What are the maternal indications for cesarean delivery (C-section)?

Updated: Dec 14, 2018
  • Author: Hedwige Saint Louis, MD, MPH, FACOG; Chief Editor: Christine Isaacs, MD  more...
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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

Relative maternal indications include conditions in which the increasing intrathoracic pressure generated by Valsalva maneuvers could lead to maternal complications. These include left heart valvular stenosis, dilated aortic valve root, certain cerebral arteriovenous malformations (AVMs), [8] and recent retinal detachment. Women who have previously undergone vaginal or perineal reparative surgery (eg, colporrhaphy or repair of major anal involvement from inflammatory bowel disease) also benefit from cesarean delivery to avoid damage to the previous surgical repair.

No clear evidence supports planned cesarean delivery for extreme maternal obesity. A prospective cohort study from the United Kingdom included women with a body mass index of 50 kg/m2 or more and noted possible increased shoulder dystocia (3% vs 0%) but found no significant differences in anesthetic, postnatal, or neonatal complications between women who underwent planned vaginal delivery and those who underwent planned caesarean delivery. [34]  However recent studies indicate that obese and extremly obese women have an increased odds ration of having a cesarean section, 2.05 and 2.89 compared with normal weight women. [35]

Dystocia in labor (labor dystocia) is a very commonly cited indication for cesarean delivery, but it is not specific. Dystocia is classified as a protraction disorder or as an arrest disorder. These can be primary or secondary disorders. Most dystocias are caused by abnormalities of the power (uterine contractions), the passage (maternal pelvis), or the passenger (the fetus). [36]

When a diagnosis of dystocia in labor is made, the indication should be detailed according to the previous classification (ie, primary or secondary disorder, arrest or protraction disorder, or a combination of the above). For further information, see Abnormal Labor.

Recently, debate has arisen over the option of elective cesarean delivery on maternal request (CDMR). Evidence shows that it is reasonable to inform the pregnant woman requesting a cesarean delivery of the associated risks and benefits for the current and any subsequent pregnancies. The clinician’s role should be to provide the best possible evidence-based counseling to the woman and to respect her autonomy and decision-making capabilities when considering route of delivery. [37]

In 2006, the National Institutes of Health (NIH) convened a consensus conference to address CDMR. They resolved that the evidence supporting this concept was not conclusive. [10] Their recommendations included the following:

  • CDMR should be avoided by women wanting several children.

  • CDMR should not be performed before the 39th week of pregnancy or without verifying fetal lung maturity.

  • CDMR has a potential benefit of decreased risk of hemorrhage for the mother and decreased risk of birth injuries for the baby.

  • CDMR has a potential risk of respiratory problems for the baby.

  • CDMR is associated with a longer maternal hospital stay and increasing risk of placenta previa and placenta accreta with each successive cesarean. [38]

The NIH further noted that the procedure requires individualized counseling by the practitioner of the potential risks and benefits of both vaginal and cesarean delivery, and it should not be motivated by the unavailability of effective pain management. [10]

Detractors of CDMR argue that the premise of cesarean on request applies to a very small portion of the population and that it should not be routinely offered on ethical grounds. [39] The emerging consensus is that a randomized prospective study is required to address this issue. [40]

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