Cesarean delivery: Preoperative issuesAuthorVincenzo Berghella, MDSection EditorCharles J Lockwood, MD, MHCMDeputy EditorVanessa A Barss, MDDisclosures:Vincenzo Berghella, MDNothing to disclose.Charles J Lockwood, MD, MHCMNothing to disclose.Vanessa A Barss, MDEmployee of UpToDate, Inc. Equity Ownership/Stock Options: Merck; Pfizer; Abbvie.Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.Conflict of interest policyAll topics are updated as new evidence becomes available and ourpeer review processis complete.Literature review current through:Jul 2014.|This topic last updated:Aug 06, 2014.INTRODUCTIONCesarean delivery (also called cesarean section and cesarean birth) refers to the delivery of a baby through surgical incisions in the abdomen and uterus. Cesarean deliveries are categorized as either primary (ie, first cesarean delivery) or repeat (ie, after a previous cesarean birth). The total cesarean delivery rate is the sum of these two components.The cesarean delivery rate worldwide is about 15 percent of births [1]. The mean cesarean delivery rate in developed countries is 21.1 percent, but only 2 percent in the least developed countries. A World Health Organization (WHO) survey of 122 facilities in nine Asian countries reported an overall rate of cesarean delivery of 27.3 percent [2]. A similar WHO survey of eight Latin American countries observed an overall cesarean delivery rate of 35.4 percent [3].In the United States, over one million cesarean deliveries are performed annually and accounted for 32.8 percent of United States births in 2011 [4]. Worldwide, Mexico, Brazil, Italy, Iran, Argentina, Dominican Republic, Cuba, and Korea have the highest rates (over 35 percent) and Africa has the lowest (under 5 percent) [5]. In Brazil, the wealthiest 10 percent of women have a cesarean delivery rate of 77 percent [6]. The cesarean delivery rate in China ranges from 20 to 60 percent, depending on whether the hospital is rural or urban [7-9]. The cesarean rate was 25 percent in teaching hospitals in India [10], but 8.5 percent overall [5].This topic will review preoperative issues relating to cesarean delivery. Surgical technique, postoperative issues, repeat cesarean delivery, and trial of labor after cesarean delivery are discussed separately:(See"Cesarean delivery: Technique".)(See"Cesarean delivery: Postoperative issues".)(See"Repeat cesarean delivery".)(See"Choosing the route of delivery after cesarean birth".)INDICATIONS AND CONTRAINDICATIONSCesarean delivery is performed when the clinician and patient feel that abdominal delivery is likely to provide a better maternaland/orfetal outcome than vaginal delivery. The term "elective cesarean delivery" should probably be eliminated because a cesarean delivery is either"medically/obstetricallyindicated" or "on maternal request," and never truly "elective." Cesarean delivery on maternal request is discussed separately. (See"Cesarean delivery on maternal request".)The decision to perform an indicated cesarean delivery may be made antepartum or as a result of concerns identified after labor has begun ("unscheduled cesarean delivery" or "unplanned cesarean delivery"). The terms "scheduled cesarean delivery" or "planned cesarean delivery" are used when the decision to perform a cesarean delivery does not occur as a consequence of a complication of labor, but is planned antepartum, such as in the case of repeat cesarean delivery, fetal malpresentation, or placenta previa.Approximately 70 percent of cesarean deliveries in the United States are primary (first) cesareans. The three most common indications for primary cesarean delivery in the United States account for almost 80 percent of these deliveries [11]:Failure to progress during labor (35 percent)Nonreassuring fetal status (24 percent)Fetal malpresentation (19 percent)Additional, less common indications for cesarean delivery include, but are not limited to:Abnormal placentation (eg, placenta previa, vasa previa, placenta accreta)Maternal infection (eg, herpes simplex or human immunodeficiency virus)Multiple gestationFetal bleeding diathesisFunic presentation or cord prolapseSuspected macrosomia (5000 grams in women without diabetes, 4500 grams in women with diabetes)Mechanical obstruction to vaginal birth (eg, large leiomyoma or condyloma acuminata, severely displaced pelvic fracture, fetal anomalies such as severe hydrocephalus)Uterine rupture(See individual topic reviews on each subject).Cesarean delivery may also be indicated in women who are at increased risk of complications from tissue trauma related to cervical dilation, the descent and expulsion of the fetus, or episiotomy. Some examples include women with invasive cervical cancer or active perianal inflammatory bowel disease, and those who have undergone repair of a rectovaginal fistula or pelvic organ prolapse. (See"Fertility, pregnancy, and nursing in inflammatory bowel disease"and"Urinary incontinence and pelvic organ prolapse associated with pregnancy and childbirth"and"Fecal incontinence associated with pregnancy and childbirth"and"Cervical cancer in pregnancy".)Cesarean delivery may be performed, but is not routinely indicated for fetal issues, such as extremely or very low birth weight (