Measures to minimise C-section risks

Professor Suzanne Delport – retired neonatologist and strong breastfeeding supporter – outlines procedures peripartum health practitioners can follow to mitigate risks to newborns of scheduled deliveries in the private sector.     

Scheduled deliveries occur commonly in the South African private sector, with the majority of women with low-risk pregnancies receiving a non-indicated caesarean section before spontaneous initiation of labour. The aim is to perform a ‘non-injurious’ delivery which will ensure a ‘healthy’ newborn infant. This is an erroneous belief since unanticipated, life-threatening complications may afflict the newborn precisely due to the absence of labour.

Consequently, meticulous surveillance from birth until discharge is of the essence because a ‘healthy’ appearance belies the fact that these infants are unprepared for an extrauterine existence. Admission to special care units to facilitate surveillance of these infants is the norm, resulting in overcrowding of these units as well as intensive care units. The inflated induction and caesarean section birth rate contributes to the unavailability of beds for other ill newborn infants and the strain on nursing resources. This scenario could be prevented by performing more vaginal deliveries. 

If performed under safe circumstances, a vaginal delivery remains the delivery mode of choice: not only do complications necessitating admission of the newborn rarely occur, but caesarean delivery is associated with long-term adverse health effects to both the mother and infant, notwithstanding a lack of evidence from randomised controlled trials – it would be unethical to assign low-risk healthy pregnant women to such trials!

Mitigating vulnerability

Midwives should be aware of the vulnerability of ‘healthy’ newborns born in the private sector as a result of caesarean section overuse, using it to strengthen their educational and advocacy roles. In addition, measures should be in place and routinely applied to help protect the mother-baby dyad from pregnancy to the postnatal phase, and babies through to childhood. 

 

1. Pregnancy 

In the light of societal and service provider pressure to select C-section as a ‘safer option’, women, and primigravidas in particular, should be informed about the benefits of a vaginal delivery following spontaneous onset of labour. The reasons for choosing a C-section delivery (by women and service providers) should be investigated and addressed to facilitate an informed choice. Counselling should take place in non-threatening and calm circumstances. The undisputed complications to both the mother and her infant of a non-indicated caesarean delivery should be highlighted, as well as the long-term deleterious effects.

In general, the choice of service provider and place of delivery determine the mode of delivery; admission to a private hospital will most likely result in a C-section – either as a scheduled pre-labour procedure or after a failed induction of labour. Women with low-risk pregnancies who desire a vaginal delivery should be made aware that a medicalised environment increases the risk of a caesarean delivery. 

Accurate gestational dating is mandatory. While the expected date of delivery (EDD) can be estimated from the first day of the last menstrual period (LMP) it needs to be confirmed by an accurate early ultrasound examination. Thereafter, the adjustment of the expected date of delivery by any service provider is NOT evidence-based and should not be permissible. This practice increases the risk of an unfavourable outcome and death for the newborn infant due to iatrogenic prematurity. A scheduled delivery should not take place before a gestational age of 39 weeks. If an accurate gestational age is not available, a scheduled delivery is contraindicated.

A suitable labour companion should be identified during pregnancy.

2. Delivery

Active measures should be implemented to maintain maternal normothermia and decrease the risk of neonatal hypothermia. These include pre-operative and intra-operative active warming and the administration of warmed intravenous fluids. The ambient temperature of a theatre should be 23 ⁰C and that of a delivery room 26 ⁰C.

Prophylactic antibiotic therapy should be administered intravenously within 60 minutes of the skin incision to effect therapeutic blood levels at the time of surgery with the objective to prevent endometritis and wound sepsis. The drug of choice is cefazolin (2g), and this dose should be repeated three hours after surgery. Women who deliver by the vaginal route, do not need antibiotic prophylaxis.          

The pharynx and upper airway of an infant born through clear amniotic fluid should not be suctioned.

Delay clamping of the cord for 30–60 seconds of delivering the infant.

Refrain from the iatrogenic transfer of vaginal microbiota (‘vaginal seeding’) to the newborn after C-section in an effort to establish a ‘normal’ microbiome. Safety of this practice as well as its effectiveness are not supported by robust evidence.

3. Stabilisation of the infant  

The oxygen saturation should be monitored in all infants by preductal pulse oximetry (SpO2) on the right hand after birth. No infant should leave the delivery room/theatre without a documented SpO2. Normal oxygenation implies an SpO2 of 90–93% in room air and a respiratory rate of 50–60 breaths per minute in a non-crying infant.

Record the SpO2 and supplemental oxygen requirement 4–6 hourly for 24 hours. Refrain from a clinical assessment of oxygenation by noting the colour of the infant’s tongue. An infant with a pink tongue can have a low SpO2, necessitating supplemental oxygen. Inadequate oxygenation and can only be diagnosed by an SpO2. Guard against an SpO2>95%.     

Skin-to-skin care on the mother’s chest (if she is normothermic) should be initiated after the infant’s stabilisation in an effort to initiate surges of oxytocin and prolactin in the mother-infant dyad to facilitate bonding, lactation and a positive maternal feeling. These surges are blunted after the first hour in the event of C-section and fail to recur thereafter. 

4. Proactive breastfeeding support

Initiate nipple contact and colostrum intake immediately after delivery to optimise the prognosis for successful short- and long-term lactation. Most mothers secrete colostrum at birth which should be aspirated with a 2cc syringe and administered to the infant should suckling be ineffective at this time. 

Proactive professional lactation support should be available at all times and in particular before difficulties with breastfeeding arise. Reactive support in response to problems are less effective at this time. Refrain from supplementary formula feeds at all times.

5. Surveillance of the newborn infant 

Monitor oxygenation (by SpO2), thermoregulation, glucose metabolism and breast milk intake at 4–6 hourly intervals for at least 72 hours after a scheduled delivery. Record the infant’s weight daily, as well as urine output (at least six wet nappies over 24 hours) to ensure that the intake of breast milk is adequate. If more than 10% of the infant’s birth weight has been lost by 72 hours, inadequate intake of breast milk should be diagnosed and treated to prevent jaundice and hypernatraemic dehydration. 

Bilirubin levels should be recorded in all infants before discharge irrespective of whether jaundice is present. The value should be plotted on a percentile chart to determine the risk after discharge of hyperbilirubinaemia necessitating intervention.

The availability of nursing personnel and relevant equipment for effective monitoring of caesarean-delivered infants is mandatory. 

6. Neurodevelopmental surveillance

Infants born before spontaneous onset of labour by means of a scheduled delivery should be offered neurodevelopmental surveillance until school-going age, as delays can only be diagnosed by this means. This is important due to physiological and organ immaturity (including the brain). Early remedial intervention improves the long-term prognosis. 

Decreasing the burden

To decrease a wide range of potential health and developmental adverse effects, the overuse of caesarean deliveries in the private sector should be acknowledged, reported and addressed. Meticulous surveillance by midwives and nurses to minimise risks to these newborn infants is essential to further decrease the burden. 

Comprehensive references

Professor Delport has provided exhaustive references to substantiate her concerns about the effects of unwarranted C-section delivery prior to spontaneous labour commencement. Sensitive Midwifery urges all readers to use these to educate unenlightened colleagues.

  • American College of Obstetricians and Gynecologists, ACOG Committee Opinion No. 561, ‘Nonmedically indicated early term deliveries’, Obstet Gynecol, 2013, 121:911–915
  • American Congress of Obstetricians and Gynecologists, ACOG Committee Opinion No. 700, ‘Methods for estimating the due date’, Obstet Gynecol, 2017, 129: e150–e154 
  • American Congress of Obstetricians and Gynecologists, ACOG Committee Opinion No. 688, ‘Management of suboptimally dated pregnancies’ Obstet Gynecol, 2017, 129: e29–e32
  • Bhutani VK, et al, ‘Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns’, Pediatrics, 1999, 103: 6–14
  • Buckley SJ, ‘Hormonal physiology of childbearing: Evidence and implications for women, babies, and maternity care’, Washington DC: Childbirth Connection Programs, National Partnership for Women & Families, 2015    
  • Caughey AB, ‘The safe prevention of the primary cesarean’, Clin Obstet Gynecol, 2015, 58: 207–210. doi: 10.1097/GRF.0000000000000111                                          
  • Competition Commission South Africa, ‘Health market inquiry: provisional findings and recommendations report’, July 5, 2018. Available: http://www.compcom.co.za/wp-content/ uploads/2018/07/Health-Market-Inquiry-1.pdf 
  • Dawson JA, et al, ‘Pulse oximetry for monitoring infants in the delivery room: a review’, Arch Dis Child Getal Neonatal Ed, 2007, 92: F4–F7                                                                                       
  • Dewey KG, et al, ‘Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss’, Pediatrics, 2003, 112: 607–619
  • Duffield A, et al, ‘Optimal administration of cefazolin prophylaxis for caesarean delivery’, J Perinatol, 2017, 37:16–20. doi:10.1038/jp.2016.210 
  • Dureya EL, et al, ‘The impact of ambient operating room temperature on neonatal and maternal hypothermia and associated morbidities: a randomized controlled trial’, Am J Obstet Gynecol, 2016, 214: 505.e1–e7. doi:10.1016/j.ajog.2016.01.190   
  • Hofmeyr GJ, ‘Caesarean Section’ in Cronje HS, Cilliers JBF, du Toit MA, (eds), Clinical Obstetrics a South African Perspective, 4th ed., Braamfontein: Van Schaik 
  • Horn E-P, et al, ‘The incidence and prevention of hypothermia in newborn bonding after caesarean delivery: a randomized controlled trial’, Anesth Analg, 2014, 118: 997–1002
  • Kelleher J, et al, ‘Oropharyngeal suction versus wiping of the mouth and nose at birth: a randomized equivalency trial’, Lancet, 2013, 382:3260330. doi:10/1016/S0140-6736(13)60775-8
  • Konstantelos D, et al, ‘Analysing support of postnatal transition in term infants after c-section’, BMC Pregnancy and Childbirth, 2014, 14:225–30. doi:10.1186/1471-2393-14-225
  • McDonald SJ, et al, ‘Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes’, Cochrane Database of Systemic Reviews, 2013, Issue 7. Art No.: CD004074. doi: 10.1002/14651858.CD004074.pub3
  • Morrison JJ, et al, ‘Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section’, BJOG, 1995, 102: 101–106
  • Renfrew MJ, et al, ‘Support for healthy breastfeeding mothers with healthy term babies’, Cochrane Database Syst Rev, 5: CD001141. doi: 10.1002/14651858.cd00141.pub4
  • Rose O, et al, ‘Developmental scores at 1 year with increasing gestational age, 37-41 weeks’, Pediatrics, 2013, 131: e1475–1481. doi: 10.1542/peds.2012-3215
  • Sakala C, et al, ‘Hormonal physiology of childbearing, an essential framework for maternal-newborn nursing’, JOGNN, 2016, 45: 264–275. doi:10.1016/j.jogn.2015.12.006    
  • Sandall J, et al ‘Short-term and long-term effects of caesarean section on the health of women and children’, Lancet, 2018, 392: 1349–57
  • Stinson LF, et al, ‘A critical review of the bacterial baptism hypothesis and the impact of cesarean delivery on the infant microbiome’, Front Med, 2018, 5:135. doi:10.3389/fmed.2018.00135
  • Swanson JR, et al, ‘Transition of fetus to newborn’, Pediatr Clin N Am, 2015, 62:329–343. Available: http://dx.doi.org/10.1016/j.pd.2014.11.002
  • Walker KF, et al, ‘The dangers of the day of birth’, BJOG, 2014, 121: 714–718

Professor Suzanne Delport is a retired neonatologist, but she is probably busier now than when she was in fulltime employment! Prof Delport worked at Kalafong Hospital in conjunction with the University of Pretoria for most of her illustrious career. She has a particular interest in the wellbeing of the mother-infant dyad during the perinatal period, and is a very strong breastfeeding supporter.

This article was originally published in Sensitive Midwifery Magazine in October 2019.