Caesarean section is generally used to reduce the risks when it is not possible to complete vaginal delivery safely or when the mother or baby’s illness or life risks increase with vaginal delivery.
Cesarean Indications in General
Conditions about the baby
- Low fetal heart beat (impaired fetal well-being)
- Fetus’ leading part of the (presentation) anomalies:
- Breech arrival
- The arrival of the forehead
- Face arrival
- Side stance
- Multiple pregnancies
- Fetal anomalies (such as hydrocephalus, sacrococcygeal teratoma)
Previous uterine surgery (such as myomectomy, cesarean section)
Systemic diseases (such as diabetes, hypertension, preeclampsia)
Presence of infections that can pass from mother to baby (herpes simplex, HIV, hepatitis C)
Conditions of birth
- Head pelvis incompatibility (Roof stenosis)
- Non-progressive labour (Prolonged action)
- Huge baby (Fetal macrosomia)
Conditions of umbilical cord and placenta
- Cord sagging
- Placenta previa (Lower placenta)
- Placental detachment (premature separation of the placenta)
- Vasa previa
Social indication: cesarean at the request of the mother
The incoming part of the baby can change constantly in the early weeks of pregnancy because the baby is small and the area where it will move is quite large. From the 36th week of pregnancy, the way of arrival is fixed. Side posture, cesarean should definitely be preferred for the arrival of the feet. Also, it is appropriate to perform cesarean delivery due to birth difficulties and possible complications, especially in the woman who has her first birth. When the baby comes into the birth canal with a very large surface, delivery may not be possible or there may be difficulties that the baby may be damaged. Therefore, it is suitable to have a cesarean.
Baby heartbeats are monitored intermittently or continuously, depending on the nature of the pregnancy during labour. If the drops in the baby’s heartbeat are in the criteria that may cause oxygenation disorder (fetal distress: deterioration of the well-being of the fetus), emergency cesarean should be performed. In case of cord sagging, emergency cesarean should be performed as the blood flow to the baby will stop. In the placental detachment, the vital area that connects the baby to the mother is the placenta; It will leave the uterus slowly or quickly with bleeding occurring behind it. It carries an emergency cesarean indication.
In the absence of head pelvis, delivery may not occur due to the large head of the baby or the narrow pelvis. Here, the risk of non-progressive labour or birth trauma increases. The large baby (baby over 4000 g) may also have a non-progressive labour and a shoulder attachment. A cesarean section reduces the likelihood of complications.
In masses like large myomas obstructing the birth tract, the baby cannot be delivered vaginally. Again, in the lower placement of the placenta (placenta previa), it will not be possible for the baby to pass into the vagina and also severe bleeding will be expected. Here, cesarean planning should be done during pregnancy. However, in placenta previa, the decision is made only around the 36th week. Because, in the early weeks of pregnancy, many placenta located downwards settle at a point above as the uterus grows and do not block the birth path. In the vasa previa, if the amniotic sac is torn, the baby can be lost with severe bleeding and cesarean should be applied.
In active herpes simplex infection, if the infection passes to the baby, severe problems that may affect the central nervous system of the baby may appear. In the presence of active genital condyloma (human papilloma virus), common condylomas can be seen in the baby’s respiratory system (respiratory papillomatosis). The presence of both infections is a cesarean indication.
Previous uterine surgeries (such as fibroid operations, previous cesarean section) may cause problems in the 1st and 2nd stages of vaginal delivery. The original state of tissue integrity is now deteriorated, although the section that had previously been incised and replanted, that is, the repaired part, healed perfectly. During the pain, that is, contractions, this old incision site can be thinned out and then torn. This table, called uterine rupture, is life-threatening for the baby and the mother and has an indication for emergency surgery. Normal delivery can be tried after a certain period of previous cesarean operations. However, it is necessary to be aware of these risks. It is useful to know the old incision shape. If the incision is made vertically, normal delivery should never be attempted. If a transverse incision has been made, normal delivery can be tried by keeping the risks in mind and keeping the emergency surgery ready.
The way of delivery can be determined during the course of pregnancy, or it can be determined during labour.
In a woman with previous history of uterine surgery, such as previous fibroid surgery, old cesarean section, in the presence of hypertension or diabetes in the mother, if the placenta is located low, this decision may be in favor of cesarean delivery during pregnancy. During the normal course of the pregnancy, it is decided during the delivery process in cases such as progression of labour (prolonged action), drops in the baby heart beats, placental detachment, cord sagging.
Indeterminate indications of cesarean section include advanced maternal age, obesity (obesity), microinjection pregnancies. In advanced maternal age, pain quality and pain resistance decreases and birth anxiety is added to the woman who is pregnant with her first baby at a later age. In this case, cooperation in the birth management of women becomes difficult. In obesity, besides pain quality, duration, large baby, small baby according to week or difficulties related to pelvic factors may be experienced. However, obesity also takes into account the healing difficulties that can be caused by excessive fat tissue at the cesarean section. As the frequency of systemic diseases such as hypertension and diabetes increases in advanced maternal age and obesity, the possibility of cesarean delivery increases. In microinjection pregnancies, when pregnancy begins, it starts out like every normal pregnancy.
The frequency of cesarean is naturally high in multiple pregnancies. However, in single pregnancies, the anxiety and desire of the mother and the medical condition of the baby and the mother should be decided.
While performing cesarean section, general anesthesia or epidural-spinal anesthesia can be applied. Prior to discussing with anesthesiologists, it is possible to decide which method is more appropriate.
The baby is removed shortly after the mother sleeps during general anesthesia. For this reason, it is not correct to mention the possibility of exposing the baby to anesthesia. General anesthesia may be preferred in mothers who are afraid of operating theater, do not want epidural-spinal anesthesia or whose medical condition is not suitable for epidural-spinal anesthesia. In epidural-spinal anesthesia, the mother remains awake during the birth of her baby without pain. However, it can perceive feelings such as withdrawal and stretching. During the procedure, low blood pressure and nausea may be experienced. The most common side effect is severe headache, which starts after 24-72 hours. It occurs due to continued leakage of cerebrospinal fluid through the epidural space, and effective pain relief with abundant fluid is required. The headache process can last 7-10 days and lying flat will relieve pain.