Caesarean birth — structured SAQ (15 marks)

(a) Urgency category (2 marks)

• Category 2 (1 mark) — maternal or fetal compromise that is not immediately life-threatening. There is fetal compromise on the CTG but no prolonged bradycardia, cord prolapse or maternal collapse.^[1]
• Audited standard 75 minutes from decision to birth (1 mark). Category 1 carries the 30-minute standard.^[1]
• Credit for adding: the category can be revised upward if she deteriorates, and constant pain with a previous caesarean means scar rupture must stay on the differential, which would make it category 1.^[1]

(b) Antibiotic prophylaxis (4 marks)

Justification for the timing (2 of the 4 marks): the Cochrane review of 10 studies and 5041 women found that giving prophylaxis before skin incision rather than after cord clamping reduced composite maternal infectious morbidity (risk ratio 0.57), endometritis (0.54) and wound infection (0.59), with no clear difference in neonatal sepsis.^[3]

Justification for azithromycin: in 2013 women having an unscheduled caesarean in labour or after membrane rupture, adding azithromycin 500 mg IV to standard prophylaxis reduced the composite of endometritis, wound infection or other infection from 12.0% to 6.1% (relative risk 0.51), with fewer serious maternal adverse events.^[4]

(c) The deeply impacted head (4 marks)

• Call for help and prepare before you commit (1 mark): a second clinician for elevation from below, adequate anaesthesia, consider tocolysis to relax the uterus, and a generous, controlled hysterotomy.^[5]
• Name the techniques (2 marks): coordinated vaginal elevation of the head from below; reverse breech extraction, delivering a foot from the fundus; the Patwardhan method, delivering the shoulders and trunk first; and a fetal elevation device placed before the operation.^[5][6]
• Comment on the evidence (1 mark): the 2024 systematic review of 24 studies and 3558 women graded all 96 outcomes as low or very low certainty and made no firm recommendation for any technique; the Cochrane review likewise found insufficient randomised evidence, with limited evidence that reverse breech extraction may improve outcomes. The defensible answer is training in all techniques and early recognition rather than a single preferred manoeuvre.^[5][6]
• Anticipate the consequence: inspect both uterine angles for a J or inverted-T extension, check the bladder, and expect a higher risk of haemorrhage.^[7]

(d) Visceral injury (3 marks)

• List (1 mark): bladder (cystotomy), ureter, bowel, and — as related surgical morbidity — uterine vessel laceration at the angles and fetal laceration.^[7][8]
• Incidence (1 mark, any two): pooled across 1,741,894 women, bladder injury occurred at about 267 per 100,000 caesareans (roughly 1 in 375) and ureteric injury at about 9 per 100,000 (roughly 1 in 11,000). Risk rises with the number of previous caesareans; in the multiple-repeat-caesarean cohort, cystotomy, bowel injury and ureteric injury all increased significantly with each additional operation.^[7][8]
• Recognising bladder injury (1 mark): direct visualisation of the defect or of the Foley balloon, blood-stained urine in the catheter bag, gas or urine in the operative field, and confirmation with intravesical dye or methylene blue. Involve urology for a large or trigonal injury, repair in layers, and leave an indwelling catheter for prolonged drainage.^[7]

(e) Thromboprophylaxis (2 marks)

• Mechanical for everyone (0.5 mark): graduated compression or intermittent pneumatic compression preoperatively, continued until she is mobile, with early mobilisation from about 4 hours.^[2][10]
• Chemoprophylaxis (1.5 marks): she has multiple risk factors — obesity, emergency caesarean in labour, age over 30 — so low molecular weight heparin is indicated for at least 10 days postpartum. Dose by weight, not by habit: a randomised trial stopped early for efficacy found weight-based enoxaparin achieved prophylactic anti-Xa levels in 66% versus 44% with fixed 40 mg dosing (relative risk 1.49), and 52% versus 15% at the postoperative visit.^[9]