What are the fetal indications for caesarean section?
Fetal distress is the most common fetal indication for caesarean section. This may be perceived or confirmed. The tendency is to err on the side of safety.
Breech presentation: When breech is the leading part of the baby, there is a high likelihood of caesarean section. A small minority of breech-presenting babies are delivered vaginally.
Multiple pregnancy: A significant proportion of twins are delivered by caesarean section. This is usually because the first twin is presenting with a part other than the head. It could also be performed because one or both twins' wellbeing is causing concern. Virtually all high-order multiple pregnancies (triplets, and so forth) are delivered by caesarean section.
Abnormal lie: It is not only breech which is the positional indication for caesarean section. Sometimes the baby is found in a ‘transverse’ or oblique lie, where the fetus is lying across so the head is on one side and the bottom on the other. This is incompatible with vaginal delivery and a caesarean section will need to be done if the mother is in labour. If she is not, an expectant management is adopted, with hope that the baby will assume a favourable position.
Cord prolapse: If the ‘waters’ break in early or mid-labour and the umbilical cord prolapses, a caesarean delivery is the only option.
Is maternal preference a valid indication for caesarean delivery?
There are many who argue strongly that maternal request or demand in the absence of any medical indication is a good example of abuse of services. An obstetrician who agrees to such a demand is not necessarily doing the woman a favour. We have a view on this but we would rather keep our counsel and leave the question to the prospective mother and her doctor.
Anaesthesia for caesarean section
How many modes of anaesthesia for caesarean section are there and how do they differ?
There are two main types of anaesthesia: general, where the patient is rendered both pain-free and unconscious (asleep) and regional, where the patient is pain-free and her lower body is paralyzed but she is fully awake.
A general anaesthetic is used when rapid induction of anaesthesia is required (it is usually reliably quicker), in case of difficulties with regional anaesthesia or where there is contraindication for this and, of course, if and when the mother concerned does not wish to be awake during the operation.
Regional anaesthesia, which is either spinal or epidural, is used much more often for caesarean section, though this differs from hospital to hospital and country to country. There is evidence that the majority of mothers prefer this method of anaesthesia.
What is the difference between spinal and epidural anaesthesia?
This is purely the space where the local anaesthetic is injected in the spine. Both are quite effective but an epidural (commonly used for labour) takes effect much more slowly. An epidural is therefore not ideal where a rapid induction of anaesthesia is required.