolonged latent phase labor is not an indication - > 20 hours in nulliparous women - > 14 hours in multiparous women Epidemiology: - 22% of singleton births in women without prior cesarean section - 13% ub Utah vs 27% in Florida & Louisianna [4] - regular audits of practices & feedback to clinicians leads to fewer cesareans without compromising maternal or newborn safety [7] Procedure: - incisions are made through a mother's abdomen (laparotomy) & uterus (hysterotomy) to deliver the unborn baby - skin preparation with 2% chlorhexidine/70% isopropanol associated with fewer surgical site infections than use of 8.3% povidone-iodine/72.5% isopropanol [9] - intravenous antibiotics, usually cefazolin, generally administered before skin incision [9,11,14] - addition of azithromycin 500 mg IV further reduces risk of infection (RR=0.5) [11] - oral cephalexin + metronidazole for 48 hours after surgery reduced infections in obese women [14] Complications: - endometritis, surgical wound infections [11] - 12% with cefazolin alone; 6% with addition of azithromycin [11] - post-operative ileus (10-15%) [6] - chewing gum for 30-60 minutes at least 3x/day may be of some benefit [6]; NNT=15 to prevent 1 post-op ileus [6] - increased autism risk observed in children born by C-section (RR=1.15-1.21) is likely due to genetic or other factors & is not caused by method of delivery [8] - opiates after cesarean section as a pathway to opiate abuse [13] Management: - DVT prophylaxis indicated prior to C-section [2] - most women with 1-2 uncomplicated low transverse caesarean sections, in an otherwise uncomplicated pregnancy at term & with no contraindications to vaginal birth, are candidates vaginal delivery [2,3] - 60-80% of women who attempt a trial of labor after C-section achieve a successful vaginal birth [15] - conditions that can make vaginal birth after C-section less likely include: - advanced maternal age - high body mass index - high birth weight - previous C-section because the cervix failed to dilate - obese women: - consult anesthesiology early - consider prophylaxis for venous thromboembolism [3] - vaginal seeding (the practice of collecting a mother's vaginal fluid on a gauze swab and wiping it over her newborn's mouth, eyes, & skin shortly after cesarean birth) is not recommended* [10] - betamethasone 12 mg IM 48 hours before delivery reduces risk of - respiratory distress syndrome - transient tachypnea of the newborn - mechanical ventilation [12] * Newborns may develop severe infections from exposure to vaginal commensals & pathogens [10]

Related

birth (childbirth, parturition) labor & delivery

General

obstetric surgery

References

  1. Wikipedia: Caesarean section http://en.wikipedia.org/wiki/caesarean_section
  2. American College of Obstetricians and Gynecologists Obstetrics & Gynecology practice bulletin (subscription required) August 31, 2011 cited in Journal Watch, Massachessetts Medical Society http://www.journalwatch.org
  3. The American College of Obstetrics and Gynecology Committee on Obstetric Practice. - Number 549 Jan 2013 Obesity in Pregnancy http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Obesity_in_Pregnancy
  4. Osterman SK and Martin JA Primary Cesarean Delivery Rates, by State: Results From the Revised Birth Certificate, 2006-2012 National Vital Statistics Reports 63(1). Jan 23, 2014 http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_01.pdf
  5. American College of Obstetricians and Gynecologists (ACOG) Safe Prevention of the Primary Cesarean Delivery Obstetric Care Consensus. Number 1, March 2014 http://www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery
  6. The NNT: Chewing Gum for Reducing Post-Caesarian Section Ileus. http://www.thennt.com/nnt/chewing-gum-for-reducing-post-caesarian-section-ileus/ - Craciunas L, Sajid MS, Ahmed AS. Chewing gum in preventing postoperative ileus in women undergoing caesarean section: a systematic review and meta- analysis of randomised controlled trials. BJOG. 2014 Jun;121(7):793-9; discussion 799 PMID: 24628729
  7. Chaillet N et al A Cluster-Randomized Trial to Reduce Cesarean Delivery Rates in Quebec. N Engl J Med 2015; 372:1710-1721. April 30, 2015. PMID: 25923551 http://www.nejm.org/doi/full/10.1056/NEJMoa1407120
  8. Curran EA et al Association Between Obstetric Mode of Delivery and Autism Spectrum Disorder. A Population-Based Sibling Design Study. JAMA Psychiatry. Published online June 24, 2015 PMID: 26107922 http://archpsyc.jamanetwork.com/article.aspx?articleid=2323630
  9. Tuuli MG, Liu J, Stout MJ, Martin S et al A Randomized Trial Comparing Skin Antiseptic Agents at Cesarean Delivery. N Engl J Med. 2016 Feb 4. [Epub ahead of print] PMID: 26844840
  10. Cunnington AJ et al "Vaginal seeding" of infants born by caesarean section. BMJ 2016;352:i227 PMID: 26906151 http://www.bmj.com/content/352/bmj.i227
  11. Tita AT, Szychowski JM, Boggess K et al Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. N Engl J Med 2016; 375:1231-1241. September 29, 2016 PMID: 27682034 http://www.nejm.org/doi/full/10.1056/NEJMoa1602044 - Weinstein RA, Boyer KM Antibiotic Prophylaxis for Cesarean Delivery - When Broader Is Better. N Engl J Med 2016; 375:1284-1286. September 29, 2016 PMID: 27682038 http://www.nejm.org/doi/full/10.1056/NEJMe1610010
  12. Saccone G, Berghella V Antenatal corticosteroids for maturity of term or near term fetuses: systematic review and meta-analysis of randomized controlled trials. BMJ 2016;355:i5044 PMID: 27733360 http://www.bmj.com/content/355/bmj.i5044
  13. Osmundson SS, Schornack LA, Grasch JL et al. Postdischarge opioid use after cesarean delivery. Obstet Gynecol. 2017 Jul;130(1):36-41 PMID: 28594766 - Bateman BT, Cole NM, Maeda A et al. Patterns of opioid prescription and use after cesarean delivery. Obstet Gynecol. 2017 Jul;130(1):29-35 PMID: 28594763 - Prabhu M, McQuaid-Hanson E, Hopp S et al. A shared decision-making intervention to guide opioid prescribing after cesarean delivery. Obstet Gynecol. 2017 Jul;130(1):42-46 PMID: 28594762
  14. Valent AM, DeArmond C, Houston JM et al Effect of Post-Cesarean Delivery Oral Cephalexin and Metronidazole on Surgical Site Infection Among Obese Women. A Randomized Clinical Trial. JAMA. 2017;318(11):1026-1034 PMID: 28975304 http://jamanetwork.com/journals/jama/article-abstract/2654382 - Calfee DP, Grunebaum A. Postoperative Antimicrobial Prophylaxis Following Cesarean Delivery in Obese WomenAn Exception to the Rule? JAMA. 2017;318(11):1012-1013 PMID: 28975285 http://jamanetwork.com/journals/jama/article-abstract/2654362
  15. Anello J, Feinberg B, Lindsey R et al Vaginal Birth After Cesarean Clinical Practice Guidelines, December 2017 Medscape. Dec 6, 2017 https://reference.medscape.com/viewarticle/889632_14 - Brown T. Updated Guidelines on VBAC Released by ACOG. Medscape News. WebMD Inc. November 7, 2017. https://www.medscape.com/viewarticle/888126 - Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 184: Vaginal Birth After Cesarean Delivery. Obstet Gynecol. 2017 Nov;130(5):e217-e233. PMID: 29064970 https://insights.ovid.com/pubmed?pmid=29064970