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A4. Forms of cesarean delivery, indications

Caesarean section (from Latin, caesura = to cut) is a surgical procedure where the foetus is delivered by open surgery, through an incision in the abdominal wall and uterus. Often called simply C-section, this procedure has no absolute contraindications and can therefore in theory be performed on anyone. This makes C-section the ideal “plan B” in case vaginal labour is too risky, not progressing properly, or frankly impossible. However, C-section is generally only used in the first stage of labour (not the second).

C-section may be performed emergently or electively (planned). In most cases, thanks to ultrasound screening, factors which may cause vaginal delivery to be impossible or too risky will be known ahead of time, and so C-section can be planned electively. However, if complications arise during vaginal labour, emergency C-section is necessary.

The rule of thumb is that women may give birth vaginally after having one C-section. However, after having two or more C-sections, the choice must be made whether to attempt vaginal birth or perform planned C-section on subsequent births (see also topic B29).

Indications

There are many possible absolute and some relative indications for C-section. In fact, there are so many possible indications that I’d rather only include those which are most common.

Most common indications for emergency C-section:

  • Failure to progress during labour
  • Worrying foetal status (usually pathological CTG)
  • Placental abruption
  • Eclampsia

Most common indications for elective C-section:

  • Foetal malpresentation
  • Cephalopelvic disproportion (foetal head too large to fit through mother’s pelvis)
  • Placenta praevia (especially totalis)
  • Pre-eclampsia
  • Maternal or foetal disease which would increase the risk for adverse outcomes
  • Multifoetal gestation

Anaesthesia

Anaesthesia during C-section is covered in topic B11.

Incision

In almost all cases, a Pfannenstiel or Joel-Cohen incision is used. These are wide transversal incisions made suprapubically, with the Joel-Cohen incision being slightly more superior on the abdominal wall than the Pfannenstiel. These incisions are preferred over vertical incisions (due to lower risk of wound disruption and hernia and other complications). Research suggests that Joel-Cohen incision is superior to Pfannenstiel as well.

A low median (low vertical) incision may be used in case of transverse lie or very small foetuses.

Complications

Possible short-term complications include:

  • Postoperative bleeding, atonia
  • Infection
  • Organ injury (bladder, ureter, bowel)

However, C-section carries some important risks for subsequent pregnancies as well. The risk for the following is increased:

  • Abnormal placentation (praevia, accreta)
  • Uterine rupture
  • Spontaneous abortion