Caesarean Section: Sectio Caesarea

Caesarean section – colloquially known as cesarean section – is an incisional delivery in which the infant is surgically removed from the mother’s uterus.Caesarean section is a standard operation in obstetrics today. Approximately 32% of women in Germany give birth by caesarean section. A distinction is made between an absolute indication and a relative indication. An absolute indication exists if the obstetrician can only advise a caesarean section for compelling obstetric reasons, namely to save the life and health of the child and/or the mother. In approximately 90 % of all incisional deliveries, there is a relative indication for which the obstetric risks for mother and child must be weighed. An elective section (synonyms: section at the request of the pregnant woman; elective caesarean section (WKS), elective section, elective section) should not be performed without justification before the 39th week of pregnancy (SSW 39 +0), as the probability of neonatal morbidity (incidence of disease in the newborn) is otherwise increased. In this regard, a meta-analysis concludes that it is not advisable to wait until the estimated term (ET), as there is a significantly increased risk of stillbirth after SSW 40, but neonatal mortality (death of infants during the first four weeks of life) does not decrease further.

Indications (areas of application)

Absolute indications (emergency cesarean section).

  • Absolute mismatch between fetal (child) head and maternal pelvis.
  • Amniotic infection syndrome (English : amniotic infection syndrome, abbreviated: AIS); infection of the egg cavity, placenta, membranes and possibly the fetus during pregnancy or birth with risk of sepsis (blood poisoning) for the child).
  • Pelvic deformities
  • Eclampsia (severe condition especially in the last trimester (third trimester of pregnancy) associated with convulsions)
  • HELLP syndrome (serious disease during pregnancy, which belongs to the hypertensive disorders. The letters HELLP stand for the English terms of the main symptoms: Haemolysis (hemolysis/dissolution of erythrocytes (red blood cells) in the blood), EL = elevated liver enzymes: Alanine aminotransferase (ALT, GPT), aspartate aminotransferase (AST, GOT), glutamate dehydrogenase (GLDH), gamma-glutamyl transferase (γ-GT, gamma-GT; GGT), bilirubin), LP = low platelets (thrombocytopenia/decrease in platelets (blood platelets)).
  • Fetal asphyxia or fetal acidosis (in the child drop in ph < 7.20) – life-threatening situation of the fetus, which can lead to a fetal oxygen deficiency supply.
  • Umbilical cord prolapse – prolapse (prolapse) of the umbilical cord between the head of the child and the vaginal outlet (can lead to fetal asphyxia).
  • Placenta praevia (malposition of the placenta (placenta); in this case, the placenta is nested near the cervix) – obstruction of the birth canal by the placenta, making vaginal birth impossible
  • Transverse position – positional anomaly of the child, making vaginal birth impossible.
  • Premature placental abruption
  • (Impending) uterine rupture (uterine rupture) – acute life-threatening situation for mother and fetus.

Note: Intrauterine growth restriction (IUGR); fetal growth restriction is not considered an indication for primary sectio. A possible decision for a sectio has to be made individually on the basis of Doppler sonography findings, gestational age (gestational age) etc. Relative indications

  • Pathologic CTG (cardiotocogram; heart sound contraction curve).
  • Inadequate progress of labor (protracted labor/prolonged opening or expulsion, labor arrest/birth arrest, and maternal exhaustion)
  • Condition after sectio or after vaginal plastic surgery.
  • Breech presentation (BEL)
  • Premature birth < 32nd week of gestation/< 1,500 g
  • Absolute fetal macrosomia (over 4,500 g).
  • Multiple pregnancy

Before surgery

  • Insofar as a selective section (elective cesarean section) is involved, in addition to general information, information about short- and long-term consequences of a cesarean section is required in particular.
  • Prepartum antibiotic therapy significantly reduces maternal infection-associated morbidity (maternal infection-related morbidity) compared with postpartum antibiotic prophylaxis (postpartum antibiotic prophylaxis). This reduces the risk of endometritis (inflammation of the uterus) and/or endomyometritis (inflammation of the endometrium (endometritis) and uterine muscle layer (endomyometritis)) and wound infections.
  • Short-term maternal inhalation (oxygen administration by the mother) of 50% oxygen in preparation for a caesarean section (cesarean section) under spinal anesthesia does not cause oxidative stress in the fetus. Neither were the malondialdehyde concentration significantly increased nor the TAS level (total antioxidant status) significantly decreased in the arterial cord blood at the time of birth.

The surgical procedure

In caesarean section, a deep lower abdominal cross-section is made at the pubic hairline (acetabular pedicle incision). This involves opening the pregnant woman’s abdominal wall just above the symphysis (shampoo) and cutting through the individual layers of tissue until the uterus (womb) is reached. This is then also opened and the child is born. Afterwards, all layers are carefully sutured again and mother and child are cared for in the delivery room.

Choice of anesthetic procedure

Surgery can be performed under epidural, peridural, spinal anesthesia, or general anesthesia (general anesthesia). The decision to use one of the respective procedures must be weighed on the basis of the situation and the patient.If there is an emergency situation and contraindications (contraindications) to regional anesthesia are present, general anesthesia is the fastest anesthetic procedure.In primary and secondary cesarean deliveries without an epidural catheter already in place-and in the absence of contraindications-spinal anesthesia is the procedure of choice.If epidural catheters are already in place, epidural anesthesia is the procedure of choice.

After surgery

Possible complications

Possible complications of the mother

  • Wound healing disorders and wound infections
  • Bleeding
  • Large blood loss due to a so-called atony (contraction weakness (atony) of the uterus after the birth of the child and the incompletely or completely born placenta, resulting in severe to life-threatening bleeding), which may lead to the administration of blood transfusions
  • Nerve or vascular damage
  • Suture insufficiency (suture leakage)
  • Injury to the urinary tract (ureter and urinary bladder).
  • Injury to the intestine (possibly ileus – intestinal obstruction) or other internal organs.
  • Adhesions
  • Keloid (excessive scarring)
  • Cystitis (inflammation of the bladder) and micturition disorders (bladder emptying disorders) due to the bladder catheter required for the operation
  • Thrombosis (vascular disease in which a blood clot (thrombus) forms in a vessel); embolism (partial or complete occlusion of a blood vessel by a thrombus)

Late effects for the mother

Increased risks in a subsequent pregnancy.

  • Risk of uterine rupture (rupture of the uterus; at the section scar/cesarean scar).
  • Malposition or placenta increta (placenta ingrown into the muscles; with risk of increased bleeding).
  • Increased risk of stillbirth
  • Slightly increased risk of infertility
  • Hysterectomy (surgical removal of the uterus) is significantly more likely to result in perioperative or postoperative complications.

Possible complications of the child

  • Injuries during the child’s surgery and development, such as abrasions, fractures/bone breaks, and cuts (rare)
  • Adjustment disorders and drowsiness may necessitate further therapy
  • Brands of suction cup or forceps sometimes still used for the development of the child.
  • Lactation problems (problems in the breastfeeding phase) and bonding problems between mother and child are more common in sectio children, for example, in the case of insufficient bonding phase (first bonding phase between mother and child) after the procedure.

Late effects on the child

Further notes

  • Genital prolapse (vaginal prolapse) appears to be less common after sectio than after vaginal delivery (delivery through the vagina).
  • Sectio protects against incontinence (bladder weakness) in the long term.
  • A meta-analysis compared Number Needed to Treat (NNT) and Number Needed to Harm (NNH), i.e., the number of cesarean deliveries followed by a favorable or unfavorable event, respectively, in relation to the benefits and harms of a sectio:
    • Prevention of urinary incontinence: NNT of 19.
    • Uterine prolapse (uterine prolapse): NNT of 2 (as calculated by the reporter).
    • Subfertility: NNH of 8
    • Miscarriages: NNH of 70
    • Stillbirths: NNH of 1,138
    • Placenta praevia (malposition of the placenta (placenta); in this case, it is nested near the cervix and covers all or part of the birth canal): NNH of 492
    • Uterine rupture (tearing of the uterus): NNH of 543
    • Asthma disease in childhood: NNH of 164.
    • Obesity at age five: NNH of 3,030 (as calculated by the reporter).