Indications for Primary Cesarean Section
• Cephalopelvic disproportion (CPD). This is the most common indication for cesar-ean delivery. This term literally means the pelvis is too small for the fetal head. In actual practice, it most commonly indicates failure of the adequate progress in labor, which may be related to dysfunctional labor or suboptimal fetal head orientation.
• Fetal malpresentation. This refers most commonly to breech presentation, but alsomeans any fetal orientation other than cephalic.
• Category III EFM strip. The FHR monitor pattern suggests the fetus may not be tol-erating labor, but commonly this is a false-positive finding.
Vaginal Birth After Cesarean (VBAC)
• Successful vaginal delivery rate is up to 80% in carefully selected patients.
• Criteria for trial of labor include patient consent, nonrepetitive cesarean indication
(e.g., breech, placenta previa), previous low segment transverse uterine incision, clini-cally adequate pelvis.
External Cephalic Version. This procedure consists of externally manipulating the gravid abdo-men without anesthesia to turn the fetus from transverse lie or breech presentation. The opti-mum time for version is 37 weeks’ gestation, and success rates are 60–70%. Potential hazards are umbilical cord compression or placental abruption requiring emergency cesarean section.
ELECTIVE CESAREAN
The U.S. National Institutes of Health (NIH) held a consensus conference in March 2006 to determine the scientific basis for maternal and fetal risks and benefits to cesarean delivery on maternal request (CDMR). After 2 days of presentations by experts in the field and input from the audience, the consensus was that “the available information comparing the risks and benefits of CDMR versus planned vaginal birth do not provide the basis for a recommendation in either direction.”
Recommendations from the independent panel of experts include:
• Individual counseling for each woman regarding risks and benefits
• Women who are considering having >2 children should be aware that a cesarean section causes uterine scarring; these women should avoid a primary cesarean section.
• Women should not have a cesarean section prior to 39 weeks’ gestation.
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Postpartum Issues 18
POSTPARTUM PHYSIOLOGIC ISSUES
Reproductive Tract Changes
Lochia. These are superficial layers of the endometrial decidua that are shed through the vaginaduring the first 3 postpartum weeks. For the first few days the color is red (lochia rubra), changing during the next week to pinkish (lochia serosa), ending with a whitish color (lochia alba) by the end of the second week.
Cramping. The myometrial contractions after delivery constrict the uterine venous sinuses, thuspreventing hemorrhage. These lower midline cramps may be painful and are managed with mild analgesics.
Perineal Pain. Discomfort from an episiotomy or perineal lacerations can be minimized in thefirst 24 hours with ice packs to decrease the inflammatory response edema. A heat lamp or sitz bath is more helpful after the first day to help mobilize tissue fluids.
Urinary Tract Changes
Hypotonic Bladder. Intrapartum bladder trauma can result in increased postvoid residual vol-umes. If the residuals exceed 250 mL, the detrusor muscle can be stimulated to contract with bethanechol (Urecholine). Occasionally an indwelling Foley catheter may need to be placed for a few days.
Dysuria. Pain with urination may be seen from urethral irritation from frequent intrapartumcatheterizations. Conservative management may be all that is necessary. A urinary analgesic may be required occasionally.
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