What are the fetal 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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Fetal indications for cesarean delivery include the following:

  • Situations in which neonatal morbidity and mortality could be decreased by the prevention of trauma

  • Malpresentations

  • Certain congenital malformations or skeletal disorders

  • Infection

  • Prolonged acidemia

A fetus in a nonvertex presentation is at increased risk for trauma, cord prolapse, and head entrapment. Malpresentation includes preterm breech presentations and non-frank breech term fetuses.

The decision to proceed with a cesarean delivery for the term frank breech singleton fetus has been challenged. Although most practitioners will always perform a cesarean delivery in this situation, ACOG has left open the option to consider a breech delivery under the appropriate circumstances, including a practitioner experienced in the evaluation and management of labor and skilled in the delivery of the breech fetus. [31]  Some state maternal care collaborative agencies are even implementing tools to decrease the likelihoond of cesarean section in the instance of a breech presentation, with guidelines recommending the formation of a team in the hospital that is trained and confortable with breach and operative deliveries. [41]

If a patient is diagnosed with a fetal malpresentation (ie, breech or transverse lie) after 36 weeks, the option for an external cephalic version is offered to try to convert the fetus to a vertex lie, thus allowing an attempt at a vaginal delivery. An external cephalic version is usually attempted at 36-38 weeks with studies underway to establish the use of performing external cephalic version at 34 weeks’ gestational age.

Ultrasonography is performed to confirm a breech presentation. If the fetus is still in a nonvertex presentation, an intravenous (IV) line is started, and the baby is monitored with an external fetal heart rate monitor prior to the procedure to confirm well-being. With a reassuring fetal heart rate tracing, the version is attempted.

An external cephalic version involves trying to externally manipulate the fetus into a vertex presentation. This is accomplished with ultrasonographic guidance to ascertain fetal lie. An attempt is made to manipulate the fetus through either a "forward roll" or "backward roll." The overall chance of success is approximately 60%. [42] Some practitioners administer an epidural to the patient before attempting version, and others may give the patient a dose of subcutaneous terbutaline (a beta-mimetic used for tocolysis) just before the attempt.

Factors that influence the success of an attempted version include multiparity, a posterior placenta, and normal amniotic fluid with a normally grown fetus. In addition, to be a candidate, a patient must be eligible for an attempted vaginal delivery.

Contraindications to external cephalic version inlclude oligohydramnios, intrauterine growth restriction with abnormal doppler or fetal heart tracing, major uterine anomalies, antepartum hemorrhage, abnormal fetal heart tracing, multiparity and rupture of memebrane. [43]

Relative contraindications include poor fetal growth or the presence of congenital anomalies. Risks of an external cephalic version include rupture of membranes, labor, fetal injury, and the need for an emergent cesarean delivery due to placental abruption. A recent review reported a severe complication rate of 0.24% and a cesarean section rate secondary to complications of 0.34%. [42]

If the version is successful, the patient is placed on a fetal monitor in close proximity to the labor and delivery unit or in the labor and delivery unit itself. If fetal heart rate testing is reassuring, the patient is discharged to await spontaneous labor, or she may be induced if the fetus is of an appropriate gestational age or the patient has a favorable cervix.

The first twin in a nonvertex presentation is an indication for a cesarean delivery, as are higher order multiples (triplets or greater). A large body of literature supports both outright cesarean delivery as well as spontaneous breech delivery or extraction of the second twin.

The decision is made in conjunction with the patient after appropriate counseling regarding the risks and benefits as well as under the supervision of a physician experienced in the management of the labor and delivery of a breech fetus. [44] Evidence suggests that the rate of severe complications of the second breech twin is independent of the mode of delivery. [45]

Several congenital anomalies are controversial indications for cesarean delivery; these include fetal neural tube defects (to avoid sac rupture), particularly defects that are larger than 5-6 cm in diameter. One study noted no difference in long-term motor or neurologic outcomes. [46] Some authors noted no relationship between mode of delivery and infant outcomes, [47] while others have advocated cesarean delivery of all infants with a neural tube defect. [48]

Cesarean delivery is indicated in certain cases of hydrocephalus with an enlarged biparietal diameter, and some skeletal dysplasias such as type III osteogenesis imperfecta.

Whether or not an outright cesarean delivery should be performed in the setting of a fetal abdominal wall defect (eg, gastroschisis or omphalocele) remains controversial. Most reviews agree that cesarean is not advantageous unless the liver is extruded, which is a very rare event. [49, 50, 51] The overall incidence of cesarean delivery in this group of patients is probably due to an increased incidence of intrauterine growth retardation and fetal distress prior to or in labor.

In the setting of a nonremediable and nonreassuring pattern remote from delivery, a cesarean delivery is recommended to prevent a mixed or metabolic acidemia that could potentially cause significant morbidity and mortality. Electronic fetal monitoring was used in 85% of labors in the United States in 2002. [52] Its use has increased the cesarean delivery rate as much as 40%. [53] This has occurred without a decrease in the cerebral palsy or perinatal death rate. [54]

ACOG has recommended that any facility providing obstetric care have the capability of performing a cesarean delivery within 30 minutes of the decision. Despite this recommendation, a decision to delivery time of more than 30 minutes is not necessarily associated with a negative neonatal outcome. [55]

Among patients with first-episode genital herpes infection, the risk of maternal-fetal transmission is 33 times higher than with recurrent outbreaks. The largest population-based study reported that for primary infection, the risk of transmission to the newborn was 35%, compared with a 2% risk for recurrent infection. Among patients with culture-positive herpes, the transmission rate with vaginal delivery was 7 times that with cesarean delivery.

Currently, all patients with active or symptomatic herpes infection are candidates for cesarean delivery. [56] Neonatal infection with herpes can lead to significant morbidity and mortality, especially with a primary outbreak. With recurrent outbreaks, the risk to the neonate is reduced by the presence of maternal antibodies. Unfortunately, not all women with active viral shedding can be detected upon admission to labor and delivery.

Treatment of women with HIV infections has undergone tremendous change in the past few years. Women with a viral count above 1,000 should be offered cesarean delivery at 38 weeks (or earlier if they go into labor). In women who are being treated with highly active antiretroviral therapy (HAART), cesarean delivery (before labor or without prolonged rupture of membranes) appears to further lower the risk for neonatal transmission, particularly among those with viral counts above 1,000.

Among patients with low or undetectable viral counts, the evidence supporting a benefit is not as clear; nevertheless, the patient should be given the option of a cesarean delivery. [57]

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