Patient Basics: Cesarean Section

Originally published by Harvard Health.

What Is It?

A cesarean section, also called a C-section, is surgery to deliver a baby through the abdomen. It’s used when:

• It’s impossible or not advised to deliver the baby through the vagina, or
• Continuing in labor seems to present a greater risk to the health of the baby or mother, even if the plan was a vaginal delivery.

A C-section sometimes is scheduled in advance. But it may also be unscheduled as circumstances change in the course of labor and delivery. An unscheduled cesarean is not the same as an emergency cesarean, which is done when there is immediate risk to a mother or baby that cannot be resolved without immediate delivery.

In the United stated, about 32% of all births are delivered by C-section. The procedure is done less often in most other countries. For example, about 15% of births are delivered via C-sections in the Netherlands, and 25% are delivered that way in England, Wales and Canada.

 What It’s Used For

A C-section may be done for reasons related to the health of the mother or baby, or conditions related to the pregnancy or process of labor.

Reasons related to a mother’s health that may lead to a C-section include:

• Past surgeries involving the uterus. The most common such surgery is a past C–section in the thick part of the uterus, a so-called classical cesarean. These are the minority of cesareans however. And many women can try to deliver a baby vaginally after a previous C-section.
• Infection. If a mother has an infection that may be passed on to the baby during a vaginal delivery, that’s another case when a C-section would be recommended. In some women with HIV or genital herpes, for example, cesarean delivery may be recommended to minimize the risk of the baby being infected during the course of labor and delivery.

Reasons for cesarean delivery related to the baby’s condition include:

• Breech position (hips or legs positioned in front of the head)
• Multiple gestation (delivering triplets or a greater number of multiples vaginally is complex, especially if all are not head-first)
• Evidence that the baby is not tolerating the process of labor (for example, changes in the fetal heart rate with contractions)

Reasons for cesarean delivery related to the pregnancy include:

• Abnormal position of the placenta (for example, the placenta covers the cervix, a condition known as placenta previa)
• Failure of the cervix to dilate during labor
• Failure of the baby to descend through the birth canal during labor and pushing.

C-sections are generally safe. But the risk of major complications during the surgery is higher than with vaginal birth. Some of the increased risk is related to the reason why cesarean delivery was recommended and not related to the procedure itself.

Vaginal birth is preferred over cesarean when labor and the delivery are proceeding without complications.

In some cases, cesarean delivery is clearly appropriate. The use of C-sections sections in these circumstances has made delivery dramatically safer for both mother and child.

Preparation

Preparation for a C-section varies depending on whether it is scheduled or is being done as an emergency, and depending on whether regional or general anesthesia is used.

Usually, women undergoing a scheduled C-section are not allowed to have anything to eat or drink 6 to 8 hours before surgery.

To reduce stomach acids, you will be given antacids to take before surgery. (Stomach acids can, in very rare cases, can leak into a woman’s lungs during a C-section.) You will also be given a dose of antibiotic just after delivery of the baby to reduce the risk of infection.

Just before surgery, an intravenous line (IV) will be placed into a vein. It will be used to deliver medications, fluids and, if needed, a blood transfusion during surgery. Wires connected to heart-monitoring equipment will be attached to your chest, and a blood pressure cuff will be placed on your upper arm. You will be given a mask through which you can breathe extra oxygen, and an oxygen monitoring device will be placed on your finger.

A flexible tube, called a Foley catheter, will be inserted into your bladder to drain urine and keep your bladder as empty as possible during the surgery. This is often done after anesthesia is started so you probably won’t feel it. Your abdomen and pubic area will be washed with an antiseptic or antibacterial soap. It may be necessary to clip the hair in the area where the incision will be.

Doctors usually prefer to use regional anesthesia for C-sections. Regional anesthesia means that you remain awake, while your abdomen and legs are numb.

Regional anesthesia for a C- section can be done a few different ways.

• Spinal anesthesia. Spinal anesthesia is given by injecting anesthesia into and around the nerves of your spinal column, near the middle to lower back. This gives a rapid and complete numbing sensation, relaxing all the muscles of your legs and abdomen. Surgery can be started soon after the anesthesia is given because the effect begins quickly.
• Epidural anesthesia. Epidural anesthesia requires a little more time and is given by inserting a small catheter into the space around the spinal column, called the epidural space. The epidural catheter is used to keep constant levels of anesthetic medication in the space around the nerves. The extent of numbing in the legs and abdomen and the length of time you are numbed can be controlled and adjusted as needed to prevent pain.
• A combined spinal/epidural, called a CSE. A CSE provides both the immediate pain relief of the spinal anesthesia and longer acting pain relief with fine tuning, if needed.

No matter which regional anesthesia is used, you are awake and alert during the baby’s birth, and can breathe naturally on your own. Some women worry that they will have pain with regional anesthesia. However, regional anesthesia numbs from the mid-chest down to the toes, and its effects last for a short time after the cesarean is completed.

General anesthesia is usually reserved for emergency C-sections in which there is not already adequate anesthesia. (In many cases, when a woman is in labor and has an epidural, this can provide the needed anesthesia for the emergency C-section.) If general anesthesia is used, you receive anesthetic medication through an IV. After you are asleep, a plastic tube called an endotracheal tube will be placed in your throat and into your trachea. The trachea, or windpipe, connects the throat to the airways of the lungs. When the endotracheal tube is in place, the anesthesiologist can manage breathing for you while you are unconscious.

Your partner or a friend can be with you during a C-section if you have regional anesthesia, but usually not if you have general anesthesia.

How It’s Done

A low, horizontal skin incision is made in the abdomen at or just above the pubic hairline. Rarely, a vertical incision is required. This is sometimes used in an emergency situation as it may be slightly faster.

After the abdomen is opened, the bladder is protected from injury, and the uterus is opened. The incision in the uterus is usually horizontal and low in the uterus. Or it may be vertical. A vertical incision is preferred when a larger uterine incision is needed, or if the lower part of the uterus has not developed or stretched enough to permit a low horizontal incision. A vertical incision is often needed to perform a preterm cesarean delivery. The bag of waters is broken, the baby is delivered, and the umbilical cord is clamped and cut.

The time from the beginning of surgery to delivery of the baby generally is less than 10 minutes, but may be longer if it is not a first cesarean and there is scarring from a past procedure, or if a woman is particularly heavy. Once the baby is delivered, it can take another 30 to 40 minutes to remove the placenta and close the uterus and abdomen with stitches or staples. The entire surgery usually takes just under an hour.

Follow-Up

The bladder catheter will usually be removed the morning after delivery, and you will be encouraged to walk and begin to drink fluids.

If staples were used to close the incision, they generally are removed within one week. Stitches almost always are the type that dissolve on their own.

During the first few weeks after a C-section, you should not carry anything heavier than the baby. Breastfeeding can be started as soon as surgery is completed and you are awake in the recovery room. Holding the baby in the “football hold,” with the baby’s body under your arm and the head near your breast, can help keep the baby’s weight off the incision.

Risks

The most common problems following cesarean delivery are:

• Bleeding (hemorrhaging)
• Infection of the uterine lining (endometritis)
• Injury to other pelvic organs, such as the bowel or bladder

Risks to the baby include:

• Skin cuts made during the uterine incision
• Delay in absorbing amniotic fluid from the lungs

There are also possible complications from anesthesia. General anesthesia provides deep, total relaxation of the body, which can lead to stomach acids flowing into the woman’s lungs. This is a rare complication. The after-effects of general anesthesia can also make the mother and baby sleepy and delay mother-infant bonding. Headache may occur after regional anesthesia, whether this is used for cesarean delivery or pain management in labor.

When To Call a Professional

After surgery, you should contact your health care professional if you develop:

• A fever
• Yellowish green or bloody discharge from your wound
• Sudden worsening of pain or redness at the incision site
• Abdominal or pelvic pain
• A foul-smelling vaginal discharge or heavy bleeding
• Unusual pain or redness in your legs
• Chest pain, shortness of breath or cough

Additional Info

American Academy of Family Physicians (AAFP)
P.O. Box 11210
Shawnee Mission, KS 66207-1210
Phone: 913-906-6000
Toll-Free: 1-800-274-2237
http://www.familydoctor.org/

American College of Obstetricians and Gynecologists
P.O. Box 96920
Washington, DC 20090-6920
Phone: 202-638-5577
http://www.acog.org/