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In the United States, the cesarean delivery rate rose most dramatically from 4.5 percent in 1970 to 32.9 percent in 2009. The rate has since plateaued and was 31.9 percent in 2018 (Martin, 2019). Some indications for performing cesarean delivery are shown in Table 30-1. More than 85 percent of these operations are performed for four reasons—prior cesarean delivery, labor dystocia or arrest, fetal jeopardy, or abnormal fetal presentation. The latter three compose the main indications for primary cesarean delivery (Barber, 2011; Boyle, 2013). Efforts to lower these rates are outlined in Safe Prevention of the Primary Cesarean Delivery by the American College of Obstetricians and Gynecologists (2019b).

TABLE 30-1Some Indications for Cesarean Delivery

Reasons for persistently elevated cesarean rates are not completely understood, but some explanations include the following:

  1. Women are having fewer children, thus, a greater percentage of births are among nulliparas, who are at increased risk for cesarean delivery.

  2. Average maternal age is rising, and older women, especially older nulliparas, have a higher cesarean delivery risk.

  3. Electronic fetal monitoring use is widespread and associated with a higher cesarean delivery rate compared with intermittent fetal heart rate auscultation.

  4. Most breech fetuses are now delivered by cesarean.

  5. The frequency of operative vaginal delivery has declined.

  6. Obesity, which is a cesarean delivery risk, has reached epidemic proportions.

  7. Rates of cesarean delivery in women with preeclampsia have risen, whereas labor induction rates for these patients have declined.

  8. The vaginal birth after cesarean (VBAC) rate has decreased from a high of 28 percent in 1996 to 13.3 percent in 2018 (Martin, 2019).

  9. Assisted reproductive technology is more widely used and is linked with greater cesarean delivery rates (Luke, 2019).


Cesarean delivery defines the birth of a fetus by laparotomy and then hysterotomy. This definition is not applied to removal of the fetus from the abdominal cavity in the case of uterine rupture or of abdominal pregnancy. Rarely, hysterotomy is performed in a woman who has just died or in whom death is expected soon—postmortem or perimortem cesarean delivery (Chap. 50, p. ...

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