In the 1970’s, alternate Cesarean surgical techniques were introduced and compared with techniques which have predominantly employed since the 1920’s. Nowadays, the newest techniques have gained popularity to become the most commonly used by obstetricians during a Cesarean section. The newest changes are favored because of time and cost savings, speedy recovery, and other short-term benefits. 

Concurrently, the last 30 years have seen an increase in long-term consequences in women with a prior C-section, not addressed by present-day techniques. These consequences, which can happen years after the operation, may present in a subsequent pregnancy or in not-pregnant women. In pregnancy, they include uterine rupture, placenta accreta and its precursor, Cesarean scar pregnancy. In non-pregnant women, they include bleeding between menses, pelvic pain, painful menses, painful sex, and trouble conceiving. Emerging evidence reveals that surgical technique and in particular surgical repair may impact positively both short- and long-term consequences for women who have had a previous C-section.

A gentle C-section also called natural cesarean or family-centered birth intended to make the birth friendlier and less sterile for the patient and partner. While the surgery part remains the same, a clear sterile plastic drape separates the mother from the operative field and allows for immediate and welcoming participation as the baby is being delivered. 

The gentle C-section is simply a change in attitude by the care team to add some similarities of the labor and delivery room experience to the C-section experience. It has been in use since 2015 as a way to improve the surgical experience and is gaining popularity. It was introduced in my hospital approximately five years ago.

Nowadays, the old dictum “Once a section, always a section” applies mostly to women who have had a classical C-section, which is a vertical cut through the uterus to deliver the baby.

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Contemporaneously, the most common cut is a transverse uterine incision which allows most women to attempt a vaginal birth after a prior cesarean delivery. This is commonly referred to as TOLAC (Trial of Labor After Cesarean Delivery). After one C-section, on average, 30% of women will have another C-section.

After one C-section, 60 to 80% of women who attempt VBAC are successful. 

After 2 C-sections, VBAC can be safe and appropriate. In these cases, 50% of women who attempt VBAC are successful. It is not recommended to attempt VBAC after 3 or more C-sections.

The indications of Cesarean delivery for twin pregnancy are prematurity with gestational age less than 32 weeks, the first twin in the non-vertex presentation, weight discordancy greater than 25%, the number of chorionic (outer) membranes that surround the babies, for example it applies to babies in one sac. 

Additionally, the indications of C-section for singleton pregnancy apply for twin pregnancy in labor. Triplet or greater number of multiple pregnancies are delivered via C-section.

Women with certain health conditions like heart disease, high blood pressure, diabetes, seizure may do better with a planned cesarean delivery. A planned C-section will reduce the maternal dangers associated with the stress, hemodynamic changes and the physical requirements of labor and will favor a better outcome for the baby.

During labor with regular contractions, if the baby’s head stops descending in the pelvis and there is arrest of cervical opening and thinning, a Cesarean section is often indicated for arrest of labor "stalled labor" or failure to progress, which is a combination of the baby’s size, position and the shape and dimensions of the mother’s pelvis. Depending on the stage of labor, the time before the decision to proceed with a Cesarean delivery may vary, as long the baby’s heart rate is normal.

Mothers with placenta previa, placenta accreta, vasa previa, and some cases of placenta abruption must be delivered by Cesarean. 

Other indications for a primary C-section include abnormal fetal heart rate tracing, baby’s malpresentation, prolonged labor, chorioamnionitis i.e. infection of the membranes that surround the baby, and cord prolapse. Certain birth defects like congenital heart diseases, excessive fluid in the brain may do better, if delivered via Cesarean.

A history of fibroid removal is not always a contraindication to vaginal delivery. The indications for a C-section depend on the number of fibroids removed and most importantly on whether the uterine cavity was entered or not during the removal.

Women who have fibroids and are currently pregnant may attempt to deliver naturally as long as the fibroids are not interfering with the normal progression of labor. Intrauterine surgery such as curettage, removal of polyp, adhesions or septum is not a contraindication to normal delivery. Women with a history of uterine surgery which requires cutting through the uterus and repair must be delivered by C-section. In these cases, an attempt to deliver naturally increases the risks for uterine rupture and other complications for both mother and baby.