What are the most common indications for a Cesarean Section (CS) delivery?

Most Common Indications for Cesarean Section Delivery

The most common indications for cesarean section (CS) delivery include failure to progress/cephalopelvic disproportion, previous cesarean section, fetal distress, and fetal malpresentation. 1, 2, 3

Primary Maternal Indications

• Failure to progress/Cephalopelvic disproportion (CPD) - The most common indication (approximately 30% of all CS), occurring when labor fails to advance despite adequate contractions due to disproportion between fetal size and maternal pelvis 1
• Previous cesarean section - Second most common indication (approximately 16% of CS), often performed to prevent uterine rupture in subsequent pregnancies 1, 2
• Failed induction of labor - When cervical changes do not occur after adequate attempts at induction, including use of prostaglandins and oxytocin 2
• Maternal medical conditions requiring expedited delivery:
  • Severe cardiac conditions (pulmonary hypertension, significant aortopathy) 3
  • HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) 3
  • Acute fatty liver of pregnancy 3
  • Maternal cardiac arrest (should occur within 5 minutes) 3

Primary Fetal Indications

• Non-reassuring fetal status/fetal distress - Third most common indication (approximately 15% of CS), performed when monitoring indicates the fetus is not tolerating labor 1, 4
• Fetal malpresentation - Fourth most common indication (approximately 11% of CS), including breech, transverse, or oblique presentations 1, 4
• Placental abnormalities:
  • Placenta previa (placenta covering the internal os) 2, 1
  • Placental abruption (premature separation of placenta) 1
• Umbilical cord prolapse with sustained fetal bradycardia 3, 1
• Fetal growth restriction with abnormal Doppler studies or other concerning features 5

Obstetric Emergencies

• Uterine rupture - Accounts for approximately 4% of CS, constituting an obstetric emergency requiring immediate delivery 1
• Pre-rupture conditions - Signs of impending uterine rupture (approximately 3% of CS) 1
• Cord prolapse - When umbilical cord precedes the fetus, compromising blood flow (approximately 2% of CS) 1
• Placental abruption - Premature separation of the placenta from the uterine wall (approximately 3% of CS) 1

Special Considerations

• HIV infection - CS recommended for women with HIV-1 RNA >1,000 copies/mL near delivery time to reduce vertical transmission 3
• Multiple gestation - Depending on presentation and number of fetuses 4
• Maternal request - Increasingly common, though guidelines recommend CS be reserved primarily for obstetric indications 3, 6

Mode of Delivery Considerations

• For early-onset fetal growth restriction with absent or reversed end-diastolic flow in umbilical artery, CS is recommended by 32-34 weeks 5
• For abnormal fetal surveillance (abnormal CTG or ductus venosus Doppler), CS is indicated 5
• Meconium-stained amniotic fluid alone is not an indication for CS 2

Surgical Technique Considerations

• Standard approach involves transverse lower uterine segment incision 5
• Classical (vertical) cesarean section may be needed in specific situations:
  • Preterm delivery with undeveloped lower segment
  • Dense adhesions
  • Placenta previa/accreta 7

Common Pitfalls to Avoid

• Performing CS solely based on estimated fetal weight of 3500g in diabetic patients is not supported by guidelines 2
• Meconium-stained amniotic fluid alone should not trigger CS 2
• Delayed decision-making in cases of true fetal distress with irreversible causes can worsen neonatal outcomes 3
• Unnecessary CS increases maternal risks, including postpartum infections which are 5-7 times more common after CS compared to vaginal delivery 3

The decision for CS should be based on clear medical indications, with consideration of both maternal and fetal outcomes in terms of morbidity, mortality, and quality of life 2, 3.