There are several reasons that a woman may need to deliver by c-section. Breech or transverse position, fetal distress, previous uterine surgery, or failure to progress are all indications for c-section. These indications can be placed into 2 broad categories; scheduled c-sections and emergency c-sections. A scheduled c-section is when the surgery is planned before labor and occurs at a scheduled time. An emergency c-section is any other c-section.
Women who have had previous uterine surgery such as a c-section or myomectomy are often advised to have a repeat c-section. There is an excellent discussion on vaginal birth after c-section (VBAC) here. The c-section is normally scheduled at 39 weeks. If the water breaks or labor starts before the scheduled time, an emergency c-section would be done. Another reason for a scheduled c-section is if the baby is not head down (vertex). There is a discussion about the baby’s position here. In this case the c-section may be scheduled closer to the due date to give the baby a greater chance to move head down. Triplets or higher order multiple also require a c-section. In a twin pregnancy vaginal delivery can sometimes be done safely depending on the position of the babies. Even with a favorable position, some people elect to have a c-section with twins as it avoids the possibility of having one baby vaginally and one by c-section. Yes, this can happen.
There is a growing trend for some women to ask for a scheduled c-section for no reason at all. I highly discourage this. Even though the c-section is a safe procedure, it is not without risk. Unless a true indication for c-section exists, it is safer to deliver vaginally. Women have the right to insist on a c-section but it is a foolish choice. A c-section increases the risks of delivery and prolongs healing. The recovery from a c-section is much harder than from a vaginal delivery. If a women is worried about the pain from a vaginal delivery, then an epidural is available. If she were to have a c-section, she wouuld still need an epidural or spinal for the surgery (See anesthesia for c-section). There are also the potential issues in the distant future. Each c-section has a little more risk than the one before. If she needs abdominal surgery for other reasons in the future, a hysterectomy or appendectomy for example, the c-section may complicate the surgery. Doing c-sections for indicated reasons balances the risks of the c-section against the risks of vaginal delivery. Doing a c-section for no true indication only assumes risk for no benefit.
Emergency c-sections happen for many reasons. Women who have a c-section scheduled but go into labor early will need an emergency c-section. If the water breaks or labor starts and the baby is not head down, then a c-section is necessary. “Fetal intolerance to labor” or formerly called “fetal distress” occurs when the fetal monitors are telling us that the baby is not tolerating the stress of labor. A c-section is done to prevent damage to the baby. If labor becomes prolonged and there is no progress even with adequate contractions, a c-section is indicated. Sometimes even with good pushing efforts the baby does not move down; this is an indication for c-section. This is caused when the baby’s head will not fit through the pelvis The pelvis may be too small, the baby may be too big, or the head may be coming down at an unfavorable angle.
Obstetricians try to deliver babies vaginally whenever possible. We believe that this is usually the best way for both the baby and the mother to deliver. We also realize that c-sections can save lives. There is often misunderstanding about doctors’ attitudes towards c-sections. We get paid the same for a c-section or a vaginal delivery, so there is no financial incentive to do more c-sections. It is illegal for hospitals in the US to give doctors incentives for doing things certain ways. We are never pressured by hospitals to do more c-sections. I can only speak for myself on this, but I have never done a c-section because I was late for the office, a golf game, or some family function. I can honestly say that I have never done a c-section that I did not think was in the best interest of the patient.