Cesarean delivery

Cesarean delivery refers to the delivery of newborns via a surgical incision through the abdominal wall and uterus. It is typically performed in situations where maternal and/or fetal health is at risk or compromised, but can also be performed as an alternative to vaginal delivery in routine pregnancies. Cesarean delivery can be planned based on known maternal and/or fetal risk factors, or performed as life-saving emergency procedures for unexpected labor and delivery complications. There are two common types of surgical incision: the classical cesarean incision, which is vertical, and the low segment transverse incision, which is horizontal. Fetal complications are rare. Maternal recovery is longer than with vaginal delivery and complications can include common surgical complications (e.g., infection, hemorrhage, venous thromboembolism) as well as an increased risk of specific mechanical complications in subsequent pregnancies. Patients who have had a Cesarean delivery often undergo planned repeat cesarean births for subsequent pregnancies, however, vaginal birth after cesarean delivery is possible in select patients.

See also “Normal labor and delivery,” and “Abnormal labor and delivery.”

• The delivery of a newborn through a vertical or horizontal incision in the lower abdominal and uterine wall

• Advantages
  • Safest method of birth if maternal and/or fetal health is compromised by a vaginal delivery
  • Fetal birth trauma is rare.
• Disadvantages
  • Postoperative complications
  • Long recovery period

There are guidelines detailing indications for cesarean delivery that are based on scientific findings. However, each hospital can individually determine how these indications are interpreted. The well-being of the mother and child should be of the utmost priority.

Maternal indications

• Primary cesarean delivery
  • Placenta praevia totalis
  • Refractory HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), severe preeclampsia
  • Severe uterine abnormalities (e.g., myoma) of the mother
  • Maternal skeletal deformities
  • Relative:
    • Severe maternal disease (e.g., cardiopulmonary disorders, uncontrolled diabetes mellitus)
    • Maternal HIV infection
    • Severe stress reactions
    • Elective cesarean delivery
  • Possible indications :
    • Fetal head is disproportionately large compared to the maternal pelvis.
    • Breech presentation in a nullipara or multiple pregnancy
    • Suspected absolute fetal macrosomia
• Secondary cesarean delivery (after PROM and/or onset of phase 1)
  • Prolonged labor in:
    • Premature birth
    • Intraamniotic infection
    • Abnormal fetal position (e.g., breech presentation, longitudinal position)
    • Maternal exhaustion; ineffective contractions
• Emergency cesarean delivery
  • Immediate threat to life of mother
  • Severe vaginal bleeding of unknown etiology (suspected placental separation)
  • Suspected uterine rupture
  • See also “Perimortem cesarean delivery.”

Fetal indications

• Primary cesarean delivery
  • Fetal growth retardation with circulatory depression
  • Premature birth, if further risk factors are present, e.g., infection
  • Fetal malformations that hinder a natural birth (e.g., severe hydrocephalus)
  • Multiple pregnancy with a significant difference in fetal weight
• Emergency cesarean delivery
  • Immediate threat to life of fetus
  • Pathological CTG (particularly persistent, severe fetal bradycardia)
  • Fetal acidosis
  • See also “Perimortem cesarean delivery.”

Cesarean delivery on maternal request (on-demand)

• Overview
  • Primary cesarean delivery that is performed on the mother's request in the absence of medical indications
  • Medically and ethically acceptable if the patient is well-informed
  • Possible reasons include:
    • Fear of the pain of labor
    • Prior negative labor experience
    • Possibility of scheduled delivery
    • Concerns about fetal harm during vaginal birth
  • Physicians are not obliged to perform a non-medically indicated cesarean delivery and may refer the patient to another obstetrician willing to perform the procedure.
• Approach
  • Explore the reasons behind the request
  • Address concerns about labor and provide information about prenatal childbirth education, obstetric analgesia, and emotional support during labor
  • Lead a balanced discussion about the risks and benefits of cesarean delivery and vaginal birth
  • If the patient insists on having a cesarean delivery, schedule the procedure for after 39 weeks of gestation

• No true contraindications

We list the most important contraindications. The selection is not exhaustive.

Procedure

• Skin incision above the pubic symphysis.
• Largely blunt penetration through the abdominal muscles, fascia, and peritoneum
• Hysterotomy
• Fetal extraction, cord clamping, and manual placental removal
• Wound closure

Surgical approach

Maternal

• Infections (i.e., of the endometrium, pelvis, lungs, urinary tract)
• Hemorrhage
• Iatrogenic: surgical injury (e.g., to the bowel, bladder, ureter)
• Postoperative incisional pain
  • Assess and monitor for signs of adequate wound healing and infection (see “Postoperative management” for more information)
  • Pain management (e.g., acetaminophen and/or NSAIDs) ^[2]
• Neuropathy (due to ilioinguinal and/or iliohypogastric nerve entrapment)
• Thromboembolic events
• Ileus and acute colonic pseudo-obstruction
• Related to the placenta and uterus
  • Abnormal placental attachment
  • Uterine rupture
  • Impaired uterine regression

Fetal

• Postnatal transient tachypnea of the newborn
• Acute respiratory distress syndrome

We list the most important complications. The selection is not exhaustive.

Mode of delivery after cesarean delivery

Patients who have undergone a previous cesarean delivery have two options for mode of delivery in a subsequent pregnancy: TOLAC and PRCB.

• Trial of labor after cesarean (TOLAC): A planned or attempted childbirth in a mother who has had a prior cesarean delivery.
  • Results in vaginal birth after cesarean (VBAC) if successful or a repeat cesarean delivery if unsuccessful.
  • Associated with increased risk of rupture of the cesarean scar on the uterus.
  • Contraindicated in patients with a history of > 2 prior low-transverse cesarean deliveries or classic cesarean delivery.
• Planned repeat cesarean birth (PRCB): A planned cesarean delivery in a patient who has had a prior cesarean section.
  • Multiple cesarean births increase the risk of uterine rupture.

Decision-making

• Patient-centered decision-making: The decision for TOLAC or PRCB should be made by the patient in collaboration with their provider.
• Factors to consider include:
  • TOLAC can only be provided at facilities with the resources for cesarean birth.
  • Potential complications associated with TOLAC or PRCB (e.g., risk of uterine rupture is higher in TOLAC), including patient factors that affect the risks and benefits for each route of delivery (e.g., prior uterine rupture) ^[3]
  • Patient's personal preferences, past birthing experiences, and future pregnancy plans
  • Probability of successful VBAC ^[4]

Examples of indications ^[5]

• TOLAC
  • ≤ 2 previous low-transverse cesarean deliveries
  • A previous cesarean delivery with unknown incision, unless there is clinical suspicion of a previous classic cesarean delivery (e.g., cesarean delivery at gestational age < 28 weeks; large lower segment uterine fibroid)
• PRCB (if TOLAC is contraindicated)
  • Patients with contraindications to labor or vaginal birth (e.g., placenta previa)
  • Patients with a prior uterine rupture
  • Patients with prior uterine incisions at cesarean birth that are associated with an increased risk of intrapartum uterine rupture during TOLAC:
    • Classical incision (TOLAC is contraindicated) ^[6]
    • T or J incisions
    • Transfundal uterine incision

TOLAC is contraindicated in patients with previous classical cesarean delivery.