Learning Objectives
By the end of this section, you will be able to:
- Explain the conditions of the person giving birth associated with an increased risk for cesarean birth
- Explain the fetal conditions associated with an increased risk for cesarean birth
- Explain the umbilical cord anomalies associated with an increased risk for cesarean birth
- Explain the placental conditions associated with an increased risk for cesarean birth
- Discuss the standards of care for a vaginal birth after cesarean (VBAC), ensuring safety of the fetus and person in labor
Cesarean birth is the birth of the newborn through an incision in the uterus. The incidence of cesarean birth has risen steadily over the past 60 years, with the present rate between 25 and 30 percent (El-Chaar, 2022). The most common indication for cesarean birth is dystocia, fetal or uterine. Fetal conditions, placental issues, and umbilical cord problems are all indications for cesarean birth.
Causes Related to the Person Giving Birth
Cesarean birth can be planned or unplanned. Planned cesarean births can be due to multiple gestation, macrosomia, previous cesarean, active herpes simplex lesions, human immunodeficiency virus (HIV) infection, malpresentation of the fetus, placenta previa, and complications during pregnancy. Unplanned cesarean births can be caused by dystocia, pregnancy complications, and complications during labor. The nurse will educate the family regarding the procedure and what to expect. Pregnant persons can experience increased anxiety and stress because of the unexpected change in their plan for birth. The nurse can help decrease anxiety and stress and, when possible, should allow the significant other to remain with the laboring person.
Dystocia
Labor dystocia can be uterine or fetal. Power, passenger, passage, position, and psyche are the components of dystocia. Therefore, if contractions are not strong enough to cause cervical dilation and fetal descent, a cesarean birth can be performed. When the fetus is unable to pass through the pelvis, fetal malpresentation/malposition or cephalopelvic disproportion can be diagnosed. Other causes of dystocia include uterine masses or neoplasms.
Complications of Pregnancy
Complications of pregnancy such as preeclampsia, gestational DM/DM, and hypertension create increased risk for cesarean birth. Congenital uterine anomaly puts the pregnant person at risk for cesarean birth. Complications of previous pregnancies can also increase a person’s risk. Previous cesarean birth, hysterotomy, myomectomy, and cervical suture can be contraindications for labor, and cesarean birth is required (El-Chaar, 2022).
Preeclampsia
Preeclampsia can cause damage to the placenta. The placenta is affected by hypertension, and perfusion of oxygen and nutrients is decreased to the fetus, which can cause fetal distress prior to or during labor. The pregnant person can become very ill with thrombocytopenia, liver and kidney dysfunction, seizure, or stroke. The cure for preeclampsia is birth and delivery of the placenta. Therefore, pregnant persons who are too ill to labor or continue the pregnancy to term are at higher risk for cesarean delivery.
Gestational Diabetes
Gestational diabetes can cause a large fetus that can be more difficult to birth vaginally. Larger fetuses can cause longer labors and uterine dystocia. Fetal dystocia can be diagnosed due to the larger fetus attempting to maneuver through the pelvis. Gestational diabetes can also affect the functioning of the placenta, causing more fetal distress during labor.
Chronic Medical Conditions
Chronic medical conditions can cause increased risk for cesarean birth. Pregnant persons with HIV are sometimes encouraged to birth via cesarean birth to decrease the vertical transmission rate, especially when the viral load is high (ACOG, 2018e). Persons with heart disease may not tolerate labor and are better suited for cesarean birth.
Hypertension
Pregnant persons with chronic hypertension are at higher risk for preeclampsia, placental abruption, stroke, kidney disease, heart failure, and heart attack. Complications are more common with uncontrolled hypertension, such as pulmonary edema and renal failure. Peripartum cardiomyopathy is another risk factor. Severe hypertension can lead to cerebral hemorrhage and heart failure. Therefore, if these pregnant persons become very ill with these complications, a cesarean birth might be better tolerated than labor.
Diabetes Mellitus
Diabetes mellitus occurring prior to pregnancy can be type 1 or type 2. Both types of diabetes lead to increased levels of circulating glucose. With uncontrolled glucose levels, arteriole damage occurs. This can affect the fetus and placenta. Diabetes is associated with an increased risk of fetal demise. Therefore, pregnant persons with diabetes are monitored more closely as labor nears. If prenatal fetal surveillance shows nonreassuring testing, these persons might undergo labor induction or cesarean birth. This allows the fetus to leave the intrauterine environment that is causing complications.
Fetal Causes
Fetal causes for cesarean birth include multiple gestation, irregular position, and fetal distress. Twins can be born via vaginal birth if the pregnancy is without complications. However, multiple gestation occurring many times ends in cesarean birth due to cord entanglement and malposition. The fetus in the breech position is most commonly born via cesarean. Fetal distress is a common reason for emergency cesarean birth.
Multiple Gestation
The recommendation for multiple gestation is birth during the 38th week of pregnancy. Labor can be complicated because the overstretched uterus can cause uterine dystocia. Malpresentation and umbilical cord accidents can occur during labor. Postpartum hemorrhage is a risk for multiple gestation pregnancies.
Twins in the vertex-vertex presentation can be delivered vaginally. Vaginal delivery of twins in the vertex-nonvertex presentation is controversial. Twins with the presenting fetus in the breech presentation are recommended to be born via cesarean birth (ACOG, 2021). During the cesarean, the nurse must ensure that the person is not lying completely supine due to the increased weight on the aorta. The nurse must also take steps to maintain family bonding as much as possible.
Breech Delivery
Breech presentation at term can pose a risk to the fetus when born vaginally, including trauma at birth, perinatal asphyxia, lower Apgar scores, and perinatal mortality (Fernández-Carrasco et al., 2022). Research has shown increased perinatal mortality in breech newborns born vaginally (ACOG, 2018b; Bjellmo et al., 2016). Breech presentation causes complications because the presenting part (knees, legs, feet, or buttocks) is smaller than the fetal head or shoulders. Therefore, if the larger head or shoulders cannot fit through the pelvic outlet, the head or shoulders could become lodged under the pubic bone. However, some pregnant persons choose to have a vaginal breech birth over a scheduled cesarean birth. ACOG (2018b) listed the following criteria for a planned vaginal breech birth: gestational age greater than 37 weeks, frank or complete breech presentation, no fetal anomalies on ultrasound examination, adequate maternal pelvis, and estimated fetal weight between 2,500 g and 4,000 g. All risks and benefits must be discussed with the pregnant person.
Indications suggesting cesarean birth include patient request, prior neonatal birth trauma, large fetus, oligohydramnios, incomplete breech, pelvic contracture, and prior cesarean delivery. Birth by cesarean must be done carefully to avoid fetal head entrapment or damage to the fetus during incision. Prolapsed cord can be avoided when cesarean birth is scheduled and labor has not started.
Fetal Stress/Distress
Abnormal fetal heart rate suggesting fetal distress can be a cause for cesarean birth. Severe bradycardia, absent variability, and late decelerations are signs of fetal distress. Some fetal distress is caused by the use of oxytocin for induction or augmentation of labor, leading to tachysystole. Umbilical cord prolapse and uteroplacental insufficiency are also causes of fetal distress that can lead to emergency cesarean births. Meconium-stained fluid can be suggestive of fetal distress, but MSF alone is not an indication for cesarean birth.
Umbilical Cord Abnormalities
The umbilical cord can exhibit many different abnormalities, such as loops, knots, vascular malformations, aneurysm, hematoma, abnormal lengths, cysts, and an abnormal amount of Wharton’s jelly (Krzyżanowski et al., 2019). The umbilical cord normally contains two arteries and one vein surrounded by Wharton’s jelly. Abnormal umbilical cords can contain only one artery and one vein. This complication can lead to fetal growth restriction and can also be associated with cardiac and renal abnormalities (Krzyżanowski et al., 2019). Extremely long umbilical cords can cause complications such as true knots, entanglement, and cord prolapse upon rupturing of the membranes. Other umbilical cord abnormalities include those where the umbilical cord is inserted abnormally into the placenta.
Marginal Insertion of the Umbilical Cord
Cord abnormalities involve cord insertions into the placenta. Marginal insertion of the cord into the placenta is any placenta in which the cord inserts along the placental margin and occurs in 6 to 7 percent of pregnancies (Aragie & Oumer, 2021). This variant has also been called battledore placenta. This marginal insertion is not a common reason for cesarean birth; however, this complication could cause fetal distress during labor, necessitating a cesarean delivery.
Velamentous Insertion of the Cord
The labor complication in which the vessels of the umbilical cord branch before reaching the placenta is called velamentous insertion of the cord. The cord is actually inserted into the membranes instead of the placenta (Krzyżanowski et al., 2019). Figure 19.14 demonstrates a velamentous insertion. Complications are fetal growth restriction, cord separation, fetal bleeding, and fetal death. A cesarean birth can prevent fetal exsanguination.
Vasa Previa
The condition in which fetal vessels implant into the membranes and cross over the cervix in front of the fetal presenting part is called vasa previa (Wagner, 2019). Figure 19.15 illustrates a vasa previa. When the membranes rupture or the cervix dilates, the vessels can rupture, causing the pregnant person to bleed excessively and the fetus to exsanguinate. Vasa previa is usually asymptomatic and diagnosed via ultrasound. Because of the very high risk of morbidity and mortality, cesarean birth is preferred, especially prior to rupture of membranes and start of labor.
Link to Learning
Watch this video about vasa previa to learn more about what it is and how it is treated.
Placental Causes
Placental causes associated with an increased risk for cesarean birth include uteroplacental insufficiency, placenta previa, placental abruption, and placenta accreta spectrum. Uteroplacental insufficiency can lead to fetal hypoxia. Placenta previa and placental abruption place the fetus at risk for hemorrhage and fetal hypoxia and the laboring person at risk for intrapartum hemorrhage and shock. Placenta accreta is associated with retained placenta.
Uteroplacental Insufficiency
Uteroplacental insufficiency is the malfunction of the uterine vessels to supply enough oxygen and nutrients to the placenta and consequently to the fetus. Risk factors for uteroplacental insufficiency include hypertensive disorders of pregnancy and congenital anomalies of the fetus. Uteroplacental insufficiency increases the risk for intrauterine growth restriction in the fetus and preterm labor (Burton & Jauniaux, 2018). If the placenta is not functioning well, the stress of labor could cause late decelerations, implying uteroplacental insufficiency. Because of this fetal distress, a cesarean birth could be necessary.
Placenta Previa
Placenta previa is the insertion of the placenta atop the cervix. A previa can be the entire placenta or a marginal portion of placenta implanted over the cervix. Any amount of previa could cause hemorrhage secondary to labor with dilation of the cervix and subsequent placental separation. To avoid hemorrhage, a cesarean birth is necessary.
Placental Abruption
Placental abruption, the separation of the placenta from the uterine lining, seen in labor can be caused by hypertensive disorders of pregnancy and external trauma such as a motor vehicle accident or aggravated assault. It can also be caused by cocaine use; therefore, a drug screen is often obtained in labor and delivery after an abruption. Abruptions can also be chronic. Chronic abruption is seen anytime during the pregnancy and may not necessitate delivery. When the abruption causes fetal distress or hemorrhage, an emergency cesarean birth is required to save the pregnant person and the fetus. The risk for death of both the laboring person and the fetus is increased with placental abruption (Li et al., 2019).
Placenta Accreta
When the placenta invasively adheres to the uterine wall, it is called placenta accreta. Some cases of placenta accreta are diagnosed by ultrasound during pregnancy. A cesarean birth is scheduled with the possibility of a hysterectomy if bleeding is uncontrolled. At other times, accreta is diagnosed at the time of delivery. These cases have higher incidences of morbidity and mortality. When an accreta is diagnosed, the nurse should anticipate an emergency hysterectomy and administration of blood products (Morlando & Collins, 2020). The nurse will call for assistance during this emergency.
Table 19.10 details nursing interventions that promote infant bonding, attachment, and breast-feeding after a cesarean birth.
| Location | Interventions |
|---|---|
| Operating room | Allow significant other to be present. Ask about any birth preferences. Place infant skin-to-skin with birthing person or significant other. Delay eye ointment for the first hour after birth. |
| Recovery | Allow significant other to be present. Place infant skin-to-skin. Initiate breast-feeding within the first hour. Take pictures or video. |
Vaginal Birth after Cesarean
Pregnant persons with a previous cesarean birth have the option in a subsequent birth to attempt a trial of labor or to have a repeat cesarean. A vaginal birth after cesarean (VBAC) is defined as a successful trial of labor and eventual birth after a previous cesarean birth. The decision between trial of labor and repeat cesarean is controversial. Because the number of births via cesarean has steadily increased, the decision for subsequent vaginal birth is a more prominent issue. The pregnant person should be counseled several times during the pregnancy regarding pros and cons of both birth options. Several predictive tools or calculators have been developed to estimate success and risk of a trial of labor. The American College of Obstetricians and Gynecologists (2019d) suggests that most persons with one prior transverse cesarean birth are candidates for a trial of labor.
Certain factors determine the safety of a trial of labor after cesarean. The type of incision is one of the most important. Classical uterine scars are more prone to rupture even before labor onset (ACOG, 2019d). The number of prior cesarean births is also a very important factor. Research has shown that persons with two cesarean births have a two to three times increased risk for uterine rupture compared to those with one cesarean (ACOG, 2019d). Persons with prior uterine rupture are at greater risk of another rupture. To decrease the risk of uterine rupture, it is suggested that the interval between pregnancies be greater than 18 months. Persons with the highest success rate of VBAC are those who have had a successful VBAC previously.
Persons attempting a trial of labor should be in a facility that can emergently perform a cesarean. No prostaglandin should be used for cervical ripening or induction of labor. Labor augmentation or induction with oxytocin has a slightly higher risk of uterine rupture. Cervical ripening with a Foley bulb does not increase the risk for uterine rupture (Atia et al., 2018). Counseling by the health-care provider must be done prior to signing consent for a trial of labor or repeat cesarean birth. The role of the nurse is to maintain continuous fetal monitoring and observe for signs of distress in the laboring person and fetus. See Table 19.11 for recommendations for VBAC candidates.
| Type of Candidate | Characteristics |
|---|---|
| Good | One previous cesarean birth Low transverse incision Person with 60%–70% likelihood of achieving a VBAC Less than 40 weeks’ gestation |
| Poor | Previous classical or T-incision cesarean Prior uterine rupture Transfundal uterine surgery More than one prior cesarean Macrosomia Unknown prior uterine incision Obesity |
Clinical Safety and Procedures (QSEN)
Preoperation Checklist for Scheduled Cesarean Birth
- Verify name, allergies, and reason for cesarean.
- Ensure consent forms are signed.
- Document pregnancy complications and medical conditions.
- Assess vital signs and FHR.
- Start IV and IV fluid bolus prior to regional anesthesia.
- Shave operative site.
- Place sequential compression device on legs.
- Apply grounding pad.
- Insert Foley catheter.
- Listen to FHR prior to start of procedure.
- Prep abdomen with antiseptic.
- Take a time-out.
- Provide support to the pregnant person and significant other.