Gynecologic Surgery C
190 Cesarean Delivery
Thomas R. Moore
BACKGROUND
Defi nition and History
The origin of the term cesarean is unclear,
but the legend of Julius Caesar’s “cesarean”
birth is unlikely to be true. In those ancient
times, cesarean delivery was universally fa-
tal, and Caesar’s mother was known to have
lived for many years after his birth. The term
may have derived from the Latin words
caedere (to cut), and caesons (the term for
children delivered by cesarean), or from the
Roman law known as Lex Cesare, which
mandated postmortem delivery so the mother
and infant could be buried sep-arately. The
term “cesarean section” is re-dundant,
derived from the Latin words cae-dere and
secare, which both mean “to cut.”
The evolution of the current surgical
technique is of interest. Maternal mortality
rates for cesarean birth prior to the 20th
century approached 100% owing to the al-
most universal uterine sepsis that followed.
Consequently, very few cesareans were per-
formed. Cesarean delivery was combined
with hysterectomy in the late 19th century in
an effort to reduce infection and thus prevent
maternal death. Although one in-novation
(the “Porro” technique) involved suturing the
edges of the uterine incision to the abdominal
wall, allowing the lochia to drain externally
significantly reduced post-partum sepsis and
death; it was not until well into the 20th
century that advances in surgical suture
material, aseptic technique, anesthetic
advances, the low-transverse in-cision, and
antibiotics improved the safety of cesarean
delivery. As a result, cesarean delivery rates
in the United States increased from 4.5% of
all deliveries in 1965 to 16.5% in 1980 to
24.5% in 1988 to 32% in 2007. Ce-sarean
rates still vary widely with geo-graphic area
and type of hospital (i.e., teach-ing vs.
nonteaching). Currently, over 1 million
cesarean deliveries are performed
annually in the United States alone,
making it is the most common surgical
procedure performed on women today.
INDICATIONS
Cesarean delivery may be indicated for fetal
and/or maternal reasons, such as failure to
progress in labor, fetal malpresentation, pla-
centa previa, nonreassuring fetal monitor-ing
(category II or III by the American Col-lege
of Obstetricians and Gynecologists (ACOG)
guidelines), suspected macrosomia (greater
than 5,000 g or 4,500 g if diabetic), active
infections like herpes simplex virus or high
viral load HIV, vertical uterine incisions from
previous deliveries, and certain fetal
anomalies such as severe fetal hydrocepha-
lus or fetal neck masses. The majority of ce-
sareans are still primary with repeat cesar-ean
as an indication for 37.5% of all cesarean
births in 1997. A most controversial topic to-
day is the “cesarean-on-demand”—elective,
patient-choice cesarean birth. There are data
suggesting less urinary incontinence and
pelvic organ prolapse after elective ce-sarean,
but the slightly increased morbidity and
mortality associated with surgical deliv-ery
make the risk/benefit ratio for elective
cesarean difficult to quantify. There is cur-
rently no standard recommendation regard-
ing patient-choice cesarean. ACOG states,
“Although the evidence does not support the
routine recommendation of elective cesar-ean
delivery, we believe that it does support a
physician’s decision to accede to an in-
formed patient’s request for such a delivery”
(ACOG Committee Opinion on Ethics 2003).
RISKS
Currently, cesarean delivery has an overall
low maternal mortality and morbidity but is
still significantly elevated over vaginal deliv-
ery. The current cesarean mortality rate in the
United States ranges from 6.1 to 22 per
100,000 live births. Maternal morbidities as-
sociated with cesarean birth depend on the
indication for surgical delivery, but include
increased risk of endometritis (up to 20%),
wound infections, increased blood loss, need
for transfusion (up to 7%), throm-boembolic
events, anesthetic complications, and surgical
complications with damage to bowel,
bladder, and major pelvic blood vessels.
Morbidity is highest in emergency cesarean
birth, especially after prolonged labor and/or
ruptured membranes.
SUBSEQUENT OUTCOMES
Long-term morbidities commonly attrib-uted
to cesarean delivery include uterine scar
dehiscence or rupture, fetal demise and
expulsion from a uterine scar, placenta previa
with or without accreta, increased surgical
complications from adhesions, bowel
obstruction, bladder injury, and in-creased
blood loss during future surgery. Uterine
rupture occurs in subsequent preg-nancy less
than 1% if a low-transverse uter-ine incision
was done, and up to 12% if a prior vertical
classical uterine incision was performed.
Uterine rupture may be an as-ymptomatic
uterine “window” with mini-mal
consequences or may be a catastrophic
expulsion of the fetus into the abdomen with
subsequent fetal demise. If risk factors such
as a previous classical uterine incision,
extensive myomectomy, or more than two
previous low-transverse uterine incisions are
present, repeat cesarean delivery prior to the
onset of labor is usually recom-mended. If a
vaginal birth after cesarean delivery (VBAC)
is considered, an appropri-ate support team
of anesthesiologist, nurse, and pediatrician
must be available in case an immediate
abdominal delivery during labor is necessary.
Women undergoing VBAC must be properly
informed about the potential risks/benefits of
vaginal versus
2013