Comprehensive Guide to Caesarean Section: Indications, Procedures, and Clinical Considerations
The term “Cesarean section” denotes the delivery of the fetus, placenta and membranes through an incision in the abdominal and uterine walls at or after 28 weeks of gestation. Also known as C-section or caesarean delivery, a caesarean section is major surgery, with real risks, and the decision to perform such an operation should not be taken lightly! The term “cesarean” more likely refers to being cut open as the Latin verb “caedare” means to cut. While originally believed to have been derived from the birth of Julius Caesar, it is unlikely that his mother, Aurelia, would have survived the operation.
Historical Context and Evolution
There is evidence from both early western and non-western societies regarding this procedure. The first recorded successful C-section (where both the mother and the infant survived) was performed on a woman in Switzerland in 1500 by her husband, Jakob Nufer. Later, the first documented operation on a living patient who died on the 25th postoperative day was done in 1610, and the first successful cesarean section in the USA was done in Virginia, in 1794.
Historically, surgeons would complete the operation without closing the uterus, leading to hemorrhage and sepsis. However, between 1880 and 1925, transverse incisions of the uterus were developed, which reduced the rate of infection and rupture. The low cervical incision, introduced by Munro Kerr in 1926, became the technique of choice. Furthermore, the introduction of penicillin in 1940 and new methods for anesthesia allowed C-sections for obstructed labor to gain popularity over destructive procedures.
Epidemiology and Prevalence
Over the past generation, there has been a universal dramatic increase in the rate of Cesarean delivery. The WHO recommends that not more than 15% of deliveries should be via c-section; however, the C-section rate worldwide is approximately 15% of births, with countries like Mexico, Brazil, and Italy seeing rates over 35%. In the UK, the rate is about 25%, and in the USA, it is about 30%.
Incidence is increasing mainly due to the increased diagnoses of fetal distress, as diagnosed by CTG monitoring, and increased use for non-longitudinal lies such as breech or transverse presentations.
| Category | Reason for C-section | Percentage |
|---|---|---|
| First Pregnancy | Fetal distress | 28% |
| First Pregnancy | Failure to progress | 25% |
| First Pregnancy | Breech | 14% |
| Subsequent Pregnancies | Previous c-section | 45% |
Indications for Surgery
Elective C-section
Common indications for elective surgery include placenta praevia, breech presentation, and twins where the first twin is not cephalic. Maternal infections, such as HIV or active herpes in the 3rd trimester, and previous vaginal surgery like fistula repair are also significant factors. Surgery is usually planned for 39 weeks because performing elective c-section at this time reduces the risk of neonatal respiratory problems.
- 37 weeks: 7x greater risk for respiratory problems compared to vaginal risk.
- 38 weeks: 3x greater risk for respiratory problems.
- 39 weeks: Risk is equal with vaginal risk.
Emergency C-section
Emergency procedures are indicated in cases of:
- Cord prolapse
- Failure to progress
- Fetal distress during the first stage of labour
- Antepartum haeomorrhage (abruption or placenta praevia)
- Transverse lie during labour
The Surgical Procedure and Anaesthesia
The procedure is usually performed under spinal or epidural block rather than general anaesthetic, which is used in only about 8% of cases. There are two types of incision that can be made: the vertical incision, which is less commonly used in modern times, and the lower uterine segment incision. The lower uterine segment incision is a smaller incision made horizontally just above the pubic bone. This method reduces the risk of infection, reduces the risk of complications, and provides a better cosmetic appearance. However, fetal laceration occurs in 2% of cases.
Prophylactic antibiotics do reduce the risk of infection for both elective and emergency c-sections. A typical regimen includes 2g cefradine IV at induction, followed by 1g at 6 hours and 12 hours post-op.
Thromboprophylaxis and Postoperative Care
Postoperative care includes 1:1 care on a recovery unit. To aid natural removal of the placenta and avoid endometritis, gentle traction should be applied to the cord. Regarding thromboprophylaxis, the regimen involves halving the dose on the day before a planned c-section and omitting the usual dose on the day of surgery.
Risk factors for thromboembolism include:
- Age >35
- Obesity (>80Kg)
- Pre-eclampsia
- Emergency c-section
- >4 days immobility
- Family history or personal history of thromboembolism
For those at high risk, give 5 days of heparin post-op, or until fully mobilised, whichever is longer. If no risk factors are present, then all that is required is good hydration and early mobilisation.