Pros and Cons of Cesarean delivery

​Overview
Cesarean delivery is defined as the delivery of a fetus through surgical incisions made through the abdominal wall (laparotomy) and the uterine wall (hysterotomy).
In 2014, 32.2% of women who gave birth in the United States did so by cesarean delivery. The rapid increase in cesarean birth rates from 1996 to 2014 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. [1]
Indications
Cesarean deliveries were initially performed to separate the mother and the fetus in an attempt to save the fetus of a moribund patient. They subsequently developed to resolve maternal or fetal complications not amenable to vaginal delivery, either for mechanical limitations or to temporize delivery for maternal or fetal benefit. The leading indications for cesarean delivery (85%) are previous cesarean delivery, breech presentation, dystocia, and fetal distress.
Maternal indications for cesarean delivery include the following:

• Repeat cesarean delivery
• Obstructive lesions in the lower genital tract, including malignancies, large vulvovaginal condylomas, obstructive vaginal septa, and leiomyomas of the lower uterine segment that interfere with engagement of the fetal head
• Pelvic abnormalities that preclude engagement or interfere with descent of the fetal presentation in labor  ​
• Certain cardiac conditions that preclude normal valsalva done by patients during a vaginal delivery . [1]

 
Fetal indications for cesarean delivery include the following:

• Situations in which neonatal morbidity and mortality could be decreased by the prevention of trauma
• Malpresentations (eg, preterm breech presentations, non-frank breech term fetuses)
• Certain congenital malformations or skeletal disorders
• Infection
• Prolonged academia [1]

 
 

​Indications for cesarean delivery that benefit the mother and the fetus include the following:

• Abnormal placentation (eg, placenta previa, placenta accreta)
• Abnormal labor due to cephalopelvic disproportion
• Situations in which labor is contraindicated [1]

Contraindications
There are few contraindications to performing a cesarean delivery. In some circumstances, a cesarean delivery should be avoided, such as the following:

• When maternal status may be compromised (eg, mother has severe pulmonary disease)
• If the fetus has a known karyotypic abnormality or known congenital anomaly that may lead to death (anencephaly) [1]

Complications

• Approximately 2-fold increase in maternal mortality and morbidity with cesarean delivery relative to a vaginal delivery Partly related to the procedure itself, and partly related to conditions that may have led to needing to perform a cesarean delivery
• Infection (eg, postpartum endomyometritis, fascial dehiscence, wound, urinary tract)
• Thromboembolic disease (eg, deep venous thrombosis, septic pelvic thrombophlebitis)
• Anesthetic complications
• Surgical injury (eg, uterine lacerations; bladder, bowel, ureteral injuries)
• Uterine atony
• Delayed return of bowel function [2]

 
ACOG/SMFM guidelines for prevention of primary cesarean delivery
The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) released joint guidelines for the safe prevention of primary cesarean delivery. These include the following :

• Prolonged latent (early)-phase labor should be permitted
• The start of active-phase labor can be defined as cervical dilation of 6 cm, rather than 4 cm
• In the active phase, more time should be permitted for labor to progress
• Multiparous women should be allowed to push for 2 or more hours and primiparous women for 3 or more hours; pushing may be allowed to continue for even longer periods in some cases, as when epidural anesthesia is administered
• Techniques to aid vaginal delivery, such as the use of forceps, should be employed
• Patients should be encouraged to avoid excessive weight gain during pregnancy

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• Access to nonmedical interventions during labor, such as continuous support during labor and delivery, should be increased
• External cephalic version should be performed for breech presentation
• Women with twin gestations should, if the first twin is in cephalic presentation, be permitted a trial of labor [2]

Adjunctive Azithromycin Prophylaxis for Cesarean Delivery
The addition of azithromycin to standard regimens for antibiotic prophylaxis before cesarean delivery may further reduce the rate of postoperative infection. We evaluated the benefits and safety of azithromycin-based extended-spectrum prophylaxis in women undergoing nonelective cesarean section. [2]
 
ConclusionReducing caesarean delivery rates in Mexico will require more than public awareness, guidelines and policies. First, an improved data collection and quality assurance system is necessary to better understand the consequences of high caesarean delivery rates over time. Second, increased oversight and regulation of private insurance companies is needed to reverse the perverse economic incentives that contribute to a very high caesarean delivery rate in the private sector. Finally, the medical and public health community must take an active role in educating the next generation of obstetricians and gynaecologists, the public and the insurance industry on the well documented benefits of vaginal delivery for both women and their newborns. Multilevel interventions, such as those available to improve quality of care for member countries of the Organization for Economic Co-operation and Development, 26 are urgently needed to safely reduce the high rate of caesarean delivery in Mexico, particularly in private-sector hospitals. [2]
 
References:
 

1. https://emedicine.medscape.com/article/263424-overview
2. https://www.who.int/bulletin/volumes/85/10/06-035808/en/

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Author details 
Shadat Nabil
Student,Department of Pharmaceutical science, North South University.