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
  • 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
  • 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

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