Describe caesarean section — its aetiology, clinical features and management.

Lower segment transverse incision is standard.

Definition

Caesarean section (CS) is the delivery of the fetus, after the period of viability, through incisions on the abdominal wall (laparotomy) and the uterine wall (hysterotomy). The lower-segment caesarean section (LSCS) is the standard operation; the classical (upper-segment) incision is now rarely used.

Indications

Absolute — cephalopelvic disproportion, central placenta praevia, transverse lie, and a previous classical scar or major uterine surgery. Relative / common — previous caesarean section, fetal distress, failed induction or failure to progress, malpresentations (breech), severe pre-eclampsia/eclampsia, antepartum haemorrhage, cord prolapse with a live fetus, and certain medical conditions.

Complications

• Intra-operative — haemorrhage, extension of the uterine incision, injury to the bladder, bowel or ureter, and anaesthetic complications (aspiration — Mendelson's syndrome).
• Post-operative — infection (wound, endometritis, urinary), paralytic ileus, venous thromboembolism, secondary haemorrhage and anaemia.
• Remote / future pregnancy — scar dehiscence or rupture in a subsequent labour, placenta praevia and morbidly adherent placenta (accreta), pelvic adhesions and an increased likelihood of repeat caesarean.

Types of Operation

• Lower-segment caesarean section (LSCS) — a transverse incision in the lower uterine segment; the standard operation (less bleeding, heals well, low rupture risk in a future pregnancy).
• Classical caesarean — a vertical incision in the upper segment, now reserved for special situations (anterior placenta praevia, transverse lie with the back down, a large lower-segment fibroid, some preterm deliveries); it carries a higher risk of scar rupture later.

Vaginal Birth After Caesarean (vbac)

A trial of labour may be offered after one previous LSCS in a suitable woman (a single low transverse scar, no recurring indication, facilities for emergency caesarean), the main risk being scar rupture.

A Note on WHY the Rising Caesarean Rate Matters

A useful point is understanding why a caesarean section, though life-saving, is not a free good. For a woman with an absolute indication, caesarean is unquestionably the right operation. But it carries immediate risks (haemorrhage, infection, anaesthetic complications, injury to the bladder or bowel, thromboembolism) and a maternal mortality several times that of vaginal delivery. Its greater cost, however, is deferred: it leaves a scarred uterus, and that scar shapes every subsequent pregnancy. The woman then faces a lifelong risk of uterine rupture in future labours and — increasingly recognised as a serious problem — of abnormal placentation: the placenta implanting over the scar, giving placenta praevia and, worse, placenta accreta, increta or percreta, in which the placenta invades the scar and cannot be separated, causing torrential haemorrhage and often requiring caesarean hysterectomy. The risk rises with each successive caesarean. This is why every caesarean should have a genuine indication, why VBAC is offered to suitable women, and why the first caesarean — which sets this chain in motion — deserves particular thought. Understanding that the scar, not the operation, is the lasting consequence explains this caution.

• Caesarean section: delivery through incisions in the abdominal and uterine walls; the lower-segment transverse incision is standard.
• Indications: absolute (CPD, placenta praevia, transverse lie, cord prolapse, previous classical scar) or relative (fetal distress, failed induction, malpresentation, previous LSCS).
• Immediate complications: haemorrhage, infection, anaesthetic problems, bladder/bowel injury, thromboembolism.
• Long-term: a scarred uterus → risk of rupture in later labour, and abnormal placentation (praevia, accreta) rising with each repeat caesarean.
• VBAC may be offered to suitable women with one previous lower-segment scar, in a facility able to perform an emergency caesarean.