eMedicine Specialties > Obstetrics and Gynecology > Labor and Delivery
Cesarean Delivery
Updated: Apr 2, 2009
Introduction
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 and by 2003, that rate had increased to 28%, almost a 22% increase.1 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 both 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 31.1% in 2006. 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.
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.1
- 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.13 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.14 This study has been criticized for differences in the standards of care among the study centers that does not allow a standard recommendation.15 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.16 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.17,18 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.19
- 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.20
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.21 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.22
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.23 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.24
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.25 The emerging consensus is that a randomized prospective study is required to address this issue.26
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).27 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.16
- 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.28 Evidence suggests that the rate of severe complications of the second breech twin is independent of the mode of delivery.29
- 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.30 Some authors noted no relationship between mode of delivery and infant outcomes31 , while others have advocated cesarean delivery of all infants with a neural tube defect.32 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.33,34,35 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 2002.36 Its use has increased the cesarean delivery rate as much as 40%.37 This has occurred without a decrease in the cerebral palsy or perinatal death rate.38 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.39
- 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.40 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.41
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.42,43,23
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.44 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.45 Less often, maternal hemorrhagic and fetal metabolic consequences occur from a uterine rupture, especially among patients with a previous cesarean delivery.46 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.47,48
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%.46
Relevant Anatomy
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).
More on Cesarean Delivery |
 Overview: Cesarean Delivery |
| Workup: Cesarean Delivery |
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Further Reading
Keywords
caesarean section, caesarean birth, cesarean section, C section, cesarean birth, vaginal delivery, childbirth, parturition, delivery, birthing, laparotomy, hysterotomy, low transverse incision, classical incision, vertical incision
