Medical indicators for a caesarean

Prior to the onset of labour certain 'medical indicators' may mean that a caesarean is more of a possibility. In some cases your health professionals may advise you that in the circumstances a caesarean is considered a safer option than attempting a vaginal delivery. In which case it can, with your consent, be scheduled prior to commencement of labour. Some medical indicators only arise during labour at which point an emergency caesarean may become necessary.

• Your baby is in a breech (bottom first) or transverse (sideways) position. Attempting to turn your baby prior to birth can remove the need for a caesarean in this instance. Approximately 4% of births involving a single baby are breech presentation 27. This is the fourth most common reason for conducting a caesarean 47
• You are carrying multiple babies
  • If your first baby is not in the breech position and the cords of both babies are not entangled, this can be negotiated. At the time of the audit 59%of twin pregnancies were delivered by caesarean, of which 63% were emergency
  • Of the emergency sections the baby's distress was the most influential factor (29%) and failure to progress (12%).
  • Caesarean for delivery of the second twin following a vaginal delivery of the first baby was carried out in 3.5% of twins
  • 92% percent of triplets were delivered by caesarean (though interestingly all babies in three sets of triplets were delivered vaginally).
• You have placenta praevia (the placenta is implanted so low in the uterus that it blocks your baby's exit), or abruptio placenta, (the placenta has separated from the uterine wall and your baby's life is in danger)
• You have pre-eclampsia and it is rapidly worsening, making it dangerous to delay delivery
• You have pregnancy induced hypertension
• You have diabetes (diabetes alone is not an indicator, it is more to do with the associated factors such as the potential size of your baby, previous obstetric history, control of diabetes etc.)
• Your baby is discovered to have a known foetal illness or abnormality
• You had heavy bleeding in pregnancy (known as an antepartum haemorrhage)
• You had a previous caesarean delivery. Alone this is not necessarily a reason for a caesarean - Vaginal Birth After Caesarean (VBAC) organisations can give you more detailed information about a vaginal delivery after a caesarean
• You had a previous traumatic vaginal delivery. This is not necessarily grounds for a caesarean if the trauma is purely psychological
• You have an infectious disease i.e. you have HIV or are currently having a genital herpes outbreak, which can be passed on to your baby if you deliver vaginally (if the out break of genital herpes was prior to the 3^rd trimester, this is negotiable)

There are a number of factors which have been shown to increase the likelihood of having a caesarean:

• Age - there is some evidence to suggest that the risk of needing a caesarean increases with the age of the mother. In the UK caesarean rates are lowest in mothers below 20 years old (13.4%) and the rate increases with age. First time mothers 35 years or older "had a 2-fold increase in cesarean delivery rate over younger nulliparae [first time mothers], and 50% more cesarean deliveries than the multiparae [women that have had previous 'viable' births] aged 35 years or more. Similar trends were observed in preterm labor, labor induction, breech presentation, and instrumental delivery." 123 Another study agreed with these findings and added "In the second stage of labour fetal distress and failure to advance, requiring instrumental delivery, were both more likely with increasing maternal age...Epidural usage in induced labour and the incidence of small for gestational age newborns did not increase with increasing maternal age." 123 As Adam Rosenthal, a Clinical research fellow at Queen Charlotte's and Chelsea Hospital in London, commented in reference to this study "It could be argued that older women or their obstetricians may be more anxious, which may prompt higher rates of intervention, but the incremental increase in operative delivery rates, and the fact that there was also an incremental increase in failure to progress as a cause of instrumental delivery, point to a genuine biological effect...If they [older women] then request an elective caesarean section to avoid the high risk of emergency operative delivery (and its proved long term sequelae), then shouldn't obstetricians grant them that wish?" 125
• Weight - a number of studies suggest that the caesarean rate increases with increasing maternal weight, short stature or body mass index 53 54 This finding is echoed in the National Sentinel Caesarean Audit 27
• Cervix length - cervical length, mid-term, may well be an indicator of whether or not a woman is likely to require a caesarean. A study found "the C-section rate was 25.7% for women with a cervix between 40 and 67 millimeters, 21.7% for 36 to 39 millimeters, 18.4% for 31 to 35 millimeters and 16% with a cervical length of 16 to 30 millimeters. An inch is about 25 millimeters." 111
• Male baby - "c-sections are also 20 percent more common for males." "Boys are 60 percent more likely to be premature and to suffer from conditions arising from being born premature, such as respiratory distress syndrome. They are also at a higher risk of birth injury and mortality due to their larger body and head size." 132
• Ethnicity - has unclear links with an increase in caesarean rates. It is thought that some complications i.e. diabetes, hypertensive disorders might be more prevalent during pregnancy in "black" mothers and therefore lead to an increased likelihood of caesarean delivery 27

If you want to avoid a caesarean there are various things you can try to reduce the likelihood of having one. It is possible that on occasions hospitals may recommend a caesarean when a vaginal delivery is still possible. You are within your rights to refuse until your carers have satisfied one of the classifications previously described.

Emergency caesareans

Most (though not all) emergency caesareans are conducted during labour and can become necessary for a variety of reasons:

• You have heavy, persistent, vaginal bleeding
• Your baby is in distress i.e. his / her heart rate trace is indicating that they are not coping with the labour and a vaginal delivery is not thought to be imminent. Such distress contributes between 20% - 24% of all caesareans 47
• You have sudden, severe high blood pressure or fitting
• You have had an unsuccessful induction or are not progressing through the first or second stage of labour (dystocia). This is quite a common reason given by health professionals, contributing to between 18% - 23% of caesareans 47. "Failure to progress" alone is not a valid reason for a caesarean - though sometimes this can lead to further complications in particular fetal distress
• Other medical interventions have failed i.e. or forceps delivery
• The umbilical cord has prolapsed (this is where the cord falls through the cervix, into the vagina in front of your baby running the risk of starving your baby of oxygen during delivery). The vast majority of these cases require immediate caesarean
• The umbilical cord is wrapped around the baby's neck. In the majority of such cases, if managed correctly, you can continue to deliver vaginally
• The uterus has ruptured. This is a complication that can occur if you have a scar on your uterus from invasive abdominal surgery or previous caesarean
• The placenta has torn

Non medical factors

Studies 47 48 14 suggest that factors totally unrelated to the physical and mental condition of the mother may contribute to an increased likelihood of a caesarean birth occurring. Such factors are:

• Hospital size
• Size of maternity unit (as assessed by annual delivery rate)
• Availability of a neonatal intensive care unit (NICU) or perinatal services
• Provision of one-to-one support in labour
• Obstetrician characteristics (such as age, experience, gender and recent medico-legal claims)
• Availability of a 24-hour anaesthetist
• Affiliation with a medical school