## Absolute Indications for Primary Cesarean Section **Key Point:** Mild gestational diabetes mellitus (GDM) controlled on diet alone is NOT an indication for cesarean delivery. Vaginal delivery is safe and recommended in uncomplicated GDM. ### Standard Absolute Indications for Cesarean Delivery | Indication | Rationale | |---|---| | **Complete placenta previa** | Placenta covers internal cervical os; vaginal delivery causes life-threatening hemorrhage | | **Vasa previa (ruptured membranes)** | Exposed fetal blood vessels rupture with membrane rupture → rapid fetal exsanguination | | **Transverse lie at term** | Fetus cannot descend through pelvis; labor leads to uterine rupture, fetal compromise | | **Umbilical cord prolapse** | Cord compression causes fetal hypoxia; emergency cesarean required | | **Placental abruption (severe)** | Massive hemorrhage and fetal distress | ### Why GDM Alone Is NOT an Indication 1. **Vaginal delivery is safe** in well-controlled GDM without fetal macrosomia (birth weight <4500 g) 2. **Cesarean indicated only if:** - Suspected fetal macrosomia (>4500 g on ultrasound) - Maternal pelvic contracture - Failed induction - Fetal distress in labor 3. **ACOG recommendation:** Vaginal delivery preferred for uncomplicated GDM [cite:ACOG Practice Bulletin 190] **High-Yield:** GDM alone does NOT mandate cesarean; the decision depends on estimated fetal weight and maternal pelvic adequacy. **Clinical Pearl:** Induction of labor is often offered at 39 weeks in GDM to reduce stillbirth risk, but vaginal delivery remains the goal. ### Distinction: Insulin-Requiring GDM Insulin-dependent GDM carries higher risk of macrosomia and fetal complications, but still permits vaginal delivery if estimated fetal weight is <4500 g and labor progresses normally.
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