ME D I C I N E
E cesarean section indications complications
2022
Indications for and Risks of Elective
Cesarean Section
Ioannis Mylonas, Klaus Friese
SUMMARY
Background: Rates of cesarean section have risen
around the world in recent years. Accordingly,
much effort is being made worldwide to understand
this trend and to counter- act it effectively. A Department of Gynecology and
number of factors have been found to make it more Obstetrics, Ludwig-Maximilians-
likely that a cesarean section will be chosen, but Universität München: Prof. Dr.
med. Dr. h.c. Mylonas, Prof. Dr.
the risks cannot yet be clearly defined. med. Friese
Methods: This review is based on pertinent
publications that were retrieved by a selective Deutsches Ärzteblatt International | Dtsch Arztebl Int
search in the PubMed, Scopus, and DIMDI 2015; 112: 489–95
databases, as well as on media com- munications,
analyses by the German Federal Statistical Office,
and guidelines of the Association of Scientific
Medical Societies in Germany (AWMF).
Results: The increased rates of cesarean section
are thought to be due mainly to changed risk
profiles both for expectant mothers and for their
yet unborn children, as well as an increase in
cesarean section by maternal request. In 1991,
15.3% of all newborn babies in Germany were
delivered by cesarean section; by 2012, the
corresponding figure was 31.7%, despite the fact
that a medical indication was present in less than
10% of all cases. This development may perhaps
be explained by an increasing tendency toward risk
avoidance, by risk- adapted obstetric practice, and
increasing media attention. The intraoperative and
postoperative risks of cesarean section must be
considered, along with compli- cations potentially
affecting subsequent pregnancies.
Conclusion: Scientific advances, social and cultural
changes, and medicolegal considerations seem to
be the main reasons for the increased acceptibility
of cesarean sections. Cesarean section is, however,
associated with increased risks to both mother and
child. It should only be performed when it is
clearly advantageous.
► Cite this as:
Mylonas I, Friese K: The indications for and risks
of elective cesarean section. Dtsch Arztebl Int
2015; 112: 489–95. DOI:
10.3238/arztebl.2015.0489
489
, ME D I C I N E
S
cientific progress, social and cultural changes, and, in particular, legal
change have led to a fundamental change in attitudes to cesarean section among
patients and doctors. In fact, the consensus around the indications for cesarean
section has changed in many countries, now including psycho- social factors such
as anxiety about the delivery, or even the mother’s wish to have a cesarean
section in the absence of any medical indication (1). N ever- theless, the reasons
for increasingly liberal attitudes toward cesarean section are diverse and not always
easily discernable.
In recent years, a number of factors have been under consideration as possible
influences on the rising cesarean rate. Changing risk profiles among increasingly
older primiparae are often cited as a reason for the rise in cesarean deliveries (2–4).
An increase in maternal request cesarean sections also plays a part (5, 6).
However, the rise in cesarean section rates should not be viewed in isolation from
changes in society. On the contrary, financial (7, 8), social (9–13), and cultural (8,
14–17) elements appear to play an important part. These factors—taken together
with the public perception that a cesarean delivery is now an almost risk-free
procedure—might well be contributing to the rise in the number of cesarean sections
performed (18).
This perspective, however, overlooks the fact that a cesarean section is a surgical
procedure with numerous potential complications for both mother and child. Apart
from the intraoperative risks (i.e., infection, organ injuries, or the need for blood
transfusion [19–27]), many side effects can occur post partum: thromboembolic
complications, for example (19, 28–33). In particular, the complications relating to
later pregnancies should be mentioned: uterine rupture (34–36), infertility (37–40),
or even placental anomalies such as placenta previa, increta, or accreta (29–32, 40,
e1–e3). In recent years a number of risks have also been described for babies
delivered by elec- tive cesarean section: the development of bronchial asthma (e4,
e5), for example, or type 1 diabetes melli- tus (e6) or allergic rhinitis (e4, e7).
Existing data are unsatisfactory, however, and a focus of current controversy. Two
review articles point to neonatal risk associated with elective cesarean section
compared with vaginal delivery, including increased mortality, in- creased risk of
respiratory disease, or type 1 diabetes
, ME D I C I N E
BOX 1 (e8, e9). Other authors, however, found no difference in
neonatal outcome between elective cesearean and
Absolute indications vaginal delivery, although they emphasize that only
(According to Association of Scientific Medical Societies in Germany [AWMF]
limited data areguideline “Absolute
available (e10). The WHOand relative
stated, onindications fo
Absolute disproportion: the basis of a study of maternal and fetal complications
Small maternal pelvis, making vaginal birth impossible between 2004 and 2008 in 24 countries, that cesarean
Chorioamnionitis (amniotic infection syndrome): sections are associated with an increase in risks for both
Infection of the placenta and possibly of the fetus, requiring immediate
mother and delivery
child compared to vaginal delivery and
Maternal pelvic deformity: should therefore be performed only when significant
Anatomical malformation, making vaginal birth impossible
advantages are expected (e11).
Eclampsia and HELLP syndrome:
Life-threatening complications of pregnancy, usually leading to cesarean delivery
Fetal asphyxia or fetal acidosis: Incidence
Around the world, a rise has been seen in cesarean rates
Life-threatening situations for the fetus that can lead to fetal hypoxia
Umbilical cord prolapse: in developed and emerging countries (5, e12). In sub-
Prolapse of the umbilical cord between the head of the fetus andsaharan regions opening,
the vaginal the cesarean rate iscan
which onlylead
3% (e13); in asphyxia
to fetal
Placenta previa: Central America it is 31% and in N orth America it is
Anomalous placental position, impeding vaginal delivery 24% (e14). The rate in Europe is around 25% of all
Abnormal lie and presentation: deliveries (eTable) (e15, e16), while in the USA the rate
Anomaly of fetal position that makes vaginal delivery impossibleis estimated at 32.2% (e54). In the year 2000 in the
Uterine rupture: European Union, 221 cesarean sections were per-
Acute situation threatening the life of both mother and fetus, requiring
formed perimmediate
1000 live delivery by cesarean
births; in 2011 the numbersection
had
risen to 268 per 1000 live births (e15–e18). In Europe,
births by cesarean section went up from 172.49 per
1000 live births in 1997 to 253.23 per 1000 live births
in 2010 (e15–e18).
In the USA, mortality rates have now gone up from
1:10 000 to 1.4:10 000 births (e19). Interestingly, it
turns out that a cesarean rate of more than 13% to 15%
(as recommended by the WHO [e20]) is not accompa-
nied by better outcomes for fetus and mother (e21).
In Germany, the percentage of deliveries by cesarean
more than doubled between 1991 (15.3%) and 2012
(31.7%) (e17, e18). A slight fall by 0.4% was seen in
comparison to the year 2011 (e17, e18). The number of
other obstetric procedures also decreased slightly. The
ventouse was used in 5.7% of deliveries, while the use
of forceps declined to 0.5% (e17, e18).
Indications
The decision to perform a cesarean section is based pri-
marily on the question of what is best for or may save
the lives of the mother and child. The indications for
cesarean section can therefore be divided into absolute
and relative indications. Elective cesarean section,
performed solely at the wish of the mother, without
any medical indication, is considered a separate
indication.
In the German-speaking countries—in contrast to
the Anglo-American world—discussion of cesarean
section revolves mainly around the validity of the
medical indications and their division into absolute and
relative indications (18, e22), especially in terms of the
existing medicolegal background. Absolute indications
(Box 1) are responsible for less than 10% of all
deliveries by cesarean section in Germany (e23). Most
cesarian sections are thus performed for relative indi-
cations (Box 2). The decision is often made on the basis
of a risk assessment, after extensive discussion with the
midwives and physicians involved, together with the
pregnant mother and her family.
490 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2015;
112: 489–95
E cesarean section indications complications
2022
Indications for and Risks of Elective
Cesarean Section
Ioannis Mylonas, Klaus Friese
SUMMARY
Background: Rates of cesarean section have risen
around the world in recent years. Accordingly,
much effort is being made worldwide to understand
this trend and to counter- act it effectively. A Department of Gynecology and
number of factors have been found to make it more Obstetrics, Ludwig-Maximilians-
likely that a cesarean section will be chosen, but Universität München: Prof. Dr.
med. Dr. h.c. Mylonas, Prof. Dr.
the risks cannot yet be clearly defined. med. Friese
Methods: This review is based on pertinent
publications that were retrieved by a selective Deutsches Ärzteblatt International | Dtsch Arztebl Int
search in the PubMed, Scopus, and DIMDI 2015; 112: 489–95
databases, as well as on media com- munications,
analyses by the German Federal Statistical Office,
and guidelines of the Association of Scientific
Medical Societies in Germany (AWMF).
Results: The increased rates of cesarean section
are thought to be due mainly to changed risk
profiles both for expectant mothers and for their
yet unborn children, as well as an increase in
cesarean section by maternal request. In 1991,
15.3% of all newborn babies in Germany were
delivered by cesarean section; by 2012, the
corresponding figure was 31.7%, despite the fact
that a medical indication was present in less than
10% of all cases. This development may perhaps
be explained by an increasing tendency toward risk
avoidance, by risk- adapted obstetric practice, and
increasing media attention. The intraoperative and
postoperative risks of cesarean section must be
considered, along with compli- cations potentially
affecting subsequent pregnancies.
Conclusion: Scientific advances, social and cultural
changes, and medicolegal considerations seem to
be the main reasons for the increased acceptibility
of cesarean sections. Cesarean section is, however,
associated with increased risks to both mother and
child. It should only be performed when it is
clearly advantageous.
► Cite this as:
Mylonas I, Friese K: The indications for and risks
of elective cesarean section. Dtsch Arztebl Int
2015; 112: 489–95. DOI:
10.3238/arztebl.2015.0489
489
, ME D I C I N E
S
cientific progress, social and cultural changes, and, in particular, legal
change have led to a fundamental change in attitudes to cesarean section among
patients and doctors. In fact, the consensus around the indications for cesarean
section has changed in many countries, now including psycho- social factors such
as anxiety about the delivery, or even the mother’s wish to have a cesarean
section in the absence of any medical indication (1). N ever- theless, the reasons
for increasingly liberal attitudes toward cesarean section are diverse and not always
easily discernable.
In recent years, a number of factors have been under consideration as possible
influences on the rising cesarean rate. Changing risk profiles among increasingly
older primiparae are often cited as a reason for the rise in cesarean deliveries (2–4).
An increase in maternal request cesarean sections also plays a part (5, 6).
However, the rise in cesarean section rates should not be viewed in isolation from
changes in society. On the contrary, financial (7, 8), social (9–13), and cultural (8,
14–17) elements appear to play an important part. These factors—taken together
with the public perception that a cesarean delivery is now an almost risk-free
procedure—might well be contributing to the rise in the number of cesarean sections
performed (18).
This perspective, however, overlooks the fact that a cesarean section is a surgical
procedure with numerous potential complications for both mother and child. Apart
from the intraoperative risks (i.e., infection, organ injuries, or the need for blood
transfusion [19–27]), many side effects can occur post partum: thromboembolic
complications, for example (19, 28–33). In particular, the complications relating to
later pregnancies should be mentioned: uterine rupture (34–36), infertility (37–40),
or even placental anomalies such as placenta previa, increta, or accreta (29–32, 40,
e1–e3). In recent years a number of risks have also been described for babies
delivered by elec- tive cesarean section: the development of bronchial asthma (e4,
e5), for example, or type 1 diabetes melli- tus (e6) or allergic rhinitis (e4, e7).
Existing data are unsatisfactory, however, and a focus of current controversy. Two
review articles point to neonatal risk associated with elective cesarean section
compared with vaginal delivery, including increased mortality, in- creased risk of
respiratory disease, or type 1 diabetes
, ME D I C I N E
BOX 1 (e8, e9). Other authors, however, found no difference in
neonatal outcome between elective cesearean and
Absolute indications vaginal delivery, although they emphasize that only
(According to Association of Scientific Medical Societies in Germany [AWMF]
limited data areguideline “Absolute
available (e10). The WHOand relative
stated, onindications fo
Absolute disproportion: the basis of a study of maternal and fetal complications
Small maternal pelvis, making vaginal birth impossible between 2004 and 2008 in 24 countries, that cesarean
Chorioamnionitis (amniotic infection syndrome): sections are associated with an increase in risks for both
Infection of the placenta and possibly of the fetus, requiring immediate
mother and delivery
child compared to vaginal delivery and
Maternal pelvic deformity: should therefore be performed only when significant
Anatomical malformation, making vaginal birth impossible
advantages are expected (e11).
Eclampsia and HELLP syndrome:
Life-threatening complications of pregnancy, usually leading to cesarean delivery
Fetal asphyxia or fetal acidosis: Incidence
Around the world, a rise has been seen in cesarean rates
Life-threatening situations for the fetus that can lead to fetal hypoxia
Umbilical cord prolapse: in developed and emerging countries (5, e12). In sub-
Prolapse of the umbilical cord between the head of the fetus andsaharan regions opening,
the vaginal the cesarean rate iscan
which onlylead
3% (e13); in asphyxia
to fetal
Placenta previa: Central America it is 31% and in N orth America it is
Anomalous placental position, impeding vaginal delivery 24% (e14). The rate in Europe is around 25% of all
Abnormal lie and presentation: deliveries (eTable) (e15, e16), while in the USA the rate
Anomaly of fetal position that makes vaginal delivery impossibleis estimated at 32.2% (e54). In the year 2000 in the
Uterine rupture: European Union, 221 cesarean sections were per-
Acute situation threatening the life of both mother and fetus, requiring
formed perimmediate
1000 live delivery by cesarean
births; in 2011 the numbersection
had
risen to 268 per 1000 live births (e15–e18). In Europe,
births by cesarean section went up from 172.49 per
1000 live births in 1997 to 253.23 per 1000 live births
in 2010 (e15–e18).
In the USA, mortality rates have now gone up from
1:10 000 to 1.4:10 000 births (e19). Interestingly, it
turns out that a cesarean rate of more than 13% to 15%
(as recommended by the WHO [e20]) is not accompa-
nied by better outcomes for fetus and mother (e21).
In Germany, the percentage of deliveries by cesarean
more than doubled between 1991 (15.3%) and 2012
(31.7%) (e17, e18). A slight fall by 0.4% was seen in
comparison to the year 2011 (e17, e18). The number of
other obstetric procedures also decreased slightly. The
ventouse was used in 5.7% of deliveries, while the use
of forceps declined to 0.5% (e17, e18).
Indications
The decision to perform a cesarean section is based pri-
marily on the question of what is best for or may save
the lives of the mother and child. The indications for
cesarean section can therefore be divided into absolute
and relative indications. Elective cesarean section,
performed solely at the wish of the mother, without
any medical indication, is considered a separate
indication.
In the German-speaking countries—in contrast to
the Anglo-American world—discussion of cesarean
section revolves mainly around the validity of the
medical indications and their division into absolute and
relative indications (18, e22), especially in terms of the
existing medicolegal background. Absolute indications
(Box 1) are responsible for less than 10% of all
deliveries by cesarean section in Germany (e23). Most
cesarian sections are thus performed for relative indi-
cations (Box 2). The decision is often made on the basis
of a risk assessment, after extensive discussion with the
midwives and physicians involved, together with the
pregnant mother and her family.
490 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2015;
112: 489–95
