Cesarean delivery (C-section) is a surgical procedure used to deliver a baby through

incisions in the abdomen and uterus.

A C-section might be planned ahead of time if you develop pregnancy complications or

you've had a previous C-section and aren't considering a vaginal birth after cesarean
(VBAC). Often, however, the need for a first-time C-section doesn't become obvious
until labor is underway.

Why it's done

Sometimes a C-section is safer for you or your baby than is a vaginal delivery. Your
health care provider might recommend a C-section if:

 Your labor isn't progressing. Stalled labor is one of the most common reasons
for a C-section. Stalled labor might occur if your cervix isn't opening enough
despite strong contractions over several hours.

 Your baby is in distress. If your health care provider is concerned about

changes in your baby's heartbeat, a C-section might be the best option.

 Your baby or babies are in an abnormal position. A C-section might be the

safest way to deliver the baby if his or her feet or buttocks enter the birth canal first
(breech) or the baby is positioned side or shoulder first (transverse).

 You're carrying multiples. A C-section might be needed if you're carrying twins

and the leading baby is in an abnormal position or if you have triplets or more
babies.

 There's a problem with your placenta. If the placenta covers the opening of
your cervix (placenta previa), a C-section is recommended for delivery.

 Prolapsed umbilical cord. A C-section might be recommended if a loop of

umbilical cord slips through your cervix ahead of your baby.

 You have a health concern. A C-section might be recommended if you have a

severe health problem, such as a heart or brain condition. A C-section is also
recommended if you have an active genital herpes infection at the time of labor.
  Mechanical obstruction. You might need a C-section if you have a large fibroid
obstructing the birth canal, a severely displaced pelvic fracture or your baby has a
condition that can cause the head to be unusually large (severe hydrocephalus).

 You've had a previous C-section. Depending on the type of uterine incision

and other factors, it's often possible to attempt a VBAC. In some cases, however,
your health care provider might recommend a repeat C-section.

Some women request C-sections with their first babies — to avoid labor or the possible
complications of vaginal birth or to take advantage of the convenience of a planned
delivery. However, this is discouraged if you plan on having several children. Women
who have multiple C-sections are at increased risk of placental problems as well as
heavy bleeding, which might require surgical removal of the uterus (hysterectomy). If
you're considering a planned C-section for your first delivery, work with your health care
provider to make the best decision for you and your baby.

Risks

Like other types of major surgery, C-sections also carry risks.

Risks to your baby include:

 Breathing problems. Babies born by scheduled C-section are more likely to

develop transient tachypnea — a breathing problem marked by abnormally fast
breathing during the first few days after birth.

 Surgical injury. Although rare, accidental nicks to the baby's skin can occur
during surgery.

Indications
Cesarean deliveries were initially performed to separate the mother and the fetus in an
attempt to save the fetus of a moribund patient. They subsequently developed to
resolve maternal or fetal complications not amenable to vaginal delivery, either for
mechanical limitations or to temporize delivery for maternal or fetal benefit.
The leading indications for cesarean delivery (85%) are previous cesarean delivery,
breech presentation, dystocia, and fetal distress.  [7]
Maternal indications for cesarean delivery include the following:
 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
 Pelvic abnormalities that preclude engagement or interfere with descent of the fetal
presentation in labor  
 Certain cardiac conditions that preclude normal valsalva done by patients during a
vaginal delivery 
Fetal indications for cesarean delivery include the following:
 Situations in which neonatal morbidity and mortality could be decreased by the
prevention of trauma
 Malpresentations (eg, preterm breech presentations, non-frank breech term
fetuses)
 Certain congenital malformations or skeletal disorders
 Infection
 Prolonged acidemia
Indications for cesarean delivery that benefit the mother and the fetus include the
following:
 Abnormal placentation (eg, placenta previa, placenta accreta)
 Abnormal labor due to cephalopelvic disproportion
 Situations in which labor is contraindicated
Complications
See the list below:
 Approximately 2-fold increase in maternal mortality and morbidity with cesarean
delivery relative to a vaginal delivery [18] : Partly related to the procedure itself, and
partly related to conditions that may have led to needing to perform a cesarean
delivery
 Infection (eg, postpartum endomyometritis, fascial dehiscence, wound, urinary
tract)
 Thromboembolic disease (eg, deep venous thrombosis, septic pelvic
thrombophlebitis)
 Anesthetic complications
 Surgical injury (eg, uterine lacerations; bladder, bowel, ureteral injuries)
 Uterine atony
 Delayed return of bowel function
Preparation
On average, patients are asked not to eat anything for 12 hours prior to the procedure,
which exceeds current guidelines. [12] 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. [11]
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.
Laboratory Tests
When patients are admitted for labor and delivery, most have blood drawn for a
complete blood count (CBC) and type and screen when an intravenous (IV) line is
started, which is a basic requirement for patients when they are admitted to the labor
floor. In addition, tests for HIV antibodies and hepatitis B surface antigen and a
screening test for syphilis are done, if these 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 utility of
submitting blood 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:
 The patient is admitted for a planned cesarean delivery.
 The patient is a grand multipara.
 The patient has 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 a condition with suspected disseminated
intravascular coagulation (DIC), whether consumptive or secondary to thromboplastin
release, a CBC and coagulation studies (including prothrombin time [PT], activated
partial thromboplastin time [aPTT], 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 before 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 cross-matched, 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.
Preoperative Monitoring
A blood pressure cuff is placed. Monitors are also placed to allow the patient’s blood
pressure, pulse, and oxygen saturation to be monitored before administration of
anesthesia through the initial postoperative period in the recovery room.
Before 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.
A review by Li et al suggests that nonuse of indwelling urinary catheters in caesarean
delivery is associated with fewer urinary tract infections and no increase in urinary
retention or intraoperative difficulties.  [64] Further trials are necessary to confirm this
finding among patients who receive spinal or epidural anesthesia for uncomplicated
cesarean delivery.
Preoperative antibiotic prophylaxis decreases the risk of endometritis after elective
cesarean delivery by 76% (relative risk [RR], 0.24; 95% confidence interval [CI], 0.25-
0.35), regardless of the type of cesarean delivery (emergent or elective).  [13]
Mackeen et al compared the effects of cesarean antibiotic prophylaxis administered
preoperatively versus after neonatal cord clamp on postoperative infectious
complications for the mother and the neonate. They searched the Cochrane Pregnancy
and Childbirth Group's Trials Register and reference lists of retrieved papers for
randomized controlled trials focused on this comparison. They included 10 studies (12
trial reports), from which 5041 women contributed data for the primary outcome. Based
on high quality evidence from studies whose overall risk of bias is low, they found
evidence that intravenous prophylactic antibiotics for cesarean administered
preoperatively significantly decrease the incidence of composite maternal postpartum
infectious morbidity as compared with administration after cord clamp. There were no
clear differences in adverse neonatal outcomes reported. The authors conclude that
women undergoing cesarean delivery should receive antibiotic prophylaxis
preoperatively to reduce maternal infectious morbidities. Further research may be
required to elucidate short- and long-term adverse effects for neonates.  [65]
Single-dose therapy is recommended for its effectiveness, lower cost, decreased
potential toxicity, and decreased development of resistance. A first-generation
cephalosporin is the first-line antibiotic of choice. In women with penicillin or
cephalosporin allergy (ie, anaphylaxis, angioedema, respiratory distress, or urticaria),
the alternative is a combination of clindamycin with an aminoglycoside. Recent studies
have shown that adding azithromycin 500mg continuous IV to cefazolin about an hour
prior to surgery further reduce the risk of endometriosis and wound
infection. [66] Prolonged surgery, excessive blood loss, and maternal obesity may require
repeat or higher dosing. [67]
A meta-analysis of three randomized trials supports the use of antibiotic prophylaxis for
cesarean delivery administered up to 60 minutes before skin incision rather than after
umbilical cord clamping. [68, 67]
There is no benefit from oral antibiotics for eradication of MRSA colonization among
patients in the health care setting, and oral antibiotics are not currently routinely
recommended for the purpose of MRSA decolonization. Routine screening of obstetric
patients for MRSA colonization is not recommended. For obstetric patients known to be
MRSA colonized, a single dose of vancomycin can be added to the antibiotic
prophylaxis regimen. Vancomycin alone does not provide sufficient coverage for
surgical prophylaxis. [67]
Infective endocarditis prophylaxis is not recommended for vaginal delivery or cesarean
delivery. Patients at highest potential risk for adverse cardiac outcomes who are
undergoing vaginal delivery may benefit from prophylaxis. Those at highest risk are
women with cyanotic cardiac disease, recently repaired cyanotic heart disease, residual
defects after repair, prosthetic valves, history of bacterial endocarditis, or history of
heart transplant. Mitral valve prolapse is not considered a lesion that ever needs
infective endocarditis prophylaxis. [69]
Skin Preparation
Before anesthesia, the surgeon should evaluate the site of the intended skin incision.
The intended area need not be shaved automatically unless the hair will interfere with
reapproximation of the skin edges. If the hair is to be removed, it should be clipped
immediately before surgery. Shaving appears to be associated with a slightly increased
risk for infection. [70]
The use of chlorohexidine solution rather than a povidone iodine solution is associated
with a decrease risk of both superficial and deep wound infection.  [71]  
Anesthesia
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.  [72] 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 preoperative 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. [73]
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 either with an iodine scrub or with 4% chlorhexidine. Before 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 T4. 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.
In patients who require a cesarean delivery secondary to a problem arising during labor,
the preparation follows essentially the same steps previously outlined. The only major
variation occurs if a patient requires general anesthesia prior to the procedure. In that
situation, before 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.
Complication Prevention
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. [74, 75]
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.  [76]
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.
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.  [

Risks to you include:

 Infection. After a C-section, you might be at risk of developing an infection of the

lining of the uterus (endometritis).

 Postpartum hemorrhage. A C-section might cause heavy bleeding during and

after delivery.

 Reactions to anesthesia. Adverse reactions to any type of anesthesia are

possible.

 Blood clots. A C-section might increase your risk of developing a blood clot
inside a deep vein, especially in the legs or pelvic organs (deep vein thrombosis). If
a blood clot travels to your lungs and blocks blood flow (pulmonary embolism), the
damage can be life-threatening.

 Wound infection. Depending on your risk factors and whether you needed an

emergency C-section, you might be at increased risk of an incision infection.

 Surgical injury. Although rare, surgical injuries to the bladder or bowel can

occur during a C-section. If there is a surgical injury during your C-section,
additional surgery might be needed.

 Increased risks during future pregnancies. After a C-section, you face a

higher risk of potentially serious complications in a subsequent pregnancy than you
would after a vaginal delivery. The more C-sections you have, the higher your risks
of placenta previa and a condition in which the placenta becomes abnormally
attached to the wall of the uterus (placenta accreta). The risk of your uterus tearing
open along the scar line from a prior C-section (uterine rupture) is also higher if
you attempt a VBAC.