Cesarean Delivery

Author: Saju Joy, MD, Associate Professor, Division Chief Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Virginia Tech Carilion School of Medicine
Coauthor(s): Stephen A Contag, MD, Assistant Professor, Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine; Attending Physician, Institute for Maternal-Fetal Medicine, Sinai Hospital of Baltimore

Cesarean delivery is defined as the delivery of a fetus through a surgical incision through the abdominal wall (laparotomy) and uterine wall (hysterotomy).

The words cesarean and section are both derived from verbs that mean to cut; thus, the phrase cesarean section is a tautology. It is preferable to use the terms cesarean delivery or cesarean birth.

In the United States, cesarean delivery has become the most common surgical procedure. In 1990, almost 23% of all live births were from cesarean deliveries.1 After a plateau in the mid 90s at 21%, the most recent data reveal a 32% cesarean delivery rate for 2007.1 This is an increase in the cesarean rate by 53% from 1996-2007 and the highest rate ever reported in the United States. The cesarean delivery has evolved from a vain attempt performed to save the fetus to one in which physician and patient both participate in the decision-making process, striving to achieve the most benefit for the patient and her unborn child.

History of the Procedure

The etymology of the term cesarean is unclear. Most authorities believe it derives from the Roman legal code, the Lex Caesare . This law originated as the Lex Regia from the eighth century BC and mandated a postmortem operative delivery so that both the mother and child could be buried separately. The derivation of Caesar and caesarean is from the Latin verb caedere (to cut). Children born by postmortem operations were referred to as caesones .

Although ancient writers, such as Pliny the Elder and Maimonides, suggest that cesarean delivery was undertaken in live mothers presumably for difficult births, the complications of hemorrhage and infection make it most unlikely that the woman could survive.

The first recorded case of a surviving mother and infant pair was in 1500 in Switzerland, where a pig gelder performed a cesarean delivery on his wife after obtaining permission from the local authorities.2 Some doubt is cast on certain details surrounding the event.

By the mid 17th century, more reports by obstetricians about this operation began to appear. Early descriptions of such procedures reveal that abdominal delivery was performed in rare circumstances with a mortality of more than 85% secondary to hemorrhagic and infectious complications. Medical education was greatly advanced during this time because of the availability of Andreas Vesalius’ publication on human anatomy in 1543 as well as increased access to cadaveric dissections.

The ability of obstetricians to perform the procedure was limited by anesthesia. In 1846 at the Massachusetts General Hospital, William Morton successfully removed a tumor from a patient using ether. In 1847 in Edinburgh, James Young Simpson experimented on himself with chloroform and induced a state of unconsciousness.3

Surgical technique was also a limiting factor for the acceptability of the procedure. Initially, maternal mortality from blood loss was high because surgeons were reluctant to close the uterine incision. In 1876, Eduardo Porro advocated hysterectomy at the time of cesarean delivery to control bleeding and decrease infection. Maternal mortality was approximately 60% and fetal survival was around 85%.3 The first successful cesarean hysterectomy in the United States was performed by Richardson in 1881.3 In 1882, a german obstetrician, Max Sanger, described the value of suturing the uterine wall with silver wire and silk in a 2-step closure. These sutures were a new material developed in the United States by J. Marion Sims who had advocated the silver wire sutures to treat vaginal tears or fistulas from traumatic childbirth. This was a significant advancement as removal of the suture material was no longer required.

Although the use of internal sutures decreased hemorrhagic morbidity, infectious morbidity from peritonitis remained substantial. Major advances in asepsis began with the introduction of hand washing by Semmelweis in 1847 at the Vienna Maternity Hospital. Subsequently Joseph Lister introduced carbolic spray in the operating theater in 1867. These 2 interventions together with not using the cesarean delivery as a measure of last resort and after extensive intrauterine instrumentation, led to a substantial reduction in infectious morbidity and mortality. Maternal mortality dropped from 65% at the beginning of the 19th century to 5-10% at the end.3

In 1907, the extraperitoneal approach was first described by Frank and modified in 1909 by Latzko. This approach appeared to decrease the risk of peritonitis, and, in 1912, Krönig described that this approach also allowed access to the thinner lower uterine segment. Krönig described a vertical median uterine incision with delivery aided by forceps. Then, the lower segment was covered with peritoneum.

This technique was modified further and introduced in the United States by Beck (1919)4 and DeLee (1922).3 Finally, in 1926, Kerr described a low transverse incision in the lower uterine segment, which did not become widely used in the United States until the 1940s and is today the most commonly used uterine incision throughout the world.5 With the discovery of penicillin by Alexander Fleming in 1928 (purified in 1940), the need for an extraperitoneal procedure was essentially eliminated.

Problem

A cesarean delivery is performed for a variety of fetal and maternal indications (see Indications). The indications have expanded to consider the patient's wishes and preferences. Controversy surrounds the current rates of cesarean delivery in developed countries and its use for indications other than medical necessity.

Frequency

From 1910-1928, the cesarean delivery rate at Chicago Lying-in Hospital increased from 0.6-3%. The cesarean delivery rate in the United States was 4.5% in 1965. By 1988, the cesarean rate had risen from 5.5% in 1970 to 24.1% in 1986 according to the National Hospital Discharge Survey. Less than 10% of mothers had a vaginal birth after a prior cesarean and women spent an average of 5 days in the hospital for a cesarean delivery and only 2.6 days for a vaginal delivery.

If age-specific cesarean rates continued at the steady pattern of increase observed since 1970, 40% of births were predicted to be by cesarean in the year 2000.6 Those predictions fell short, but not by much. In 2006, the National Center for Health Statistics reported that the percentage of cesarean births in the United States had increased from 20.7% in 1996 to 32% in 2007. Cesarean rates increased for women of all ages, race/ethnic groups, and gestational ages and in all states. Both primary and repeat cesareans had increased.

Cesarean delivery rates, United States.

Cesarean delivery rates, United States.


Increases in the primary cesareans with no specified indication were faster than in the overall population and appear to be the result of changes in obstetric practice rather than changes in the medical risk profile or increases in maternal request.7 This has occurred despite several studies that note an increased risk for neonatal and maternal mortality for all cesarean deliveries as well as for medically elective cesareans compared with vaginal births.8 The decrease in total and repeat cesarean delivery rates noted between 1990 and 2000 was due to a transient increase in the rate of vaginal births after cesarean delivery.9

The cesarean delivery rate has also increased throughout the world, but rates in certain parts of the world are still substantially lower than in America. The cesarean delivery rate is approximately 21.1% for the most developed regions of the globe, 14.3% for the less developed regions, and 2% for the least developed regions.10 In a 2006 publication reviewing cesarean delivery rates in South America, the median rate was 33% with rates fluctuating between 28% and 75% depending on public service versus a private provider. The authors conclude that higher rates of cesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.11

Why the rate of cesarean delivery has increased so dramatically in the United States is not entirely clear. Following are some reasons that may account for the increase.

  • Repeat cesarean delivery: In 1988, when the cesarean delivery rate peaked at 24.7%, 36.3% (351,000) of all cesarean deliveries were repeat procedures. Although reports concerning the safety of allowing vaginal birth after a cesarean delivery had been present since the 1960s12 , by 1987, less than 10% of women with a prior cesarean delivery were attempting a vaginal delivery. In 2003, the repeat cesarean delivery rate for all women was 89.4%; the rate for low-risk women was 88.7%. Today, low-risk women giving birth for the first time who have a cesarean delivery are more likely to have a subsequent cesarean delivery.13
  • Delay in childbirth and reduced parity: In the last decade, an increase in the percentage of births to women aged 30-50 years has occurred despite a decrease in their relative size within the population.14 The cesarean rate for mothers aged 40-54 years in 2007 was more than twice the cesarean rate for mothers younger than 20 years (48% and 23%, respectively).14 The risk of having a cesarean delivery is higher in nulliparous patients, and, with increasing maternal age, the risk for cesarean delivery is increased secondary to medical complications such as diabetes and preeclampsia.
  • Decrease in the rate of vaginal breech delivery: By 1985, almost 85% of all breech presentations (3% of term fetuses) were delivered by cesarean. In 2001, a multicenter and multinational prospective study determined that the safest mode of delivery for a breech presentation was cesarean delivery.15 This study has been criticized for differences in the standards of care among the study centers that does not allow a standard recommendation.16 The most recent recommendation from the American College of Obstetricians and Gynecologists (ACOG) regarding breech delivery is that planned vaginal delivery may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management.17 This may lead to a small decrease in breech delivery rates, but the overwhelming majority of cases will probably continue to be delivered by elective cesarean.
  • Decreased perinatal mortality with cesarean delivery: Perinatal outcome is influenced by gestational age at delivery, the presence of congenital abnormalities and growth abnormalities, and the indication for delivery itself. Improvement in perinatal outcome has been greatly enhanced by improved technology available to neonatologists and by improvements in prenatal care (eg, identification of patients at high risk, ultrasonography, and increased usage of antenatal steroids, progesterone, and most recently magnesium sulfate cerebral palsy prophylaxis in those at risk for preterm delivery.18 ,19 Unfortunately, despite the dramatic rise in the rate of cesarean delivery, the overall rate of cerebral palsy has not decreased. The only perinatal intervention for which strong evidence shows a beneficial effect on both mortality and the risk of cerebral palsy is antenatal treatment of the mother with glucocorticoids.20
  • Nonreassuring fetal heart rate testing: A minority of cesarean deliveries are performed for fetal distress, where fetal heart rate tracings are clearly associated with an increased risk of fetal hypoxia and acidosis. Fetal heart rate monitoring has not decreased the overall rate of cerebral palsy; rather, it has decreased the threshold to perform cesarean deliveries for nonreassuring fetal status.
  • Fear of malpractice litigation: Unfortunately, many obstetricians admit that their practice of medicine has become more defensive. Given the fear of inquiry regarding how a particular patient's labor was managed, many obstetricians may have a lower threshold to perform a cesarean delivery despite the fact that the incidence of neonatal seizures or cerebral palsy has not been affected by increasing cesarean delivery rates.21

Etiology

Cesarean deliveries were initially performed to separate the mother and the fetus in an attempt to save the fetus of a moribund patient. This operation subsequently developed into a surgical procedure to resolve maternal or fetal complications not amenable to vaginal delivery, either for mechanical limitations or to temporize delivery for maternal or fetal benefit.

Pathophysiology

Most of the physiological changes occurring during a cesarean delivery are secondary to the physiological adaptations to pregnancy, the medical or obstetrical complication affecting the mother, or secondary to obstetrical complications directly related to the pregnancy (eg, preeclampsia). The method of anesthesia used to perform the procedure also impacts the physiological adaptations that the mother undergoes during the procedure.

Presentation

See Indications.

Indications

A cesarean delivery is performed for maternal indications or fetal indications, or both. The leading indications for cesarean delivery are previous cesarean delivery, breech presentation, dystocia, and fetal distress. These indications are responsible for 85% of all cesarean deliveries.22 Recently, debate has ensued over the option of elective cesarean delivery on maternal request. Evidence shows that informing the pregnant woman requesting a cesarean delivery of the associated risks and benefits for the current and any subsequent pregnancies is reasonable. The clinician’s role should be to provide the best evidence-based counseling possible to the woman and to respect her autonomy and decision-making capabilities when considering route of delivery.23

In 2006, the NIH convened a consensus conference to address cesarean delivery on maternal request. They resolved that the evidence supporting this concept was not conclusive. Their recommendations included that cesarean delivery on request should be avoided by women wanting several children, should not be performed before the 39th week of pregnancy or without verifying fetal lung maturity, has a potential benefit of decreased risk of hemorrhage for the mother and decreased risk of birth injuries for the baby, has a potential risk of respiratory problems for the baby, and is associated with a longer maternal hospital stay and increasing risk of placenta previa and placenta accreta with each successive cesarean.24 The procedure requires individualized counseling by the practitioner of the potential risks and benefits of both vaginal and cesarean delivery and it should not be motivated by the unavailability of effective pain management.25

Detractors of cesarean delivery on request argue that the premise of cesarean on request applies to a very small portion of the population and that it should not be routinely offered on ethical grounds.26 The emerging consensus is that a randomized prospective study is required to address this issue.27

Maternal indications

Maternal indications include repeat cesarean delivery; obstructive lesions in the lower genital tract including malignancies, large vulvovaginal condylomas, obstructive vaginal septa, and leiomyomas of the lower uterine segment that interfere with engagement of the fetal head; and pelvic abnormalities that preclude engagement or interfere with descent of the fetal presentation in labor. Relative maternal indications for cesarean delivery are situations where the increasing intrathoracic pressure generated by Valsalva maneuvers could lead to maternal complications. These include left heart valvular stenosis, dilated aortic valve root, certain cerebral AVMs, and recent retinal detachment. Women with a prior vaginal or perineal reparative surgery, such as colporrhaphy and repair of major anal involvement from inflammatory bowel disease, also benefit from cesarean delivery to avoid damage to the previous surgical repair.

The term dystocia in labor is a very commonly cited indication but it is not specific. Dystocia is classified as a protraction disorder or as an arrest disorder. These can be primary or secondary disorders. Most dystocias are caused by abnormalities of the power (uterine contractions), the passage (maternal pelvis), or the passenger (the fetus).28 When a diagnosis of dystocia in labor is made, the indication should be detailed according to the previous classification (ie, primary or secondary disorder, arrest or protraction disorder, or a combination of the above). For further information, see eMedicine’s article Abnormal Labor.
 
Fetal indications

Fetal indications for cesarean delivery include those in which neonatal morbidity and mortality could be decreased by the prevention of trauma, malpresentations, certain congenital malformations or skeletal disorders, infection, and prolonged acidemia.

  • Malpresentation: A fetus in a nonvertex presentation is at increased risk for trauma, cord prolapse, and head entrapment. Malpresentation includes preterm breech presentations and nonfrank breech term fetuses. As previously discussed, the decision to proceed with a cesarean delivery for the term frank breech singleton fetus has been challenged. Although most practitioners will always perform a cesarean delivery in this situation, ACOG has left open the option to consider a breech delivery under the appropriate circumstances, including a practitioner experienced in the evaluation and management of labor and skilled in the delivery of the breech fetus.17
  • Twin gestations: The first twin in a nonvertex presentation is an indication for a cesarean delivery, as are higher order multiples (triplets or greater). A large body of literature supports both outright cesarean delivery as well as spontaneous breech delivery or extraction of the second twin. The decision is made in conjunction with the patient after appropriate counseling regarding the risks and benefits as well as under the supervision of a physician experienced in the management of the labor and delivery of a breech fetus.29 Evidence suggests that the rate of severe complications of the second breech twin is independent of the mode of delivery.30
  • Congenital anomalies: Cesarean delivery is a controversial indication for several congenital anomalies; these include fetal neural tube defects (to avoid sac rupture), particularly defects that are larger than 5-6 cm in diameter. One study noted no difference in long-term motor or neurologic outcomes.31 Some authors noted no relationship between mode of delivery and infant outcomes32 , while others have advocated cesarean delivery of all infants with a neural tube defect.33 Cesarean delivery is indicated in certain cases of hydrocephalus with an enlarged biparietal diameter, and some skeletal dysplasias such as type III osteogenesis imperfecta.

    Whether or not an outright cesarean delivery should be performed in the setting of a fetal abdominal wall defect (ie, gastroschisis and omphalocele) remains controversial. Most reviews agree that cesarean is not advantageous unless the liver is extruded, which is a very rare event.34 ,35 ,36 The overall incidence of cesarean delivery in this group of patients is probably due to an increased incidence of intrauterine growth retardation and fetal distress prior to or in labor.
  • Fetal distress: In the setting of a nonremediable and nonreassuring pattern remote from delivery, a cesarean delivery is recommended to prevent a mixed or metabolic acidemia that could potentially cause significant morbidity and mortality. Electronic fetal monitoring was used in 85% of labors in the United States in 2002.37 Its use has increased the cesarean delivery rate as much as 40%.38 This has occurred without a decrease in the cerebral palsy or perinatal death rate.39 ACOG has recommended that any facility providing obstetric care have the capability of performing a cesarean delivery within 30 minutes of the decision. Despite this recommendation, a decision to delivery time of more than 30 minutes is not necessarily associated with a negative neonatal outcome.40
  • Maternal infections: Among patients with first episode genital herpes infection, the risk of maternal fetal transmission is 33 times higher than with recurrent outbreaks. The largest population-based study reported that among primary infections risk of transmission to the newborn was 35% compared with a 2% risk of recurrent infection. Among patients with culture positive herpes, the transmission rate with vaginal delivery was 7 times that with cesarean delivery. Currently, all patients with active or symptomatic herpes infection are candidates for cesarean delivery.41 Neonatal infection with herpes can lead to significant morbidity and mortality, especially with a primary outbreak. With recurrent outbreaks, the risk to the neonate is reduced by the presence of maternal antibodies. Unfortunately, not all women with active viral shedding can be detected upon admission to labor and delivery.
  • Human immunodeficiency virus infections: Treatment of women with the HIV has undergone tremendous change in the past few years. Women with a viral count above 1,000 should be offered cesarean delivery at 38 weeks (or earlier if they go into labor). In women who are being treated with HAART, cesarean delivery (prior to labor or without prolonged rupture of membranes) appears to further lower the risk for neonatal transmission, particularly among those with viral counts above 1,000. Among patients with low or undetectable viral counts, the evidence supporting a benefit is not as clear; nevertheless, the patient should be given the option of a cesarean delivery.42

Maternal and fetal indications

Indications for cesarean delivery that benefit both the mother and the fetus include abnormal placentation, abnormal labor due to cephalopelvic disproportion, and those situations in which labor is contraindicated.

In the presence of a placenta previa (ie, the placenta covering the internal cervical os), attempting vaginal delivery places both the mother and the fetus at risk for hemorrhagic complications. This complication has actually increased as a result of the increased incidence of repeat cesarean deliveries, which is a risk factor for placenta previa and placenta accreta. Both placenta previa and placenta accreta carry increased morbidity related to hemorrhage and need for hysterectomy.43 ,44 ,24

Cephalopelvic disproportion can be suspected based on possible macrosomia or an arrest of labor despite augmentation. Many cases diagnosed as cephalopelvic disproportion are the result of a primary or secondary arrest of dilatation or arrest of descent. Predicting true primary or secondary arrest of descent due to cephalopelvic disproportion is best assessed by sagittal suture overlap, but not lambdoid suture overlap, particularly where progress is poor in a trial of labor.45 Continuing to attempt a vaginal delivery in this setting increases the risk of infectious complications to both mother and fetus from prolonged rupture of membranes.46 Less often, maternal hemorrhagic and fetal metabolic consequences occur from a uterine rupture, especially among patients with a previous cesarean delivery.47 Vaginal delivery can also increase the risk of maternal trauma and fetal trauma (eg, Erb-Duchenne or Klumpke palsy and metabolic acidosis) from a shoulder dystocia.48 ,49

Contraindications to labor: Among women who have a uterine scar (prior transmural myomectomy or cesarean delivery by high vertical incision), a cesarean delivery should be performed prior to the onset of labor to prevent the risk of uterine rupture, which is approximately 4-10%.47

Relevant Anatomy

See Intraoperative details.

Contraindications

Few contraindications exist to performing a cesarean delivery. If the fetus is alive and of viable gestational age, then cesarean delivery can be performed in the appropriate setting. In some instances, a cesarean delivery should be avoided. Rarely, maternal status may be compromised (eg, with severe pulmonary disease) such that an operation may jeopardize maternal survival. In such difficult situations, a care plan outlining when and if to intervene should be made with the family in the setting of a multidisciplinary meeting. A cesarean delivery may not be recommended if the fetus has a known karyotypic abnormality (trisomy 13 or 18) or known congenital anomaly that may lead to death (anencephaly).

Workup

Laboratory Studies

When patients are admitted for labor and delivery, most have blood for a CBC count and type and screen drawn when an intravenous line is started, which is a basic requirement for patients when they are admitted to the labor floor. These tests are drawn in addition to HIV antibodies, hepatitis B surface antigen, and a screening test for syphilis if they have not been recently obtained. If the patient has a hemoglobin level within the reference range, has had an uncomplicated pregnancy, and is anticipated to have a vaginal delivery, the use of having blood submitted to the lab for a routine CBC and type and screen has been debated from a cost-benefit standpoint. In many centers, blood is drawn and simply held in case the patient's course changes. If the decision is made to perform a cesarean delivery for an abnormal labor course, nonreassuring fetal testing, or abnormal bleeding, then the blood work is submitted.
 
Several situations can occur in which a CBC count and type and screen will be submitted upon admission to labor and delivery: (1) when a patient is admitted for a planned cesarean delivery, (2) a grand multipara, or (3) a history of postpartum hemorrhage or a bleeding disorder. Occasionally, a coagulation profile is necessary. In patients with thrombocytopenia, a history of a bleeding disorder, preeclampsia, or conditions with suspect DIC whether consumptive or secondary to thromboplastin release, a CBC and coagulation studies including prothrombin time, activated partial thromboplastin time, and fibrinogen may be ordered to assist the attending anesthesiologist in determining the safety of attempting regional anesthesia with an epidural or spinal procedure.
 
Most known thrombophilias, hemophilias, or other medical conditions that could compromise cardiac, circulatory, or respiratory function during surgery should be addressed with the anesthesiologist prior to admission for cesarean delivery. This includes patients with morbid obesity in which airway access as well as vascular access can be extremely challenging.
 
Some patients require blood to be crossmatched, with blood in storage available. The most common situation is a patient who has had prior laparotomies (including several prior cesarean deliveries), patients with known or suspect placenta previa or placenta accreta, or one who develops a coagulopathy from either severe preeclampsia or significant hemorrhage.

Imaging Studies

Upon arrival to labor and delivery, fetal position and estimated fetal weight should be always be documented. Ultrasonography is commonly used to estimate fetal weight despite evidence from a prospective study reporting the sensitivity of clinical and ultrasonographic prediction of macrosomia as 68% and 58%, respectively.50 Despite the notion that estimations have an inherent margin of error, legal texts and journals have maintained that a physician’s failure to assess fetal weight during pregnancy or labor constitutes a deviation from standards of practice.49

Treatment

Medical Therapy

Many indications exist for performing a cesarean delivery. In those women who are having a scheduled procedure (ie, an elective or indicated repeat, for malpresentation or placental abnormalities), the decision has already been made that the alternate of medical therapy, ie, a vaginal delivery, is least optimal. For other patients admitted to labor and delivery, the anticipation is for a vaginal delivery. Every patient admitted in this circumstance is admitted with the thought of a successful vaginal delivery. However, if the patient's situation should change, a cesarean delivery is performed because it is believed that outcome for the fetus and/or the mother may be better.
 
If a patient is diagnosed with a fetal malpresentation (ie, breech or transverse lie) after 36 weeks, the option for an external cephalic version is offered to try to convert the fetus to a vertex lie, thus allowing an attempt at a vaginal delivery. An external cephalic version is usually attempted at 36-38 weeks with studies underway to establish the use of performing external cephalic version at 34 weeks’ gestational age. Ultrasonography is performed to confirm a breech presentation. If the fetus is still in a nonvertex presentation, an intravenous line is started and the baby is monitored with an external fetal heart rate monitor prior to the procedure to confirm well being.
 
With a reassuring fetal heart rate tracing, the version is attempted. An external cephalic version involves trying to externally manipulate the fetus into a vertex presentation. This is accomplished with ultrasonographic guidance to ascertain fetal lie. An attempt is made to manipulate the fetus through either a "forward roll" or "backward roll." The overall chance of success is approximately 60%.51 Some practitioners administer an epidural to the patient prior to the attempted version, and others may give the patient a dose of subcutaneous terbutaline (a beta-mimetic used for tocolysis) just prior to the attempt.
 
Factors that influence the success of an attempted version include multiparity, a posterior placenta, and normal amniotic fluid with a normally grown fetus. Also, to be a candidate, a patient must be eligible for an attempted vaginal delivery. Relative contraindications include poor fetal growth or the presence of congenital anomalies. Risks of an external cephalic version include rupture of membranes, labor, fetal injury, and the need for an emergent cesarean delivery due to placental abruption. A recent review reported a severe complication rate of 0.24% and a cesarean section rate secondary to complications of 0.34%.51
 
If the version is successful, the patient is placed on a fetal monitor in close proximity to the labor and delivery unit or in the labor and delivery unit itself. If fetal heart rate testing is reassuring, either the patient is discharged to await spontaneous labor or she is induced if the fetus is of an appropriate gestational age and/or the patient has a favorable cervix.

Surgical Therapy

See Intraoperative details.

Preoperative Details

On average, patients are asked not to eat anything for 12 hours prior to the procedure, which exceeds current guidelines.52 The guidelines recommend a minimum preoperative fasting time of at least 2 hours from clear liquids, 6 hours from a light meal, and 8 hours from a regular meal.53 After arrival, an intravenous line is placed and IV fluids are infused. Preoperative lab samples are drawn. If a difficult procedure is anticipated with an increased risk for blood loss, cross-matched blood should be available for the start of the procedure. Intravenous fluid consists of either lactated Ringer solution or saline with 5% dextrose. The patient is placed on an external fetal monitor, and should be evaluated by the surgeon and the anesthesiologist.
 
The anesthesiologist will review regional anesthetic techniques. Regional anesthesia is used for 95% of planned cesarean deliveries in the United States. The 3 main regional anesthetic techniques are spinal, epidural, and combined spinal epidural.54 Every patient is evaluated for general anesthesia in case an emergency should arise and establishment of an airway becomes necessary. A review by Afolabi et al found that patients undergoing local anesthetic techniques were found to have a significantly lower difference between pre- and postoperative hematocrit levels when compared with patients undergoing general anesthesia. Women having either an epidural anesthesia or spinal have a lower estimated maternal blood loss.55
 
A blood pressure cuff is placed. Monitors are also placed to allow the patient's blood pressure, pulse, and oxygen saturation to be monitored prior to administering anesthesia through the initial postoperative period in the recovery room.
 
Prior to surgery, a Foley catheter is placed so that the bladder can be drained during the procedure and urine output can be monitored to help evaluate fluid status. After regional anesthesia, patients are unable to void spontaneously for as long as 24 hours.
 
Prior to anesthesia, the surgeon should evaluate the site of the intended skin incision. The intended area does not need to be shaved automatically unless the hair will interfere with the re-approximation of the skin edges. If the hair is to be removed, it should be clipped immediately prior to surgery. Shaving appears to be associated with a slightly increased risk for infection.56

After placement of the regional anesthetic, monitor the fetus until an adequate surgical level has been achieved. When the level of anesthesia is adequate, the skin can be prepared with either an iodine scrub or with 4% chlorhexidine. Prior to making the initial incision, grasp the patient's skin bilaterally with an instrument such as an Allis clamp at the level of and above the incision to confirm anesthesia up to the level of T-4. This ensures that the anesthetic level is appropriate. The dermatomal level of anesthesia required for cesarean delivery is higher than that required for labor analgesia. A sensory block to the 10th thoracic dermatome is sufficient to achieve analgesia for labor, but for cesarean, the anesthetic level must be extended cephalad to at least the fourth thoracic dermatome to prevent nociceptive input from the peritoneal manipulation.

Prior to beginning the surgery, inform the nursery so that a member of the nursery staff can be present to evaluate the baby after delivery and resuscitate as necessary.

In patients who require a cesarean delivery secondary to a problem arising during labor, the same steps as above are followed. The only major variation occurs if a patient requires general anesthesia prior to the procedure. In that situation, prior to intubation, the patient should be prepped and draped and the surgical team should be ready to begin as soon as the patient's airway is secured.

Intraoperative Details

As with any procedure, take care to avoid injury to adjacent organs. Potential complications include bladder or bowel injury. If a cystotomy or bowel injury is suspected, it should be evaluated thoroughly after the baby is delivered and hemostasis of the uterus is achieved.
 
The anesthesiologist monitors the patient's vital signs and tracks fluid intake and urine output. The average blood loss associated with a cesarean delivery is approximately 1000 mL.57 A patient at term will have up to a 50% expansion in their blood volume and can lose up to 1500 mL without showing any change in their vital signs. If a significant blood loss is encountered or anticipated, assess the hemoglobin level and cross-match blood.
 
Abdominal incision
 
One option is to use a midline infraumbilical incision to enter the peritoneal cavity. This incision provides quicker access to the uterus. In pregnancy, entry is commonly enhanced by diastasis of the rectus muscles. This incision is associated with less blood loss, easier examination of the upper abdomen, and easy extension cephalad around the umbilicus. If a patient is anticipated to have significant intra-abdominal adhesions from prior surgeries, a vertical incision may provide easier access into the abdomen, with better visualization. Upon reaching the rectus sheath, either the rectus sheath can be incised with a scalpel for the entire length of the incision or a small incision in the fascia can be made with a scalpel and then extended superiorly and inferiorly with scissors. Then, the rectus muscles (and pyramidalis muscles) are separated in the midline by sharp and blunt dissection. This act exposes the transversalis fascia and the peritoneum.
 
The peritoneum is identified and entered at the superior aspect of the incision to avoid bladder injury. Prior to entering the peritoneum, care is taken to avoid incising adjacent bowel or omentum. Once the peritoneal cavity is entered, the peritoneal incision is extended sharply to the upper aspect of the incision superiorly and to the reflection over the bladder inferiorly.
 
Most commonly, a transverse incision through the lower abdomen is made. The incision is a Maylard, Joel Cohen, or, more commonly, a Pfannenstiel incision. Transverse incisions take slightly longer to enter the peritoneal cavity, are usually less painful, have been associated with a smaller risk of developing an incisional hernia, are preferred cosmetically, and can provide excellent visualization of the pelvis.
 
The Pfannenstiel incision is curved slightly cephalad at the level of the pubic hairline. The incision extends slightly beyond the lateral borders of the rectus muscle bilaterally and is carried to the fascia. Then, the fascia is incised bilaterally for the full length of the incision. Then, the underlying rectus muscle is separated from the fascia both superiorly and inferiorly with blunt and sharp dissection. Clamp and ligate any blood vessels encountered. The rectus muscles are separated in the midline, and the peritoneum is entered.
 
A Maylard incision is made approximately 2-3 cm above the symphysis and is quicker than a Pfannenstiel incision. It involves a transverse incision of the anterior rectus sheath and rectus muscle bilaterally. Identify and possibly ligate the superficial inferior epigastric vessels (located in the lateral third of each rectus). For most cesarean deliveries, only the medial two thirds of each rectus muscle usually needs to be divided. If more than two thirds of the rectus muscle is divided, identify and ligate the deep inferior epigastric vessels. The transversalis fascia and peritoneum are identified and incised transversely.
 
The Joel Cohen incision is a straight transverse incision made 3 centimeters below the level of a straight line joining the anterosuperior iliac spines. The skin incision is made and carried down to the anterior sheath of the rectus fascia. A 3-4 cm incision is made in the fascia and bluntly opened by stretching in a craniocaudal fashion. The rectus muscles are retracted laterally and the parietal peritoneum is bluntly opened by digital dissection. The peritoneum is then retracted cephalocaudally to avoid injury to the bladder. Transverse incisions are associated with less blood loss, shorter operating time, reduced time to oral intake, less risk of fever, shorter duration of postoperative pain, lower analgesic requirements, and shorter time from skin incision to birth of the baby.58 ,59
 
No evidence reports an advantage of electrocautery over sharp knife dissection or digital dissection of the subcutaneous tissues, or whether sharp or blunt retraction of the fascial tissues is preferable. Blunt dissection tends to be associated with reduced blood loss.60
 
The Maylard incision with transection of the rectus muscles is associated with increased blood loss.61
 
Uterine incision
 
Upon entering the peritoneal cavity by blunt or sharp dissection and blunt extension, inspect the lower abdomen. The uterus is palpated and is commonly found to be dextrorotated such that the left round ligament is more anterior and closer to the midline. Evidence suggests that development of a bladder flap is not always necessary, especially in the nonlabored patient.62 When it is created, dissect the bladder free of the lower uterine segment. Grasp the loose uterovesical peritoneum with forceps, and incise it with Metzenbaum scissors. The incision is extended bilaterally in an upward curvilinear fashion. The lower flap is grasped gently, and the bladder is separated from the lower uterus with blunt and sharp dissection. A bladder blade is placed to both displace and protect the bladder inferiorly and to provide exposure for the lower uterine segment (the least contractile portion of the uterus).
 
One of essentially 2 incisions can be made on the uterus, either a transverse (Monroe-Kerr) or vertical (Kronig or DeLee) incision. The decision for the type of incision is based on several factors, including fetal presentation, gestational age, placental location, and presence of a well-developed lower uterine segment. The choice of incision must allow enough room to deliver the fetus without risking injury (either tearing or cutting) to the uterine arteries and veins that are located at the lateral margins of the uterus.
 
In more than 90% of cesarean deliveries, a low transverse (Monroe-Kerr) incision is made. The incision is made 1-2 cm above the original upper margin of the bladder with a scalpel. The initial incision is small and is continued into the uterine wall until either the fetal membranes are visualized or the cavity is entered (take care to not injure the underlying fetus especially in well-labored patients with thinned out lower uterine segments).
 
The incision is extended bilaterally and slightly cephalad. The incision can be extended with either sharp dissection or blunt dissection (usually with the index fingers of the surgeon). Blunt dissection is associated with decreased blood loss but has the potential for unpredictable extension, and care should be taken to avoid injury to the uterine vessels.63 ,64 Uterine and vaginal extensions after a low transverse incision are more common after prolonged second stage of labor.65 The presenting part of the fetus is identified, and the fetus is delivered either as a vertex presentation or as a breech. With a low transverse incision, the risk for uterine rupture in subsequent pregnancies is approximately 0.5-1%, and patients can be counseled about the safety of an attempted trial of labor and vaginal birth.47
 
In some instances, a vertical incision is used. A vertical incision may be used if the lower segment is not well developed (ie, narrow), if an anterior placenta previa is present, or if the fetus is in a transverse lie or in a preterm nonvertex presentation. Again, the bladder has been dissected inferiorly to expose the lower segment, and the bladder blade has been placed.
 
The vertical incision is initiated with a scalpel in the inferior portion of the lower uterine segment. Care is taken to avoid injury to the underlying fetus, and the incision is carried into the uterus until the cavity is entered. When the cavity is entered, the incision is extended superiorly with sharp dissection. The fetus is identified and delivered. Note the extent of the superior portion of the uterine incision.
 
If the incision is confined to the lower uterine segment, it is considered a low vertical incision and patients can be counseled for a trial of labor and vaginal delivery in subsequent pregnancies. With a true low vertical incision, the risk of uterine rupture with a trial of labor is similar to that associated with a low transverse incision, with most recent reports finding a risk for uterine rupture of less than 1.5%.47 If the incision should be either extended into the contractile portion of the uterus or is made almost completely in the upper contractile portion, the risk of uterine rupture in future pregnancies is 4-10% and patients are counseled to undergo a repeat cesarean delivery with all subsequent pregnancies.47
 
A vertical incision may also be considered in those cases where a hysterectomy may be planned in the setting of a placenta accreta or if the patient has a coexisting cervical cancer for which a hysterectomy would be the appropriate treatment. A vertical incision is associated with increased blood loss and longer operating time (takes longer to close) with less risk of injury to the uterine vessels than a low transverse incision.
 
Delivery
 
Two important aspects of the delivery are the incision to delivery time, especially in previously compromised fetuses and delivery of the impacted fetal head. Longer incision to delivery times are associated with worsening neonatal outcomes.66 The impacted fetal head can be delivered either through pushing the head up from the vagina and elevating it up through the incision or by pulling it up as if it were a breech delivery. This may require extending the incision to make room to maneuver.67 After the fetus is delivered, the umbilical cord is doubly clamped and cut. Blood is obtained from the cord for fetal blood typing, and a segment of cord is placed aside for obtaining blood gas results if a concern exists regarding fetal status.

Following delivery, oxytocin (20 U) is placed in the intravenous fluid to increase contractions of the uterus. The placenta is usually delivered manually. Awaiting spontaneous delivery of the placenta with gentle traction is more time consuming but is associated with decreased blood loss, lower risk of endometritis, and lower maternal exposure to fetal red blood cells, which can be important to Rh-negative mothers delivering an Rh-positive fetus.68 ,69
 
The ACOG Committee on Obstetric Practice recommends antimicrobial prophylaxis for all cesarean deliveries unless the patient is already receiving appropriate antibiotics (eg, for chorioamnionitis) and that prophylaxis should be administered within 60 minutes of the start of the cesarean delivery or as soon as possible. A larger dose may be indicated if a woman is obese.70

If the surgery is prolonged, a second dose can be administered every 2 hours to maintain adequate serum concentrations. If the patient has chorioamnionitis, broader-spectrum antibiotics, such as gentamicin and clindamycin or a penicillin with a beta-lactamase inhibitor such as piperacillin-tazobactam are indicated and should be continued in the postoperative period until the patient is afebrile. If methicillin-resistant Staphylococcus epidermidis (MRSA) is suspected as a pathogen, especially in abdominal wall infections, vancomycin will need to be added.
 
Repair of the uterine incision
 
Repair of the uterus can be facilitated by manual delivery of the uterine fundus through the abdominal incision. Externalizing the uterine fundus facilitates uterine massage, the ability to assess whether the uterus is atonic, and the examination of the adnexa.71
 
The uterine cavity is usually wiped clean of all membranes with a dry laparotomy sponge. Typically, a clamp is placed at the angles of the uterine incision. The incision is inspected for other bleeding vessels, and any extensions of the incision are evaluated. Inspect the bladder and lower segment inferior to the incision.
 
Repair of a low transverse uterine incision can be performed in either a 1-layer or 2-layer fashion with zero or double-zero chromic or Vicryl suture. The first layer should include stitches placed lateral to each angle, with prior palpation of the location of the lateral uterine vessels. Most physicians use a continuous locking stitch. If the first layer is hemostatic, a second layer (Lembert stitch), which is used to imbricate the incision, does not need to be placed.

A large prospective study has shown no increase in postoperative complications with a 1-layer versus 2-layer closure. Single layer closure compared with double layer closure was associated with a statistically significant reduction in mean blood loss, duration of the operative procedure, and presence of postoperative pain.64 Most studies have not demonstrated any advantage of 2-layer closure compared with 1-layer closure in decreasing the rate of uterine rupture in a subsequent pregnancy.72 ,73 At least 1 study reported a 4-fold increase in the risk of uterine rupture when comparing 2- to 1-layer closure.74 ,75
 
Closure of a vertical incision usually requires several layers because the incision is through a thicker portion of the uterus. Again, a heavy suture material is used, and usually the first layer closes the inner half of the incision, with a second and possibly third layer used to close the outer half and serosal edges. The extent of a vertical uterine incision impacts how a patient should be counseled regarding future pregnancies.
 
When the uterus is closed, attention must be paid to its overall tone. An atonic uterus can be encountered in a patient with a multiple gestation, polyhydramnios, or a failed attempt at a vaginal delivery in which the patient was on oxytocin augmentation for a prolonged period. If the uterus does not feel firm and contracted with massage and intravenous oxytocin, consider intramuscular injections of prostaglandin (15-methyl-prostaglandin, Hemabate) or methyl-ergonovine, and repeat as appropriate.

Continued closure

If the uterine incision is hemostatic, the uterine fundus is replaced into the abdominal cavity (unless a concurrent tubal ligation is to be performed). The incision is re-inspected for hemostasis, and the bladder flap is also inspected. The paracolic gutters are visualized, and any blood clots are removed with laparotomy sponges. The vesicouterine peritoneum and parietal peritoneum can be reapproximated with a running chromic stitch or synthetic monofilament stitch. Although many surgeons perform abdominal irrigation, this does not appear advantageous.76 Many physicians prefer to not close the peritoneum because these surfaces reapproximate within 24-48 hours and can heal without scar formation.77 Furthermore, the rectus muscles to do not need to be reapproximated.

The subfascial and muscle tissue is inspected for bleeding, and, if hemostatic, the fascia is closed. The fascia can be closed with a running nonlocking stitch, and synthetic braided or monofilament sutures are preferred over chromic sutures. Chromic sutures do not maintain their tensile strength as long or as predictably as synthetic material. If the patient is at risk for poor wound healing (eg, those with chronic steroid use), then a delayed absorbable or permanent suture can be used. Place stitches at approximately 1-cm intervals and more than 1 cm away from the incision line.

The subcutaneous tissue should be inspected for hemostasis and can be irrigated according to physician preference. The subcutaneous tissue usually does not have to be reapproximated, but patients with subcutaneous depth greater than 2 cm may benefit from subcutaneous tissue closure.78 Placement of drains does not appear to aid in decreasing the risk of surgical site infection.79 The skin edges can be closed either with a subcuticular stitch or with staples (removed 3 or 4 d postoperatively).

In a randomized controlled trial, Rousseau et al compared postoperative pain according to method of skin closure after a cesarean delivery. The authors found that in the staple group, as compared with the subcuticular sutures group, postoperative pain was significantly less and operative time was shorter. They concluded that staples should be the skin closure of choice for elective term cesareans.80

Postoperative Details

In the recovery room, vital signs are taken every 15 minutes for the first 1-2 hours, and urine output is monitored on an hourly basis. In addition to routine assessment, palpate the fundus to ensure that it feels firm. Pay attention to the amount of vaginal bleeding.
 
If the patient had regional anesthesia, they usually receive a long-acting analgesic with the regional anesthetic. Therefore, pain control is usually not an issue in the first 24 hours. If a patient did not receive a long-acting analgesic or had general anesthesia, administer narcotics either intramuscularly or intravenously (on schedule or with a basal rate supplemented with patient-controlled boluses). When the patient is tolerating liquids, administer narcotics orally as needed.
 
When patients recover sensation after a regional anesthetic and vital signs have been stable with minimal vaginal bleeding, they can be taken to their room. The patient should have vital signs taken every hour for at least the first 4 hours and, again, pay attention to urine output.
 
Overall, a patient should receive approximately 3-4 L of intravenous fluid from initiation of the intravenous line through the first 24 hours. The patient can be started on clear liquids 12-24 hours after an uncomplicated procedure, and diet can be advanced accordingly. When the patient is able to tolerate good oral intake, the intravenous fluids can be stopped.
 
The bladder catheter can be removed 12-24 hours postoperatively once the patient is ambulatory. If the patient is unable to void in 6 hours, consider replacing the Foley for an additional 12-24 hours.
 
On the first postoperative day, encourage the patient to ambulate. Increase ambulation every day as tolerated by the patient. The dressing can be removed 12-24 hours after surgery and can be left open after that time. Typically, the blood count is checked 12-24 hours after surgery, or sooner if a greater than average blood loss has occurred.
 
If a patient plans to breastfeed, this can be initiated within a few hours after delivery. If a patient plans to bottle feed, a tight bra or breast binder should be used in the postoperative period.
 
If the patient has recovered well postoperatively, she can be discharged safely 3-4 days after surgery. If staples were used to approximate the skin, remove them prior to discharge. If the patient has had a vertical skin incision or is at risk for poor healing (eg, diabetes or long-term steroid use), the physician may elect to keep the staples in for 2-3 extra days and have the patient return to the office at that time.
 
Prior to discharge, a discussion about contraception should take place. Stress that even if a mother is breastfeeding, she still can conceive. Ask patients to refrain from intercourse for 4-6 weeks postpartum.

Follow-up

After a cesarean delivery, the patient can be observed as a patient who delivered vaginally. The normal recommendation is to have the patient make a follow-up appointment 4-6 weeks after delivery. If bleeding has stopped, a repeat Papanicolaou test is customary. During this visit, review any notable findings from the surgery and discuss delivery options for future pregnancies.

Complications

Compared with a vaginal delivery, maternal mortality and especially morbidity is increased with cesarean delivery to approximately twice the rate after a vaginal delivery.47 The overall maternal mortality rate is 6-22 deaths per 100,000 live births, with approximately one third to one half of maternal deaths after cesarean delivery being directly attributable to the operative procedure itself. Part of this increase in mortality is that associated with a surgical procedure and, in part, related to the conditions that may have led to needing to perform a cesarean delivery.
 
Major sources of morbidity and mortality can be related to sequelae of infection, thromboembolic disease, anesthetic complications, and surgical injury.
 
Intraoperative complications

  • Uterine lacerations: Uterine lacerations, especially of the lower uterine segment, are more common with a transverse uterine incision. These lacerations can extend laterally or inferiorly. They are repaired easily. Take care to identify the uterine vessels when repairing lateral extensions, and, when repairing inferior extensions, the surgeon needs to think about the ureters. If the laceration extends into the broad ligament, strongly consider opening the broad ligament medial to the ovaries and identifying the course of the ureters. 
  • Bladder injury: This is an infrequent complication. It is more common with transverse abdominal incisions and in repeat cesarean deliveries. The bladder most commonly is injured when entering the peritoneal cavity or when separating the bladder from the lower uterine segment. Bladder injury has been reported to occur in more than 10% of uterine ruptures and in approximately 4% of cesarean hysterectomies. If a possibility exists that a cesarean hysterectomy may be performed, mobilize the bladder inferiorly as well as possible when dissecting it free of the lower uterine segment. If the dome of the bladder is lacerated, it can be repaired simply with a 2-layer closure of 2-0 or 3-0 chromic sutures, with the Foley catheter left in place for a few extra days. If the bladder is injured in the region of the trigone, consider ureteral catheterization with possible assistance from a urologist or gynecological surgeon. 
  • Ureteral injury: Injury to the ureter occurs in up to 0.1% of all cesarean deliveries and up to 0.5% of cesarean hysterectomies. It is most likely to occur when repairing extensive lacerations of the uterus. Ureteral injury, most commonly occlusion or transection, is usually not recognized during the time of the operation. 
  • Bowel injury: Bowel injuries occur in less than 0.1% of all cesarean deliveries. The most common risk factor for bowel injury at the time of cesarean delivery is adhesions from prior cesarean deliveries or prior bowel surgery. If the bowel is adherent to the lower portion of the uterus, dissect it sharply. Injuries to the serosa can be repaired with interrupted silk sutures. If the injury is into the lumen, perform a 2-layer closure. The mucosa can be closed with interrupted 3-0 absorbable sutures placed in a transverse fashion for a longitudinal injury. For multiple injuries and injury to the large intestine, consider intraoperative consultation with a general surgeon or gynecologic oncologist. 
  • Uterine atony: Uterine atony is another intraoperative complication that can be encountered in a patient with a multiple gestation, polyhydramnios, or a failed attempt at a vaginal delivery in which the patient was on oxytocin augmentation for a prolonged period. When the uterus is closed, attention must be paid to its overall tone.81  

Postoperative complications  

  • Postpartum endomyometritis: This is increased significantly in patients who have had a cesarean delivery. The rate of endomyometritis is up to 20-fold higher than with a vaginal delivery. Major risk factors include whether the cesarean delivery was the intended (primary) procedure and the socioeconomic status of the patient. Other major risk factors include duration of membrane rupture, duration of labor, number of pelvic examinations, length of time with internal fetal monitors in place, and the presence of chorioamnionitis prior to initiating cesarean delivery. Blood cultures are positive in approximately 10% of patients with postoperative febrile morbidity, and broad-spectrum antibiotics should be used. The postcesarean rate of endomyometritis can be decreased to approximately 5% with the use prophylactic antibiotics.82 ,83 ,84 ,85
  • Wound infection: Following a cesarean delivery, the risk of a wound infection ranges from 2.5% to higher than 15%. Risk factors are similar to those noted for endomyometritis, with the lowest risk associated with those having a planned cesarean delivery. If chorioamnionitis is present at the time of the procedure, the risk for a wound infection can be as high as 20%. If a wound infection is suspected, open, irrigate, and debride the incision. Then, the open wound can be packed and cleaned several times a day. The wound can be allowed to heal by secondary intention, or, when it has begun to granulate, it can be closed.83 ,84  
  • Fascial dehiscence: An infrequent but emergent complication of a wound breakdown is a fascial dehiscence. It occurs in approximately 5% of patients with a wound infection and is suggested when excessive discharge from the wound is present. If a fascial dehiscence is observed, the patient should be taken immediately to the operating room where the wound can be opened, debrided, and reclosed in a sterile environment.82 ,83 ,86  
  • Urinary tract infections: The second most common etiology for postcesarean febrile morbidity is urinary tract infections. The incidence ranges from 2-16%, and the process of placing an indwelling catheter for the surgery is a risk factor in itself. The incidence of urinary tract infections is increased in patients with diabetes, those who have other comorbidity, and those who have a longer duration of use of the indwelling catheter.83  
  • Bowel function: Postoperatively, some patients may experience a slow return of bowel function. Postoperative narcotics may delay return of normal bowel function in a few patients. Most respond to conservative therapy, but a small portion may require decompression. In those with a slow return of bowel function, assessment of fluid and electrolyte status needs to be a priority.82  
  • Thromboembolic complications: These are also increased in the patient who has undergone a cesarean delivery. Approximately 0.5-1 in 500 pregnant women experience a deep venous thrombosis.87 ,88 The risk for developing a thrombus is increased 3- to 5-fold with a cesarean delivery and in the postpartum.88 Other risks include obesity, advanced maternal age, higher parity, and poor postoperative ambulation. In those with risk factors, consider pneumatic compression stockings or low molecular weight heparin among a patients with additional risk factors. If a deep venous thrombosis is not treated, up to one quarter of patients will develop pulmonary emboli and 15% of these could be fatal. A deep venous thrombosis is sometimes difficult to diagnose, and the first sign may be a pulmonary embolus.89  
  • Pelvic thrombophlebitis: Another infection-related complication of a cesarean delivery is septic pelvic thrombophlebitis. As many as 2% of patients with an endomyometritis or wound infection can develop this complication, and it is largely a diagnosis of exclusion. Suspect this diagnosis if a patient fails to respond initially to broad-spectrum antibiotics. Physical examination may detect a tender cordlike mass lateral to the uterus.90 Ultrasonography, pelvic CT scan, or MRI may aid in the diagnosis. Some authors advocate placing patients on therapeutic heparin along with continuing broad-spectrum antibiotics; however, this treatment has been questioned.91 The length of adequate treatment once a patient has defervesced is subject to debate (anywhere from 48-h afebrile to a total of 7-10 d of treatment). After completing the desired treatment course, patients do not need to be anticoagulated further.

Outcome and Prognosis

Patients who undergo cesarean delivery usually take slightly longer to fully recover than those who have a vaginal delivery. However, the overall long-term condition of the patient is not adversely affected. Occasionally, some patients can experience pelvic pain associated with intra-abdominal adhesions, a situation that can be aggravated in those who have multiple procedures.
 
The most important things for patients to know about their cesarean delivery are why they had one and what kind of incision was performed on the uterus.
 
If a patient had a cesarean delivery for presumed cephalopelvic disproportion, then attempting a vaginal birth with the next pregnancy is associated with a decreased risk of success. Overall, patients attempting a vaginal birth after a prior cesarean delivery can expect success approximately 70% of the time. If the cesarean delivery was performed because of an abnormal fetal heart pattern or for a malpresentation, then expectations for a successful vaginal birth can be higher than 70%. If the uterine incision was vertical, the risk of uterine rupture is increased above the approximate 1% risk associated with a low transverse incision. If the incision was confined to the lower segment, many physicians allow patients to attempt a vaginal birth in subsequent pregnancies. However, if the incision extended into the upper contractile portion, the risk of uterine rupture can approach 10%, with 50% of these occurring prior to the onset of labor.47
 
A previous cesarean delivery can increase the risk of developing placenta accreta if placenta previa is present in any subsequent pregnancies. The risk of placenta accreta in a patient with previa is approximately 4% with no prior cesarean deliveries; the risk increases to approximately 25% with 1 prior cesarean delivery and to 40% with 2 prior cesarean deliveries.44

Vaginal birth after cesarean delivery rates.

Vaginal birth after cesarean delivery rates.


A large prospective randomized study is needed to look at single-layer versus double-layer closure and risk of future uterine rupture when attempting a trial of labor after previous low-transverse cesarean section.
 
Current recommendation that all breech presentations should be delivered by a cesarean delivery is a subject of active debate. Additional information is required to address this issue in the setting of appropriately trained and under well-established guidelines.
 
Urogynecologists suggest that all women should consider outright cesarean delivery to prevent pelvic floor dysfunction. This is an extremely controversial area that continues to receive attention, particularly since short-term outcomes do not appear to relate to long-term outcomes.93 Genetic factors appear to play an important role in long-term outcomes, which overshadows the effects that laboring and delivery itself have on short-term outcomes.

Cesarean delivery on maternal request (CDMR) also continues to be an area of debate. A recent survey of participants in the 2006 state of the science conference reveals that most obstetrician/gynecologists believe that a woman has the right to CDMR, but fewer agree to perform the procedure than they did in 2006. In general, obstetricians/gynecologists associate more risks and fewer benefits to cesarean delivery.94

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