Cesarean Section Cons and Pros

Cesarean section is the most common surgical procedure performed in obstetrics. It is a life-saving operation for both the mother and the fetus.

Globally, the recommended cesarean section rate should not exceed 23% of all deliveries. Unfortunately, cesarean section rates have been increasing dramatically worldwide.

At the same time, a low cesarean section rate may reflect issues within the healthcare system. Mainly, shortage of resources.

Cesarean section can be classified as either emergency or elective (planned), additionally; it can be categorized based on the type of uterine incision into:

• Classical cesarean section: Involves an incision in the upper uterine segment (now largely abandoned due to high risks).
• Lower uterine segment cesarean section: The routine and safer incision.

Obtaining Informed consent is necessary before proceeding with surgery, explaining the indications, necessity and possible complications.

Anesthesia

The preferred anesthesia for a cesarean section is spinal or epidural anesthesia, which allows the mother to remain awake, initiate skin-to-skin contact, and begin breastfeeding immediately.

Administration of General anesthesia is more risky than regional anesthesia, only given when epidural or spinal anesthesia is contraindicated, patient request, failed regional anesthesia, or high emergencies.

Procedure

A cesarean section involves delivering the baby through a surgical incision in the lower abdominal wall and involving a transverse incision in lower uterine segment.

Lower segment scar weather longitudinal or transverse promote better healing and a stronger scar.

Delivery of The baby head-either first or breech, depending on its position. Once the baby is out, extraction of the placenta ensuring complete removal with membranes, followed by closing of the lower uterine segment incision in two layers, ensuring proper hemostasis. Finishing by cleaning of the abdominal cavity, checking urine output and inspection of the ovaries and finally counting the towels and instruments before closing the abdominal wall.

Post-Operative Care

Enhancement of early recovery after surgery is an evidence based beneficial practice to promote maternal wellbeing, minimize hospital stay, and facilitate early discharge. It includes encouraging early ambulation, resuming food intake, and initiating breastfeeding as soon as possible after surgery. Women should receive home postnatal visits and care to address common concerns such as pain, breastfeeding challenges, and early detection of serious complications like post-partum depression, puerperal sepsis and thrombosis.

Indications for Cesarean Section

Maternal and fetal indications for cesarean section include:

1. Previous cesarean sections or uterine surgery – Any prior operation on the uterine muscle (myometrium) may result in a weak fibrotic scar, which can rupture during next labor.
2. Cephalo-pelvic disproportion (CPD): A small or narrow pelvis that prevents the baby’s head from passing through the birth canal.
3. Obstructing pelvic tumors: Uterine fibroids or other pelvic tumors that hinder and interfere with fetal head descent.
4. Maternal infections: Active genital herpes simplex virus infection, which could cause severe neonatal encephalitis.
5. Abnormal fetal presentations: Breech, transverse, or brow presentations.
6. Multiple pregnancies: Twin or higher-order gestations.
7. Macrosomia: Large babies that increase the risk of birth trauma.
8. History of poor obstetric outcomes: Recurrent pregnancy loss or stillbirth.
9. Fetal distress: Umbilical cord issues, such as cord prolapse or abnormal fetal heart rate.
10. Placental abnormalities: Placental abruption, placenta Previa, or placenta accrete.

Complications of Cesarean Section

Although cesarean sections are generally safe and improve pregnancy outcomes, they still pose significant risks, including the following intraoperative and Postpartum Risks:

• Hemorrhage: Excessive bleeding may require blood transfusion, increasing the risk of anemia.
• Infections; Higher risk of surgical site infections, endometritis, and puerperal sepsis.
• Deep vein thrombosis (DVT) and pulmonary embolism: prolonged immobility together with increase of coagulations factors during pregnancy will increase risk of thrombosis.
• Bladder and bowel injuries: More common in repeat cesarean sections.
• Long-Term Risks: include chronic pelvic pain and adhesions that may affect fertility.
• Uterine niche formation – Can affect future pregnancies and menstrual pattern.
• Scar rupture in future pregnancies – Particularly in cases of poorly managed vaginal birth after cesarean (VBAC).

Strategies to Reduce Cesarean Section Rates

To minimize unnecessary cesarean sections, healthcare providers should:

• Provide comprehensive antenatal care and risk assessment.
• Offer antenatal classes to educate expectant mothers about labor and delivery.
• Follow evidence-based medical practices and avoid unnecessary interventions.
• Use oxytocin judiciously to induce or augment labor only when medically necessary.
• Ensure proper fetal heart monitoring and accurate interpretation of cardiotocography (CTG).
• Perform external cephalic version (ECV) when appropriate to correct breech presentation.
• Educate women who request cesarean sections without medical indications about the short- and long-term risks affecting their future fertility.
• Encourage trial of labor after cesarean (TOLAC) when appropriate, with careful risk assessment.

Finally to unify the fees to be the same for both cesarean section and normal vaginal delivery.

VBAC (Vaginal Birth after Cesarean) Considerations

A ruptured uterine scar is a serious complication of VBAC, posing life-threatening risks to both the mother and fetus. Therefore, the decision to attempt VBAC should be made carefully, with detailed counseling and a thorough risk evaluation. VBAC should be conducted inside well-equipped hospitals with blood transfusion service, intensive care unit and well-qualified surgeons capable to deal with high-risk near miss complications.

The possibility of successful VBAC increases if there is history of previous normal vaginal delivery, if there is a history of previous successful VBAC, lapse of 18 months interval or more between the cesarean section and the VBAC and if the previous cesarean section was done for temporary reason like Breech presentation or fetal distress.

VBAC is contraindicated if the previous cesarean section was done in upper segment of the uterus, or because of obstructed labor or during second stage of labor with failure to progress and descend, or after ruptured uterus and if the woman has history of previous two cesarean sections or more.