Cesarean

Cesarean Section (c-section) is the surgical delivery of a baby through an incision (a cut) in the abdomen and the uterus. It can be a lifesaving operation when you or your baby experience certain problems before or during labor. Most mothers would prefer a vaginal birth but all would agree that having a healthy baby is more important than the method of delivery.

Being prepared for a cesarean birth includes knowing when it is indicated, what can be done to reduce your chances of having one, what is involved in this surgical procedure, and being able to accept the disappointment that some women feel about not being able to deliver vaginally.

Repeat c-sections used to be the rule -- "once a c-section, always a c-section." That was because years ago doctors feared a rupture along the previous incision, which was usually a high, up-and-down cut in the uterus. Today most women can try to give birth through the vagina after having a previous c-section and have a successful vaginal delivery if no other risk factors are present. The horizontal incision, which is made low across the uterus, has made such ruptures rare. Talk with your provider about wanting to try a vaginal delivery and about your medical risks. You may be a candidate for vaginal birth after cesarean (VBAC) if:

- A low, horizontal uterine incision was used previously.

- You experienced no complications during or after your c-section, which could affect this pregnancy and birth.

- You will deliver your baby in a hospital or birth center where an emergency c-section can be performed, if needed.

A cesarean section delivery is major surgery and should only be done when the health of the mother or baby is at risk. It should not be an option for the convenience of the doctor or the parents, or for any other non-medical reason.

Cesareans are done for the following reasons:

- Cord prolapse (when the umbilical cord falls into the vagina).

- Bleeding from the placenta.

- Abnormal pelvic structure, for example as a result of a serious injury.

- Shoulder presentation of the baby.

Serious maternal health problems (e.g., infection, diabetes, heart disease, high blood pressure, etc.) when labor would not be safe for either mother or baby.

- Dystocia (difficult childbirth), which includes labor that fails to progress, prolonged labor, and CPD (cephalopelvic disproportion) when the baby is too large to pass safely through the mother's pelvis.

- Breech presentation (buttocks or feet first).

- Fetal distress. The baby may show signs of distress such as slowing of heart rate or acid in the blood before vaginal delivery can be completed quickly.

Some experts estimate that half of all c-sections performed aren't necessary! Part of the reason some doctors may turn to c-sections is due to their fear of malpractice suits. You may not need a cesarean section under these circumstances:

- Repeat cesarean. Unless there are serious medical risks, fewer than half of women who have previously had c-sections need them again.

- Breech presentation (buttocks or feet first). You may still be able to deliver vaginally. Discuss this with your provider.

- Dystocia (difficult childbirth). Often c-sections are performed at the slightest indication of difficulty.

- Over-reliance on electronic fetal monitoring. These devices aren't perfect. Even when they indicate problems, chances are only one in four that the fetus is in danger. Actions, such as a fetal scalp blood sample test, are needed to make sure the baby is not in danger or to plan next steps.

- Fetal distress. Monitoring for uterine pressure and testing the fetal scalp for the amount of acid in the baby can give more precise information about the baby's safety.

- Overdue delivery. Often the conception date is not accurate.

The anesthesia.

Either general or regional anesthesia (epidural or spinal) is used during a cesarean birth. If your c-section is an emergency procedure, general anesthesia may be needed and you will be asleep during the delivery. If spinal or epidural is chosen, you will be awake for the birth of your baby, but numb from below your breasts to your toes.

The surgery.

- A catheter is placed into the bladder to drain urine during surgery.

- A needle will be inserted in a vein in your hand or arm to give you fluids during the operation and medications if needed.

- After your abdomen is shaved and washed and you are numb, the doctor makes the first incision -- a vertical (up-and-down) one from your navel to your pubic bone or a horizontal or "bikini" cut (across) just above your pubic bone.

- The second incision is made in the wall of the uterus. A horizontal incision is preferred because there is less bleeding and it heals with a stronger scar. Sometimes a vertical incision is needed for reasons such as certain positions of the baby or the placenta.

- The doctor can then open the amniotic sac and deliver the baby. You may feel some tugging, pulling and some pressure.

- Next the placenta is detached and removed.

- Finally, the incisions in the uterus and abdomen are closed.

The procedure usually takes about an hour. If you're feeling up to it, you may be able to hold your baby in the delivery room once the baby's nose and mouth have been suctioned and he or she has been checked, just like a vaginally delivered baby would be.

Cesarean birth carries greater risk for both the mother and the baby. Some of the increased risks for the mother include:

- Infection. Women develop post-operative infection of the uterus and nearby pelvic organs less than 10% of the time.

- Increased bleeding. Twice as much blood loss as a vaginal birth.

- Blood clots in the legs, pelvic organs, and sometimes the lungs.

- Death. Although maternal death is very rare, it is four times more likely with a cesarean birth than in vaginal delivery.

- Prematurity, if the due date is not accurately calculated. This can mean difficulty breathing (respiratory distress) and low birthweight.

- Depressed activity due to the anesthesia being absorbed by the baby.

A cesarean birth also is more painful, more expensive, and takes longer to recover from than a vaginal birth. You can expect two to four days in the hospital, and four to six weeks before full recovery.

 See your health care provider for a prepregnancy visit.

 Get early prenatal care.

 Stay fit and maintain a healthy lifestyle during your pregnancy.

 Watch for any signs of trouble and alert your provider immediately.

 Drink plenty of fluids during early labor and suck on ice chips during active labor. Remember to urinate too!

 Walk around as much as possible or change positions frequently during labor. An upright position can shorten labor but try different positions to see what is best for you.

Many medically necessary cesarean births are unavoidable, but others are simply not necessary. You can reduce your chances of having a c-section.

- Learn all you can about c-sections. Educate yourself. That way, you'll know when it's appropriate and what to expect.

- Choose the right provider. Choose a doctor who is board-certified in obstetrics and gynecology or in family practice, or a licensed midwife, who delivers a large number of babies with a low overall percentage of c-sections. Discuss these questions with your provider:

- Do you deliver babies in breech positions?

- Do you try to turn the baby (external cephalic version) after 37 weeks if it's breech?

- How many of your patients who have had a cesarean birth try to deliver vaginally with later babies?

- How do you help women cope with long labors?

- During labor, do you encourage women to walk around?

- What positions other than the flat-on-the-back delivery position do you use?

* Get a second opinion. If a cesarean birth is recommended prior to delivery you may want to get a second opinion.

* Check out your hospital. Ask what hospitals your provider is affiliated with and find out what their c-section rate is. The goal of U.S. hospitals is to reduce the c-section rate to no more than fifteen percent of deliveries by the year 2000.

- Plan ahead. No one can predict whether or not you'll need an emergency c-section. So prepare yourself with information. If you know you'll be having a cesarean, take special c-section prenatal classes.

- Request regional anesthesia. Unless your c-section is an emergency, you should be able to have an epidural or spinal that will allow you to be awake for the birth of your baby.

- Ask that your partner be allowed in the operating room. Support during the birth of your baby is important.

- Discuss having an ultrasound screening and/or a Non-Stress Test (NST) with your provider to determine how well the placenta is working and the age of your baby if there is any question about your date of conception.

- Ask to wait for labor to begin before having your planned c-section. Many experts believe that even a little bit of labor gives the baby some of the advantages of uterine contractions in stimulating breathing and ensuring maturity. If you have had a previous c-section with a vertical uterine incision or have a long way to travel to get to your hospital, this may not be advisable.

- Request a running commentary on the delivery process and to watch the actual delivery if you would like.

- Tell the staff that you and your partner want to hold the baby right after delivery. You and your partner should be allowed to hold your baby in the recovery room unless the baby needs medical attention. If you feel up to it, you can breastfeed immediately, too.

- And don't be afraid to ask questions throughout your labor and delivery so you are comfortable with every procedure.

Recovery from a cesarean birth takes time. You may feel nauseated or cold from the anesthesia and your incision will hurt. But you can help yourself feel better faster.

-Request pain medication if it isn't offered. Usually this doesn't interfere with breastfeeding.

- Plan to get out of bed and walk around 8 to 24 hours after surgery. You may not feel like it, but the movement will help your bowels move and get your circulation flowing so you don't develop clots.

- Have someone "hold down the fort." Arrange for someone to take care of your home and other children while you are in the hospital and when you return home.

- Ask that your older children be allowed to visit you and the baby in the hospital. Take pictures of them to the hospital to put in your new baby's bassinet.

- If you feel good,request early discharge. You may be able to go home earlier.

- Take it easy. Even after you go home, plan on resting most of the time. Getting up every now and then will help you recover, but don't overdo it. Avoid climbing stairs and lifting until you feel better. Sleep when your baby does!

- Ask for help. You probably won't be back to 100 percent for about six weeks. Plan ahead and have your partner, a friend or another relative on hand to help. Consider hiring a nurse or doula who has been professionally trained to care for new mothers and babies.

Cesarean birth can be difficult for many parents, especially if they have been planning for a vaginal delivery. Women often feel disappointed, angry or depressed; their partners may have similar feelings.

- Ask your doctor to explain exactly why the cesarean birth was necessary. This can help you understand why you needed this procedure this time.

- Give up the idea that your delivery wasn't "normal." The most important thing is the health and safety of you and your baby.

- Accept that you can't control everything. Many women who have c-sections feel like they have somehow "failed." You cannot control unexpected events that sometimes make cesarean birth the safest route.

- Allow yourself to feel all the emotions. Every mother feels a wide range of emotions after birth. Some of these rollercoaster feelings are due to shifting hormones. Give yourself permission to cry, to laugh, to experience the full range of your feelings.

- Talk about how you feel. One of the best ways to deal with your emotions is to share them with those close to you -- your partner, friends, relatives, your doctor or midwife.

- Get help. If negative feelings like anger and depression persist, talk with a professional or join a cesarean birth support group.

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