What is a cesarean (C-section) section?

Cesarean Section: A Comprehensive Overview

A cesarean section (C-section) is a surgical procedure in which an incision is made through the mother's abdomen and uterus to deliver the baby when vaginal delivery is not possible or safe for the mother or baby. This procedure can be life-saving when medically indicated but also carries specific risks and benefits that must be considered.

Types and Techniques

• Cesarean sections are typically performed through a low transverse incision in the lower uterine segment, which offers better healing and lower risk of rupture in subsequent pregnancies 1
• Classical cesarean sections involve a vertical incision in the contractile corpus of the uterus and are typically reserved for specific situations such as preterm deliveries, dense adhesions, or placenta previa/accreta 2
• The surgical approach typically involves a laparotomy followed by hysterotomy to access and deliver the baby 2

Indications for Cesarean Section

• Common indications include previous cesarean delivery, dystocia (difficult labor), breech presentation, and fetal distress 3
• Emergency cesarean sections may be performed in cases of maternal cardiac arrest when the gravid uterus is large enough to cause aortocaval compression (typically after 20 weeks gestation) 1
• For pregnant women with cancer, cesarean delivery is indicated for cervical and most vulvar cancers, but not necessarily for ovarian cancer or cervical cancer that was completely excised during pregnancy 1

Perioperative Management

• Intravenous antibiotics should be administered routinely within 60 minutes before the cesarean delivery skin incision 1, 4
• A first-generation cephalosporin is recommended for all women; for those in labor or with ruptured membranes, adding azithromycin provides additional reduction in postoperative infections 4
• Chlorhexidine-alcohol is preferred over aqueous povidone-iodine for abdominal skin preparation 4
• Regional anesthesia is the preferred method for cesarean delivery as part of an enhanced recovery protocol 4
• Pregnant women after 20 weeks should be positioned with left uterine displacement to prevent aortocaval compression 1

Surgical Techniques

• Closure of the hysterotomy in 2 layers is associated with a lower rate of uterine rupture and niche formation 4
• The peritoneum does not need to be closed as closure is not associated with improved outcomes and increases operative time 4
• In women with ≥2 cm of subcutaneous tissue, reapproximation of that tissue layer should be performed to reduce wound complications 4
• The skin should be closed with subcuticular suture in most cases, as this technique shows reduced wound separation compared to staples 4

Postoperative Care

• Gum chewing appears effective and low-risk for preventing postoperative ileus 1
• Thromboprophylaxis with low-molecular-weight heparin should be considered, especially in the postoperative setting or in case of immobilization 1
• Standardized written discharge instructions should be used to facilitate discharge counseling 4
• Chemotherapy can resume within a few days after a vaginal birth and 7 days after C-section if there's no evidence of infection and the incision is healing well 1

Risks and Benefits

Maternal Risks

• Maternal mortality is 2-4 times higher and morbidity is 5-10 times higher after a cesarean compared to vaginal birth 3
• Women with multiple previous cesarean deliveries have increased risks for wound and uterine hematoma (4-6%), placenta previa (1-2%), red cell transfusions (1-4%), hysterectomy (0.5-4%), and placenta accreta (0.25-3%) 4
• Long-term risks include increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth in subsequent pregnancies 5

Neonatal Considerations

• Babies born by cesarean section have different hormonal, physical, bacterial, and medical exposures that can alter neonatal physiology 5
• Short-term risks include altered immune development, increased likelihood of allergy, atopy, and asthma, and reduced intestinal gut microbiome diversity 5
• Long-term associations include greater incidence of late childhood obesity and asthma 5

Special Situations

Cesarean Section in Pregnancy Complicated by Cancer

• The mode or timing of delivery is generally not affected by a diagnosis of breast cancer during pregnancy 1
• Chemotherapy should be stopped at week 35 for weekly schedules to avoid myelosuppression at delivery 1
• Vaginal delivery should be aimed for as there is no absolute obstetric or oncological contraindication 1

Cesarean Section in HIV-Positive Women

• If elective cesarean delivery was planned and the woman presents with ruptured membranes or labor, the benefit of cesarean section becomes unclear if membrane rupture exceeds 4 hours 1
• If cesarean delivery is chosen, the loading dose of ZDV (zidovudine) should be administered while preparations are made for cesarean delivery 1
• Prophylactic antibiotics given after cord clamping reduce the rate of postpartum infection 1

Enhanced Recovery After Surgery (ERAS) for Cesarean Delivery

• Implementation of ERAS protocols has been shown to result in clinical benefits (reduced length of stay, complications, and readmissions) and health system benefits (reduced cost) 1, 4
• The ERAS cesarean delivery pathway starts 30-60 minutes before cesarean incision and continues until maternal discharge 1
• Continuous assessment of outcomes and quality improvement approaches are needed to incorporate best practices in cesarean delivery care 4

Global Perspective

• Cesarean section rates have risen dramatically in many countries, with varying rates according to regional human development indexes 6
• In Brazil, regions with high human development indexes had significantly higher cesarean section rates than those with low human development indexes 6
• Efforts are being made globally to ensure that cesarean sections are performed only when necessary 6