What are the indications for an urgent caesarean section?

Indications for Urgent Caesarean Section

Urgent caesarean section is indicated when there is significant risk to maternal or fetal health that requires expedited delivery but allows time for appropriate preparation and anesthesia.

Primary Indications

Fetal Indications

• Fetal distress/non-reassuring fetal status - particularly with irreversible causes 1
  • Sustained fetal bradycardia
  • Abnormal fetal heart rate patterns unresponsive to intrauterine resuscitation

Maternal-Fetal Emergencies

• Umbilical cord prolapse with sustained bradycardia 2
• Placental abruption (major) 2
• Uterine rupture - requires immediate intervention 3
  • Time-critical: delivery within 18 minutes of suspected rupture significantly improves outcomes
  • Activate emergency caesarean section team immediately upon suspicion
• Placenta previa with active bleeding 4
• Vasa previa rupture with fetal hemorrhage 2

Maternal Indications

• Failed instrumental delivery 2
• Obstructed labor or failure to progress
• Maternal hemorrhage requiring urgent delivery 4
• Severe preeclampsia/eclampsia not responding to medical management 2
• Maternal cardiac disease with deterioration 2
  • Particularly when vaginal delivery with Valsalva maneuvers may precipitate complications

Special Considerations

Cardiac Arrest in Pregnancy

• If cardiac arrest occurs in a pregnant woman with fundal height at or above umbilicus (≥20 weeks):
  • Emergency caesarean section should be performed within 5 minutes if resuscitation is unsuccessful 2
  • This improves both maternal and fetal outcomes
  • No maternal survival reported after 15 minutes of resuscitation, and no fetal survival after 30 minutes 2

Anticoagulation Considerations

• For women on warfarin:
  • If labor starts while on warfarin or within 2 weeks after discontinuation, caesarean section is recommended 2
  • Vaginal delivery on warfarin is contraindicated due to risk of fetal intracranial bleeding 2

Vascular Liver Disease

• Women with severe portal hypertension may require caesarean section to avoid Valsalva maneuvers during vaginal delivery that could precipitate variceal bleeding 2

Classification of Urgency

Urgent caesarean sections are typically classified into three categories 1:

1. Immediate - life-threatening condition requiring delivery within minutes (e.g., sustained fetal bradycardia, maternal cardiopulmonary arrest)
2. Urgent - maternal and/or fetal physiology is unstable but not immediately life-threatening
3. Stable emergency - maternal and fetal condition stable but requires delivery before deterioration occurs

Critical Time Frames

• For sustained fetal bradycardia: delivery within 25 minutes improves long-term neonatal neurologic outcomes 1
• For maternal cardiac arrest: peripartum caesarean section within 5 minutes 2
• For uterine rupture: delivery within 18 minutes of suspected rupture 3

Important Caveats

• Maternal and fetal outcomes are significantly worse in emergency versus elective caesarean sections 5

• Emergency caesarean sections are associated with higher rates of:

  • Post-operative wound infection
  • Postpartum hemorrhage
  • Urinary tract infection
  • Need for blood transfusion
  • Maternal ICU admission
  • Neonatal complications (birth asphyxia, meconium-stained liquor, NICU admission) 5

• Intrauterine fetal resuscitation should be employed when appropriate before emergency operative delivery, and the urgency of surgery should be re-evaluated after transfer to the operating theater 2

• Clear communication between obstetricians and anesthesiologists is essential for optimal management of urgent caesarean sections 1