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Cesarean Sections

Types of cesereans

A cesarean section is the delivery of your baby by means of a cut in the abdomen. A cesarean rate of around 10-15 percent is thought to be reasonable, although in most Western countries the rate has risen beyond 20 percent and around 30 percent of all babies in the US are now delivered by cesarean, an all-time high.

The increase is due to a higher incidence of cesareans in first-time mothers and a lower incidence of vaginal birth after cesarean (VBAC) in subsequent pregnancies. Some women may think that cesareans are safer for the baby than a vaginal birth. In fact, if you've had an uncomplicated pregnancy, a cesarean is hard to justify on medical grounds.

Types of cesarean

Cesareans are either emergency or planned procedures. The doctor will assess its urgency with a grading scale. A Grade 1 cesarean is one that is done if there is an immediate threat to the baby's or mother's life. A Grade 2 cesarean is one where there is concern for the baby's or mother's well-being, but no immediate threat to life. A Grade 3 cesarean is done when there is no immediate concern for the mother or the baby, but an early delivery is advised, perhaps because of a condition in the mother or baby. A Grade 4 cesarean is an elective delivery planned to suit the woman and the hospital.

Emergency cesareans

A Grade 1 cesarean is most commonly carried out when the baby is thought to be at risk, for example if the baby's oxygen supply has been reduced and there are signs of fetal distress. In this case, the staff will try to do the cesarean rapidly-within 30 minutes when possible, although it's important that shortcuts aren't taken that could put your own health at unnecessary risk.

Grade 2 and Grade 3 cesareans take place when there's no immediate threat to life, and these are more common than Grade 1 procedures. A Grade 2 cesarean may be done if your baby's heart rate is causing concern very early in labor and the prospect of a vaginal delivery taking place within a reasonably short time is low. An example of a Grade 3 cesarean is one that is done because of a failed induction of labor.

Elective cesareans

Around one third of cesareans are elective, or Grade 4 procedures, and the number of these has increased greatly in recent years. Reasons for an elective cesarean include a breech baby; a tear involving the back passage, or another traumatic event, during a previous vaginal delivery; a previous cesarean; a larger than average baby; and maternal choice. In these situations, although a cesarean is reasonable, an attempt at a vaginal birth is also reasonable with the right precautions. It's uncommon for maternal choice to be the sole reason for a cesarean, and there's likely to be another factor, such as one of those cited above.

In some situations, it would be hazardous for either you or your baby if you were to try for a vaginal birth; for example you've had multiple previous cesareans or other major surgery to the uterus; the baby can't be moved from lying horizontally; the placenta is lying very low; or there are severe pelvic abnormalities in the birth canal. Some maternal medical conditions also mean that vaginal birth is not advisable.

What to expect

Giving your consent

The doctor will need your consent prior to doing a cesarean. He should tell you why the procedure is being proposed, and what its benefits and risks are. Ideally, you should have plenty of time to decide whether you want the surgery or not, although with an emergency cesarean, the time to think things over may be limited. Even so, you are always within your rights to say no to a cesarean, even if this means that your life or that of your baby is at risk.

Your anesthesia

Before the surgery, you will meet an anesthesiologist, who will make sure that you have no pain during your surgery and will help you with pain control afterward. Most women are awake during a cesarean. An injection of medication into the spinal fluid in your back, called a spinal block, numbs any sensation of pain. Or, if you've been using an epidural for pain relief in labor, this can be used for the surgery. After your anesthetic has been given, the anesthesiologist will check that it is working properly.

Being awake usually means that your birthing partner can stay with you and it's also a little safer for you and for your baby than a general anesthetic. Very occasionally a general anesthetic is needed.

The surgery

Before the surgery, an IV line will be put in your hand or your arm so that fluids or medications can be given intraveneously if necessary. Also, the pubic hair on your belly may be shaved downward by about 1 in (3 cm) to clear the way for the cut. Both of these may be done before you go to the operation room or after you arrive there.

Once the anesthesiologist is assured you're pain free, a catheter will be inserted into your bladder and will stay in until the next day while your sensation recovers. Your abdomen will be cleaned with an antiseptic solution and sterile drapes will be placed over you, which prevent you and your partner from seeing the surgery.

During the surgery, a 4 in (10 cm) long cut will be made, usually horizontally, on the abdomen wall, across the bikini line, although occasionally an up-and-down cut below the belly button is done. Your bladder will be pushed down and the front of the uterus opened so that the doctor can access the baby. If your water hasn't already broken, this will be done now before the baby and placenta are delivered. The surgeon will release the baby's head from the pelvic brim and lift the baby out. Sometimes, another member of the team needs to put pressure on the uterus to assist this. You'll be able to see your baby when the cord has been cut, and once initial checkups have been done on your baby, either you or your partner should be able to hold him while the surgery is completed. After the umbilical cord is cut, your doctor will remove the placenta.

To finish the cesarean, the uterus will be closed up with one or two layers of stitches, then the abdomen wall will be stitched in separate layers. This takes about half an hour, although it can take longer, especially if you've had previous surgeries. You may have dissolvable stitches, or stitches that have to be taken out after four or five days; less commonly, small staples may be used. The choice is usually made by the doctor, but if you have a preference, make this known to the team caring for you before the surgery starts.

Possible complications and your recovery

Your recovery

Your nurses will encourage you to get out of bed the following day, and by the day after this you may be well enough to do most things for yourself, with help. Women usually go home on the fourth day after the cesarean.

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