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Cesarean Delivery

Last Updated: August 6, 2005

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INTRODUCTION Section 2 of 10

The term cesarean deliver is defined as the deliver of a fetus through asurgical incision through the a!dominal "all #la$arotom% and uterine "all

#hsterotom%& 'n the (nited )tates, it is customar to use onl the letter e in thefirst slla!le of cesarean& 'n Australia and England, the letters a and e still areused #ie, caesarean%&

The "ords cesarean and section !oth are derived from ver!s that mean to cut*thus, the $hrase cesarean section is a tautolog& 't is $refera!le to use the termscesarean deliver or cesarean !irth&

'n the (nited )tates, cesarean deliver has !ecome the most common surgical$rocedure& + the earl --0s, almost 25. of all live !irths "ere from cesareandeliveries& 'n the last decade, acce$tance has !een gro"ing for allo"ing "omen

to have a vaginal deliver after having had a $rior cesarean deliver&

History of te !roced"re: The eact origin of the term cesarean is unclear&The term cesarean ma have arisen in the Middle Ages from the atin ver!caedere #to cut%& Children of such !irths "ere referred to as caesones. The termalso ma originate "ith an eighth centur +C Roman la", lex regis& ater calledlex cesarea, this la" mandated a $ostmortem o$erative deliver so that !oth themother and child could !e !uried se$aratel&

Although man references to a!dominal deliver are made in man cultures,man of the ancient medical "riters #eg, Galen, 1i$$ocrates, )oranus% do not

descri!e such a $rocedure&

'n 5, 3ran4ois Rousset "rote a!out cesarean deliveries& 1e descri!es such $rocedures from information he received from letters, !ut he never actuall"itnessed such a $rocedure& + the mid th centur, more re$orts !o!stetricians a!out this o$eration !egan to a$$ear& Earl descri$tions of such$rocedures reveal that a!dominal deliver "as $erformed in rare circumstances&

The a!ilit of o!stetricians to $erform the $rocedure "as limited ! anesthesiaand infection control& 'n 6, the anesthetic agent diethl ether "as introduced

at Massachusetts General 1os$ital& 7ueen 8ictoria delivered eo$old #59%and +eatrice #5% ! cesarean deliver "ith the administration of chloroform&1o"ever, des$ite the increased $otential for a!dominal $rocedures $rovided !

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anesthesia, mortalit from the $rocedure from infectious mor!idit remainedhigh follo"ing cesarean deliver&

)urgical techni:ue also "as a limiting factor for the acce$ta!ilit of the$rocedure& 'nitiall, maternal mortalit from !lood loss also "as high !ecausesurgeons "ere reluctant to close the uterine incision& )ome advocatedhsterectom at the time of cesarean deliver to control !leeding and decreaseinfection& 'n 2, Ma )anger, from ei$;ig, descri!ed the value of suturing theuterine "all "ith silver "ire #develo$ed ! -th centur gnecologist <& Marion)ims% and sil= in a 2>ste$ closure& 1is re$ort documented the survival of of mothers delivered ! American surgeons&

Although the introduction of internal sutures decreased hemorrhagic mor!idit,

infectious mor!idit from $eritonitis remained su!stantial& 'n -0, theetra$eritoneal a$$roach "as first descri!ed ! 3ran= and modified in -0- !at;=o& This a$$roach a$$eared to decrease the ris= of $eritonitis, and, in -2,?r@nig descri!ed that this a$$roach also allo"ed access to the thinner lo"eruterine segment& ?r@nig descri!ed a vertical median uterine incision "ithdeliver aided ! force$s& Then, the lo"er segment "as covered "ith$eritoneum&

This techni:ue "as modified further and introduced in the (nited )tates ! +ec=#--% and eee #-22%& 3inall, in -26, ?err descri!ed a lo" transverseincision in the lo"er uterine segment, the most commonl used uterine incisionthroughout the "orld toda& Bith the discover of $enicillin ! Aleander3leming in -2 #$urified in -0%, the need for an etra$eritoneal $rocedureessentiall "as eliminated&

!ro#le$: A cesarean deliver is $erformed for a vast arra of indications #see'ndications%& As such, no single reason eists for an o!stetrician to recommendand $erform a cesarean deliver&

%re&"ency: 3rom -0>-2, the cesarean deliver rate at Chicago ing>in1os$ital increased from 0&6. to 9.& 'n -65, the cesarean deliver rate in the

(nited )tates "as &5.& 'n -0, the cesarean deliver rate "as 6&5., and it$ea=ed at 2&. in -& )ince then, the rate has decreased slightl and "as22&. #--,000 $rocedures in & million !irths% in --0&

The cesarean deliver rate also has increased throughout the "orld, !ut it still issu!stantiall lo"er than that in America& 'n -5, the cesarean deliver rate in America "as 22&.* this com$ares to -. in Canada, 9. in enmar=, 0. inEngland, and . in <a$an&

Bh the rate of cesarean deliver has increased so dramaticall in the (nited)tates is not entirel clear& The follo"ing is a list of some of the reasons that

ma account for the increase&



• Re$eat cesarean deliver 'n -, "hen the cesarean deliver rate$ea=ed at 2&., 96&9. #95,000% of all cesarean deliveries "ere re$eat$rocedures& Re$orts concerning the safet of allo"ing vaginal !irth after

a cesarean deliver have !een $resented since the -60s& es$ite this,! -, less than 0. of "omen "ith a $rior cesarean deliver "ereattem$ting a vaginal deliver&

• ela in child!irth and reduced $arit 'n the last 2 decades, an increase

in the $ercentage of !irths to "omen older than 90, 95, and even 0ears has occurred& The ris= of having a cesarean deliver is higher innulli$arous $atients, and, "ith increasing maternal age, the ris= forcesarean deliver is increased secondar to medical com$lications suchas dia!etes #including gestational% and $reeclam$sia&

• ecrease in the rate of vaginal !reech deliver + -5, almost 5. of

all !reech $resentations #9. of term fetuses% "ere delivered !

cesarean& At this time, the de!ate regarding the safet of a vaginal!reech deliver is !eing investigated in a randomi;ed controlled trial&

• ecreased $erinatal mortalit "ith cesarean deliver This is anetremel com$le issue to full discuss in this setting& Derinatal outcomeis greatl influenced ! gestational age at deliver, ! the $resence ofcongenital a!normalities and gro"th a!normalities, and ! the indicationfor deliver itself& 'm$rovement in $erinatal outcome has !een greatlenhanced ! im$roved technolog availa!le to neonatologists and !im$rovements in $renatal care #eg, identification of $atients at high ris=,ultrasound, and increased usage of antenatal steroids in those at ris= for

$reterm deliver%& (nfortunatel, des$ite the dramatic rise in the rate ofcesarean deliver, the overall rate of cere!ral $als has not decreaseddramaticall&

• onreassuring fetal heart rate testing More than 5. of all cesarean

deliveries are for this indication& Again, although it is !elieved that acesarean deliver for a fetus "ith an a!normal fetal heart rate $atterncould !e $rotected from future adverse $ro!lems, the overall rate ofcere!ral $als has not decreased dramaticall& At this time, the use offetal $ulse oimetr is gaining acce$tance and ma !ecome more "idelavaila!le& 3etal $ulse oimetr is a useful aid in assessing fetal ogenstatus and has !een sho"n to decrease the need for cesarean deliver in

the setting of a nonreassuring fetal heart rate $attern&• 3ear of mal$ractice litigation (nfortunatel, man o!stetricians admit that

their $ractice of medicine has !ecome more defensive& Given the fear ofin:uir regarding ho" a $articular $atientFs la!or "as managed, mano!stetricians ma have a lo"er threshold to $erform a cesarean deliver&

Clinical: A cesarean deliver is $erformed for man reasons& Therefore, tringto $resent a single clinical situation is etremel difficult and limiting #see'ndications%&

INDIC'TIONS Section ( of 10

Author 'nformation 'ntroduction 'ndications Relevant Anatom And Contraindications Bor=u$ Treatment Com$lications utcome And Drognosis 3uture And Controversies +i!liogra$h



A cesarean deliver is recommended to $revent maternal and/or fetal mor!idit"hen a contraindication to allo"ing la!or is $resent or "hen a com$letion of a

vaginal deliver is antici$ated to !e unsafe or length& )ome indications are formaternal !enefit alone, some are for fetal !enefit alone, and some are for !othmaternal and fetal !enefit&

)aternal indications

Relativel fe" indications for a cesarean deliver solel !enefit the mother&

• Bomen "ith an a!dominal cerclage in $lace Those mothers "ith an

incom$etent cervi in "hom vaginal cervical cerclages have failed !ut"ho "ish to have more children should have a cesarean deliver&

• !structive lesions in the lo"er genital tract Cesarean deliver "ould !e$erformed in the setting of o!structive lesions in the lo"er genital tract,including malignancies and large vulvovaginal condloma&

• Bomen "ith $rior vaginal col$orrha$h and maHor anal involvement from

inflammator !o"el disease These $atients "ould !e candidates for anoutright cesarean deliver&

%etal indications

3etal indications for cesarean deliver include those in "hich neonatal mor!idit

and mortalit could !e decreased ! the $revention of trauma, infection, and$rolonged acidemia&

• Mal$resentation A fetus in a nonverte $resentation is at increased ris=for trauma, cord $rola$se, and head entra$ment& Mal$resentationincludes $reterm !reech $resentations and nonfran= !reech term fetuses& A randomi;ed controlled trial assessing the safet of term !reechdeliveries has !een com$leted and is a"aiting $u!lication& 3urthermore,in t"in gestations, a second t"in in a nonverte $resentation is a relativeindication for an outright cesarean deliver, as are higher order multi$les#tri$lets or greater%&

• Congenital anomalies A cesarean deliver is recommended for severalcongenital anomalies* these include fetal neural tu!e defects, somecases of hdroce$halus, and some s=eletal ds$lasias& Bhether or notan outright cesarean deliver should !e $erformed in the setting of a fetala!dominal "all defect #ie, gastroschisis and om$halocele% remainscontroversial&

• onreassuring fetal heart rate 'n the setting of a nonremedia!le and

nonreassuring $attern remote from deliver, a cesarean deliver isrecommended to $revent a mied meta!olic or meta!olic acidemia thatcould $otentiall cause significant mor!idit and mortalit&

• Genital her$es infections Mothers "ith an active vaginal her$es infection

#es$eciall "ith $rimar out!rea=% are candidates for cesarean deliver&eonatal infection "ith her$es can lead to significant mor!idit and



mortalit, es$eciall "ith a $rimar out!rea=& Bith recurrent out!rea=s,the ris= to the neonate is reduced ! the $resence of maternal anti!odies&(nfortunatel, not all "omen "ith active viral shedding can !e detected

u$on admission to la!or and deliver&• 1uman immunodeficienc virus infections Treatment of "omen "ith the

human immunodeficienc virus has undergone tremendous change in the$ast fe" ears& Bomen "ith a lo" C count and high viral titers should!e offered cesarean deliver at 9 "ee=s #or earlier if the go into la!or%&'n "omen "ho are !eing treated "ith antiretrovirals, cesarean deliver#$rior to la!or or "ithout $rolonged ru$ture of mem!ranes% a$$ears tofurther lo"er the ris= for neonatal transmission&

)aternal and fetal indications

'ndications for cesarean deliver that !enefit !oth the mother and the fetusinclude a!normal $lacentation, a!normal la!or due to ce$halo$elvicdis$ro$ortion, and those situations in "hich la!or is contraindicated&

• A!normal $lacentation 'n the $resence of a $lacenta $revia #ie, the

$lacenta covering the internal cervical os%, attem$ting vaginal deliver$laces !oth the mother and the fetus at ris= for hemorrhagiccom$lications&

• A!normal la!or due to ce$halo$elvic dis$ro$ortion Ce$halo$elvicdis$ro$ortion can !e sus$ected on the !asis of $ossi!le macrosomia or

an arrest of la!or des$ite augmentation& Continuing to attem$t a vaginaldeliver in this setting increases the ris= of hemorrhagic and meta!olicconse:uences from a uterine ru$ture, increases the chance of infectiouscom$lications to !oth mother and fetus from $rolonged ru$ture ofmem!ranes, and increases the ris= of maternal trauma and fetal trauma#eg, Er! or ?lum$=e $als and meta!olic acidosis% from a shoulderdstocia&

• Contraindications to la!or 'n "omen "ho have a uterine scar #$rior

momectom in "hich the uterine cavit "as entered or cesareandeliver in "hich the u$$er contractile $ortion of the uterus "as incised%,a cesarean deliver should !e $erformed to $revent the ris= of uterine

ru$ture&

R*L*+'NT 'N'TO), 'NDCONTR'INDIC'TIONS

Section - of 10


Relevant 'nato$y: )ee 'ntrao$erative details&

Contraindications: 3e" contraindications eist to $erforming a cesareandeliver& 'f the fetus is alive and of via!le gestational age, then cesarean delivercan !e $erformed in the a$$ro$riate setting& 'n some instances, a cesareandeliver should !e avoided& Rarel, maternal status ma !e com$romised #eg,



"ith severe $ulmonar disease% such that an o$eration ma Heo$ardi;e maternalsurvival& 'n such difficult situations, a care $lan outlining "hen and if to interveneshould !e made "ith the famil in the setting of a multidisci$linar meeting&

3urthermore, a cesarean deliver ma not !e recommended if the fetus has a=no"n =arot$ic a!normalit #trisom 9 or % or =no"n congenital anomalthat ma lead to death #anence$hal%&

.OR/U! Section of 10


La# St"dies:

• Bhen $atients are admitted for la!or and deliver, most have !lood for aC+C count and t$e and screen dra"n "hen an intravenous line is started#a !asic re:uirement for $atients "hen the are admitted to the la!or floor%&'f a $atient has a hemoglo!in level "ithin the reference range, has had anuncom$licated $regnanc, and is antici$ated to have a vaginal deliver, theuse of having !lood su!mitted to the la! for a routine C+C count and t$eand screen currentl is !eing scrutini;ed from a cost>!enefit stand$oint& 'nman centers, !lood is dra"n and sim$l held in case the $atientFs coursechanges& amel, if the decision is made to $erform a cesarean deliver for an a!normal la!or course, nonreassuring fetal testing, or a!normal!leeding, then the !lood "or= is su!mitted&

• The follo"ing are several situations in "hich a C+C count and t$e and

screen al"as "ill !e su!mitted u$on admission to la!or and deliver

o 'f a $atient is admitted for a $lanned cesarean deliver

o A grand multi$ara

o 1istor of $ost$artum hemorrhage

o 1istor of a !leeding disorder

• n occasion, a coagulation $rofile is ordered& 'n $atients "ith

throm!octo$enia, a histor of a !leeding disorder, or $reeclam$sia,coagulation studies #$rothrom!in time and activated $artial throm!o$lastintime% ma !e ordered to assist the attending anesthesiologist indetermining the safet of attem$ting regional anesthesia "ith an e$idural or s$inal $rocedure&

• n occasion, a $atient has a s$ecimen crossmatched, "ith !lood availa!le&

The most common situation is a $atient "ho has had several $riorla$arotomies #including several $rior cesarean deliveries% or one "hodevelo$s a coagulo$ath from either severe $reeclam$sia or significant



hemorrhage&

TR*'T)*NT Section of 10


)edical terapy: As stated, man indications eist for $erforming a cesareandeliver& 'n those "omen "ho are having a scheduled $rocedure #ie, an elective or indicated re$eat, for mal$resentation, $lacental a!normalities%, the decision hasalread !een made that the alternate of Imedical thera$,I ie, a vaginal deliver, isleast o$timal& 3or other $atients admitted to la!or and deliver, the antici$ation isfor a vaginal deliver& Ever $atient admitted in this circumstance is admitted "iththe thought of a successful vaginal deliver& 1o"ever, if the $atientFs situation

should change, a cesarean deliver is $erformed !ecause it is !elieved thatoutcome for the fetus and/or mother ma !e !etter&

'f a $atient is diagnosed "ith a fetal mal$resentation #ie, !reech or transverse lie%after 96 "ee=s, the o$tion for an eternal ce$halic version is offered to tr toconvert the fetus to a verte lie, thus allo"ing an attem$t at a vaginal deliver& Aneternal ce$halic version usuall is attem$ted at 96>9 "ee=s& The $atient usuallis o!served in close $roimit to the la!or and deliver unit or in the la!or anddeliver unit itself& The $atient has !een as=ed to not eat for hours $rior to the$rocedure& An ultrasound is $erformed to confirm fetal $resentation& 'f the fetus isstill in a nonverte $resentation, an intravenous line is started and the !a! is

monitored "ith an eternal fetal heart rate monitor&

'f fetal heart rate testing is reassuring, the version is attem$ted& An eternalce$halic version involves tring to eternall mani$ulate the fetus into a verte$resentation& (suall, this is accom$lished "ith ultrasound guidance to ascertainfetal lie& An attem$t is made to mani$ulate the fetus through either a Ifor"ard rollIor I!ac="ard roll&I The overall chance of success is a$$roimatel 0.& )ome$ractitioners administer an e$idural to the $atient $rior to the attem$ted version,and others ma give the $atient a dose of su!cutaneous ter!utaline #a !eta>mimetic used for tocolsis% Hust $rior to the attem$t&

3actors that influence the success of an attem$ted version include multi$arit, a$osterior $lacenta, and normal amniotic fluid "ith a normall gro"n fetus& Also, to!e a candidate, a $atient must !e eligi!le for an attem$ted vaginal deliver&Relative contraindications include $oor fetal gro"th or the $resence of congenitalanomalies& Ris=s of an eternal ce$halic version include ru$ture of mem!ranes,la!or, fetal inHur, and the need for an emergent cesarean deliver due to $ossi!ledisru$tion of the $lacenta&

'f the version is successful, the $atient is $laced on a fetal monitor& 'f fetal heartrate testing is reassuring, either the $atient is discharged to a"ait s$ontaneousla!or or she is induced if the fetus is of an a$$ro$riate gestational age and/or the$atient has a favora!le cervi&



S"rical terapy: )ee 'ntrao$erative details&

!reoperative details: 'f $atients are admitted for an elective cesarean deliver,the are as=ed to not eat for at least hours $rior to arriving& ($on admission, anintravenous line is started and !lood for a C+C count and t$e and screen isdra"n& 'f a difficult $rocedure is antici$ated, crossmatch !lood to !e availa!le forthe start of the $rocedure& 'ntravenous fluid consists of either lactated Ringersolution or saline "ith 5. detrose& The $atient is $laced on an eternal fetalmonitor, and the $atient is evaluated ! the o$erating $hsician and ananesthesiologist&

The anesthesiologist revie"s regional anesthetic $rocedures and offers a s$inal or an e$idural agent if $otential eists for a $rolonged case, such as in a $atient "ith

multi$le $rior la$arotomies& The $atient is evaluated for general anesthesia incase an emergenc should arise "here esta!lishment of an air"a !ecomesnecessar&

A !lood $ressure cuff is $laced, and monitors also are $laced that allo" the$atientFs !lood $ressure, $ulse, and ogen saturation to !e monitored $rior toadministering anesthesia through the initial $osto$erative $eriod in the recoverroom&

A 3ole catheter is $laced so that the !ladder can !e drained during the $rocedureand so that urine out$ut can !e monitored to hel$ evaluate fluid status&3urthermore, after regional anesthesia, $atients are una!le to void s$ontaneouslfor as long as 2 hours&

Drior to anesthesia, evaluate the site of the intended s=in incision& The intendedarea does not need to !e shaved automaticall unless the hair "ill interfere "iththe rea$$roimation of the s=in edges& 'f the hair is to !e shaved, it should !eshaved immediatel $rior to the surger&

After $lacement of the regional anesthetic, monitor the fetus until an ade:uatesurgical level has !een achieved& Bhen the level of anesthesia is ade:uate, the

s=in can !e $re$ared "ith either alcohol and an iodine>im$regnated sterile dra$eor "ith an iodine scru!& Drior to ma=ing the initial incision, gras$ the $atientFs s=in!ilaterall "ith an instrument, such as an Allis clam$, to ensure that the anestheticlevel is a$$ro$riate& Drior to !eginning the surger, inform the nurser so that amem!er of the nurser staff can !e $resent to evaluate the !a! after deliver&

'n $atients "ho re:uire a cesarean deliver secondar to a $ro!lem arising duringla!or, the same ste$s as a!ove are follo"ed& The onl maHor variation occurs if a$atient re:uires general anesthesia $rior to the $rocedure& 'n that situation, $riorto intu!ation, the $atient should !e $re$$ed and dra$ed and the surgical teamshould !e read to !egin as soon as the $atientFs air"a is secured&

Intraoperative details: As "ith an $rocedure, ta=e care to avoid inHur to



adHacent organs& Dotential com$lications include !ladder or !o"el inHur& 'f acstotom or !o"el inHur is sus$ected, it should !e evaluated thoroughl after the

!a! is delivered and hemostasis of the uterus is achieved&

The anesthesiologist monitors the $atientFs vital signs and trac=s fluid inta=e andurine out$ut& The average !lood loss associated "ith a cesarean deliver isa$$roimatel 000 cc& A $atient at term "ill have u$ to a 50. e$ansion in their!lood volume and could lose u$ to 500 cc "ithout sho"ing an change in theirvital signs& 'f a significant !lood loss is encountered or antici$ated, assess thehemoglo!in level and crossmatch !lood&

'#do$inal incision

ne o$tion is to use a midline infraum!ilical incision to enter the $eritoneal cavit&This incision $rovides :uic=er access to the uterus& 'n $regnanc, entr commonlis enhanced ! diastasis of the rectus muscles& This incision is associated "ithless !lood loss, easier eamination of the u$$er a!domen, and eas etensionce$halad around the um!ilicus& 'f a $atient is antici$ated to have significant intra>a!dominal adhesions from $rior surgeries, a vertical incision ma $rovide easieraccess into the a!domen, "ith !etter visuali;ation& ($on reaching the rectussheath, either the rectus sheath can !e incised "ith a scal$el for the entire lengthof the incision or a small incision in the fascia can !e made "ith a scal$el andthen etended su$eriorl and inferiorl "ith scissors& Then, the rectus muscles#and $ramidalis muscles% are se$arated in the midline ! shar$ and !luntdissection& This act e$oses the transversalis fascia and the $eritoneum&

The $eritoneum is identified and entered at the su$erior as$ect of the incision toavoid !ladder inHur& Drior to entering the $eritoneum, care is ta=en to avoidincising adHacent !o"el or omentum& nce the $eritoneal cavit is entered, the$eritoneal incision is etended shar$l to the u$$er as$ect of the incisionsu$eriorl and to the reflection over the !ladder inferiorl&

Most commonl, a transverse incision through the lo"er a!domen is made& Theincision is either a Malard or, more commonl, a Dfannenstiel incision&

Transverse incisions ta=e slightl longer to enter the $eritoneal cavit, usuall areless $ainful, have !een associated "ith a smaller ris= of develo$ing an incisionalhernia, are $referred cosmeticall, and can $rovide ecellent visuali;ation of the$elvis&

The Dfannenstiel incision is curved slightl ce$halad at the level of the $u!ichairline& The incision etends slightl !eond the lateral !orders of the rectusmuscle !ilaterall and is carried to the fascia& Then, the fascia is incised !ilaterallfor the full length of the incision& Then, the underling rectus muscle is se$aratedfrom the fascia !oth su$eriorl and inferiorl "ith !lunt and shar$ dissection&Clam$ and ligate an !lood vessels encountered& The rectus muscles are

se$arated in the midline, and the $eritoneum is entered&



A Malard incision is made a$$roimatel 2>9 cm a!ove the sm$hsis and is:uic=er than a Dfannenstiel incision& 't involves a transverse incision of the

anterior rectus sheath and rectus muscle !ilaterall& 'dentif and $ossi!l ligatethe su$erficial inferior e$igastric vessels #located in the lateral third of eachrectus%& 3or most cesarean deliveries, onl the medial t"o thirds of each rectusmuscle usuall needs to !e divided& 'f more than t"o thirds of the rectus muscle isdivided, identif and ligate the dee$ inferior e$igastric vessels& The transversalisfascia and $eritoneum are identified and incised transversel&

Uterine incision

($on entering the $eritoneal cavit, ins$ect the lo"er a!domen& The uterus is$al$ated and commonl is found to !e detrorotated such that the left round

ligament is more anterior and closer to the midline& issect the !ladder free of thelo"er uterine segment& Gras$ the loose uterovesical $eritoneum "ith force$s, andincise it "ith Met;en!aum scissors& The incision is etended !ilaterall in anu$"ard curvilinear fashion& The lo"er fla$ is gras$ed gentl, and the !ladder isse$arated from the lo"er uterus "ith !lunt and shar$ dissection& A !ladder !ladeis $laced to !oth dis$lace and $rotect the !ladder inferiorl and to $rovidee$osure for the lo"er uterine segment #the acontractile $ortion of the uterus%&

ne of essentiall 2 incisions can !e made on the uterus, either a transverse orvertical incision& The decision for the t$e of incision is !ased on several factors,including fetal $resentation, gestational age, $lacental location, and $resence of a"ell>develo$ed lo"er uterine segment& The choice of incision must allo" enoughroom to deliver the fetus "ithout ris=ing inHur #either tearing or cutting% to theuterine arteries and veins that are located at the lateral margins of the uterus&

'n more than -0. of cesarean deliveries, a lo" transverse #Monroe>?err% incisionis made& The incision is made >2 cm a!ove the original u$$er margin of the!ladder "ith a scal$el& The initial incision is small and is continued into the uterine"all until either the fetal mem!ranes are visuali;ed or the cavit is entered #ta=ecare to not inHure the underling fetus%&

The incision is etended !ilaterall and slightl ce$halad& The incision can !eetended "ith either shar$ dissection or !lunt dissection #usuall "ith the indefingers of the surgeon%& +lunt dissection has the $otential for un$redicta!leetension, and care should !e ta=en to avoid inHur to the uterine vessels& The$resenting $art of the fetus is identified, and the fetus is delivered either as averte $resentation or as a !reech& Bith a lo" transverse incision, the ris= foruterine ru$ture in su!se:uent $regnancies is a$$roimatel ., and $atients can!e counseled a!out the safet of an attem$ted trial of la!or and vaginal !irth&

'n some instances, a vertical incision is used& A vertical incision ma !e used if thelo"er segment is not "ell develo$ed #ie, narro"%, if an anterior $lacenta $revia is

$resent, or if the fetus is in a transverse lie or in a $reterm nonverte $resentation& Again, the !ladder has !een dissected inferiorl to e$ose the lo"er segment, and



the !ladder !lade has !een $laced&

The vertical incision again is initiated "ith a scal$el in the inferior $ortion of thelo"er uterine segment& Care is ta=en to avoid inHur to the underling fetus, andthe incision is carried into the uterus until the cavit is entered& Bhen the cavit isentered, the incision is etended su$eriorl "ith shar$ dissection& The fetus isidentified and delivered& ote the etent of the su$erior $ortion of the uterineincision&

'f the incision is confined to the lo"er acontractile $ortion, it is considered a lo"vertical incision and $atients can !e counseled for a trial of la!or and vaginaldeliver in su!se:uent $regnancies& Bith a true lo" vertical incision, the ris= ofuterine ru$ture "ith a trial of la!or is a$$roimatel >., "ith most recent re$orts

finding a ris= for uterine ru$ture of less than 2.& 'f the incision should !e eitheretended into the contractile $ortion of the uterus or is made almost com$letel inthe u$$er contractile $ortion, the ris= of uterine ru$ture in future $regnancies is >0. and $atients are counseled to undergo a re$eat cesarean deliver "ith allsu!se:uent $regnancies&

A vertical incision also ma !e considered in those cases "here a hsterectomma !e $lanned in the setting of a $lacenta accreta or if the $atient has acoeisting cervical cancer for "hich a hsterectom "ould !e the a$$ro$riatetreatment& A vertical incision is associated "ith increased !lood loss and longero$erating time #ta=es longer to close% "ith less ris= of inHur to the uterine vesselsthan a lo" transverse incision&

Delivery

Bhen the fetus is delivered, the um!ilical cord is dou!l clam$ed and cut& +lood iso!tained from the cord for fetal !lood t$ing, and a segment of cord is $lacedaside for attaining !lood gas results if a concern eists regarding fetal status&3ollo"ing deliver, otocin #20 (% is $laced in the intravenous fluid to increasecontractions of the uterus& The $lacenta usuall is delivered manuall& A"aitings$ontaneous deliver of the $lacenta "ith gentle traction is more time consuming

!ut is associated "ith decreased !lood loss, lo"er ris= of endometritis, and lo"ermaternal e$osure to fetal red !lood cells, "hich can !e im$ortant to Rh>negativemothers delivering an Rh>$ositive fetus&

After deliver of the !a!, administer $ro$hlactic anti!iotics& A single dose ofam$icillin or a first>generation or second>generation ce$halos$orin is a$$ro$riate&'f the surger is $rolonged, a second dose can !e administered later& 'f the $atienthas chorioamnionitis, !roader>s$ectrum anti!iotics, such as gentamicin andclindamcin or (nasn, are indicated and should !e continued in the$osto$erative $eriod until the $atient is afe!rile&

Repair of te "terine incision



Re$air of the uterus can !e facilitated ! manual deliver of the uterine fundusthrough the a!dominal incision& Eternali;ing the uterine fundus facilitates uterine

massage, the a!ilit to assess "hether the uterus is atonic, and the eaminationof the adnea&

The uterine cavit usuall is "i$ed clean of all mem!ranes "ith a dr la$arotoms$onge, and the cervi can !e dilated "ith an instrument, such as a ?ell clam$, if the $atient under"ent deliver "ith a $reviousl undilated cervi& T$icall, an Allisclam$ is $laced at the angles of the uterine incision& The incision is ins$ected forother !leeding vessels, and an etensions of the incision are evaluated& 'ns$ectthe !ladder and lo"er segment inferior to the incision&

Re$air of a lo" transverse uterine incision can !e $erformed in either a >laer or

2>laer fashion "ith ;ero or dou!le>;ero chromic or 8icrl suture& The first laershould include stitches $laced lateral to each angle, "ith $rior $al$ation of thelocation of the lateral uterine vessels& Most $hsicians use a continuous loc=ingstitch& 'f the first laer is hemostatic, a second laer #em!ert stitch%, "hich is usedto im!ricate the incision, does not need to !e $laced& A large $ros$ective studhas sho"n no increase in $osto$erative com$lications "ith a >laer versus 2>laer closure& Although the ris= of uterine ru$ture "ith su!se:uent trials of la!ora$$ears to not !e increased "ith a >laer closure, the authors a"ait follo">u$data from this trial&

Closure of a vertical incision usuall re:uires several laers !ecause the incisionis through a thic=er $ortion of the uterus& Again, a heav suture material is used,and usuall the first laer closes the inner half of the incision, "ith a second and$ossi!le third laer used to close the outer half and serosal edges& Again, note theetent of a vertical uterine incision !ecause it im$acts ho" a $atient should !ecounseled regarding future $regnancies&

Bhen the uterus is closed, attention must !e $aid to its overall tone& An atonicuterus can !e encountered in a $atient "ith a multi$le gestation, $olhdramnios,or a failed attem$t at a vaginal deliver in "hich the $atient "as on Ditocinaugmentation for a $rolonged $eriod& 'f the uterus does not feel firm and

contracted "ith massage and intravenous otocin, consider intramuscularinHections of $rostaglandin #5>methl>$rostaglandin, 1ema!ate% ormethlergonovine and re$eat as a$$ro$riate&

Contin"ed clos"re

'f the uterine incision is hemostatic, the uterine fundus is re$laced into thea!dominal cavit #unless a concurrent tu!al ligation is to !e $erformed%& Theincision is reins$ected for hemostasis, and the !ladder fla$ also is ins$ected& The$aracolic gutters are visuali;ed, and an !lood clots are removed "ith drla$arotom s$onges& The vesicouterine $eritoneum and $arietal $eritoneum can

!e rea$$roimated "ith a running chromic stitch& Man $hsicians $refer to notclose the $eritoneum !ecause these surfaces rea$$roimate "ithin 2> hours



and can heal "ithout scar formation& 3urthermore, the rectus muscles to do notneed to !e rea$$roimated&

The su!fascial tissue is ins$ected for !leeding, and, if hemostatic, the fascia isclosed& The fascia can !e closed "ith a running stitch, and snthetic !raidedsutures are $referred over chromic sutures& Chromic sutures do not maintain theirtensile strength as long or as $redicta!l as snthetic !raided material& 'f the$atient is at ris= for $oor "ound healing #eg, those "ith chronic steroid use%, thena delaed a!sor!a!le or $ermanent suture can !e used& Dlace stitches ata$$roimatel >cm intervals and more than cm a"a from the incision line&

The su!cutaneous tissue should !e ins$ected for hemostasis and can !e irrigatedaccording to $hsician $reference& The su!cutaneous tissue does not have to !e

rea$$roimated, !ut in $atients "ho are o!ese #su!cutaneous de$th J2 cm%, adrain ma !e $laced and connected to an eternal !ul! suction a$$aratus& Thes=in edges can !e closed either "ith a su!cuticular stitch or "ith sta$les #removed9 or d $osto$erativel%&

!ostoperative details: 'n the recover room, vital signs are ta=en ever 5minutes for the first >2 hours, and urine out$ut is monitored on an hourl !asis& 'naddition to routine assessment, $al$ate the fundus to ensure that it feels firm& Attention needs to !e $aid to the amount of vaginal !leeding&

'f the $atient had regional anesthesia, the usuall receive a long>acting analgesic"ith the regional anesthetic& Therefore, $ain control usuall is not an issue in thefirst 2 hours& 'f a $atient did not receive a long>acting analgesic or had generalanesthesia, narcotics can !e administered either intramuscularl or intravenousl#on schedule or "ith a !asal rate su$$lemented "ith $atient>controlled !oluses%&Bhen the $atient is tolerating li:uids, narcotics can !e administered orall asneeded&

Bhen $atients recover sensation after a regional anesthetic and vital signs have!een sta!le "ith minimal vaginal !leeding, the can !e ta=en to their room& The$atient should have vital signs ta=en ever hour for at least the first hours and,

again, attention should !e $aid to urine out$ut&

verall, a $atient should receive a$$roimatel 9> of intravenous fluid frominitiation of the intravenous line through the first 2 hours& The $atient can !estarted on clear li:uids 2>2 hours after an uncom$licated $rocedure, and dietcan !e advanced accordingl& Bhen the $atient is a!le to tolerate good oralinta=e, the intravenous fluids can !e sto$$ed&

The !ladder catheter can !e removed 2>2 hours $osto$erativel& 'f the $atient isuna!le to void in 6 hours, consider re$lacing the 3ole for an additional 2>2hours&

n the first $osto$erative da, encourage the $atient to am!ulate& 'ncrease



am!ulation ever da as tolerated ! the $atient& The dressing can !e removed2>2 hours after surger and can !e left o$en after that time& T$icall, the !lood

count is chec=ed 2>2 hours after surger, or sooner if a greater than average!lood loss has occurred&

'f a $atient $lans to !reastfeed, this can !e initiated "ithin a fe" hours afterdeliver& 'f a $atient $lans to !ottle feed, a tight !ra or !reast !inder should !eused in the $osto$erative $eriod&

'f the $atient has recovered "ell $osto$erativel, she can !e discharged safel 9>das after surger& 'f sta$les "ere used to a$$roimate the s=in, remove them$rior to discharge& 'f the $atient has had a vertical s=in incision or is at ris= for $oor healing #eg, dia!etes or long>term steroid use%, the $hsician ma elect to =ee$

the sta$les in for 2>9 etra das and have the $atient return to the office at thattime&

Drior to discharge, a discussion a!out contrace$tion should ta=e $lace& )tress thateven if a mother is !reastfeeding, she still can conceive& As= $atients to refrainfrom intercourse for >6 "ee=s $ost$artum&

%ollo34"p care: After a cesarean deliver, the $atient can !e o!served as a$atient "ho delivered vaginall& The normal recommendation is to have the $atientma=e a follo">u$ a$$ointment >6 "ee=s after deliver& 'f !leeding has sto$$ed, are$eat Da$anicolaou test is customar& uring this visit, revie" an nota!lefindings from the surger and discuss deliver o$tions for future $regnancies&

3or ecellent $atient education resources, visit eMedicineFs Dregnanc andRe$roduction Center & Also, see eMedicineFs $atient education articles a!or )ignsand Cesarean Child!irth&

CO)!LIC'TIONS Section 5 of 10


Com$ared to a vaginal deliver, maternal mortalit and es$eciall mor!idit isincreased "ith cesarean deliver& The overall maternal mortalit rate is 6>22deaths $er 00,000 live !irths, "ith a$$roimatel one third to one half of maternaldeaths after cesarean deliver !eing directl attri!uta!le to the o$erative$rocedure itself& Dart of this increase in mortalit is that associated "ith a surgical$rocedure and, in $art, related to the conditions that ma have led to needing to$erform a cesarean deliver&

MaHor sources of mor!idit and mortalit can !e related to se:uelae of infection,throm!oem!olic disease, anesthetic com$lications, and surgical inHur&

Intraoperative co$plications

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• (terine lacerations (terine lacerations, es$eciall of the lo"er uterinesegment, are more common "ith a transverse uterine incision& Theselacerations can etend laterall or inferiorl& The are re$aired easil& Ta=e

care to identif the uterine vessels "hen re$airing lateral etensions, and,"hen re$airing inferior etensions, the surgeon needs to thin= a!out theureters& 'f the laceration etends into the !road ligament, strongl considero$ening the !road ligament and identifing the course of the ureters&

• +ladder inHur This is an infre:uent com$lication& 't is more common "ith

transverse a!dominal incisions and in re$eat cesarean deliveries& The!ladder most commonl is inHured "hen entering the $eritoneal cavit or"hen se$arating the !ladder from the lo"er uterine segment& +ladder inHurhas !een re$orted to occur in more than 0. of uterine ru$tures and ina$$roimatel . of cesarean hsterectomies& 'f a $ossi!ilit eists that acesarean hsterectom ma !e $erformed, mo!ili;e the !ladder inferiorl

as "ell as $ossi!le "hen dissecting it free of the lo"er uterine segment& 'fthe dome of the !ladder is lacerated, it can !e re$aired sim$l "ith a 2>laer closure of 2>0 or 9>0 chromic sutures, "ith the 3ole catheter left in$lace for a fe" etra das& 'f the !ladder is inHured in the region of thetrigone, consider ureteral catheteri;ation "ith $ossi!le assistance from aurologist&

• (reteral inHur 'nHur to the ureter occurs in u$ to 0&. of all cesarean

deliveries and u$ to 0&5. of cesarean hsterectomies& 't is most li=el tooccur "hen re$airing etensive lacerations of the uterus& (reteral inHur,most commonl occlusion or transection, usuall is not recogni;ed duringthe time of the o$eration&

• +o"el inHur +o"el inHuries occur in less than 0&. of all cesarean

deliveries& The most common ris= factor for !o"el inHur at the time ofcesarean deliver is adhesions from $rior cesarean deliveries or $rior!o"el surger& 'f the !o"el is adherent to the lo"er $ortion of the uterus,dissect it shar$l& 'nHuries to the serosa can !e re$aired "ith interru$ted sil=sutures& 'f the inHur is into the lumen, $erform a 2>laer closure& Themucosa can !e closed "ith interru$ted 9>0 a!sor!a!le sutures $laced in atransverse fashion for a longitudinal inHur& 3or multi$le inHuries and inHur tothe large intestine, consider intrao$erative consultation "ith a generalsurgeon or gnecologic oncologist&

•

(terine aton Another intrao$erative com$lication that can !e encounteredin a $atient "ith a multi$le gestation, $olhdramnios, or a failed attem$t ata vaginal deliver in "hich the $atient "as on Ditocin augmentation for a$rolonged $eriod is uterine aton& Bhen the uterus is closed, attention must!e $aid to its overall tone&

!ostoperative co$plications

• Dost$artum endomometritis This is increased significantl in $atients "ho

have had a cesarean deliver& The rate of endomometritis is u$ to 20>foldhigher than "ith a vaginal deliver, "ith a re$orted mean of 95>0.

occurrence after a cesarean deliver& MaHor ris= factors include "hether thecesarean deliver "as the intended #$rimar% $rocedure and the



socioeconomic status of the $atient& ther maHor ris= factors includeduration of mem!rane ru$ture, duration of la!or, num!er of $elviceaminations, length of time "ith internal fetal monitors in $lace, and the

$resence of chorioamnionitis $rior to initiating cesarean deliver& +loodcultures are $ositive in a$$roimatel 0. of $atients "ith $osto$erativefe!rile mor!idit, and !road>s$ectrum anti!iotics should !e used& The$ostcesarean rate of endomometritis can !e decreased to a$$roimatel5. "ith the use $ro$hlactic anti!iotics&

• Bound infection 3ollo"ing a cesarean deliver, the ris= of a "oundinfection ranges from 2&5. to higher than 5.& Ris= factors are similar tothose noted for endomometritis, "ith the lo"est ris= associated "ith thosehaving a $lanned cesarean deliver& 'f chorioamnionitis is $resent at thetime of the $rocedure, the ris= for a "ound infection can !e as high as 20.&'f a "ound infection is sus$ected, o$en, irrigate, and de!ride the incision&

Then, the o$en "ound can !e $ac=ed and cleaned several times a da&The "ound can !e allo"ed to heal ! secondar intention, or, "hen it has!egun to granulate, it can !e closed&

• 3ascial dehiscence An infre:uent !ut emergent com$lication of a "ound

!rea=do"n is a fascial dehiscence& 't occurs in a$$roimatel 5. of$atients "ith a "ound infection and is suggested "hen ecessive dischargefrom the "ound is $resent& 'f a fascial dehiscence is o!served, the $atientshould !e ta=en immediatel to the o$erating room "here the "ound can!e o$ened, de!rided, and reclosed in a sterile environment&

• (rinar tract infections The second most common etiolog for$ostcesarean fe!rile mor!idit is urinar tract infections& The incidenceranges from 2>6., and the $rocess of $lacing an ind"elling catheter forthe surger is a ris= factor in itself& The incidence of urinar tract infectionsis increased in $atients "ith dia!etes, those "ho have other comor!idit,and those "ho have a longer duration of use of the ind"elling catheter&

• +o"el function Dosto$erativel, some $atients ma e$erience a slo"

return of !o"el function& Dosto$erative narcotics ma dela return ofnormal !o"el function in a fe" $atients& Most res$ond to conservativethera$, !ut a small $ortion ma re:uire decom$ression& 'n those "ith aslo" return of !o"el function, assessment of fluid and electrolte statusneeds to !e a $riorit&

•

Throm!oem!olic com$lications These also are increased in the $atient"ho has undergone a cesarean deliver& A$$roimatel in 00 $regnant$atients e$erience a dee$ venous throm!osis& The ris= for develo$ing athrom!us is increased 9> to 5>fold "ith a cesarean deliver& ther ris=sinclude o!esit, advanced maternal age, higher $arit, and $oor$osto$erative am!ulation& 'n those "ith ris= factors, consider $neumaticcom$ression stoc=ings& 'f a dee$ venous throm!osis is not treated, u$ toone :uarter of $atients "ill develo$ $ulmonar em!oli and 5. of thesecould !e fatal& A dee$ venous throm!osis sometimes is difficult todiagnose, and the first sign ma !e associated "ith a $ulmonar em!olus&

• Delvic throm!o$hle!itis Another infection>related com$lication of a

cesarean deliver is se$tic $elvic throm!o$hle!itis& As man as 2. of$atients "ith an endomometritis or "ound infection can develo$ this



com$lication, and it is largel a diagnosis of eclusion& )us$ect thisdiagnosis if a $atient fails to res$ond to !road>s$ectrum anti!iotics&Dhsical eamination ma detect a tender cordli=e mass lateral to the

uterus& (ltrasound, $elvic CT scan, or MR' ma aid in the diagnosis& Dlace$atients on thera$eutic he$arin along "ith continuing !road>s$ectrumanti!iotics& The length of ade:uate treatment once a $atient hasdefervesced is su!Hect to de!ate #an"here from >h afe!rile to a total of>0 d of treatment%& After com$leting the desired treatment course,$atients do not need to !e anticoagulated further&

OUTCO)* 'ND !RO6NOSIS Section 7 of 10


Datients "ho undergo cesarean deliver usuall ta=e slightl longer to fullrecover than those "ho have a vaginal deliver& 1o"ever, the overall long>termcondition of the $atient is not adversel affected& ccasionall, some $atients cane$erience $elvic $ain associated "ith intra>a!dominal adhesions, a situation thatcan !e aggravated in those "ho have multi$le $rocedures&

The most im$ortant things for $atients to =no" a!out their cesarean deliver are"h the had one and "hat =ind of incision "as $erformed on the uterus&

'f a $atient had a cesarean deliver for $resumed ce$halo$elvic dis$ro$ortion,

then attem$ting a vaginal !irth "ith the net $regnanc is associated "ith adecreased ris= of success& verall, $atients attem$ting a vaginal !irth after a $riorcesarean deliver can e$ect success a$$roimatel 0. of the time& 'f thecesarean deliver "as $erformed !ecause of an a!normal fetal heart $attern orfor a mal$resentation, then e$ectations for a successful vaginal !irth can !ehigher than 0.& 'f the uterine incision "as vertical, the ris= of uterine ru$ture isincreased a!ove the a$$roimate . ris= associated "ith a lo" transverseincision& 'f the incision "as confined to the lo"er segment, man $hsicians allo"$atients to attem$t a vaginal !irth in su!se:uent $regnancies& 1o"ever, if theincision etended into the u$$er contractile $ortion, the ris= of uterine ru$ture cana$$roach 0., "ith 50. of these occurring $rior to the onset of la!or&

A $revious cesarean deliver can increase the ris= of develo$ing $lacenta accretaif $lacenta $revia is $resent in an su!se:uent $regnancies& The ris= of $lacentaaccreta in a $atient "ith $revia is a$$roimatel . "ith no $rior cesareandeliveries* the ris= increases to a$$roimatel 25. "ith $rior cesarean deliverand to 0. "ith 2 $rior cesarean deliveries&

%UTUR* 'ND CONTRO+*RSI*S Section 8 of 10


3urther investigation continues to evaluate "hich $atients should undergo a trial of



la!or after having a cesarean deliver&

'nformation a!out "hether a cesarean deliver should !e $erformed for all term!reech $resentations is currentl !eing collected and "ill !e $u!lished soon&

(rognecologists are suggesting that all "omen should consider outrightcesarean deliver to $revent $elvic floor dsfunction& This is an etremelcontroversial area that "ill receive more attention in the net fe" ears&

cesarean delivery

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