What are the indications for a caesarian section (C-section) for delivery?

Indications for Caesarian Section for Delivery

Caesarian section (C-section) should be performed for specific obstetric and medical indications that prioritize maternal and fetal morbidity, mortality, and quality of life outcomes.

Maternal Indications

• Significant cardiac disease: C-section is indicated in women with severe pulmonary hypertension, significant aortopathy (e.g., >40mm in Marfan syndrome, aortic diameter >45mm), and in cases of maternal cardiac instability such as acute heart failure 1

• Anticoagulation therapy: Women on warfarin or requiring continuous anticoagulation for mechanical heart valves should undergo C-section to minimize the period off anticoagulation and reduce risk of maternal valve thrombosis 1

• Severe liver disease: In acute fatty liver of pregnancy (AFLP), C-section is associated with improved maternal and perinatal outcomes compared to vaginal delivery 1

• Maternal instability: Immediate C-section delivery should be considered in life-threatening maternal complications to improve maternal outcomes 1

• Cardiac arrest: In the event of maternal cardiac arrest, C-section delivery should occur within 5 minutes to optimize both maternal and fetal outcomes 1

Fetal Indications

• Fetal distress with irreversible causes: Conditions including major placental abruption, fetal hemorrhage (e.g., from ruptured vasa praevia), ruptured uterine scar with placental/fetal extrusion, umbilical cord prolapse with sustained bradycardia, and failed instrumental delivery 1

• Abnormal fetal presentation: Breech presentation at term has significantly lower perinatal mortality, neonatal mortality, and serious neonatal morbidity with planned C-section compared to planned vaginal birth (1.6% vs 5.0%) 2

Obstetric Indications

• Placental abnormalities: Placenta previa and other placental abnormalities that prevent safe vaginal delivery 3

• Cephalopelvic disproportion: When the fetal head cannot safely pass through the maternal pelvis 4

• Failed progression of labor: When labor fails to progress despite adequate uterine contractions 3

• Previous C-section: Though vaginal birth after cesarean (VBAC) may be appropriate in selected cases, repeat C-section remains common practice 3, 4

Special Considerations

• High-risk pregnancies with anticipated airway difficulties: For women with anticipated difficult airways, elective C-section may be planned to avoid emergency general anesthesia 1

• Hepatitis C with high viral load: To reduce vertical transmission risk, invasive procedures during vaginal delivery (internal monitoring, fetal scalp sampling, vacuum extraction) should be avoided, making C-section a safer alternative 1

• Multidisciplinary planning: Women with complex medical conditions require individualized delivery plans developed by a multidisciplinary team including obstetricians, anesthesiologists, and relevant specialists 1

Risks and Considerations

• Maternal risks: C-section carries 2-4 times higher mortality and 5-10 times higher morbidity compared to vaginal delivery 3

• Long-term complications: These include chronic wound pain (15.4% at 3-6 months postpartum), increased risk of placenta previa and accreta in subsequent pregnancies, uterine rupture risk in subsequent pregnancies (22 per 10,000 births), venous thromboembolism (2.6 per 1000 CS births), and potential secondary infertility (up to 43% of women) 5

• Neonatal considerations: While C-section can be life-saving, it may increase risk of iatrogenic prematurity or respiratory disease in infants 3

Anesthetic Considerations

• Regional anesthesia preferred: For most C-sections, regional anesthesia (spinal or epidural) is recommended over general anesthesia 6

• General anesthesia risks: General anesthesia can precipitate uncontrolled hypertension in women with preeclampsia and carries higher maternal risks 1

• Optimal positioning: The 20-30° head-up position increases functional residual capacity in pregnant women, improves laryngoscopic view, and may reduce gastroesophageal reflux when general anesthesia is required 1

Common Pitfalls to Avoid

• Unnecessary C-sections: Approximately half of C-sections performed in the US may be medically unnecessary, resulting in avoidable maternal morbidity and mortality 3

• Inadequate preparation: For high-risk cases, failure to have a multidisciplinary team and appropriate equipment readily available can lead to poor outcomes 1

• Delayed decision-making: In cases of true fetal distress with irreversible causes, delays in proceeding to C-section can result in worse neonatal outcomes 1

• Overlooking maternal cardiac status: Women with cardiac disease require careful hemodynamic monitoring and management during delivery, with C-section indicated for specific cardiac conditions 1