Cesarean Delivery

Although morbidity and mortality rates of cesarean delivery are low, they are still several times higher than those of vaginal delivery; thus, cesarean delivery should be done only when it is safer for the woman or fetus than vaginal delivery.

The most common specific indications for cesarean delivery are

• Previous cesarean delivery

• Protracted labor

• Abnormal fetal presentation or lie (particularly breech presentation or transverse lie)

• A nonreassuring fetal heart rate pattern, which requires rapid delivery

• Excessive bleeding, possibly indicating placental abruption

• Placenta previa

Many women are interested in elective cesarean delivery on demand. The rationale includes avoiding damage to the pelvic floor (and subsequent incontinence) and serious intrapartum fetal complications. However, such use is controversial, has limited supporting data, and requires discussion between the woman and her physician. The discussion should include immediate risks and long-term reproductive planning regarding how many children the woman intends to have, because the risk of surgical complications increases with an increasing number of cesarean deliveries.

Women with a previous cesarean delivery may choose a repeat cesarean because of concern about a risk of uterine rupture; however, risk of rupture with vaginal delivery is only about 1% overall (risk is higher for women who have had multiple cesarean deliveries or a vertical incision, particularly if it extends through the thickened, muscular portion of the uterus).

Vaginal birth is successful in about 60 to 80% of women who have had a single prior cesarean delivery with a low transverse uterine incision (1). This option should be offered to those who have had a single prior cesarean delivery by low transverse uterine incision. Success of TOLAC depends on the indication for the initial cesarean delivery. TOLAC should be done in a facility where an obstetrician, anesthesiologist, and surgical team are immediately available, which makes TOLAC impractical in some situations.

During cesarean delivery, practitioners skilled in neonatal resuscitation should be readily available.

The uterine incision can be classical or lower segment.

• Lower segment: Lower-segment incisions are done most often. A low transverse incision is made in the thinned, elongated lower portion of the uterine body, and the bladder reflection is dissected off the uterus. A vertical lower-segment incision is used only for certain abnormal presentations and for excessively large fetuses. In such cases, a transverse incision is not used because it can extend laterally into the uterine arteries, sometimes causing excessive blood loss. Women who have had deliveries by a low transverse uterine incision are advised about the safety of a trial of labor in subsequent pregnancies.

• Classical: The incision is made vertically in the anterior wall of the uterus, ascending to the upper uterine segment or fundus. This incision typically results in more blood loss than a lower-segment incision and is usually done only when placenta previa is present, fetal position is transverse with the back down, the fetus is preterm, the lower uterine segment is poorly developed, or a fetal anomaly is present.

Care after cesarean delivery follows postoperative care principles similar to those for other abdominal surgeries, including appropriate pain management and wound care.

In addition, particular postpartum issues should be addressed, including support for care of the infant and breastfeeding.

Patients are typically discharged from the hospital when they are hemodynamically stable, are able to tolerate oral intake, have normal bowel and bladder function, and have no complications that require inpatient care. They should be given instructions about precautions at home (eg, wound care) and counseled to call their health care professional if they have fever, wound redness or discharge, heavy and persistent vaginal bleeding, persistent headache, persistent abdominal pain, vision changes, leg swelling, chest pain, shortness of breath, or other concerning symptoms.