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Cesarean section (c-sections) rates vary from 23-40% across the United States. There are risks and benefits to vaginal birth and c-sections. There are certain circumstances in which a c-section is the safest delivery route, even with the increased risks of surgery.
A c-section can save the life of a mother or fetus. Reasons for performing a c-section include, but are not limited to, small maternal pelvis, chorioamnionitis requiring immediate delivery, maternal pelvic deformity, eclampsia, life-threatening complications of pregnancy, a woman with cardiac disease that may not tolerate the stress of labor, fetal asphyxia, or fetal acidosis, life-threatening situations for the fetus that can lead to fetal hypoxia, umbilical cord prolapse, placenta previa, abnormal lie or presentation of the fetus, or uterine rupture. A fetal heart tracing is most commonly used to assess fetal acidosis. It is not accurate, but there are no better options. A category III fetal heart rate requires a c-section if the woman is remote from delivery. A category II fetal heart rate is a larger, harder to interpret category that may also lead to a c-section. For cesarean birth, multiple gestation pregnancies and women with active herpes simplex virus are also recommended. One (or even two) c-sections does not mean that a woman must have a c-section delivery with her next pregnancy. The woman should be evaluated and have discussions with her provider. The risk of uterine rupture is slightly higher, but she can be monitored for signs of uterine rupture during labor. A vertical incision in the uterus would not make her a candidate for a trial of labor after cesarean (TOLAC).
Some reasons likely have increased the risk of a c-section over time. These include increased maternal age during pregnancy, increased obesity and incidences of gestational diabetes, and increased use of fertility treatments. Another factor that may increase the c-section rate is the medical-legal aspect of labor and delivery. Malpractice rates and no cap limits on birth injuries may influence a provider’s decision to perform a c-section.
Intraoperative complications that could occur during a c-section are hemorrhage and surgical injury to the mother, such as a bladder injury, or the fetus, such as a facial laceration. Endometritis, infections, and wound complications all can occur with a c-section. Pain after a c-section is usually more intense than after vaginal delivery. A woman may have more difficulty moving and caring for her newborn. A thrombotic event such as ischemic stroke, acute myocardial infarction, venous thromboembolism during the first 6 weeks postpartum occurs significantly more after a c-section birth than vaginal birth. Ileus can also occur after surgery. Adhesions are possible after a c-section, causing problems with future pregnancies. A woman undergoing a c-section could react to anesthesia. Spinal anesthesia is often used with few complications, but general anesthesia may be used in an emergency case and can cause life-threatening complications, such as malignant hyperthermia.
ot all of the associated complications can be prevented. Infections can be prevented by using a strict sterile technique, providing intravenous (IV) antibiotics within 60 minutes before incision, and using a chlorhexidine-alcohol scrub before the surgery (Tuuli et al., 2016). A vaginal cleanse should also be performed if the woman has labored before the c-section. If hair removal is needed, this should be done by clipping, not shaving. For all women undergoing cesarean delivery, mechanical thromboprophylaxis is recommended. For women with a high risk of venous thromboembolism (VTE), mechanical thromboprophylaxis and pharmacologic thromboprophylaxis (Lovenox, Heparin) is recommended. Pharmacologic prophylaxis should begin at 6 to 12 hours postoperatively. Mechanical and pharmacologic prophylaxis should be continued until the woman is fully ambulating. Multimodal pain relief options should help the woman move easier and care for her baby while preventing the overuse of narcotics. Early ambulation and oral intake have been shown to promote recovery (WHONN, 2019).
Long-term risks from a c-section can be serious. A cesarean delivery significantly increases the risk of abnormal placentation in future pregnancies. This risk increases with each c-section. Placenta previa occurs when the placenta implants and covers part or all of the woman’s cervix, making vaginal delivery impossible. This can cause bleeding throughout pregnancy or significant hemorrhage. The severity of bleeding will determine the delivery timing and may lead to preterm delivery. The placenta accreta spectrum refers to the range of adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. The placenta accreta spectrum is the invasion of part or all of the placenta into the myometrium of the uterine wall. Placenta accreta is serious and requires extensive surgery. The woman may require a hysterectomy to prevent death from hemorrhage. A surgical team must plan blood product replacements and hemodynamic monitoring for the woman (OB Care Consensus, 2018). Ectopic pregnancies in the future are a risk. Women with c-sections are at risk for preterm delivery and stillbirth with future pregnancies. Women with c-sections are also at risk for uterine rupture in future pregnancies. This risk increases with a trial of labor after a cesarean (ACOG, 2019).
Patient A.S. comes to your labor and delivery unit. She wants to have a trial of labor after cesarean (TOLAC). Her first c-section was for a non-reassuring fetal heart rate. That baby was born with an umbilical cord around the neck but was fine after delivery. She is 6cm dilated and contracting every 2 minutes. Her vital signs are normal.
Is she a candidate for a TOLAC?
- Yes, she is. She had the first c-section for fetal distress. She is a candidate as long as she did not have a vertical uterine incision with her first baby.
What is the biggest risk for this woman during labor, given that the pregnancy has been normal until labor?
- A uterine rupture would be the only risk for this woman. Her placenta is normal, so that a uterine rupture would be her biggest risk during labor.
Cesarean sections are necessary to prevent maternal or fetal risks or death in certain circumstances. A c-section is not the appropriate method of delivery for every woman. There are risks to both the mom and fetus. The benefits and risks must be weighed before a c-section delivery.
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Implicit Bias Statement
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.
- Tuuli MG, Liu J, Stout MJ, et al. A Randomized Trial Comparing Skin Antiseptic Agents at Cesarean Delivery. N Engl J Med 2016; 374:647.
- PERIOPERATIVE CARE OF THE PREGNANT WOMAN. Place of publication not identified: AWHONN; 2019.
- Obstetric Care Consensus No. 7. Obstetrics & Gynecology. 2018;132(6). doi:10.1097/aog.0000000000002983.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin no. 205: Vaginal Birth After Cesarean Delivery. Obstet Gynecol 2019.