Caesarean Delivery

Caesarean delivery is surgical delivery of the fetus through an abdominal and uterine incision. It is one of the commonest major surgical procedures performed worldwide.

It is classified as elective (planned in advance of labour onset, for an identified, specific indication) or emergency (performed during labour, or before planned delivery, in response to an evolving maternal or fetal concern), with a broad range of maternal and fetal indications.

Full understanding of both the immediate perioperative considerations and the important, longer-term implications for future pregnancy is essential to full obstetric care.

Indications and classification

• Elective caesarean delivery is performed for a range of specific, identified indications including breech presentation not amenable to or declined for external cephalic version or vaginal breech delivery. Other indications are placenta praevia, previous classical (vertical) uterine incision, maternal request (following full, informed counselling), and specific maternal medical conditions where vaginal delivery carries particular relevant risk.
• Emergency caesarean delivery is performed for indications arising during labour or acutely before planned delivery, including fetal compromise (identified through fetal heart rate monitoring abnormality), failure to progress not responding to augmentation. Further indications are cord prolapse (representing a genuine obstetric emergency requiring immediate delivery), placental abruption, and uterine rupture.
• The specific urgency classification (typically categorised on a structured scale reflecting the immediacy of threat to maternal or fetal wellbeing) directly informs the required speed of surgical mobilisation and delivery.
• Vaginal birth after caesarean represents an important, appropriate option for many women with a previous single lower segment caesarean delivery and no other specific contraindication, following full, informed counselling regarding the relative risks and benefits compared with planned repeat caesarean delivery.

• The specific clinical presentation prompting caesarean delivery reflects the underlying indication, addressed under the relevant specific conditions throughout this Atlas (including abnormal labour and delivery, placenta praevia, placental abruption, cord prolapse, and uterine rupture), rather than representing a distinct presentation in itself.
• Postoperative recovery following caesarean delivery involves the standard considerations relevant to any major abdominal surgery, including wound healing, pain management, and mobilisation, together with the specific, additional considerations relevant to the postpartum period, including breastfeeding support and neonatal care.
• Recognised complications of caesarean delivery include infection (wound, endometrial, or urinary tract), haemorrhage, and venous thromboembolism (with caesarean delivery representing an independent risk factor warranting specific, structured thromboprophylaxis assessment).
• Relevant to future pregnancies is the placenta accreta spectrum (with risk directly related to the number of previous caesarean deliveries, particularly in the context of a subsequent pregnancy with placenta praevia overlying the previous uterine scar).

• The decision for caesarean delivery is made based on full clinical assessment of the specific maternal or fetal indication present, following the diagnostic principles detailed under the relevant, specific underlying conditions addressed throughout this Atlas, rather than representing a distinct diagnostic process in itself.
• Full preoperative assessment, including relevant blood tests, cross-matching where clinically indicated by the specific circumstances, and appropriate anaesthetic assessment, forms an essential component of preparation for both elective and emergency caesarean delivery. The specific time available for this assessment is substantially compressed in the emergency setting according to the urgency classification of the specific indication.

• Caesarean delivery is generally performed under regional (spinal or epidural) anaesthesia in the great majority of cases, given the substantial safety advantages of this approach compared with general anaesthesia. General anaesthesia is reserved for specific circumstances including the most urgent emergency deliveries or where regional anaesthesia is contraindicated or has failed.
• The lower segment (Pfannenstiel) approach is the standard surgical technique for the overwhelming majority of caesarean deliveries. It is associated with reduced blood loss and a substantially lower risk of subsequent uterine rupture in any future pregnancy compared with the classical (vertical, upper segment) incision.
• The classical incision is reserved for specific, uncommon circumstances including very preterm delivery with an inadequately developed lower uterine segment, or specific placental location precluding a lower segment approach.
• Full perioperative management, including prophylactic antibiotic administration (given clear evidence of reduced postoperative infection risk with this approach), appropriate thromboprophylaxis according to individual risk assessment, and standard surgical safety protocols, underpins safe surgical practice.
• Postoperative care comprises standard postsurgical monitoring together with the specific considerations relevant to the postpartum period, including early mobilisation, pain management, and support for skin-to-skin contact and breastfeeding initiation wherever clinically appropriate. The approach increasingly incorporates enhanced recovery principles aiming to support earlier mobilisation and discharge where clinically appropriate.
• Full counselling regarding implications for future pregnancy includes discussion of vaginal birth after caesarean as an appropriate option for many women with a single previous lower segment caesarean delivery.
• The decision is individualised according to the original indication, any relevant intervening factors, and the woman's own informed preference, following full discussion of the relative risks. These include the specific, though generally low absolute, risk of uterine rupture with attempted vaginal birth after caesarean.
• Counselling also covers the specific, increased risks associated with multiple repeat caesarean deliveries, including placenta accreta spectrum. This underpins full, forward-looking obstetric care extending beyond the immediate delivery itself.