In the USA, approximately 30% of deliveries occur through a surgery called Cesarean Section ( CDC source). Some women request to have a C section as their preferred mode of delivering the baby. However, the majority of women are concerned about these surgeries and, if possible, would want to avoid them.
Not surprisingly, pregnant women often inquire when or in what situations they may need a C section.
Generally speaking, cesarean sections are done when the clinical team and expecting mother believe that the surgical approach will lead to better outcomes in the mother and the baby.
Sometimes, all risks have to be carefully balanced before the right decision can be made.
Indications for C section:
Doctors do C sections due to maternal reasons and fetal factors. Additionally, all C sections can be classified as an emergency C section, an urgent C section, or a regular non-urgent C section. If you have a C section for the first time, it is called the primary C section. You would have a secondary C section if you had at least one C section in the past.
I want to emphasize here that most of the statistical numbers cited by me in the article apply to the United States. Other countries may have very different numbers (Source article).
Failure to progress during labor.
Failure to progress during labor is the reason for the C section in 35% of primary C sections. It means that you were a good candidate to have a baby natural way. However, your labor did not progress well enough, and you got tired, or baby inside you is showing signs of exhaustion, and it is recommended to you that doctors perform C section to deliver your baby.
Failure to progress is a good reason to recommend C section to a mother; however, there may be differences of opinion on how it is defined. You should definitely discuss and ask your obstetrician when he would do C section for failure to progress.
Non-reassuring fetal status.
Non-reassuring fetal status can be a reason for the C section in up to 24% of all primary C sections. It means that in the assessment of your obstetrician, the condition of your baby is compromised, and prolonging the delivery process more may contribute to poor outcomes in your baby or even death.
We may observe non-reassuring fetal status in two situations: with failure to progress during labor or in normally advancing labor.
You may ask how doctors evaluate well being of the baby that did not get born yet? The majority of laboring mothers are monitored with external doppler probes, providing a continuous display of the baby’s heart rate. In some cases, we may also use an internal electrode attached to the baby’s scalp through the mother’s vagina and cervix.
We know from the experience that specific heart rate patterns are associated with less favorable outcomes in a baby, therefore in those situations, we can recommend to the mother to do a C section.
In situations where a baby’s heart rate dropped suddenly and did not recover right away, the case may be extremely urgent.
In cases where obstetricians want to obtain an additional piece of information about the baby’s condition before deciding on the need for C section, they can get a drop of blood from the baby’s scalp to check a pH level. (pH level measures indirectly amount of acid in our blood and is an indicator of the “metabolic” well being of the baby).
Fetal malpresentation or malposition.
Fetal malpresentation can be cause for a C section in up to 20% of all primary sections.
For the baby, the healthiest way and easiest for natural delivery is to enter the birth canal with the head going down first with the presenting part being back of the head. Malpresentation occurs when presenting part is the forehead, face, or top of the head.
Breech and transverse positions are also associated with higher rates of cesarean sections.
Whenever an obstetrician identifies that your baby is malpositioned, he has three choices:
- continue the delivery process without modifications
- attempt manual version
- proceed directly to C section
The choice of how to proceed will depend on your particular situation (exact positioning of the baby, size of your baby and your pelvis, and if it is your first birth), obstetrician’s experience and comfort level, and your preferences as a mother.
The mother’s request to have a cesarean section.
Some women ask to have a cesarean section even if it is not medically indicated. The medical community tends to grant that wish to the women provided they are appropriately counseled regarding any risks and perceived benefits. I covered this topic thoroughly in another article.
Certain types of placentas such as placenta previa or placenta accretea can lead to intrapartum or post-partum hemorrhage and endanger mother’s or baby’s lives.
In placenta previa, the placenta is located low in the uterus, often covering partially or entirely the cervix.
In placenta accreta, the placenta grows into the uterus very deeply, and after delivery of the baby, it may lead to severe bleeding.
Doctors may be able to diagnose both conditions before your labor starts; therefore, they can offer an appropriate approach to minimize adverse outcomes. Frequently, they will offer you to have a scheduled cesarean section.
Scheduling C section in women with active HIV and high viral load decreases rates of mother-baby transmission of the virus. In addition to the C section, both mother and baby should receive appropriate medications to treat or prevent HIV infection.
In mothers who have active herpetic lesions in their genital areas, C section may decrease the likelihood of Herpes infection in a baby. To be effective, it is essential to perform cesarean section before amniotic membranes rupture or as soon as feasible after membranes ruptured. Again, both mother and baby need additional evaluations and medical treatment depending on the circumstances.
Cord prolapse is an emergency indication for the C section. Cord prolapse may lead to significant compromise in the amount of blood flowing to the baby and very poor outcomes.
Large baby or disproportion between the size of the baby and maternal pelvic size.
Large babies (also called macrosomic) may have difficulty descending into the birth canal. Typically, doctors expect problems if the baby is bigger than 5000 grams in a non-diabetic woman and more than 4500 grams in women with diabetes.
In petite women or women with a very small pelvis, babies with much lower predicted weight may pose problems during natural delivery.
Another example of a disproportion will be a case in which the baby has massive hydrocephalus, and the baby’s head would not be able to descend fully through the birth canal despite the typical size of the maternal pelvis.
Mechanical obstructions in the birth canal.
Mechanical obstruction in the birth canal may occur due to many reasons. Two examples of such conditions are large fibroids or a history of displaced pelvic fracture.
Uterine rupture constitutes an absolute emergency, and delivery by cesarean section will be almost always immediately recommended. In this case, both mother’s and baby’s lives are in jeopardy, and doctors must act very fast.
Uterine rupture is a tearing of the uterus wall resulting in the fetus being expelled into the belly of the woman. Women who had previous surgeries on their uterus (for example, previous C section) are at higher risk to have this complication. Women who had a C section previously are carefully counseled about those risks so that the best birth plan can be made for them.
Some women still want to do VBAC (vaginal birth attempt after C section), and some want to arrange for a scheduled C section.
Maternal risks for complications during natural labor.
Natural delivery involves a lot of changes in the mother’s body leading to dilation and stretching of many organs. In those rare cases, the mother should deliver her baby by cesarean section to avoid some complications. Examples of those conditions are listed below:
- invasive cervical cancer
- inflammatory bowel disease
- uterus prolapse
- anal prolapse
- urethra prolapse
- rectovaginal fistulas or status after their repair surgeries
If a mother is pregnant with twins, triplets, or even more babies, it may be challenging to deliver them all safely, and a C section may be the preferred delivery mode. Except for twins, almost all other multiple pregnancies would result in cesarean delivery.
Fetal bleeding disorders.
If the fetus was diagnosed with a condition affecting its ability to stop bleeding, this condition might also be an indication for a C section to avoid pressure on the baby’s head that might cause an intracranial bleed.
An example of such a condition would be severe thrombocytopenia (abnormally low platelet count in a baby).
Other essential questions related to the topic of Cesarean Sections.
When should I have a “normal non-urgent” C section scheduled?
For most expecting mothers, it is recommended to wait with a scheduled C section until completed 39 weeks of gestational age. Delivery of the baby before 39 weeks of gestational age is associated with a higher incidence of respiratory problems after birth (Source article)
Each situation is different, and for example, mothers suffering from uncontrolled high blood pressure or mothers with diabetes may need to have C section much earlier than 39 weeks.
Also, if the baby’s condition is severely compromised, providing baby is viable, doctors will choose to perform a C section regardless of fetal age.
How soon after the decision, the cesarean section should be done?
Time-lapse between decision and actual surgery will depend on many factors. If the indication for C section is an emergency (for example, uterine rupture or cord prolapse), surgery should be done immediately.
If indications for delivery of the baby are softer, for example, the mother came in early labor with a fetus in the breech position, but she just ate breakfast. It may be safer for her and her baby to wait some time, so it will be safer for her to undergo anesthesia when her stomach is empty.
All hospitals in the USA providing full delivery services are expected to be able to perform C section within 30 minutes from the decision to do it. However, that does not mean it is OK to wait that long if there is an emergency condition that warrants an immediate delivery of the baby.
Are any alternatives to the C section?
That will depend on the phase of labor in which you are. If you are really close to delivering your baby, sometimes vacuum extraction or forceps assisted delivery can be considered.
Whether forceps or vacuum delivery is the right choice for you, will depend on your unique situation (urgency, your health, your baby’s health, time to expected delivery without C section, and obstetrician’s experience in those other delivery operative techniques).
There are many reasons why a C-section may be indicated rather than delivering a baby by natural vaginal route. All the risks and potential benefits of this surgical approach should be always thoroughly discussed with your obstetrician.
If you would like to learn whether you can request a C-section without any medical indications, read my article here.
This article is only for general information purposes. It should not be viewed as any medical advice. There is a small chance that information here may be inaccurate. You should always discuss all health-related matters with your doctor before making any decisions that may affect your health or health of your family members.