Cesarean Delivery

CESAREAN DELIVERY

Cesarean delivery is the most frequent major operationperformed in the United States. Until 1965, the rate of cesarean delivery was stable at less than 5%, when it began to increase; it was more than 30% in 2005. Reasons for this increase include the ready availability of improved neonatal intensive care units in which infants with com-plications have a significantly greater survival rate, use in breech deliveries, and use in situations in which more sophisticated fetal monitoring is nonreassuring. How-ever, no major improvements in newborn outcomes have occurred as a result.

The decision regarding mode of delivery should be made by the health care provider together with the patient. Advantages of a successful vaginal delivery include reduced risks of hemorrhage and infection; shorter postpartum hos-pital stay; and a less painful, more rapid recovery. However, cesarean delivery may be necessary. Examples of indications for cesarean delivery include hemorrhage from placenta previa, abruptio placentae, prolapse of the umbilical cord, and uterine rupture, as these conditions require prompt delivery. Planned vaginal delivery may be a reasonable approach for a fetus in breech presentation, but depends on the experience of the health care provider. In such circumstances, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher with a vaginal delivery than with a cesarean delivery, and the patient’s informed consent should be documented.

An estimated 2.5% of all births in the United States are cesarean delivery on maternal request. This procedure should not be performed before 39 weeks of gestation, unless lung maturity can be documented. It is not recom-mended for women desiring several children, because the risks of placenta previa, placenta accreta, and gravid hys-terectomy increase with each cesarean delivery.

Decisions regarding cesarean delivery have important ramifications, because the maternal mortality rate associ-ated with cesarean delivery is two to four times that of a vaginal birth (i.e., 1 per 2500 to 1 per 5000 operations). Cesarean delivery can be performed through various inci-sions in the uterus. An incision through the thin, lower uterine segment allows for subsequent trials of vaginal birth after cesarean (VBAC) delivery if the patient has had one prior cesarean delivery. An incision through the thick, muscular upper portion of the uterus, a classical cesarean section, carries such a great risk of subsequent uterine rupture that repeat cesarean delivery for these patients is recommended.