Caesarean section
A Caesarean section (C-section) is a surgical procedure for delivering one or more babies through incisions in the mother's abdominal wall and uterus.[1] It is typically indicated when vaginal birth is unsafe or infeasible, such as due to fetal distress, abnormal fetal presentation, maternal conditions like placenta previa, or failure to progress in labor.[1] While essential for averting maternal and neonatal mortality in high-risk scenarios, the procedure carries risks including infection, hemorrhage, thromboembolism, and longer-term complications like uterine rupture in subsequent pregnancies or placental abnormalities.[2][3] Global Caesarean section rates have risen sharply, from approximately 7% in 1990 to 21% by recent estimates, with stark disparities: under 5% in some low-resource regions like southern Africa, exceeding 50% in parts of Latin America and certain high-income countries.[4]32394-8/fulltext) This escalation has sparked debate over optimal utilization, as evidence indicates maternal and perinatal mortality decline with rates up to 10%, beyond which additional benefits plateau or risks may outweigh advantages, though some analyses suggest a ceiling as high as 15-19% in developed settings without further harm.[5][6] Concerns include overuse driven by non-medical factors, contributing to higher neonatal respiratory issues, altered infant gut microbiota, and maternal morbidity without commensurate improvements in outcomes.32394-8/fulltext)[7]Indications and Uses
Medical Indications
Caesarean sections are medically indicated when vaginal delivery presents substantial risks to maternal or fetal health that exceed those of the surgical procedure, as determined by clinical guidelines emphasizing evidence-based thresholds for intervention.[1] Primary indications typically arise from failure of labor progress, fetal compromise, or anatomical/physiological incompatibilities, with labor dystocia accounting for the leading cause in many cohorts, followed by abnormal fetal heart rate tracings and malpresentation.[8] [9] These criteria prioritize scenarios where empirical data demonstrate improved outcomes, such as reduced perinatal mortality in cases of acute fetal distress, though overuse for borderline dystocia has prompted quality-improvement initiatives to favor operative vaginal delivery or augmented labor when feasible.[10] Fetal indications include nonreassuring fetal status, evidenced by persistent category III heart rate patterns indicating hypoxia, which necessitates immediate delivery to avert acidosis or neurological injury; randomized trials and observational data link timely caesarean intervention in such cases to lower rates of neonatal encephalopathy.[1] Abnormal lie or presentation, such as breech (frank, complete, or footling) in term singleton pregnancies, warrants caesarean when external version fails, as the Term Breech Trial demonstrated a 2-5 fold reduction in perinatal mortality and short-term morbidity compared to planned vaginal birth.[9] Suspected macrosomia exceeding 5000 grams in diabetic mothers or 4500 grams in nondiabetic cases raises cephalopelvic disproportion risk, though meta-analyses indicate routine caesarean solely for estimated fetal weight over 4000 grams lacks robust support without additional labor complications, due to ultrasound inaccuracies.[11] Maternal indications encompass conditions like active genital herpes simplex infection, where caesarean reduces neonatal transmission risk from over 30% in vaginal delivery with lesions to under 2%, per cohort studies; similarly, prior classical uterine incision or uterine rupture history contraindicates trial of labor owing to recurrence risks up to 6-12%.[12] Severe cardiopulmonary disease or aortic stenosis may necessitate caesarean to avoid hemodynamic stresses of labor, with guidelines recommending multidisciplinary assessment showing lower maternal mortality in controlled surgical settings versus spontaneous delivery.[1] Placental and uterine abnormalities form critical obstetric indications: complete placenta previa, covering the internal os, mandates caesarean due to hemorrhage risk during cervical dilation, with population data reporting maternal transfusion needs in 20-40% of attempted vaginal cases; placental abruption with fetal compromise similarly requires urgent delivery, as delays correlate with 10-20% stillbirth rates.[13] Umbilical cord prolapse, occurring in 0.1-0.6% of deliveries, constitutes an emergency absolute indication, with fetal mortality approaching 10-20% without immediate caesarean, underscoring the causal imperative of rapid surgical access.[14] Multiple gestation, particularly non-vertex presenting twins, elevates risks of interlocking or cord issues, justifying planned caesarean in select configurations per randomized evidence of reduced composite adverse outcomes.[15] Absolute indications like transverse fetal lie or vasa previa, though rare (comprising under 10% of total caesareans), demand intervention to prevent catastrophic vascular disruption or dystocia.[3]Elective Indications and Maternal Request
Elective caesarean sections are scheduled procedures performed prior to the onset of labor, typically for indications that permit advance planning and do not require immediate intervention. These include a history of prior caesarean delivery, where women may opt for a repeat procedure to avoid the approximately 0.5–0.9% risk of uterine rupture associated with trial of labor after caesarean (TOLAC) in low-risk cases with one previous low transverse incision.[16] Other elective indications encompass persistent breech presentation in singleton term pregnancies after external cephalic version has failed, multiple gestations with non-vertex presentations, and select maternal comorbidities such as severe cardiopulmonary conditions that increase risks during vaginal labor.[3] Guidelines from organizations like the American College of Obstetricians and Gynecologists (ACOG) and the Royal College of Obstetricians and Gynaecologists (RCOG) recommend scheduling such procedures no earlier than 39 weeks of gestation to reduce neonatal respiratory morbidity, absent urgent fetal or maternal concerns.[16][17] Caesarean delivery on maternal request (CDMR), distinct from medically indicated elective procedures, occurs without obstetric or fetal contraindications to vaginal birth and stems from the woman's autonomous preference following informed discussion. ACOG recognizes CDMR as an acceptable option after comprehensive counseling on comparative outcomes, emphasizing that planned vaginal delivery generally entails lower maternal risks such as infection, hemorrhage, and thromboembolism, though repeat caesarean rates exceed 90% among those electing CDMR.[16] Common motivations include fear of labor pain, anxiety over potential perineal trauma or incontinence, prior traumatic vaginal deliveries, or perceptions of enhanced fetal safety, with studies reporting these factors in up to 70% of requesting women in surveyed cohorts.[18] RCOG guidance advises against routine promotion of CDMR due to insufficient long-term evidence favoring it over vaginal birth for outcomes like childhood obesity or asthma, but supports shared decision-making respecting patient values.[17] Globally, CDMR accounts for 0.2–42% of all caesarean sections, varying by region and healthcare system, with higher proportions in settings like parts of Asia and Latin America where cultural or access factors amplify requests.[19][20] Empirical data from population studies indicate planned CDMR may correlate with reduced short-term neonatal risks, such as lower rates of low umbilical artery pH or birth trauma compared to planned vaginal deliveries that convert to emergency caesareans, though maternal recovery times are prolonged.[21] Professional bodies caution that acceding to requests should not occur without documented informed consent addressing these trade-offs, as institutional pressures to minimize overall caesarean rates—now at 21% worldwide—may influence clinician reluctance despite ethical imperatives for autonomy.[22][16]Risks and Complications
Maternal Risks
Caesarean sections are associated with elevated maternal risks compared to vaginal deliveries, including immediate postoperative complications such as infection, hemorrhage, venous thromboembolism, and surgical injuries, as well as long-term issues like subfertility and complications in subsequent pregnancies.[23] These risks stem from the invasive nature of the procedure, involving abdominal incision, uterine entry, and potential anesthesia exposure, which introduce opportunities for bacterial contamination, vascular disruption, and tissue trauma not present in spontaneous labor.32386-9/abstract) Empirical data from large-scale reviews indicate that while elective caesareans may mitigate some intrapartum emergencies, overall maternal morbidity remains higher, particularly for emergency procedures performed after labor onset.[24] Infection rates are substantially higher following caesarean delivery, with women facing a 5- to 20-fold increased risk of surgical site infections or endometritis relative to vaginal birth.[25] Postpartum infections occur in up to 60% more cases after planned caesareans than planned vaginal deliveries, driven by factors like wound contamination and impaired immune response postpartum.[26] Wound infections specifically affect around 20% of caesarean patients in some cohorts, versus near-zero in vaginal births, often requiring antibiotics or reoperation.[27] The overall postpartum infection risk is nearly fivefold elevated, contributing to prolonged hospital stays and readmissions.[28] Hemorrhage poses another acute threat, with caesarean deliveries linked to greater blood loss due to uterine incision and placental separation challenges, especially in intrapartum cases.[29] Postpartum hemorrhage (PPH) affects 1-5% of caesarean patients, exceeding vaginal birth rates, and intraoperative losses exceeding 1 liter occur in approximately 8% of cases.[24] [30] Risk factors include prior caesareans, emergency timing, and conditions like preeclampsia, amplifying the need for transfusions or hysterectomy in severe instances.[31] Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is fourfold more common after caesareans than vaginal deliveries, with absolute risks of 2.6-4.3 per 1,000 postpartum cases, heightened by immobility, hypercoagulability, and surgical trauma.[32] [33] This elevation persists independently of other factors and is more pronounced in emergency caesareans or those in obese patients.49108-7/abstract) Surgical injuries, such as bladder or bowel perforation, arise in 0.5-2% of procedures, more frequently during emergencies due to adhesions or distorted anatomy from labor.32386-9/abstract) Maternal mortality tied to caesareans reaches 7.6 per 1,000 procedures globally, often from hemorrhage or infection, underscoring the procedure's inherent hazards despite advances in technique.32386-9/abstract) Long-term, caesareans elevate risks of subfertility, with odds ratios indicating reduced conception rates post-procedure, possibly from adhesions or endometrial damage.[23] Subsequent pregnancies face heightened dangers of placenta previa (odds ratio ~2-3), uterine rupture (especially with trial of labor after caesarean), and hysterectomy, alongside increased stillbirth and preterm birth rates.[23] [34] These persist across studies, reflecting scar-related placental abnormalities and weakened uterine integrity, though data quality varies due to confounding by indication for initial caesarean.[35]Neonatal and Long-term Child Outcomes
Neonates born via caesarean section face elevated risks of transient tachypnea of the newborn and respiratory distress syndrome compared to those delivered vaginally, particularly in term pregnancies without preceding labor, due to delayed clearance of fetal lung fluid and reduced catecholamine surge.[36][37] A meta-analysis of randomized trials found planned caesarean delivery associated with similar perinatal mortality rates to planned vaginal delivery but higher incidences of respiratory morbidity in the former.[38] In preterm infants at or below 32 weeks, planned caesarean does not improve survival over vaginal delivery, with odds ratios indicating no significant benefit (OR 0.87, 95% CI 0.74-1.02).[39] However, for term breech presentations, caesarean delivery reduces perinatal morbidity and mortality, with vaginal breech linked to higher adverse neonatal outcomes such as low Apgar scores and trauma.[40][41] Caesarean-born neonates also exhibit higher rates of neonatal intensive care unit admission, independent of gestational age, attributed to factors like anesthesia effects and lack of labor-induced stress responses.[42] In extremely preterm infants (22-28 weeks), caesarean delivery correlates with lower adjusted rates of mortality or severe morbidity (26.1% vs. 33.7% for vaginal), though overall survival differences remain debated.[43] Long-term, children delivered by caesarean section show increased risks of asthma (OR 1.20, 95% CI 1.15-1.25 in meta-analyses), allergic rhinitis, atopic dermatitis, and obesity, potentially linked to altered gut microbiome colonization bypassing vaginal microbial transfer.[44][45][46] Systematic reviews confirm higher incidences of respiratory tract infections and immune-mediated disorders in caesarean cohorts, with microbiome dysbiosis—characterized by reduced Bifidobacteria and increased Enterobacteriaceae—implicated as a causal pathway, though confounded by intrapartum antibiotics and familial factors.[47][48] Sibling comparison designs partially attenuate these associations for asthma and allergies, suggesting confounding by unmeasured shared genetics or environment, yet obesity risks persist independently.[49][50] Neurodevelopmental outcomes reveal mixed evidence: some population studies report modestly elevated risks of autism spectrum disorder and attention-deficit/hyperactivity disorder (e.g., HR 1.17 for neurodevelopmental disorders in Swedish cohorts), potentially tied to microbiome-immune axis disruptions or anesthesia exposure.[51][52] However, other analyses, including sex-stratified data, find no differences in developmental delay or cognitive scores between caesarean and vaginal groups after adjusting for confounders.[53][54] Early childhood motor and language scores may be transiently lower in caesarean-born children during the first three years, normalizing later.[55] Overall hospitalization rates in childhood are reduced with caesarean delivery in quasi-experimental designs, countering some morbidity narratives.[56]Benefits and Comparative Outcomes
Life-Saving Role
Caesarean sections serve a critical life-saving function in obstetrics by enabling timely delivery when vaginal birth poses imminent risks to the mother or fetus. In conditions such as obstructed labor, where the fetus cannot pass through the birth canal due to cephalopelvic disproportion or malposition, caesarean delivery prevents maternal exhaustion, uterine rupture, and fetal asphyxia, which historically resulted in high mortality rates before surgical intervention became routine. Similarly, for placenta previa—where the placenta covers the cervix—caesarean section averts severe hemorrhage during labor, a leading cause of maternal death without intervention.[4] Empirical data underscore the procedure's impact on mortality reduction. A global analysis of countries with low caesarean rates indicates that increasing access to the procedure could prevent approximately 160,000 maternal deaths and 800,000 neonatal deaths annually, particularly in low- and middle-income countries where emergency obstetric care is limited. In high-risk scenarios like fetal distress from cord prolapse or severe preeclampsia, caesarean sections have demonstrably lowered perinatal mortality; for instance, timely intervention in breech presentations reduces the risk of neonatal trauma and hypoxia compared to attempted vaginal delivery. Historical advancements in caesarean techniques, from the late 19th century onward, dramatically decreased maternal mortality from over 50% in early procedures to under 0.1% in modern settings with proper anesthesia and antibiotics.[57][58] Cross-country studies further quantify benefits: caesarean rates up to 19% correlate with optimal reductions in maternal and infant mortality, beyond which additional procedures do not yield proportional gains but still affirm the threshold's life-preserving threshold in under-served regions. The World Health Organization recognizes caesarean sections as essential for averting deaths in medically indicated cases, though access disparities exacerbate outcomes in developing nations, where procedure-related mortality can reach 100 times higher rates due to inadequate facilities rather than the surgery itself. These outcomes highlight causal mechanisms: caesarean bypasses physiological barriers in labor, directly interrupting lethal cascades like prolonged hypoxia or postpartum hemorrhage.[59][60][4]Versus Vaginal Delivery: Empirical Evidence
Empirical studies indicate that planned cesarean delivery carries higher short-term maternal risks compared to planned vaginal delivery in low-risk pregnancies, including a 60% increased risk of postpartum infection across age and parity strata.[61] Maternal mortality rates remain similar between the two modes, as shown in meta-analyses of randomized controlled trials.[38] Cesarean delivery is linked to elevated morbidity such as hemorrhage, infections, hysterectomy, uterine rupture, and prolonged hospital stays.[34] In contrast, vaginal delivery is associated with higher rates of perineal trauma, but cesarean reduces long-term pelvic floor issues, with odds ratios of 0.56 for urinary incontinence (95% CI 0.47-0.66) and lower prolapse incidence.[35][62] For neonatal short-term outcomes in term singleton cephalic presentations, planned cesarean and vaginal deliveries yield comparable perinatal mortality and severe morbidity rates.[38] However, in term breech presentations, planned cesarean significantly lowers perinatal death or serious morbidity, with meta-analyses confirming reduced NICU admissions (0.8% vs. 2.8% for vaginal) and adverse events.[41][40] For extremely preterm deliveries (≤32 weeks), planned cesarean does not improve overall survival compared to vaginal (OR 0.87, 95% CI 0.70-1.09), though it benefits breech preterm infants by reducing mortality.[63] Vaginal birth avoids cesarean-related neonatal respiratory issues like transient tachypnea, but carries risks of birth trauma in malpresentations.[39] Long-term child outcomes reveal associations between cesarean delivery and elevated risks, though causality remains debated due to confounding factors like gestational age and maternal health. Meta-analyses report a 19% increased odds of type 1 diabetes mellitus in cesarean-born children after confounder adjustment.[64] Cesarean delivery correlates with higher odds of autism spectrum disorders (OR 1.33, 95% CI 1.04-1.70) and potential links to allergies and asthma, potentially via disrupted microbiome acquisition.[65][64] Sibling-comparison studies yield inconsistent findings on broader health impacts, suggesting observational biases may inflate associations.[49] Repeat cesareans further elevate child risks for developmental issues, asthma, and allergies compared to spontaneous vaginal birth.[66]| Outcome Category | Cesarean vs. Vaginal Delivery Risk Estimate | Source |
|---|---|---|
| Maternal postpartum infection | OR 1.60 (60% higher) | [61] |
| Urinary incontinence (long-term) | OR 0.56 (reduced) | [62] |
| Perinatal mortality (cephalic term) | Similar rates | [38] |
| Perinatal morbidity (breech term) | Reduced with cesarean | [40] |
| Type 1 diabetes (child long-term) | OR 1.19 (increased) | [64] |
Classification
By Urgency and Timing
Caesarean sections are categorized by urgency into a four-tier system that recognizes a continuum of risk, rather than absolute thresholds, to guide clinical decision-making and resource allocation. This classification, endorsed by the Royal College of Obstetricians and Gynaecologists (RCOG), prioritizes the degree of maternal or fetal compromise while avoiding overly rigid decision-to-delivery (DD) intervals, as evidence indicates that strict time targets like 30 minutes for emergencies do not consistently correlate with improved outcomes.[67][68] Category 1 encompasses situations with an immediate threat to the life of the woman or fetus, such as uterine rupture, cord prolapse, or severe placental abruption with hemodynamic instability, necessitating the most rapid intervention possible. Although a DD interval of under 30 minutes is often targeted in practice, studies show variability in adherence and no definitive evidence that achieving this benchmark universally prevents adverse events, emphasizing the need for individualized assessment over arbitrary timing.[67][69] Category 2 involves maternal or fetal compromise that is not immediately life-threatening, including non-reassuring fetal heart rate patterns without acidosis, failure to progress in labor with suspected fetal distress, or maternal exhaustion with ongoing contractions. Delivery is aimed within 30 to 75 minutes in many protocols, but the focus remains on stabilizing the patient en route to surgery, as delays beyond this window do not always worsen prognosis when monitoring is continuous.[68][70] Category 3 applies to antenatal conditions requiring early delivery without current maternal or fetal compromise, such as severe preeclampsia at term or intrauterine growth restriction necessitating timed birth to prevent deterioration. Procedures in this category are scheduled within hours to days, allowing for preparatory measures like corticosteroid administration for fetal lung maturity if preterm, with timing optimized to balance risks of continued pregnancy against surgical intervention.[67][68] Category 4 denotes elective caesarean sections, planned for non-urgent indications like prior classical uterine incision or maternal preference at term (typically after 39 weeks gestation to minimize neonatal respiratory risks), with delivery timed during standard operating hours to facilitate multidisciplinary support. This category constitutes a significant proportion of procedures in high-resource settings, though overuse has raised concerns about population-level morbidity without corresponding benefits in uncomplicated cases.[67][68]By Maternal and Fetal Characteristics
The Robson Ten Group Classification System (TGCS), developed in 2001, categorizes all caesarean sections into ten mutually exclusive and collectively exhaustive groups based on five objective maternal and fetal characteristics: parity (nulliparous or multiparous excluding previous caesarean), previous caesarean section history, gestational age, fetal presentation and lie, number of fetuses, and onset of labour.[71][72] This system enables standardized monitoring, auditing, and international comparison of caesarean rates by identifying contributions from specific obstetric subgroups, facilitating targeted interventions to optimize rates without compromising maternal or fetal outcomes.[71][73] Endorsed by the World Health Organization in 2015 as a global standard, it addresses limitations of unstratified caesarean rates, which fail to account for varying baseline risks across populations.[71][74] The groups prioritize term (≥37 weeks) singleton cephalic presentations in nulliparous and multiparous women, which account for the majority of deliveries, while separating high-risk categories like preterm, breech, or multiples.[72] Group 5, encompassing women with prior caesarean sections, often drives elevated rates due to policies favoring repeat procedures over vaginal birth after caesarean (VBAC), though VBAC success varies by 60-80% in suitable candidates per empirical data.[71][75]| Group | Description |
|---|---|
| 1 | Nulliparous women with singleton cephalic pregnancy at ≥37 weeks in spontaneous labour.[71] |
| 2 | Nulliparous women with singleton cephalic pregnancy at ≥37 weeks who had labour induced or caesarean before labour.[71] |
| 3 | Multiparous women (no prior caesarean) with singleton cephalic pregnancy at ≥37 weeks in spontaneous labour.[71] |
| 4 | Multiparous women (no prior caesarean) with singleton cephalic pregnancy at ≥37 weeks who had labour induced or caesarean before labour.[71] |
| 5 | All women with prior caesarean section(s), singleton cephalic pregnancy at ≥37 weeks (includes spontaneous, induced labour, or pre-labour caesarean).[71] |
| 6 | All nulliparous women with singleton breech presentation.[71] |
| 7 | All multiparous women (including prior caesarean) with singleton breech presentation.[71] |
| 8 | All women with singleton transverse or oblique fetal lie, regardless of parity or gestational age.[71] |
| 9 | All women with singleton cephalic pregnancy at <37 weeks gestation, regardless of parity or labour onset.[71] |
| 10 | All women with multiple pregnancies, regardless of fetal presentation, parity, or gestational age.[71] |
Surgical Technique
Anesthesia and Pain Management
Neuraxial anesthesia, encompassing spinal, epidural, and combined spinal-epidural techniques, is the preferred method for most cesarean sections due to superior maternal and fetal outcomes compared to general anesthesia.[77][78] Spinal anesthesia involves a single intrathecal injection of local anesthetic, typically bupivacaine with an opioid like fentanyl, providing rapid onset within 5 minutes and dense sensory block for 90-120 minutes, suitable for elective procedures.[79][77] Epidural anesthesia, administered via catheter, allows titration and prolongation if labor analgesia was previously established, though it has slower onset and requires higher anesthetic volumes.[80][81] Combined spinal-epidural combines rapid spinal block with epidural catheter for extended use, reducing failure rates to under 1% in experienced settings.[77] General anesthesia is reserved for emergencies, such as fetal distress or failed neuraxial attempts, involving rapid sequence induction with agents like propofol and succinylcholine, followed by intubation; however, it carries higher risks including difficult airway management in up to 1-2% of cases and neonatal depression from anesthetic exposure.[82][83] Empirical data from large cohorts show general anesthesia associated with increased maternal morbidity, including hemorrhage and infection, and a dose-dependent risk of neuroapoptosis in neonates, though long-term effects remain debated.[84][85] Neuraxial techniques mitigate these by avoiding fetal drug exposure, with hypotension—the most common complication—affecting 10-20% of spinal cases, primarily managed with phenylephrine vasopressors rather than fluids alone per enhanced recovery protocols.[86][78] Intraoperative pain during neuraxial anesthesia occurs in approximately 6% of cases, often due to inadequate block height, and is addressed by supplemental local infiltration, intravenous opioids, or conversion to general anesthesia if unresolved.[83] Postoperatively, multimodal analgesia forms the cornerstone, initiating intraoperatively with paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen after cord clamping to minimize opioid needs, achieving pain scores below 4/10 in 80-90% of patients without excessive sedation.[87][88] Intrathecal opioids, such as morphine (100-200 mcg), extend analgesia to 12-24 hours but increase risks of pruritus (up to 60%) and respiratory depression (0.1-0.5%), necessitating monitoring.[89] Opioids are reserved for breakthrough pain, with scheduled acetaminophen and NSAIDs reducing total opioid consumption by 50% compared to opioid monotherapy, per PROSPECT guidelines.[90][87] Patient-controlled analgesia or tapentadol may supplement for severe pain, though evidence favors minimizing opioids to avoid neonatal transfer via breastfeeding and maternal side effects like nausea.[91]Procedure and Recent Advances
The Caesarean section procedure typically begins with preoperative preparation, including placement of an intravenous line for fluid administration and antibiotics, insertion of a urinary catheter to empty the bladder, and administration of regional anesthesia such as spinal or epidural block in most elective cases.[1] [2] The patient is positioned supine with a left lateral tilt to avoid aortocaval compression, and the abdomen is prepped and draped sterilely.[9] Surgical access involves a transverse Pfannenstiel incision, approximately 10-15 cm long, 2 cm above the pubic symphysis, extending through skin and subcutaneous tissue to the rectus fascia, which is incised transversely and separated from the underlying muscle.[1] [2] The peritoneum is opened, the bladder is dissected inferiorly to form a flap, and a low transverse incision is made in the lower uterine segment, extended manually or with scissors to avoid irregular tears.[92] The fetus is delivered by manual extraction, the amniotic fluid is suctioned, the umbilical cord is clamped and cut, and the newborn is handed to neonatal care providers.[12] The placenta is then manually removed, and the uterine incision is closed with a single or double layer of absorbable sutures.[1] Closure proceeds layer by layer: the visceral and parietal peritoneum may be left unsutured based on evidence of no benefit in reducing adhesions, the rectus fascia is closed with continuous absorbable suture to minimize dehiscence risk, subcutaneous tissue is approximated if thick, and the skin is closed with staples, subcuticular suture, or glue.[9] [93] The entire operation lasts 30-60 minutes, with fetal delivery occurring within 5-10 minutes of uterine incision in uncomplicated cases.[1] Variations include vertical incisions for emergencies or prior surgeries, but the transverse approach predominates for its lower infection and rupture risks in future pregnancies.[92] Recent advances emphasize evidence-based optimizations to enhance safety and recovery. Enhanced Recovery After Caesarean (ERAC) protocols, updated in 2025 by the Enhanced Recovery After Surgery Society, recommend multimodal interventions such as preoperative carbohydrate loading, intraoperative goal-directed fluid therapy with vasopressors for hemodynamic stability, and standardized uterine closure techniques to reduce blood loss and operative time.00121-8/abstract) 00071-7/abstract) These guidelines, derived from systematic reviews of randomized trials, promote active warming, minimized opioid use via non-opioid analgesics, and early mobilization to shorten hospital stays without increasing complications.[94] 00144-0/fulltext) Further innovations include the adoption of checklists and protocols for complex cases to mitigate hemorrhage risks, such as uterine artery ligation or compression sutures when needed, and increased use of misoprostol or tranexamic acid prophylactically in high-risk settings based on 2020-2025 trials showing reduced transfusion rates.[95] Robotic-assisted laparoscopy for select repeat Caesareans has emerged experimentally since 2020, offering precision in adhesiolysis but with longer operative times and higher costs, limiting routine application pending larger outcome data.[96] WHO's 2025 surgical subgroup efforts focus on standardizing techniques in low-resource settings to curb rising global rates projected at 38 million by 2030, prioritizing appropriate indications to avoid overuse.[97]Prevention of Intraoperative Complications
Preoperative administration of intravenous antibiotic prophylaxis, such as a first-generation cephalosporin, within 60 minutes before skin incision significantly reduces the risk of endometritis (relative risk [RR] 0.47) and overall infectious morbidity (RR 0.50) during cesarean delivery.[93] [98] Additional azithromycin is recommended for patients with labor or ruptured membranes to further mitigate infection risks.[98] Vaginal preparation with povidone-iodine solution prior to surgery decreases endometritis incidence (RR 0.57), though chlorhexidine-alcohol is preferred for skin antisepsis to lower superficial surgical site infections.[93] [98] To prevent hemorrhage from uterine atony, oxytocin infusion (10-40 IU in 1 L crystalloid over 4-8 hours) is standard immediately after delivery, with carbetocin as an alternative in resource-available settings for superior efficacy in high-risk cases.[93] [99] Blunt expansion of the uterine incision in a cephalad-caudad direction minimizes unintended extensions (3.7% vs. 7.4%) and severe blood loss exceeding 1500 mL (0.2% vs. 2.0%).[93] Tranexamic acid (10 mg/kg IV) adjunctively reduces blood loss by 100-200 mL, particularly in patients with placenta accreta spectrum or prior cesareans.[93] Visceral injuries, notably to the bladder, are mitigated by cautious dissection and avoidance of routine bladder flap development, which shortens incision-to-delivery interval without elevating complication rates.[93] In high-risk scenarios such as adhesions or placenta previa, antenatal risk stratification enables tailored techniques like bladder filling to protect against injury during entry.[100] Regional anesthesia is prioritized over general to diminish associated intraoperative risks, including aspiration and hemodynamic instability.[98] Intraoperative hypothermia, which exacerbates bleeding and infection, is prevented by monitoring core temperature, employing forced-air warming devices, warming intravenous fluids, and maintaining operating room temperatures at least 23°C.[98] Surgical teams should change gloves after placental delivery and before abdominal closure to curb contamination and subsequent wound issues.[99] For closure, double-layer uterine repair preserves myometrial thickness, while subcutaneous closure (if ≥2 cm depth) and monofilament sutures for skin reduce disruption without drains or irrigation, which offer no benefit.[93] [99] These measures, derived from randomized trials, underscore technique over adjuncts in averting complications.[93]Recovery and Post-Operative Care
Immediate Postpartum Period
Following a caesarean section, the immediate postpartum period encompasses the first 24 to 72 hours, during which maternal vital signs are closely monitored for stability, including blood pressure, heart rate, respiratory rate, and oxygen saturation, to detect early signs of hemorrhage or infection.[101] Uterine tone is assessed frequently to ensure contraction and minimize blood loss, with average postpartum hemorrhage risk elevated compared to vaginal delivery due to surgical trauma, though prophylactic oxytocin administration reduces this incidence.[102] The incision site is inspected for redness, swelling, or discharge indicative of infection, which occurs in approximately 3-17% of cases without preventive measures.[103] Pain management involves multimodal analgesia, including opioids initially and transition to non-opioids, alongside non-pharmacologic methods like ice packs, to facilitate mobility.[104] Early ambulation, often within 6-12 hours post-surgery, is promoted to prevent deep vein thrombosis, with sequential compression devices used prophylactically in high-risk patients.[104] Urinary catheters, if placed, are removed promptly after resolution of spinal anesthesia effects to reduce urinary tract infection risk.[104] Prophylactic antibiotics are administered to all patients undergoing the procedure to lower surgical site infection rates.[105] For the newborn, Apgar scores are evaluated at 1 and 5 minutes, and skin-to-skin contact is encouraged as soon as maternal stability allows, typically within the first hour, to promote bonding and thermoregulation.[106] Breastfeeding initiation may be delayed compared to vaginal births due to maternal anesthesia recovery and positioning challenges from the incision, with studies showing lower rates of initiation within the first hour post-C-section.[107] Supportive positioning, such as the football hold, aids latching despite abdominal pain.[108] Hospital discharge typically occurs after 2 to 4 days if uncomplicated, allowing time for wound healing assessment and education on self-care, including signs of complications like excessive bleeding or fever.[12] Common immediate issues include fatigue, anemia from blood loss (reported in 10.5-57.1% of cases), and perineal or abdominal pain, necessitating rest and hydration.[109] Emotional support is provided to address potential anxiety from surgical recovery and separation from the infant if neonatal intensive care is required.[110]Long-Term Recovery
Most women achieve full physical recovery from caesarean section within 6 to 12 weeks, with the abdominal incision healing externally by 2-3 weeks and internally requiring up to 6 months for complete strength restoration; however, adhesions forming between organs can lead to chronic complications such as bowel obstruction or infertility in rare cases.[23] [111] Incisional hernias occur in approximately 10-20% of cases without preventive measures like mesh reinforcement, necessitating surgical repair in symptomatic patients.[2] Chronic pain syndromes, including neuropathic pain at the scar site, persist in 1-18% of women beyond 3 months postpartum, often linked to nerve entrapment or incomplete fascial healing; interventions such as scar mobilization therapy have shown efficacy in reducing symptoms in observational studies.[112] [113] Isthmocele, a defect in the uterine scar, develops in up to 60% of low transverse incisions as detected by ultrasound, potentially causing abnormal uterine bleeding, pelvic pain, or secondary infertility requiring hysteroscopic or laparoscopic repair.[114] Caesarean delivery elevates risks in subsequent pregnancies, including subfertility (with reduced conception rates observed in cohort studies), placenta previa (odds ratio 1.4-2.0), placental accreta (risk increasing with each prior section, up to 3% after two), and uterine rupture during trial of labor (0.5-0.9% incidence).[23] [115] [116] These complications contribute to higher rates of hysterectomy (up to 2-fold increase) and severe maternal morbidity in parous women with prior sections.[117] Long-term maternal health data indicate elevated odds of chronic conditions like asthma or obesity in offspring, though direct causal links remain debated due to confounding factors such as maternal indications for the initial section.[50]Epidemiology and Trends
Global and Regional Rates
The global caesarean section rate stood at 21% of all births as of the 2015–2020 period, representing a tripling from approximately 7% in 1990, according to World Health Organization (WHO) estimates derived from national health surveys and vital registration data across 126 countries.[22] This figure encompasses both medically indicated and elective procedures, with projections indicating a further rise to 28.5–29% by 2030, driven primarily by increases in low- and middle-income countries (LMICs).[118] [119] The WHO posits an optimal rate of 10–15% to minimize maternal and neonatal mortality without introducing excess surgical risks, though empirical analyses suggest rates up to 19% may align with life-saving benefits in varied contexts.[22] [120] Regional disparities reflect differences in healthcare infrastructure, socioeconomic factors, and access to emergency obstetric care. In Latin America and the Caribbean, rates average 43%, with countries like Brazil (55.6% in 2019 data) and the Dominican Republic exceeding 50%, often linked to higher utilization in private sectors.[22] Conversely, sub-Saharan Africa exhibits the lowest rates, averaging below 10% in many nations, such as 5% in Ethiopia and Nigeria based on 2018–2021 surveys, where limited surgical capacity contributes to elevated maternal mortality from obstructed labor.[22] [121] In more developed regions, rates cluster around 24–27%, with North America at 32.3% in the United States for 2023 (1,161,896 procedures out of 3.6 million live births).[118] [122]| Region/Development Level | Caesarean Rate (%) | Time Period | Source |
|---|---|---|---|
| Global | 21 | 2015–2020 | WHO |
| Least Developed Regions | 8.2 | 2015–2020 | BMJ Global Health |
| Less Developed Regions | 24.2 | 2015–2020 | BMJ Global Health |
| More Developed Regions | 27.2 | 2015–2020 | BMJ Global Health |
| Latin America/Caribbean | 43 | 2015–2020 | WHO |
| Europe (average range) | 16–52 | 2015–2019 | European Perinatal Health Report |
| United States | 32.3 | 2023 | CDC |