Updated: 5/7/2020

Indications for Cesarean

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Snapshot
  • A 28-year-old G0P1 woman presents to the hospital in active labor. Transabdominal ultrasound demonstrates her fetus to have a transverse lie. She is taken to the operating room for a cesarean delivery. 
Introduction
  • Overview
    • one of the most frequently performed surgeries in the world
  • Epidemiology
    • incidence
      • ~1/3 of US births
    • demographics
      • increased likelihood with:
        • age greater than 30 years
        • primiparity
        • multi-gestational pregnancy
        • prior cesarean delivery
        • obesity
        • wealth
    • location
      • vertical incision
        •  mid-abdomen
      • horizontal incision
        • lower abdomen 
    • prognosis
      • advantages
        • less pain during delivery
        • avoids perineal trauma
        • women can plan time of delivery
        • may prevent incontinence and pelvic organ prolapse
        • reduced likelihood of neonatal infections
        • reduced birth trauma for neonates
        • reduced risk of intrapartum fetal cerebral damage
      • disadvantages
        • potential for anesthetic complications
        • potential for surgical site infections
        • potential for organ injury
        • longer recovery
        • potential for decreased ability to breastfeed
        • may cause complications in future pregnancies
        • longer hospital stay
        • increased cost
Classification
  • Primary cesarean section
    •  the 1st cesarean delivery a woman has
  • Urgent cesarean section
    • performed for maternal or fetal physiological distress that is not immediately life-threatening
  • Emergent cesarean section
    • performed for immediate life-threatening maternal or fetal instability 
  • Robson's classification system
    • 10 categories to assess and compare cesarean delivery rates between hospitals
    • takes into account 
      • parity
      • single versus multiple gestation
      • spontanous versus induced labor
      • previous cesarean delivery
      • fetal lie
      • gestational age
Indications
  • Maternal indications
    • vaginal delivery would cause increased morbidity or risk of mortality for the pregnant patient
  • Fetal indications
    • vaginal delivery would cause increased morbidity or risk of mortality for the fetus
  • Most common indications
    • failure of labor progression
    • nonreassuring FHR/fetal distress
      • cord prolapse
    • fetal malpresentation
      • posterior chin position
      • transverse lie
      • brow presentation
      • shoulder presentation
      • compound presentation
  • Other indications
    • abnormal placentation
      • placenta previa
      • vasa previa
      • placenta accreta
      • placental abruption
    • high potential for fetal macrosomia
      • 5000 grams
      • 4500 grams in women with diabetes
    • prior uterine surgeries
      • previous cesarean
      • myomectomy (if entered uterine cavity)
    • obstructed labor
      • cervical cancer
      • large fibroid
      • pelvic fracture
      • cephalopelvic disproportion
    • high risk of perinatal infection transmission
      • active genital herpes
      • HIV with viral load > 1000 copies/mL
    • failed operative vaginal delivery
    • maternal trauma
Techniques
  • Skin incision
    • transverse
      • improved cosmesis
      • reduced postoperative pain
      • reduced hernia formation
      • 2 most common types
        • Pfannenstiel
          • curved
          • 2-3 cm above symphysis pubis
          • best cosmetic outcomes
        • Joel-Cohen
          • straight
          • 3 cm below anterior superior iliac spines
          • better infectious, bleeding, and operating room time outcomes
    • vertical midline
      • "classical"
      • reduced time from incision to delivery
      • least risk of bleeding
      • least risk of nerve injury
      • improved exposure
      • easy to extend
      • worse cosmetic outcomes
  • Hysterotomy (uterine incision)
    • typically transverse
    • must be large enough to fit fetus through without trauma
  • Fetal extraction
    • place fingers around the head and lift
  • Placental extraction
    • typically occurs spontaneously
Complications
  • Surgical site infection
    • incidence
      • 3-15%
    • risk factors
      • obesity
      • rural residence
      • older or younger maternal age
      • pregestational or gestational diabetes mellitus
      • prior cesarean delivery
      • hypertension of pregnancy
      • chorioamnionitis
      • premature rupture of membranes
      • twin pregnancy
      • greater number of vaginal exams
      • prolonged labor prior to cesarean
      • internal fetal monitoring
      • prolonged surgical duration
    • treatment
      • antibiotic therapy
      • wound exploration
      • debridement
  • Endometritis
    • incidence
      • 7-30%
    • risk factors
      • cesarean delivery performed during labor
      • no prior cesarean section
      • rupture of membranes for > 24 hours
      • young maternal age
      • greater number of vaginal examinations
      • internal fetal monitoring
      • manual placenta removal
    • treatment
      • broad-spectrum antibiotic therapy
        • most commonly IV clindamycin + gentamicin
  • Hemorrhage
    • incidence
      • 4-7%
    • risk factors
      • fibroids
      • blood clotting disorders
      • abnormal placentation
      • antepartum bleeding
      • preterm birth
      • general anesthesia
      • retained placenta 
      • macrosomia
    • treatment
      • fluid administration
      • oxygen
      • rapid surgical hemostasis
      • IV oxytocin
      • uterotonics
      • blood transfusion
      • potential for hysterectomy
 

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