Indications for Cesarean Birth
Cesarean deliveries are performed for many reasons. Because opinions vary concerning these reasons, you might want to get a second opinion if you are told that you need a c-section.
Over one-third of the cesareans that are performed in the United States are done because of previous cesarean birth. In 1988, the American College of Obstetricians and Gynecologists issued the statement that in the absence of medical complications of pregnancy, women who previously had a cesarean should be encouraged to attempt a vaginal birth. As more and more doctors incorporate this philosophy, the outdated practice of “once a cesarean, always a cesarean” will continue to decline.
Cephalopelvic disproportion (CPD) occurs when the baby’s head does not fit through the woman’s pelvis. This diagnosis is also often used to indicate a labor that fails to progress. Failure to progress may refer to a prolonged labor with no change in cervical dilation or station of the baby, an extended period of time since the rupture of the membranes, or weak and ineffectual uterine contractions. This is the most common indication for a cesarean occurring during labor.
Fetal distress is a condition in which the baby is not receiving enough oxygen. It may be indicated by an abnormal fetal heart rate pattern or low fetal blood pH. Meconium-stained amniotic fluid, which is greenish in color, may also be associated with the condition. Another condition is fetal intolerance of labor. This means that even though the baby is not currently in distress, the fetal heart rate pattern observed on the electronic fetal monitor is somewhat questionable. If the woman is not close to delivery, the doctor may decide to perform a cesarean rather than to wait and see if the fetus has distress. If the amount of amniotic fluid is too low, fetal distress may be noted when the umbilical cord becomes compressed during contractions. The volume of amniotic fluid may be increased by a saline solution that is infused into the uterus. The infusion process is called amnioinfusion and may be a way of allowing labor to continue when a cesarean would otherwise be necessary.
If the baby is in an abnormal presentation within the uterus, a cesarean may be indicated. One example is a transverse lie, in which the baby is lying side¬ways in the uterus and a vaginal delivery is impossible. A baby who is in a breech presentation may be delivered either vaginally or by cesarean section, depending on several factors. If the doctor is experienced in delivering breech babies, he may more readily agree to a vaginal birth. He will need to make sure that the woman’s pelvis is adequate and that the baby is not too large. He will also need to determine the type of breech presentation, including the position of the baby’s head, and will need to confirm that the labor is progressing normally. Many newer doctors are not trained in the vaginal delivery of breech babies. Others feel that the additional risks involved do not warrant attempting a vaginal breech delivery and deliver all breech babies by cesarean. With both a transverse lie and breech position, the physician may attempt an external version prior to or even during labor.
In abruptio placentae, the placenta partially or completely separates from the uterine wall before the baby is born. An immediate cesarean is necessary in this emergency situation because the woman may hemorrhage and the baby may lose all or part of his oxygen supply. This condition is rare in low-risk women.
A prolapsed cord occurs when the umbilical cord protrudes into the vagina ahead of the baby. (See Figure 9.1) This usually happens after the membranes rapture and the baby is in a breech position or his head is not well engaged in the pelvis. The baby’s oxygen supply is cut off as the presenting part compresses the cord. If you feel that this may be happening to you while you are still at home, immediately get down on your hands and knees, and position your hips higher than your head to relieve the pressure on the cord.
Call 911 and remain in the knee-chest position until help arrives. If the cord is protruding from your vagina, place a wet cloth on it to keep it moist. However, do this only if you can accomplish it without leaving the knee-chest position. When you arrive at the hospital, your doctor will perform an immediate cesarean.
Placenta previa is a condition in which the placenta partially or completely covers the cervix. The degree of severity determines whether or not a cesarean is necessary. If the cervix is completely covered, a cesarean is mandatory because the placenta would deliver first and the baby would lose his oxygen supply. This is usually identified prior to labor by an ultrasound.
When preeclampsia (severe PIH) is present, the woman may have a stroke or kidney failure. The treatment for preeclampsia is delivery. PIH affects the welfare of the fetus as well as that of the woman, thereby necessitating delivery, either by induction or cesarean.
If the woman is diabetic, early delivery is necessary for the baby’s sake. The placental blood flow may be poor, the baby may be excessively large, or he may respond poorly to the stress of labor. If induction is unsuccessful, a cesarean will need to be performed.
When an Rh-negative woman has been sensitized by Rh-positive blood, her baby may develop erythroblastosis fetalis. During the pregnancy, antibodies may pass through the placenta and attack the Rh-positive baby’s blood cells, leading to anemia and other problems that necessitate delivery. With the advent of Rh-immune globulin (RhoGAM), which can be given to the Rh-negative woman during pregnancy and after every birth of an Rh-positive infant, as well as after miscarriage, abortion, amniocentesis, and chorionic villus sampling, erythroblastosis fetalis is now rare.
A woman who has an active herpes simplex virus II (HSVII) infection on her vulva and/or vagina at the time of birth needs a cesarean section to prevent infecting the baby. HSVII can be transmitted to the baby if he comes in contact with an active lesion or even if the membranes have ruptured. It is an untreatable illness that causes death in 50 percent of the infants infected.
Some doctors schedule a cesarean if they feel that the baby’s size is excessive (macrosomia). They are concerned that the baby’s shoulders would become stuck (shoulder dystocia), which can be a serious complication. Since the methods of determining a baby’s size are inaccurate, many doctors observe the woman’s progress during labor and while pushing to determine whether a cesarean is necessary.