Cesarean Section

A cesarean section is a surgical procedure to deliver the baby through an incision made in the mother's abdomen and uterus. Vaginal birth is the preferred route of delivery. It is usually easier and safer for the mother and her baby. However, a cesarean section is sometimes the best way to deliver for the mother and / or her baby. Some cesarean sections are anticipated long before the arrival of the baby and can be scheduled. Other cesarean sections are performed emergently for problems that arise during labor. There are many reasons why a cesarean section may need to be performed.

Reasons for Cesarean Section

Concern for the baby's oxygen: Sometimes a baby has trouble getting the oxygen it needs during the labor process. Sometimes this occurs because oxygen has trouble crossing the placenta and entering the baby's blood. This can also occur when the umbilical cord becomes trapped between the baby and the uterus. The umbilical cord is squeezed when the uterus contracts and that slows down the blood bringing oxygen from the placenta to the baby. These problems can be indicated by changes in the baby's heart rate on a fetal heart rate monitor.

Concern for the baby's size or position: Extremely large babies may have difficulty moving through the birth canal and are at risk of their shoulders becoming trapped by the bones of the mother's pelvis. Babies in a breech position are also at risk of becoming trapped in the pelvis during labor. Babies in a transverse lie (lying sideways) will not come through the birth canal.

Problems with the placenta: A placenta previa is a placenta that covers the opening of the cervix. The placenta has to deliver before the baby can deliver. When the placenta separates from the wall of the uterus, the mother can lose excessive blood and the baby's oxygen supply will be lost. An abruptio placenta occurs when the placenta separates from the uterine wall before the baby delivers. This also causes a mother to bleed excessively and it decreases the oxygen loss of oxygen to the baby.

Problems with the mother's pelvis: A mother's pelvis may be too small or it may be the wrong shape for the baby to fit through.

Problems with labor process: Sometimes the labor process is too slow. The cervix is not dilating (opening up) as fast as it should or it completely stops dilating. At other times, the baby is not coming through the vagina as fast as it should. This can occur because uterine contractions are not strong enough to force the baby through the pelvis. Labor can also slow down or stop when the baby is too large or the mother's pelvis is too small.

Problems with the mother's health: A woman may have a medical condition that will not allow her to tolerate the stress of labor or the pushing needed to deliver vaginally. Sometimes a mother's medical condition will only improve after her baby delivers. The sooner a mother delivers, the faster she will recover. Some conditions can prevent a vaginal birth such as a tumor blocking the pelvis.

Multiple fetuses: Twins that are both vertex (head down) can usually deliver vaginally. Babies in other positions are typically better off if they deliver by cesarean section. Three or more babies are almost always delivered by cesarean section.

Previous cesarean section: Many women can safely have a vaginal delivery after they have had a cesarean section (VBAC). However, this is not always true. There are many factors involved when deciding which delivery route is best for you and you should discuss the risks, benefits, and factors involved with your physician.

Cesarean Section Risks

• More pain and more difficulty moving than with a vaginal delivery
• Infection of your incision, uterus, bladder, or lungs
• Excess blood loss and possible need for a blood transfusion
• Damage to other organs like your bladder or your bowel
• Blood clots in your lungs or your legs
• Severe reactions to medications / anesthesia

Timing of Cesarean Section

Elective cesarean sections can be safely performed at any time after the baby is mature. They are often scheduled about one week before the due date. If an earlier delivery is necessary, the doctor may want to check the maturity of the baby. This is done by a procedure called amniocentesis. A needle is passed through the mother's abdominal wall and the wall of the uterus into the fluid around the baby. Enough fluid to fill one test tube is drawn out and the needle is removed. The fluid is tested by the lab for substances that indicate the baby is mature. Urgent cesarean sections need to be performed in the near future (usually within an hour or two). Emergency cesarean sections need to be performed as soon as possible.

Preparation for Surgery

In elective situations, you should not eat or drink anything for eight hours before the surgery. Medications should be taken with a sip of water only if your doctor or the anesthesiologist tells you to take them. An intravenous (IV) line will be started in a vein on your arm or on your hand. This allows you to receive fluids and medications. A catheter will be placed into your bladder. This keeps the bladder empty. It helps monitor the amount of fluids you need and it helps prevent the bladder from being injured. You will receive medications to take that reduce the acid in your stomach. This helps prevent stomach acids from getting into your lungs and causing pneumonia. Your vital signs and the baby's heart rate will be monitored. You will then be taken to the operating room.

Anesthesia

Monitor pads will be placed on your chest and on your finger before you receive your anesthesia. These constantly monitor your vital signs during the surgery. Cesarean sections can be performed using general anesthesia (going to sleep), epidural blocks, or spinal blocks. An epidural places the medicine into a space between the bones of the spinal column and the spinal fluid. This numbs your body from the middle of the abdomen down. A plastic tube is inserted into the space and the medicine passes through the plastic tube. Sometimes the tube is left in place so you can receive pain medications after the surgery. A spinal block also numbs you from the middle of the abdomen down, but the medicine is placed directly into the spinal fluid.

General anesthesia is used primarily for emergency cesarean sections, but it can be used if there is a problem with your epidural block or your spinal block. It is also used when an epidural or spinal block cannot be performed. If you have an epidural placed to relive pain during labor, the same epidural can typically be used if a cesarean section is needed. Epidural and spinal blocks are preferred, because they allow you to remain awake. This helps your lungs to function and it allows you to immediately see your baby.

Surgery

You will be placed on the operating room table and made as comfortable as possible. You may need to roll on your side (or sit up) to receive your epidural or spinal block. You will then return to where you were laying and a rolled up blanket will be placed under your right hip. Your abdomen will be washed with an antiseptic solution to kill bacteria and prevent an infection. A drape will be placed over your body to keep the area sterile. The drape will be held up at the level of your shoulders so you cannot see the operation. The lower abdomen will be checked to make sure you cannot feel any pain. If hospital policy and circumstances allow a support person to be present at cesarean deliveries, the support person will be brought into the room at this time. A support person is typically not allowed in the operating room if a general anesthetic is used, the procedure is an emergency cesarean section, or if hospital policy does not allow a support person to be present.

An incision (cut) will be made in your abdomen. The incision is usually a transverse incision that runs from side to side on the abdomen and it is usually placed just above the pubic hair line. In some case a vertical incision may be performed. This type of incision is made in the middle of your abdomen and runs from your pubic hair line to just below your umbilicus (belly button). The abdominal muscles are pushed to the side. The tissue covering your uterus is cut and the bladder is pushed out of the way. An incision is then made in your uterus. These incisions (cut) are usually transverse (side to side) in the lower uterus. They cause less bleeding, heal better, and form a stronger scar. Sometimes a vertical incision (classical incision) is needed. Vertical incisions are placed in the middle of the uterus. They run from just above the bladder toward the top of the uterus. These incisions bleed more and form weaker scars. The baby is then delivered through the incision. The umbilical cord is cut and the baby is handed to the nurses for further care. Each layer of the incision is then sewn together. The skin will be sewn with suture or closed with staples.

Post-operative Care

After your surgery, you will be taken to the recovery room. Your blood pressure and other vital signs will be closely monitored. Most patients experience increased pain when they first wake up or as their spinal and epidural blocks wear off. You will be given additional pain medicines through your IV line to control this. It is also common to become nauseated after surgery and you will be given medicine to help your nausea. You should be able to hold your baby in the recovery room. If you and your baby have no problems, you can try to start breastfeeding if you desire. You will be taken to your room within a few hours.

Your vital signs will be checked at regular intervals as long as you are in the hospital. You will continue to receive pain medications by mouth, by a shot, or through the IV, depending on your circumstances. Be sure to let your doctor and your nurses know if you have had any problem with medicines in the past. Your doctor or nurses will let you know when it is time to get out of bed. This will typically be later in the day you deliver, or the day after you deliver. The first few times you get up out of bed, always have someone else with you. It is common to get weak or dizzy, and you may feel like you will faint. The catheter in your bladder is usually removed the day after surgery. Your IV will be taken out as soon as you are able to eat and drink. You will be in the hospital for two to four days after your surgery, depending on how you are doing. Before you leave the hospital, you will receive help on how to take care of yourself and your baby. You will be taught about infant CPR (resuscitation) and you need to have a car seat for your baby (some hospitals provide a car seat for you). You will receive a prescription for pain medication to use at home (and other medicines you will need).

After You Return Home

You have just had major surgery and you need time to heal. Do not try to do too much too fast. You may increase your activity a little bit each day, but only if you feel up to it. You will continue to have some pain from your incision for a while. You will have light bleeding for four to six weeks after you deliver. You may have episodes of increased bleeding and you may pass small clots. You can expect cramping in your abdomen, especially if you are breastfeeding. For the first three weeks after you deliver, do not drive and do not lift anything heavier than your baby. Do not exercise until your doctor tells you to. To help prevent an infection, do not place anything into your vagina and do not have sex for at least six weeks. Call your doctor if you have a fever, heavy bleeding, severe pain, or a foul odor from your vagina.