Cesarean delivery, also known as C-section, is the birth of a baby through surgical openings made in the mother's abdomen and uterus. This document discusses the history, indications, risks and complications of cesarean delivery. It notes that the C-section rate has quadrupled since 1965 due to various factors like older maternal age, obesity, litigation concerns and increased use of electronic fetal monitoring. The risks of a C-section include infection, hemorrhage, injury to organs and increased risks with additional C-sections like placenta accreta. The document provides an in-depth overview of cesarean delivery.

1. Cesarean Delivery
Dawit Desalegn
November, 2010

2. Cesarean Section
• The birth of a fetus through incisions in the
abdominal wall (Laparatomy) and the uterine
wall (Hysteretomy).
• This definition does not include removal of the
fetus from the abdominal cavity
– in the case of rupture of the uterus
– in the case of an abdominal pregnancy

3. HISTORY OF CESAREAN DELIVERY
• there is evidence from both early Western and
non-Western societies
• the term “cesarean” has been debated over time.
• originally believed to have been derived from the
birth of Julius Caesar,
• it is unlikely that his mother, Aurelia, would have
survived the operation.
• Her knowledge of her son's invasion of Europe
many years later indicates that she survived
childbirth

4. History cont…
• Roman law under Caesar specified surgical removal of
the fetus before burial of deceased pregnant women.
• Religious edicts required separate burial for the infant
and mother.
• Thus, the term cesarean more likely refers to
– being cut open as the Latin verb “caedare” means to cut.
• Cesarean operation was the preferred term before the
1598 publication of Guillimeau,
– introduced the term “section.

5. Cont…
• New methods for anesthesia = C/S for obstructed labor
gained popularity over destructive procedures
• But mortality rates remained very high,
– sepsis and peritonitis
• Surgeons complete the operation without closing the
uterus – hemorrhage, sepsis
• 1876, Eduardo Porro advocated routine hysterectomy
with cesarean delivery
• Silver wire stitches were developed by the gynecologist
J. Marion Sims

6. Cont…
• 1880 - 1925 = transverse incisions of the uterus
– reduced the rate of infection and rupture
• Extraperitoneal c/s
• introduction of penicillin in 1940
• low cervical incision = Munro Kerr, 1926
• became technique of choice
• Rate increasing since then ;
– 1970 = 5% ;
– 2004 = 29%

7. • Cesarean deliveries are categorized as
either:-
• primary = first cesarean delivery
• repeat = after a previous cesarean birth
• The total cesarean delivery rate is the sum
of these two components.

8. PREVALENCE
• C/S rate worldwide = 15 % of births
• Mexico, Brazil, and Italy = over 35 %
• Africa has the lowest = < 5%
• China = 20 to 60 %, ( rural/urban)
• Teaching hospitals in India = 25%
• Here = 20 – 25%

9. • Reasons why the cesarean rate quadrupled
between 1965 and 1988
1. Women are having fewer children, thus, a
greater percentage of births are among
nulliparas,
2. Average maternal age is rising, old-nullipara
3. The use of electronic fetal monitoring
4. Breech presentation
5. Incidence of midpelvic forceps and vacuum
deliveries has decreased

10. 6. Rates of labor induction continue to rise
7. Obesity
8. Concern for malpractice litigation
9. Concern over pelvic floor injury
associated with vaginal birth
10. Socioeconomic and Demographic
factors

11. INDICATIONS
• performed when the clinician and patient feel that
abdominal delivery is likely to provide a better
maternal and/or fetal outcome than vaginal delivery.
• “Unscheduled " or "unplanned “ or “Emergency”
– as a result of concerns identified after labor has
begun
• “Scheduled " or "planned” “Elective”
– are used when the decision to perform is planned
antepartum

12. • not possible to catalog comprehensively
all appropriate indications for cesarean
delivery,
• over 80 percent are performed because
of :-
1. Prior cesarean delivery = 30%
2. Dystocia = 30%
3. Fetal distress = 10%
4. Breech presentation = 11%

13. Additional, less common indications include:-
• Abnormal placentation
– placenta previa, vasa previa, placenta accreta
• Maternal infection
– HSV, HIV
• Multiple gestation
• Fetal bleeding diathesis
• Mechanical obstruction to vaginal birth
– tumor previa
• Women at increased risk of complications from tissue trauma
– invasive cervical ca.,
– active perianal IBD,
– repair of a VVF/RVF
– Repair of pelvic organ prolapse

14. Prior Cesarean Delivery
• For many decades, a scarred uterus was believed to
contraindicate labor out of fear of uterine rupture.
• In 1916, Cragin =
– "Once a cesarean, always a cesarean."
• Whitridge Williams (1917) termed the statement "an
exaggeration."
• 1978 was another milestone in the history of prior cesarean
delivery = 83% VBAC vs 2%
• Evidence had accrued that uterine rupture was infrequent
and rarely catastrophic

15. • ACOG (1988) recommended that, in the
absence of a contraindication, a woman with one
previous low-transverse cesarean delivery be
counseled to attempt labor in a subsequent
pregnancy
• By 1996 = 30 percent of women with a prior
cesarean were being delivered vaginally
• The most remarkable change in obstetric
practice over the last two decades

16. Trial of Labor versus Repeat Cesarean
• Studies after 1989 = VBAC might be riskier than
anticipated
• uterine rupture and its associated complications clearly
are increased with a trial of labor
• But absolute risk of rupture = 7 per 1000
• Maternal mortality does not appear to differ significantly
• A trial of labor resulting in death or injury to the fetus is
about 1 per 1000
 Is a 1 per 1000 risk of having an otherwise healthy
fetus die or be damaged as a result of a trial of labor
acceptable?

17. Elective Repeat Cesarean Delivery
• compared with vaginal delivery, cesarean birth is
associated with increased risks, including
– anesthesia,
– hemorrhage,
– damage to the bladder and other organs,
– pelvic infection,
– scarring,
• Despite this, an elective repeat cesarean is
considered by many women to be preferable to
attempting a trial of labor

18. Assure fetal maturity!!!

19. • Establishment of Fetal Maturity Prior to Elective Repeat
C/S (ACOG Guidline)
1. Fetal heart sounds have been documented for 20
weeks by nonelectronic fetoscope or for 30 weeks by
Doppler ultrasound
2. It has been 36 weeks since a positive serum or urine
chorionic gonadotropin pregnancy test
3. An ultrasound measurement of crown-rump length,
obtained at 6–11 weeks, supports current gestational
age of 39 weeks or more
4. Clinical history and physical and ultrasound
examination performed at 12–20 weeks support current
gestational age of 39 weeks or more

20. • In all other instances, fetal pulmonary
maturity must be documented by :-
Amniocentesis for Fetal Lung Maturity
The onset of spontaneous labor is
awaited.

21. • The most recent recommendations of the ACOG
(2004) for selecting appropriate candidates:-
1. No more than 1 prior low-transverse cesarean
delivery
2. Clinically adequate pelvis
3. No other uterine scars or previous rupture
4. Physician immediately available throughout active
labor who is capable of monitoring labor and
performing emergency cesarean delivery
5. Availability of anesthesia and personnel for
emergency cesarean delivery

22. Type of Prior Uterine Incision
• LUST C/S = lowest risk of symptomatic rupture
• Classical incision = highest rates of rupture
• Importantly, in about one third of classical scar:-
 rupture before the onset of labor.
 several weeks before term

23. Estimated Risks for Uterine Rupture in Women
with a Prior Cesarean Delivery
Prior Uterine Incision Estimated Rupture (%)
Classical 4 – 9
T-Shaped 4 – 9
Low Vertical 1 – 7
Low Transverse 0.2 – 1.5

24. Risk Factors for Rupture
• women with uterine malformations who have
undergone cesarean delivery = 8%
• women with a prior vertical incision in the
lower uterine segment without fundal extension
may be candidates for VBAC
• Women who have previously sustained a uterine
rupture:-
– LUS-rupture = 6%
– Fundal- rupture = 32%

25. • Closure of Prior Incision
– Single Vs Double layer
• Healing of the Cesarean Incision
– regeneration of the muscular fibers?
– fibroblast proliferation?
• If the cut surfaces is closely apposed,
– minimal proliferation of connective tissue
• Inter delivery Interval
– MRI = complete uterine involution and restoration of anatomy
may require at least 6 months
– <18 Vs >18 months

26. • Number of Prior Cesarean Incisions
– 0.8% Vs 1.8% - 3.7% = prior one Vs two
• Indication for Prior Cesarean Delivery
• success rate = 60 – 80%
– Breech = 91%
– Distress = 84%
– Dystocia = 67 – 77%
– Stage of labor at decision 73% Vs 13%
• Prior Successful Vaginal birth (before or after a C/S)!!!

27. • Labor Induction or augmentation
– 2.3% Vs 0.4%
• Epidural analgesia
– Masks the pain of rupture

28. PREOPERATIVE ISSUES
Laboratory testing
– hemoglobin & blood type and antibody screen
Aspiration Prevention
Antibiotic prophylaxis
• a single IV & narrow spectrum antibiotic; 30min
– (eg, ampicillin 2 g or cefazolin 1 to 2 g)
• significantly reduced the incidence of
– postoperative fever,
– endometritis,
– wound infection,
– urinary tract infection, and
– serious infection

29. Cont…
Thromboembolism prophylaxis
• Intermittent intra- and post-operative pneumatic
leg compression and
• Early ambulation,
• Prophylactic anticoagulation in high-risk women
Bladder catheterization
• Convenience Vs UTI
Hair removal
• clipped rather than shaved

30. POSTOPERATIVE CARE
Monitor for evidence of :-
– uterine atony
– excessive vaginal or incisional bleeding
– oliguria
– Blood pressure for hypo or hypertension,
• Patient controlled opioid analgesia followed by
oral NSAID = adequate analgesia
• Early ambulation (when the effects of anesthesia
have abated)
• Oral intake (4-8 hrs of surgery) are encouraged.
– stimulating the gastrocolic reflex.

31. COMPLICATIONS
• Endometritis
– 35 to 40 percent without prophylaxis
– 4 to 5 % after scheduled c/s with intact membranes,
– 85 % after an extended labor with ROM
• Wound infection
– 2.5 to 16 percent; four to seven days c/s
• septic pelvic thrombophlebitis
• Hemorrhage
– mean blood loss =1000 mL
– 2 to 3 % require blood transfusion
– uterine atony - placenta accreta
– extensive uterine injury - extension

32. • Urinary and gastrointestinal injuries
– Bladder injury = 0.28%
– Ureteral injury= 0.10%
– Ileus
• Maternal mortality
– related to the underlying medical and obstetrical
factors
– Vaginal birth = 0.04 per 1000
– Cesarean birth = 0.53 per 1000
• Iatrogenic prematurity and birth trauma

33. LONG-TERM RISKS
• Abnormal placentation
– Placenta previa, Accreta,
• Subfertility
• Scar complications
– Ectopic pregnancy in the scar = 1/1000
– Numbness or pain (Ilioinguinal and
Iliohypogastric)
– Incisional endometriosis
• Uterine rupture

34. - IS THERE AN UNSAFE NUMBER OF REPEAT C/S?
• insufficient data on which to base recommendations
for the "safe" number of repeat cesarean deliveries
• Several issues should be considered and discussed
with the patient preoperatively:
1. Complications relating to abnormal placentation
2. Complications relating to adhesion formation
3. Complications relating to trial of labor
4. Other long-term complications

35. Stay Natural

36. Thank You