What are the medical risks and management strategies for an elective cesarean section (C-section)?

Medical Risks of Elective Cesarean Section

Elective cesarean section carries significant medical risks including increased maternal mortality (2-4 times higher), morbidity (5-10 times higher), postpartum infections, wound complications, and future pregnancy complications compared to vaginal delivery, and should only be performed when medically indicated rather than by maternal request alone. 1

Maternal Risks

• Postpartum fever occurs in approximately 6.7% of cesarean deliveries compared to 1.1% in vaginal deliveries 2
• Increased risk of endometritis, wound infection, and pneumonia compared to vaginal delivery 2
• Postoperative complications are more common after emergency cesarean delivery (relative risk 4.17) than after elective cesarean (relative risk 1.85) compared to vaginal delivery 2
• Chronic wound pain affects 15.4% of women at 3-6 months postpartum 3
• Higher risk of venous thromboembolism (2.6 per 1000 cesarean births) 3
• Increased risk of wound infection and separation, particularly in women with more than 2 cm of subcutaneous fat 2, 4
• Women with obesity have higher complication rates, with risk inversely related to CD4+ count or clinical stage in HIV-infected women 2

Future Pregnancy Complications

• Increased risk of placenta previa and placenta accreta in subsequent pregnancies 3
• Uterine rupture in subsequent pregnancies (22 per 10,000 births in women with previous cesarean) 3
• Secondary infertility reported in up to 43% of women following cesarean section 3
• Vertical (classical) cesarean incisions carry a significantly higher risk of uterine rupture in subsequent pregnancies compared to low transverse incisions 5

Management Strategies to Reduce Risks

Preoperative Planning and Assessment

• Comprehensive multidisciplinary planning involving anesthesiologists and obstetric teams is essential to minimize maternal and fetal morbidity 6
• Women with anticipated airway difficulties should be identified during antenatal care and referred for specific anesthetic and obstetric management planning 6
• Thorough airway assessment should document Mallampati grade, neck movement, mouth opening, thyromental distance, and jaw protrusion 6
• Early establishment of venous access is recommended, particularly in women with BMI above 40 2

Anesthetic Considerations

• Rapid sequence induction remains the standard technique when general anesthesia is required 6
• Proper positioning is crucial - the "ramped" position optimizes laryngoscopic view in pregnant patients 6
• Have difficult airway equipment immediately available, including video laryngoscopes and supraglottic airway devices 6
• Antenatal patient referral to an anesthesiologist is recommended, particularly for women with BMI greater than 40 kg/m² 2

Surgical Technique

• Use electric clippers rather than razors to remove hair at the surgical site 4
• Wash skin with chlorhexidine solution before incision 4
• Administer broad-spectrum antibiotic prophylaxis before surgery rather than after cord clamping 4
• Remove placenta by traction on umbilical cord rather than manual extraction to reduce risk of endometritis 4
• Close the uterine incision in two layers rather than one to reduce risk of future scar dehiscence 4
• Suture the subcutaneous tissue space in women with more than 2 cm of subcutaneous fat to reduce wound complications 2, 4

Thromboprophylaxis

• Apply mechanical thromboprophylaxis using pneumatic compression devices before cesarean section when possible 2
• Consider weight-based dosing of pharmacologic thromboprophylaxis, particularly in women with class III obesity 2

Special Considerations for High-Risk Populations

Women with Obesity

• Alert operating room staff regarding any woman whose weight exceeds 120 kg to ensure adequate staffing and equipment availability 2
• Obesity alone is not an indication for elective cesarean section, though informed discussion should be held regarding mode of delivery due to higher risks of emergency cesarean 2
• All women with BMI ≥30 should have active management of the third stage of labor due to increased risk of postpartum hemorrhage 2

Women with Previous Bariatric Surgery

• Bariatric surgery should not be considered an indication for cesarean delivery 2
• Good communication between the obstetrician and bariatric surgery team is important 2

Postpartum Care

• Behavioral interventions including diet and exercise should be recommended for weight reduction postpartum 2
• Additional support for breastfeeding may be needed, particularly for women with obesity 2
• Monitor for signs of wound infection and provide appropriate wound care 4

Remember that cesarean section rates have risen dramatically without clear evidence of proportional improvement in outcomes 1. Approximately half of cesareans performed in the US have been estimated to be medically unnecessary, resulting in avoidable complications and increased healthcare costs 1.