What is a Cesarean Section? Why? When is a C-section not done?

What is Cesarean Section?

Cesarean section or C-section for short is the delivery of baby, placenta, and membranes through a surgical incision in the abdominal wall and the uterine wall.

Contrary to popular belief, the term “Cesarean section” has no relation to birth of the Roman emperor Julius Caesar, who is erroneously believed to have been delivered by this operation. It has been suggested that the term is derived from the “lex caesarea”, a decree which is said to have continued under the rule of the Caesars from the 8th century BC. In accordance with this law, before burial of any woman dying in late pregnancy, the child was to be removed from the uterus. Another probable source of the term could be the Latin word “caedere” (to cut), the past participle of which is “caesum” (cut).

Primary cesarean section refers to the first cesarean section performed on a woman, while repeat cesarean section may include secondary, tertiary, and other similar repeated procedures. The surgical delivery of a pre-viable fetus (before the time a fetus is capable of maintaining a separate existence outside the uterus) is not considered as cesarean section, but is known as a hysterotomy.

A cesarean section may be done either as an elective or as an emergency procedure.

  • An elective cesarean section is one that is done before the onset of labor or before the development of any complication which may require urgent delivery of the baby.
  • An emergency cesarean section, as the name denotes, is one that is done as an emergency procedure where a complication of pregnancy or labor necessitates urgent delivery of the baby.

The saying “once a cesarean, always a cesarean” no longer holds true. Many women who have had a cesarean delivery can go for subsequent vaginal delivery, especially when the indication for the previous procedure is no longer present.

Why is a cesarean section done?

Although a relatively safe surgery, a cesarean section does carry more risks than vaginal delivery. Keeping this in mind, a cesarean section is usually done in those cases where a vaginal delivery is not feasible or would expose the mother or baby to undue risks.

Some indications are absolute, such as central placenta previa and obvious cephalopelvic disproportion, while others are relative. Each case has to be judged on its own merit so as to decide whether cesarean section or vaginal delivery would be better.

Indications for Elective Cesarean Section

  • Known cephalopelvic disproportion – the head of the baby is too large to come out through the maternal pelvis).
  • Very large baby.
  • Placenta previa– the placenta is low-lying and totally covers the internal os, the opening of the cervix through which the baby passes during delivery.
  • Breech presentation – the buttocks or feet are in place to come out first instead of the normal head down position.
  • Multiple pregnancy, such as twin or triplets, especially when the first baby is not cephalic (head down position).
  • Malpresentations, such as face, brow, or transverse lie.
  • Birth defects in the baby, such as spina bifida and certain cases of hydrocephalus.
  • After vaginal surgery, such as vesico-vaginal fistula repair.
  • Maternal infections, such as active genital herpes or HIV which may be passed on to the baby during vaginal delivery.
  • Tumor obstructing the birth canal, either cancerous or benign (fibroid).
  • High risk of uterine rupture during labor such as a vertical uterine scar due to previous cesarean section or myomectomy for removal of uterine fibroid.
  • Repeat cesarean section.
  • Severe pre-existing disease, like heart disease or other debilitating conditions where a vaginal delivery would impose a greater threat than cesarean section.
  • Choice – sometimes, a woman chooses to deliver her baby by cesarean section, in spite of there being no medical reason for her to do so. There is much controversy regarding this issue. The attending doctor will have to judge the merit of the case on an individual basis and discuss the associated risks with the patient before arriving at a decision.

When is a cesarean section immediately necessary?

Indications for Emergency Cesarean Section

Antenatal complications

  • Severe pre-eclampsia and eclampsia.
  • Abruptio placentae – premature separation of placenta with the baby still being alive.
  • Some cases of severe hypertension (high blood pressure) and diabetes.

Complications during labor

  • Fetal distress – the baby shows signs of distress such as a very fast or very slow heart rate.
  • Prolapsed cord – where the umbilical cord slips into the birth canal ahead of the fetus. Cesarean section is done only if the fetus is alive.
  • Cord compression – twisting of the umbilical cord round the baby’s neck or body.
  • Uterine inertia or absence of effective uterine contractions during labor.
  • After failed induction of labor.
  • Dystocia or failure of labor to progress.

When should a cesarean section not be done?

Contraindications of Cesarean Section

  • Absence of an appropriate indication for cesarean section may be considered as a contraindication.
  • Pyogenic infections of the abdominal wall.
  • Dead fetus.
  • Abnormal fetus, such as having a known congenital anomaly that may lead to death (anencephaly).
  • Lack of proper facilities and assistants.

Each case has to be considered individually, weighing the risks of performing the operation in spite of contraindication, as against the consequences of not performing it.

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