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