Cesarean Childbirth (cont.)
The Most Frequent Reasons for Performing a Cesarean Childbirth
The most frequent reasons for performing a cesarean delivery are discussed below.
- Repeat cesarean delivery: There are two types of uterine incisions - a
low transverse incision and a vertical uterine incision. The direction of the incision on the skin (up and down or side to side) does not necessarily match the direction of the incision made in the uterus.
- As the name implies, the low transverse incision is a horizontal cut across the lower part of the uterus. In the United States, whenever possible, a low skin incision below or at the bikini line with a low transverse uterine incision is the approach of choice.
- A vertical incision on the uterus may be used for delivering preterm babies, abnormally positioned placentas, pregnancies with more than one fetus, and in extreme emergencies.
- In the last decade, studies have shown that women who have had a prior cesarean section with a low transverse incision may safely and successfully go through labor and have a
vaginal delivery in later pregnancies. The same, however, cannot be said of women who have had vertical incisions on the uterus.
- In about 10% of women with vertical uterine incisions, their uterus will rupture (break open).
- The uterus may rupture even before labor begins in up to 50% of these women.
- Uterine rupture can be dangerous to the fetus even if delivery is accomplished immediately after a uterine rupture. Diagnosing a uterine rupture can be difficult, and signs of a rupture can include
increased bleeding, increased pain, or an abnormal fetal heart rate tracing.
- Previous cesarean deliveries: Women with a prior history of more than
one low transverse cesarean section are at slightly increased risk for uterine rupture. This risk increases significantly when the woman has had
three cesarean deliveries. If an abdominal delivery is planned and a trial of labor is not an option, the best time for delivery is determined when the lungs of the fetus are mature.
- Lack of labor progression: If the woman is having adequate contractions but no change in the cervix (opening to the uterus) beyond 3 centimeters dilation or the woman is unable to deliver the fetus despite complete dilation of the cervix and "adequate" pushing for 2
to 3 hours, cesarean delivery may be performed.
- Abnormal position of the fetus: In a normal delivery, the baby presents head first. In this position - as it is in most births; the smallest diameter of the human skull is presented to the pelvis in the best way. This, of course, increases the success of a vaginal delivery.
- There are, however, various other presentations of the fetus, which make vaginal delivery difficult, including the commonly known breech position (when the baby's buttocks are in the lower portion of the uterus). Certain forms of breech delivery have a very low increased risk to the fetus. But, as a rule, breech deliveries may cause more complications, including death and neurologic disability.
- Careful counseling, analysis of the exact type of breech position, and an estimate of the baby's weight are required before making any decision about an attempted vaginal delivery or delivery by cesarean section.
- Fetal status: Although an attractive and much-used tool, the fetal heart rate monitor has not improved birth outcomes as once expected. Some believe the lack of improved outcomes is because many current practicing doctors are poorly trained in interpreting the subtleties of fetal heart rate patterns. Since the use of continuous fetal heart rate monitoring in labor was begun, however, birth experts say death of a fetus during labor is much more rare than in the past.
- Emergency situations: If the woman is severely ill or has a life-threatening injury or illness with interruption of the normal heart or lung function, she may be a candidate for an emergency cesarean section. When performed within 6-10 minutes of the onset of cardiac arrest, the procedure may save the newborn and improve the resuscitation rate for the mother. This procedure, obviously, is performed only in the direst circumstances.
- Elective sterilization: A desire for elective sterilization is not an indication for cesarean delivery. Sterilization after a vaginal delivery can be performed via a tiny 3-cm incision along the lower edge of the umbilicus or as a delayed procedure 6 weeks after delivery with
laparoscopic surgery or vaginal surgery.
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