Chapter 22: Cesarean Section

INTRODUCTION

Cesarean section is an operation by which a child is delivered through an incision in the abdominal wall and the uterus. The first professional cesarean section was performed in the United States in 1827. Before 1800, cesarean section was performed rarely and was usually fatal. In London and Edinburgh in 1877, of 35 cesareans performed, 33 resulted in the death of the mother. By 1877, there had been 71 cesarean section operations in the United States. The mortality rate was 52 percent, mainly because of infection and hemorrhage.

FREQUENCY OF CESAREAN SECTION

The rate of cesarean section has risen steadily from an incidence of 3 to 4 percent, over 30 years ago, to the present rate 25 to 30 percent depending on region. Not only has the operation become safer for the mother, but the number of infants damaged by prolonged labor and traumatic vaginal operations has been reduced. In addition, concern for the quality of life and the intellectual development of the child has widened the indications for cesarean section.

The largest increase in the use of cesarean section is in those cases described as having “dystocia.” Although conditions such as disproportion, malpresentation, and incoordinate uterine action are included in this group, in many instances, the exact diagnosis is not made, and the diagnosis of “dystocia” represents slow progress in labor from whatever cause. The use of cesarean section for these patients is part of a more aggressive management of poor progress in labor and the abandonment of difficult midforceps operations.

Although it appears clear that the replacement of high forceps and difficult midforceps operations by cesarean section has reduced the perinatal morbidity and mortality in this area, the available evidence does not support the contention that the great expansion in the rates of cesarean section for other indications has contributed significantly to the reduction in the rates of perinatal mortality in recent years. Certainly, the more frequent use of cesarean section has led to an increase in the rate of maternal morbidity. Higher rates of repeat cesarean sections are a cause for complications with placental anomalies in subsequent pregnancies.

INDICATIONS FOR CESAREAN SECTION

Indications for cesarean section are absolute or relative. Any condition that makes delivery via the birth canal impossible is an absolute indication for abdominal delivery. Among these are extreme degrees of pelvic contraction and neoplasms blocking the passage. With a relative indication, vaginal birth is possible, but the conditions are such that cesarean section is safer for the mother, the child, or both.

Pelvic Contraction and Dystocia

1. Fetopelvic disproportion

2. Malpresentation and malposition

3. Uterine dysfunction

4. Soft tissue dystocia

5. Neoplasms

6. Failure to progress

7. Previous shoulder dystocia

Previous Uterine Surgery

1. Cesarean section

2. Hysterotomy

3. Myomectomy

4. Cervical suture

Hemorrhage