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Cesarean Section

  • Definition

    Cesarean childbirth consists of an operation to deliver a baby through an incision in the abdomen.


    Until recently the operation was usually used as a last resort because of a high rate of maternal complications and death. With the availability of antibiotics to fight infection and the development of modern surgical techniques, the once high maternal mortality rate has dropped dramatically. As a result, the cesarean childbirth rate has increased dramatically.

    There are three main types of cesarean operations, each named according the location and direction of the uterine incision:

    Low Transverse, a transverse (horizontal) incision in the lower uterus

    Low Vertical, a vertical incision in the lower uterus

    Classical, a vertical incision in the main body of the uterus

    Today, the low transverse incision is used almost exclusively. It has the lowest incidence of hemorrhage during surgery as well as the least chance of rupturing in later pregnancies.

    Sometimes, because of fetal size (very large or very small) or position problems (breech or transverse), a low vertical cesarean may be performed.

    In the classical operation, a larger vertical incision allows a greater opening; it is used in some emergency situations as well as for fetal size or position problems. This approach involves more bleeding in surgery and a higher risk of abdominal infection. All subsequent deliveries must be by cesarean section after a classical delivery due to the higher risk of uterine rupture.

    Although any uterine incision may rupture during a subsequent labor, the classical is more likely to do so, and more likely to result in death for the mother and fetus than a low transverse or low vertical incision.

    There are many reasons why a woman might need to deliver by Cesarean section, although not all doctors agree on when one is really necessary. The most common reason is failure to progress (FTP) in labor, where labor has stalled because the cervix has stopped dilating or uterine contractions are weak. The second most common reason for cesarean section is fetal distress. Sometimes the baby can not tolerate the strong contractions associated with labor. When the fetal heart tracing becomes non-reassuring, a cesarean section is usually performed. Another common reason for cesarean section is previous cesarean section or surgery on the uterus. Women who delivered by a classical cesarean section in a previous pregnancy must deliver by cesarean section for all following pregnancies. However, women with a history delivering by low transverse cesarean section are given the choice of scheduling a repeat cesarean section or trying to deliver vaginally. Also some women with a history of surgery to remove fibroids may need to deliver by cesarean section.

    Other less common reasons for a cesarean section are listed below:

    Cephalopelvic Distortion (CPD. Another indication of cesarean delivery is cephalopelvic disproportion (CPD), a rare condition in which the baby's head is too large to fit through the mother's pelvis.

    Malposition of the fetus. In breech position, the baby's buttocks or feet are positioned to come out first instead of the head. Twins might need to be delivered by cesarean if the first baby or both are breech. Malposition of the fetus does not necessarily mean a cesarean delivery.

    Vaginal bleeding/placenta previa/placental abruption. Vaginal bleeding late in pregnancy often indicates placenta previa, a low-lying placenta that covers part or all of the inner opening of the cervix. If the bleeding does not stop with bedrest, the doctor probably will perform a cesarean, to prevent hemorrhage. Vaginal bleeding late in pregnancy also may indicate placental abruption, where the placenta separates from the uterine wall before delivery. In some cases of mild abruption, it may be possible to deliver vaginally. If there is heavy bleeding or fetal distress caused by abruption (abruption can lead to maternal shock, which, together with a reduced amount of functioning placenta, can deprive the fetus of adequate oxygen), a cesarean generally is necessary.

    Other situations. If you have vaginal herpes and active sores in the vaginal area, your doctor might do a cesarean to try to prevent your passing on the disease to your baby. A cesarean section is usually performed in mothers with HIV before labor to prevent transmission HIV from mother to baby. Women diagnosed with invasive cervical cancer who have bulky cancer lesions on the cervix are offered classical cesarean section to deliver the baby. Lastly, women pregnant with a baby with bleeding problems may be offered a cesarean section to prevent birth trauma to the infant.

    Malpractice concerns, a woman’s preference, obesity and insurance coverage are also factors which may play a role in whether to perform a cesarean delivery.

    Until recently, it was medically accepted that once a woman had a cesarean, she should have all of her children by cesarean because of the concern about tearing the incision. Yet studies have shown "once a cesarean, always a cesarean," no longer holds true for most women. Today, the option of attempting to give birth through the vagina is open to women who have had previous low transverse incision cesarean births, and over half of these have successful vaginal deliveries.

    If vaginal delivery is a possibility for you, here are some reasons why you may wish to attempt it:

    Less risk. A vaginal delivery usually has fewer complications for the mother than a cesarean birth. As there is no abdominal incision, the risks of infection, bleeding, or other problems resulting from surgery or anesthesia are much lower.

    Shorter recovery. Your stay in the hospital is likely to be briefer after vaginal delivery. The average time spent in the hospital is 1 to 3 days, whereas the average stay after a cesarean birth is 3 to 5 days. Recovery at home is faster as well, since women who deliver by cesarean must limit their activity for 4 to 6 weeks to allow the abdominal incision to heal.

    More involvement. Some women wish to be awake and fully involved in the birth process. There may also be more limitations on the presence of others in the room during the cesarean birth process.


    What circumstances require cesarean delivery?

    Are indications of fetal distress confirmed by a fetal scalp blood test?

    Is a second opinion sought before proceeding to all but emergency surgery?

    Must I have intravenous infusion during labor, or can I eat and drink lightly?

    What are some specifics about the facility where I will deliver. Does it require a specific management plan, such as active management of labor?

    Does it offer a constant labor companion, or allow you to bring your own?