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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- UK CS rate ~30–35%. Most common operation performed in the NHS
- Classification: Cat 1 = immediate threat to mother/fetus (<30 min), Cat 2 = compromise not immediately life-threatening, Cat 3 = needs early delivery but no compromise, Cat 4 = elective
- Common indications: failure to progress, fetal distress, malpresentation (breech), placenta praevia, previous CS
- VBAC (vaginal birth after caesarean): success rate ~72–75%. Discuss risks (0.5% uterine rupture) vs benefits
- Lower segment transverse incision (Joel-Cohen or Pfannenstiel). Classical (vertical) only if specific indications
- Prophylactic antibiotics (single dose IV co-amoxiclav or cefuroxime) before skin incision
Overview
Caesarean section (CS) is the delivery of a baby through a surgical incision in the mother's abdomen and uterus. It is the most common major operation performed in NHS hospitals, with approximately 30–35% of births in England delivered by CS. CS may be planned (elective/category 4) or unplanned (emergency/categories 1–3). NICE NG192 provides guidance on when to offer and discuss CS, procedural aspects, and postnatal care. The increasing CS rate has implications for future pregnancies, including risks of placenta praevia, placenta accreta, and uterine rupture.
Epidemiology
The overall CS rate in England is approximately 30–35%, having risen from ~10% in the 1980s. Approximately 15% are elective (planned) and 15–20% are emergency (unplanned). The most common indications for emergency CS are failure to progress in labour (30%), pathological CTG/fetal distress (30%), and failed induction (10%). The most common indications for elective CS are previous CS, malpresentation (breech), maternal request, and placenta praevia.
Clinical Features
Symptoms
Indications depend on the underlying reason for CS (e.g., non-progressing labour, fetal distress)
Signs
Category 1: acute fetal bradycardia, cord prolapse, uterine rupture, severe APH, eclampsia
Category 2: pathological CTG with some fetal compromise, failure to progress with concerns
Category 3: early delivery needed but no immediate compromise (e.g., failed IOL)
Category 4: planned elective CS (e.g., breech at term, previous CS, maternal choice)
Investigations
First-line
FBC, group and savePre-operative bloods — crossmatch if high risk of haemorrhage (e.g., placenta praevia)
CTGContinuous fetal monitoring before and until delivery in emergency CS
Second-line
Coagulation screenIf pre-eclampsia, APH, or sepsis
USSConfirm presentation, placental site if not already known
Specialist
MRIIf placenta accreta suspected (praevia over previous CS scar)
Management
NICE NG192 (Caesarean birth), 20211
Pre-operative
- Informed consent — discuss risks, benefits, alternatives
- Prophylactic antibiotics: single dose IV before skin incision (co-amoxiclav or cefuroxime + metronidazole)
- Ranitidine and sodium citrate (aspiration prophylaxis)
- Regional anaesthesia (spinal or epidural) preferred over GA — lower risk, mother awake for delivery
- GA only if: emergency where time critical, regional anaesthesia contraindicated/failed
- Thromboprophylaxis: TED stockings + LMWH postoperatively (risk-based duration)
2
Intra-operative
- Lower segment transverse incision (Joel-Cohen or Pfannenstiel)
- Classical (vertical) incision only if: extreme prematurity, transverse lie with back down, or anterior placenta praevia
- Delayed cord clamping (≥1 min) unless specific indication for early clamping
- Active management of 3rd stage: IV oxytocin 5 IU (slow IV) after delivery of baby
- Intraperitoneal closure of uterus in two layers
3
Post-operative
- Remove catheter after 12 hours (when mobile)
- Early mobilisation and oral fluids within 6 hours
- Thromboprophylaxis: LMWH for minimum 7 days (10 days for emergency CS, longer if additional risk factors)
- Wound care: remove dressing at 24 hours. Sutures/clips removal at 5 days
- Advise: no driving for 6 weeks, avoid heavy lifting, wound review by community midwife
4
VBAC counselling
- VBAC success rate approximately 72–75%
- Risk of uterine rupture ~0.5% (1 in 200)
- Contraindications to VBAC: previous classical CS incision, previous uterine rupture, ≥3 previous CS
- VBAC should take place in a consultant-led unit with continuous CTG and immediate CS availability
- Discuss that successful VBAC has lower morbidity than elective repeat CS
Complications
- Haemorrhage: Average blood loss ~500–1000 mL. Risk of PPH and need for transfusion
- Infection: Wound infection, endometritis, UTI — reduced by prophylactic antibiotics
- VTE: Major risk factor — thromboprophylaxis essential
- Injury: Bladder injury (most common visceral injury), bowel injury, ureteric injury
- Adhesions: Increasing with each CS — can cause chronic pain, bowel obstruction, and complicate future surgery
- Future pregnancy risks: Placenta praevia, placenta accreta, uterine rupture, increased CS rate
- Neonatal: Transient tachypnoea of the newborn (wet lung), fetal lacerations (rare)
UKMLA Exam Tips
- 1Category 1 = immediate threat to life (deliver within 30 min). Category 4 = elective
- 2Spinal anaesthesia is preferred for CS — GA only if absolute time pressure or contraindication
- 3Prophylactic antibiotics BEFORE skin incision — reduces wound infection by 50%
- 4VBAC: 72–75% success. 0.5% uterine rupture risk. Contraindicated if previous classical (vertical) incision
- 5Each additional CS increases risk of placenta praevia and accreta in future pregnancies
- 6Thromboprophylaxis: LMWH for ≥7 days post-CS + TED stockings
practicetest your knowledge on caesarean sectionApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — obstetrics and beyond.
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