The moot threats to women undergoing cesarean section have been anesthesia, severe sepsis, and thromboembolic episodes. Each of these areas has been or will be considered in great detail. However, it is worth emphasizing that aspiration pneumonia, which had previously been the leading cause of cesarean section deaths at Parklanf Hospital, has been avoided completely since the routine practice of ingesting 30 mL of milk of magnesia, or more recently a solution of sodium citrate acid.
Despite such efforts to decrease mortality, it is unlikely that deaths from either cesarean or vaginal delivery can be reduced more in severely compromised women who elect, rightly or not, to pursue pregnancies despite their already tenuous medical status. Therefore, one must consider whether the death was related to a complication of the delivery per se or due at least on part to underlying factor, such as heart disease.
It is reasonable to assume that if the frequency of the cesarean deliveries can be reduced without compromising the fetus, significant reductions not only in cesarean section mortality rates but in overall maternal mortality rates as well may be achieved. Thus, a major challenge in obstetrics is to answer correctly the question “Can a significant reduction in cesarean section rate be achieved without increasing perinatal mortality and morbidity? ”
Even when morbidity and mortality associated with the problem that led to cesarean section are excluded, maternal morbidity is more frequent and likely to be more severe following cesarean section than following vaginal delivery. The common causes of morbidity from cesarean delivery remain infection, hemorrhage, and injury of the urinary tract. The frequency of stillbirth and neonatal mortality will depend, of course, on the underlying reason for the cesarean section and the gestational age of the fetus.
Although the decreasing perinatal mortality rate observed sine then mid-1960s in many instances has been associated with and even been attributed to the marked increase in cesarean section rates in the United States, have questioned this assumption. Specifically, they reported similar and equally dramatic decreases in perinatal mortality rates in patients at the National maternity hospital in Dublin without an increase in cesarean section rates.
Birth trauma in general is much likely with cesarean section than with vaginal delivery; however, cesarean section is not a guarantee against fetal injury. For example, the head of a preterm breech can be entrapped in a small transverse uterine incision that was judged incorrectly to be large enough for delivery. Such an error in judgment may result in either extension of the uterine incision into the uterine vessels or lower uterine segment or both. Finally, the fetus can be wounded during the incision into the uterus.
It is important to emphasize that fetal morbidity has been decreased dramatically with the use of cesarean section in instances of breech presentations, transverse lie of the fetus, and placenta previa. Also of importance is the fact that the opportunities for obstetricians-in-training to develop and maintain the skills necessary to accomplish successfully a potentially difficult breech delivery or to do an internal podalic version for a second twin have diminished greatly and for sound reasons.
Although respiratory distress has been claimed to be higher fro repeat cesarean section than for vaginal delivery, it is unlikely that there is a significant difference when gestational ages of the fetuses are identical and fetal hypoxia and axidosis are avoided. There are advantages to a predetermined time for carrying out repeat cesarean sections. For example, the family can better arrange for assistance in caring for other children while the mother is hospitalized and for the care of the mother and infant after leaving the hospital.
Importantly, a competent team can be assembled more easily to provide optimal care, including anesthesia, infant resuscitation if needed, and subsequent care of the newborn. Conversely, with emergency repeat cesarean section, an operating room may not be immediately available, or the mother may have very recently eaten, which increases the anesthetic risk. Of considerable importance when dealing with a gravida with a previous cesarean section is whether a vertical uterine incision was made that might rupture with the onset of labor, resulting in the death of the fetus and serious morbidity or even death of the mother.
The likelihood of theses disastrous consequences from rupture of a transverse scar in the lower uterine segment is very low. Elective termination of pregnancy with the delivery of as preter infabt has been a major problem at some institutions. This unfortunate circumstance has led to the strong recommendation by some that amniocentesis with appropriate studies on the amnionic fluid be performed before any elective delivery.
This approach is not without complications, however, for at times, trauma to the placenta or fetus is caused by attempts to obtain amnionic fluid, which may be of scant volume in pregnancies at or near term. Moreover, after an unsuccessful attempt at amniocentesis, the fetus has been known to succumb in utero awaiting a subsequent and hopefully successful attempt at aspiration of amnionic fluid. Sonography at the time of amniocentesis diminishes the risk somewhat but adds further to the cost.