Cesarean delivery

Last updated: October 12, 2022

Summarytoggle arrow icon

Cesarean delivery (or C-section) refers to the delivery of newborns via a surgical incision through the abdominal wall and uterus. It is typically performed in situations where maternal and/or fetal health is at risk or compromised, but can also be performed as an alternative to vaginal delivery in routine pregnancies. C-sections can be planned based on known maternal and/or fetal risk factors, or performed as life-saving emergency procedures for unexpected labor and delivery complications. There are two common types of surgical incision: the classical C-section incision, which is vertical, and the low segment transverse incision, which is horizontal. Fetal complications are rare. Maternal recovery is longer than with vaginal delivery and complications can include common surgical complications (e.g., infection, hemorrhage, venous thromboembolism) as well as an increased risk of specific mechanical complications in subsequent pregnancies. Patients who have had a C-section often undergo planned repeat cesarean births for subsequent pregnancies, however, vaginal birth after C-section is possible in select patients.

See also “Normal labor and delivery,” and “Abnormal labor and delivery.”

  • The delivery of a newborn through a vertical or horizontal incision in the lower abdominal and uterine wall

There are guidelines detailing indications for cesarean delivery that are based on scientific findings. However, each hospital can individually determine how these indications are interpreted. The well-being of the mother and child should be of the utmost priority.

Maternal indications

Fetal indications

Cesarean delivery on maternal request (“on-demand”)

  • Overview
    • Primary cesarean delivery that is performed on the mother's request in the absence of medical indications
    • Medically and ethically acceptable if the patient is well-informed
    • Possible reasons include:
      • Fear of the pain of labor
      • Prior negative labor experience
      • Possibility of scheduled delivery
      • Concerns about fetal harm during vaginal birth
    • Physicians are not obliged to perform a non-medically indicated cesarean delivery and may refer the patient to another obstetrician willing to perform the procedure.
  • Approach
    • Explore the reasons behind the request
    • Address concerns about labor and provide information about prenatal childbirth education, obstetric analgesia, and emotional support during labor
    • Lead a balanced discussion about the risks and benefits of cesarean delivery and vaginal birth
    • If the patient insists on having a cesarean delivery, schedule the procedure for after 39 weeks of gestation
  • No true contraindications

We list the most important contraindications. The selection is not exhaustive.

Procedure

Surgical approach

Types of incisions [1]

Low segment transverse incision

Classical incision
Definition
Advantages
  • ↓ Risk of:
    • Adhesions
    • Hemorrhage
  • Trial of labor in subsequent pregnancy is possible in the absence of any conditions requiring cesarean delivery.
  • Better cosmetic outcomes
  • Can be performed in the presence of conditions affecting the lower segment (e.g., myoma)
  • Fetus can be delivered regardless of lie
  • Easily permits intraoperative extension of incision
  • Shorter incision-to-delivery period
Disadvantages

We list the most important complications. The selection is not exhaustive.

Mode of delivery after cesarean delivery

Patients who have undergone a previous cesarean delivery have two options for mode of delivery in a subsequent pregnancy.

Decision-making

  • Patient-centered decision-making: The decision for TOLAC or PRCB should be made by the patient in collaboration with their provider.
  • Factors to consider include:
    • TOLAC can only be provided at facilities with the resources for cesarean birth.
    • Potential complications associated with TOLAC or PRCB (e.g., risk of uterine rupture is higher in TOLAC), including patient factors that affect the risks and benefits for each route of delivery (e.g., prior uterine rupture) [2]
    • Patient's personal preferences, past birthing experiences, and future pregnancy plans
    • Probability of VBAC [3]

Examples of indications [4]

TOLAC is contraindicated in patients with previous classical cesarean delivery.

  1. Fortner KB. The Johns Hopkins Manual of Gynecology and Obstetrics. Lippincott Williams & Wilkins ; 2007
  2. Guise JM, Denman MA, Emeis C, et al. Vaginal birth after cesarean: new insights on maternal and neonatal outcomes.. Obstet Gynecol. 2010; 115 (6): p.1267-1278. doi: 10.1097/AOG.0b013e3181df925f . | Open in Read by QxMD
  3. Eden KB, McDonagh M, Denman MA, et al. New insights on vaginal birth after cesarean: can it be predicted?. Obstet Gynecol. 2010; 116 (4): p.967-981. doi: 10.1097/AOG.0b013e3181f2de49 . | Open in Read by QxMD
  4. Vaginal Birth After Cesarean Delivery. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/02/vaginal-birth-after-cesarean-delivery. Updated: February 1, 2019. Accessed: August 23, 2022.
  5. Sabol B, Denman MA, Guise JM. Vaginal birth after cesarean: an effective method to reduce cesarean.. Clin Obstet Gynecol. 2015; 58 (2): p.309-19. doi: 10.1097/GRF.0000000000000101 . | Open in Read by QxMD

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