Morbidly adherent placent and planned caesarian section

Indications for planned caesarian section (CS):

• breech presentation
  • offer women who have an uncomplicated singleton breech pregnancy after 36+0 weeks, external cephalic version, unless:
    • the woman is in established labour
    • there is fetal compromise
    • the woman has ruptured membranes or vaginal bleeding
    • the woman has any other medical conditions (for example, severe hypertension) that would make external cephalic version inadvisable
    • other contraindications include women in labour and women with a uterine scar or abnormality, fetal compromise, ruptured membranes, vaginal bleeding or medical conditions
    • before carrying out a caesarean birth for an uncomplicated singleton breech pregnancy, carry out an ultrasound scan to check that the baby is in the breech position. Do this as late as possible before the caesarean birth procedure
      
      
  • pregnant women with a singleton breech presentation at term, for whom external cephalic version is contraindicated or has been unsuccessful, should be offered CS because it reduces perinatal mortality and neonatal morbidity
• multiple pregnancy
  • twin pregnancy: dichorionic diamniotic or monochorionic diamniotic
    • Explain to women with an uncomplicated twin pregnancy planning their mode of birth that planned vaginal birth and planned caesarean section are both safe choices for them and their babies if all of the following apply:
      • the pregnancy remains uncomplicated and has progressed beyond 32 weeks
      • there are no obstetric contraindications to labour
      • the first baby is in a cephalic (head-first) presentation
      • there is no significant size discordance between the twins
    • Explain to women with an uncomplicated twin pregnancy that for women giving birth after 32 weeks
      • more than a third of women who plan a vaginal birth go on to have a caesarean section
      • almost all women who plan a caesarean section do have one, but a few women have a vaginal birth before caesarean section can be carried out
      • small number of women who plan a vaginal birth will need an emergency caesarean section to deliver the second twin after vaginal birth of the first twin.
    • offer caesarean section to women if the first twin is not cephalic at the time of planned birth
    • offer caesarean section to women if the first twin is not cephalic at the time of planned birth
    • offer caesarean section to women in established preterm labour between 26 and 32 weeks if the first twin is not cephalic
    • offer an individualised assessment of mode of birth to women in suspected, diagnosed or established preterm labour before 26 weeks. Take into account the risks of caesarean section and the chance of survival of the babies
      
      
  • twin pregnancy: monochorionic monoamniotic
    • offer a caesarean section to women with a monochorionic monoamniotic twin pregnancy:
      • at the time of planned birth (between 32+0 and 33+6 weeks) or
      • after any complication is diagnosed in her pregnancy requiring earlier delivery or
      • if she is in established preterm labour, and gestational age suggests there is a reasonable chance of survival of the babies (unless the first twin is close to vaginal birth and a senior obstetrician advises continuing to vaginal birth)
        
        
  • triplet pregnancy
    • offer a caesarean section to women with a triplet pregnancy:
      • at the time of planned birth (35 weeks) or
      • after any complication is diagnosed in her pregnancy requiring earlier delivery or
      • if she is in established preterm labour, and gestational age suggests there is a reasonable chance of survival of the babies
• preterm birth and CS
  
  • explain to women in suspected, diagnosed or established preterm labour and women with P-PROM about the benefits and risks of caesarean section that are specific to gestational age. In particular, highlight the difficulties associated with performing a caesarean section for a preterm birth, especially the increased likelihood of a vertical uterine incision and the implications of this for future pregnancies.
  • explain to women in suspected, diagnosed or established preterm labour that there are no known benefits or harms for the baby from caesarean section, but the evidence is very limited
  • consider caesarean section for women presenting in suspected, diagnosed or established preterm labour between 26+0 and 36+6 weeks of pregnancy with breech presentation
• small for gestational age and CS
  • the risk of neonatal morbidity and mortality is higher with 'small for gestational age' babies. However, the effect of planned CS in improving these outcomes remains uncertain and therefore CS should not routinely be offered
    
    
• placenta praevia
  • offer caesarean birth to women with a placenta that partly or completely covers the internal cervical os (minor or major placenta praevia)
    
• morbidly adherent placenta
  • if low-lying placenta is confirmed at 32-34 weeks in women who have had a previous CS, offer colour-flow doppler ultrasound as the first diagnostic test for morbidly adherent placenta
    • if a colour-flow doppler ultrasound scan result suggests morbidly adherent placenta:
      • discuss with the woman the improved accuracy of magnetic resonance imaging (MRI) in addition to ultrasound to help diagnose morbidly adherent placenta and clarify the degree of invasion
      • explain what to expect during an MRI procedure
      • inform the woman that current experience suggests that MRI is safe, but that there is a lack of evidence about any long-term risks to the baby
      • offer MRI if acceptable to the woman
• maternal request for CS
  • if a woman requests a caesarean birth, discuss the overall benefits and risks of caesarean birth compared with vaginal birth and record that this discussion has taken place
  • if a woman requests a caesarean birth, offer discussions with the woman, a senior midwife and/or obstetrician and other members of the team if necessary, for example an anaesthetist, to explore the reasons for the request, and ensure the woman has accurate information
  • if a woman requests a caesarean birth because she has tokophobia or other severe anxiety about childbirth (for example, following abuse or a previous traumatic event), offer referral to a healthcare professional with expertise in providing perinatal mental health support to help with her anxiety
  • ensure healthcare professionals providing perinatal mental health support to women requesting a caesarean birth have access to the planned place of birth during the antenatal period in order to provide care
  • if a vaginal birth is still not an acceptable option after discussion of the benefits and risks and offer of support, offer a planned caesarean birth for women requesting a caesarean birth
  • if a woman requests a caesarean birth but her current healthcare team are unwilling to offer this, refer the woman to an obstetrician willing to perform a caesarean birth
    
    
• body mass index
  • do not use a body mass index (BMI) of over 50 alone as an indication for planned CS
    
    
• mother-to-child transmission of maternal infections and caesarian section (see linked item below)

Reference:

• 1) NICE (March 2021). Caesarian Section