Cesarean section (C-section)

A cesarean section (C-section) is the delivery of a baby through an incision in the mother's abdomen and uterus. The placenta (a structure in the womb that develops during pregnancy to nourish the fetus and help it discard waste) is also delivered through this incision.


Purpose
A cesarean section is done when a vaginal delivery would be hazardous for the mother, the baby or both. A C-section may be scheduled near the due date or become necessary during labor.

Indications
As many as 25 percent of all deliveries in the United States are done by cesarean section. Considered a major surgery, a C-section should be done only when the health of the mother, baby or both are at risk. A C-section may be needed if:
the mother has a certain medical condition, such as a severe infection, complicated diabetes, advanced heart disease, high blood pressure or active genital herpes
the mother had a previous C-section and VBAC was not desired, possible or failed for some reason
labor doesn't progress as it should
the mother develops placenta previa (when the placenta blocks the birth canal) or abruptio placenta (when the placenta detaches from the uterus)
the umbilical cord begins to come out of the vagina during labor, a condition known as umbilical cord prolapse
the baby is in distress due to lack of adequate oxygen in the womb
the baby is too large or in the wrong position to pass through the birth canal (such as breech or sideways)

Patient preparation
If your doctor has planned a C-section ahead of time or it may be a possibility, learn about the procedure. Talk with your doctor, and consider attending a C-section childbirth class.
With a planned C-section, you'll be asked not to eat or drink eight hours before surgery. You'll need a variety of lab tests, such as blood tests, a urinalysis, an electrocardiogram (a recording of the electrical activity of your heart) and a blood match for a possible transfusion. Just before surgery, your abdomen will be washed and the incision area will be shaved. You may be given a medication to dry the secretions in your mouth and air passages. An IV will be placed in your arm so you can receive fluid and medications. A catheter will be placed in your bladder to drain urine and keep the bladder small and out of the way during surgery.

Preparation will be rapid in an emergency situation, such as a baby in distress, a prolapsed cord or a separation of the placenta from the uterus. Within a matter of minutes, blood may be drawn, an IV started and anesthesia given.

The type of anesthesia used during a C-section depends on the health of the mother and baby. To minimize any effects on the baby, the least possible amount of medication is used.

An epidural block numbs the lower part of your body. A thin needle is placed outside the epidural space (the space between the spinal cord and the outer membrane) and a small plastic tube is threaded into the area. When the needle is removed, medication is given through the tube. After surgery, you may receive pain medication through the same tube.

A spinal block also numbs the lower part of your body. Medication is injected through a small needle into the fluid-filled space surrounding the spinal cord in the low back.

General anesthesia, which induces temporary unconsciousness, is the fastest-acting form of anesthesia and is often used in emergencies. You'll be given medication through an IV, followed by a gas that you'll breathe into your lungs.

Procedure
Once the anesthesia takes effect, the doctor will make an incision into the abdomen and another into the uterus. The abdominal incision is usually a horizontal or "bikini cut." The uterus incision is also made horizontally into the lower part of the uterus, where stretching is greatest during labor. Horizontal uterine incisions often have fewer complications and heal more quickly than vertical cuts. They're also the safest incision for subsequent pregnancies and allow for the possibility of future vaginal deliveries. A vertical cut is made in an emergency or if the position of the placenta or baby won't allow a horizontal incision.
Once the incision is made, the amniotic sac is ruptured if it's still intact. If you're awake during the procedure you may feel a tugging sensation in your abdomen as your baby is carefully lifted through your abdomen. Fluid will be suctioned from the baby's mouth and nose to help him or her breathe. The umbilical cord will be clamped and cut, and the placenta will be removed. You'll be given medication to help the uterus contract, and the incisions will be closed with sutures or staples. The entire procedure lasts about an hour.


Postprocedure care
Specifics after the procedure will depend on your health, as well as your baby's health. Generally, however, you can expect the following.
If you're awake for the surgery, you can usually hold your baby just after birth. If you're planning to breastfeed, this may also be possible with some assistance. If you received general anesthesia, you may see your baby shortly after waking up and breastfeed when you feel ready.

Your temperature, blood pressure and pulse will be checked often. The medical staff will also look for signs of bleeding or infection in your abdomen. With help, you may be out of bed within several hours. If you had spinal anesthesia, you may need to lie in bed for several hours to avoid developing a spinal headache (a headache caused by a leakage of spinal fluid through a puncture hole in the dura, the membrane that surrounds the brain and spinal cord, followed by a decrease in cerebrospinal fluid volume and pressure). You'll be encouraged to cough frequently and breathe deeply.

Your catheter may be taken out at some point during the first day after surgery. The IV will be removed when you can drink on your own, typically after 24 or more hours. Your doctor will prescribe pain medication for the abdominal discomfort you can expect to have for a few days. Take the medication when needed so that you can care for your baby more easily. If you're breastfeeding, try to take the minimum amount of medication necessary to control your pain so that your baby receives the least amount of medication through your milk. After a few days, acetaminophen may be enough to control postsurgical pain.

Sutures or staples are typically removed within three to seven days after delivery. Steri-strips (a suture-like tape) may be applied to the incision for one week after the sutures or staples are removed to reinforce the incision. Bathe carefully during this time to avoid getting the steri-streps wet. Once the tape is removed, you may shower or bathe as usual. The incision will first appear as a firm, raised line. It will gradually flatten out over time.

If you choose to breastfeed your baby, you'll probably need help putting the baby to your breast at first. Finding a comfortable position that doesn't put pressure on your incision is essential. In the early days after surgery, lying on your side or using a football hold are usually most comfortable.

You'll probably be in the hospital for about four days, and it may take four to six weeks until you can resume most of your normal activities. Discuss strenuous activities, such as jogging or lifting even light objects, with your doctor.


Benefits
When a safe vaginal delivery isn't possible, a cesarean section can provide a good alternative.

Risks
As with any surgery, there's the possibility of infection, blood clots, blood loss or complications from the anesthesia. With a cesarean section, there's also a risk of injury to abdominal organs, the bladder, the bowel or the baby. The baby may be born prematurely if the due date was inaccurate or the surgery was done in an emergency situation before the pregnancy reached full term. Anesthesia used during surgery or for pain relief afterward may cause the baby to be excessively sleepy and have trouble feeding.

Considerations
After a C-section, some women feel a sense of failure because they weren't able to deliver vaginally. It's important to remember you have succeeded in giving birth -- not failed. Be sure to discuss any of these feelings with someone close to you, such as your partner or another loved one. You may also want to consult your doctor or a mental health professional.

Vaginal birth after cesarean (VBAC)
If the incision made in your uterus during the C-section was horizontal, you may be able to deliver any future babies vaginally. In fact, when the baby is stable, VBAC has a 60 to 80 percent success rate. The major VBAC risks include a cesarean delivery after going through labor and rupture of the uterus, which puts both mother and baby at risk.
If you and your baby are healthy, VBAC may be appropriate when:

you've had only one or two prior cesarean deliveries with low horizontal incisions
you have no other uterine scars
your pelvic structure will allow the baby to pass through the birth canal
a doctor, anesthesiologist and surgical personnel can be readily available throughout labor in case an emergency C-section becomes necessary
If you're considering VBAC, discuss any questions or concerns with your doctor.