When is an elective cesarean section (c-section) recommended?

Indications for Elective Cesarean Section

Elective cesarean sections should be performed at 39 completed weeks of gestation to optimize maternal and neonatal outcomes, except in specific clinical scenarios that warrant earlier delivery. 1

Timing Considerations

• Performing elective cesarean delivery at 39 completed weeks minimizes neonatal respiratory morbidity while balancing maternal risks 1
• Elective cesarean deliveries performed before 39 weeks are associated with significantly increased risk of neonatal respiratory complications, NICU admission, hypoglycemia, and longer hospital stays 2, 3
• Early term (37-38 weeks) cesarean deliveries have 1.5-2.1 times higher risk of adverse neonatal outcomes compared to those performed at 39 weeks 3
• Respiratory morbidity is independently associated with gestational age even in normal birth weight newborns 4, 5

Special Clinical Scenarios Warranting Earlier Delivery

HIV Infection

• For HIV-infected women requiring cesarean delivery to prevent mother-to-child transmission, delivery should be performed at 38 completed weeks of gestation 6, 1
• This timing reduces the likelihood of spontaneous labor or membrane rupture before the scheduled procedure 6
• Intravenous zidovudine should be started at least 3 hours before the operation 6

Cardiac Disease

• Women with severe cardiac conditions (aortopathy >40mm in Marfan syndrome, aortic diameter >45mm, vascular Ehlers-Danlos) should undergo elective cesarean section 6
• Those requiring ongoing anticoagulation or with severe pulmonary hypertension should also have planned cesarean delivery 6
• Maternal or fetal instability, such as in acute heart failure, is an indication for cesarean delivery 6

Anticipated Difficult Airway

• Elective cesarean section may be indicated when airway management is deemed too difficult should emergency cesarean section and general anesthesia be required 6
• This requires thorough antenatal planning with multidisciplinary input 6

Severe Pre-eclampsia

• All women with severe pre-eclampsia should be delivered promptly, either vaginally or by cesarean section, regardless of gestational age 6

Contraindications and Cautions

• Vaginal delivery should be considered for women with any hypertensive disorders unless cesarean delivery is required for obstetric indications 6
• Cesarean section carries significant risks including:
  • Chronic wound pain (15.4% at 3-6 months postpartum)
  • Increased risk of placenta previa and accreta in subsequent pregnancies
  • Uterine rupture in subsequent pregnancies (22 per 10,000 births)
  • Venous thromboembolism (2.6 per 1000 CS births)
  • Secondary infertility (reported in up to 43% of women) 7

Special Considerations

HIV-Infected Women in Labor

• If an HIV-infected woman who planned elective cesarean presents in early labor or shortly after membrane rupture:
  • Intravenous zidovudine should be started immediately 6
  • If labor is progressing rapidly, vaginal delivery may be allowed 6
  • If cervical dilation is minimal and a long period of labor is anticipated, cesarean section may be performed to minimize membrane rupture duration 6
  • The benefit of cesarean section diminishes after 4 hours of membrane rupture 6

Anesthetic Considerations

• Regional anesthesia (epidural or spinal) is preferred for cesarean delivery 8
• For women with anticipated difficult airways, advance planning is essential, including consideration of awake flexible bronchoscopic intubation 6
• Prophylactic antibiotics should be administered to all women undergoing cesarean section to reduce postpartum infection risk 6

Perioperative Management

• Maintain normothermia during cesarean delivery through forced-air warming and warming of intravenous fluids 8
• Implement thromboprophylaxis for patients with additional risk factors for venous thromboembolism 8
• Encourage early mobilization and regular diet within 2 hours after cesarean delivery 8
• Delayed cord clamping for at least 1 minute is recommended for term births 8