Indications for a caesarean section
by Dr. Derrick Thompson (Obstetrician & Gynaecologist)
With improved technology and postoperative pain relief, and with many women deciding to limit their family to 2 children, an increasing number of women are choosing to have a planned elective caesarean section. The decision to have a planned caesarean section is an individual one made between the woman and her doctor. However, the number of women requesting a planned caesarean section is still small, less than 5%.
Factors against having a planned caesarean section on request are:
- recovery after birth may be slower
- there is at least a 50% chance that you will need to give birth by caesarean section in the future
- there is an increased chance that in the next pregnancy the placenta may lie over the uterine scar and become adherent (placenta accreta)
- there is a small increased risk of deep vein thrombosis and pulmonary embolus
- the risk of blood loss associated with caesarean section is increased compared with a normal vaginal delivery
The benefit of a planned caesarean section is that it is a predictable procedure, compared to labour where the outcomes are not predictable.
An elective caesarean sidesteps all of the above uncertainties.
The development of the spinal needle has made a huge difference to anesthesia for caesarean section. It is much finer than an epidural needle which has been used. The benefit of spinal anaesthesia is that the anaesthetic acts immediately and gives much more reliable pain relief. It eliminates the potential complication of a spinal tap. Because of the wider diameter of the epidural needle, there was a chance of the spinal fluid could leak int o the epidural space if the spinal canal was accidentally entered. This causes severe headache that required the woman to lie on her back for a number of days and take strong analgesia. Often a blood patch was placed over the puncture site to stop leakage of spinal fluid.
After a spinal anaesthetic, sensation returns to your lower abdomen and legs within 2-3 hours. You are able to get out of bed within 24 hours, reducing the risk of deep vein thrombosis. your hospital stay is only marginally longer that if you have had a vaginal birth. A caesarean section also reduces your risk of developing stress urinary of faecal incontinence, which can happen after a vaginal birth, and it may even reduce your chances of developing vaginal prolapse in later life.
Aside form an elective caesarean section, there are some specific conditions where giving birth by caesarean section is necessary.
- If you have had a previous classical caesarean section, that is, a vertical incision in the upper segment of the uterus. This situation can also arise from a previous hysterectomy or myomectomy.
- two or more previous lower-segment caesaren sections would generally be an indication for a repeat caesarean section.
- if you have a major degree of placenta previa where the placenta is situated over the cervix. (see placenta previa)
- a markedly contracted pelvis, small or misshapen from a previous injury or disease
- Malpresentation of the fetus such as a transverse lie
- Active, primary genital herpes at the onset of labour
In the following cases, a caesarean section might be preferable if:
- you have a multiple pregnancy, especially triplets. Many obstetricians now recommend an elective caesarean section to overcome potential problems that can occur delivering the second twin or the second and third triplet.
- the baby has a breech presentation, especially a footling breech where the umbilical cord can prolapse when the membranes rupture.
- if the fetus is small for dates or intrauterine growth retardation (IUGR) is present due to placental insufficiency. Labour is a potential stress on the fetus, and an elective caesarean section will prevent the need for an emergency caesarean section if acute fetal distress develops in labour.
- if there is a medical reason to deliver the fetus, for example, poorly controlled maternal diabetes, hypertension or pre-eclampsia, and the cervix is found to be unfavorable for induction.
You are unlikely to need a caesarean section if:
- the fetus is head down (cephalic).
- the fetal head is engaged with only one to 2 finger breadths of head palpable abdominally.
- you come into spontaneous labour at term.
- there has been normal fetal growth as per the growth chart; your baby is not too small or not too big.
- your membranes do not rupture prior to the onset of labour.
- the liquor is clear when your membranes rupture.
- your rate of progress in labour is normal.
- established labour occurs naturally and progresses with good descent of the head into your pelvis.
There is increased chance you will need a caesarean section if:
- the presentation is not cephalic (head first).
- the fetus is too big or too small, that is, above the 90th percentile or below the 10th percentile on the growth chart respectively.
- you are more that one week overdue (post-term) especially if it is your first pregnancy and the head remains high and the cervix is unfavourable.
- your membranes rupture before labour.
- the liqour us heavily meconium-stained.
- your contractions are in coordinate with poor progress, and the head does not descend into your pelvis.