From the Guidelines
Cesarean delivery is indicated when the risks of vaginal delivery outweigh its benefits for either the mother or baby, and should be considered for obstetric indications or for patients with specific medical conditions, such as dilatation of the ascending aorta >45 mm, severe aortic stenosis, pre-term labour while on oral anticoagulants, Eisenmenger syndrome, or severe heart failure, as recommended by the European Society of Cardiology 1.
Indications for Cesarean Delivery
The decision for cesarean delivery should balance maternal and fetal risks and benefits, considering factors like gestational age, maternal health, and available resources.
- Common maternal indications include:
- Obstructed labor
- Failed induction
- Abnormal placentation (such as placenta previa or placenta accreta)
- Active genital herpes
- Prior uterine surgery with high risk of rupture
- Certain maternal medical conditions that make pushing unsafe
- Fetal indications include:
- Malpresentation (especially breech position)
- Certain congenital anomalies
- Non-reassuring fetal status
- Macrosomia (particularly in diabetic mothers)
Specific Considerations
- Multiple gestation, especially with the first twin in non-cephalic presentation, often requires cesarean delivery.
- Prior cesarean delivery may necessitate repeat cesarean, though vaginal birth after cesarean (VBAC) may be an option for selected patients with one prior low transverse cesarean.
- The American College of Obstetricians and Gynecologists recommends that suspected fetal macrosomia is not an indication for induction of labor, but a prolonged second stage of labor or arrest of descent in the second stage with an estimated fetal weight more than 4,500 g is an indication for cesarean delivery 1.
Risks and Benefits
While cesarean delivery can be life-saving, it carries increased risks of hemorrhage, infection, thromboembolism, and complications in future pregnancies compared to vaginal delivery, so it should be performed when medically indicated rather than electively without medical necessity.
- A study on pulmonary arterial hypertension in adults found that the optimal mode of delivery remains controversial, but cesarean section delivery may be considered in certain cases 1.
- The European Society of Cardiology recommends that cesarean delivery should be considered for patients with specific medical conditions, such as dilatation of the ascending aorta >45 mm, severe aortic stenosis, pre-term labour while on oral anticoagulants, Eisenmenger syndrome, or severe heart failure 1.
From the Research
Indications for Cesarean Delivery
The indications for a Cesarean (C-Section) delivery include:
- Elective repeat cesarean delivery 2
- Dystocia or failure to progress 2
- Malpresentation 2
- Fetal heart rate tracings that suggest fetal distress 2
- Fetal distress 3
- Prolapsed cord 3
- Maternal hemorrhage from previa or trauma 3
- Uterine rupture 3
- Complete placental abruption 3
- Cesarean delivery on maternal request, which accounts for approximately 2.5% of all births in the United States 4, 5
Maternal and Fetal Risks
Cesarean delivery is associated with increased maternal and neonatal morbidity and mortality compared to spontaneous vaginal delivery 2. Maternal complications following cesarean delivery are three-fold higher than vaginal delivery 6. The risks of placenta previa, placenta accreta spectrum, and gravid hysterectomy increase with each subsequent cesarean delivery 4, 5.
Decision-Making for Cesarean Delivery
The decision to attempt a trial of labor after cesarean delivery or have a planned repeat cesarean delivery involves a balancing of maternal and neonatal risks, as well as personal preference after counseling by a physician 2. A trial of labor after cesarean delivery (TOLAC) should be pursued when feasible, and the indications, contraindications, safeguards, and steps of safe labor induction should be delineated 6.