Candidate’s instruction
On labour ward you meet a 39 year-old primigravid woman who has been admitted to hospital for an elective caesarean.
This is a singleton pregnancy and the gestation of 39 weeks is verified by ultrasound dating. You are asked to complete the consent form.
- What complications would you routinely discuss with all patients undergoing caesarean section?
You review the notes
Scan result this morning shows that she has multiple fibroids and the fetus is lying transversely. Clinical examination confirms that this is still the case
- What are the key issues and potential problems you would anticipate with this particular caesarean section?
- Describe how you would prepare for the operation and what precautions you would take to ensure that the caesarean proceeds as safely as possible.
Answers
- What complications would you routinely discuss?
Frequent risks
- Post-operative pain – very common
- Haemorrhage need blood transfusion – 5/1,000
- Infection: wound – 6/100
- Laceration to baby – 2/100
Serious risks
- Damage to ureter – 3/10,000
- Damage to bladder – 1/1,000
- Damage to bowel – very rare
- Risk of Thromboembolism – 4-16/10,000
- Need of emergency hysterectomy – 8/1,000
- Need for further surgery – 5/1,000
- ICU admission – 5/1,000
- Death – 1/12,000
Future pregnancy risks
- Uterine rupture – 5/1,000
- Placenta previa – 8/1,000
- Placenta accreta – 4/1,000
- Antenatal stillbirth – 1-4/1,000
- possible reduced future fertility
- What are the key issues and potential problems with this particular caesarean section?
- It is a high risk technically difficult section
- It may be difficult to get the baby out of the uterus via lower segment
- May need to consider midline skin incision
- May need to do classical caesarean section
- Placenta may be abnormally adherent
- Expect excess bleeding because of fibroids
- May need blood transfusion
- May be difficult to close the uterus afterwards
- Should not plan to remove any fibroids during caesarean
- Possibility of hysterectomy
- How would you prepare for theatre?
- Review scan for location of fibroids to decide on classical or lower segment
- Check position of placenta
- Position of baby (Dorso- superior/ Dorso-anterior)
- Check recent FBC for Hb and platelets
- Cross match 1/2 units blood
- Check the consent form is signed
- Consultant involvement advisable
- Discuss with anaesthetist & theatre staff
- Paediatrician should be informed (may be difficulty delivering baby)
- Adequate fasting
- Premedication
- Antibiotic prophylaxis
- Thromboprophylaxis
- WHO checklist
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