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What to Expect in a C-Section

Let's start by defining a C-section. A vaginal delivery occurs when the baby is delivered through the vagina by natural means. In a C-section the baby does not go through the birth canal, but rather is pulled out through an incision made in the mother's abdomen and uterus. Unlike a vaginal delivery, a C-section involves a surgical procedure and is performed in an operating room under sterile conditions.

In the United States, approximately one in four babies is delivered by C-section, according to the American College of Obstetricians and Gynecologists.

When to Perform a C-Section
It's important to note that, in most cases, doctors will opt for a vaginal delivery over a C-section. The reason is that a vaginal delivery is almost always considered to be safer for the mother and baby unless extreme health conditions warrant otherwise. C-sections may be scheduled in advance if certain conditions are present and both the mother and doctor agree that it is necessary.

Often, however, C-sections are performed in emergency circumstances because conditions indicate that the mother or baby is at risk for a potential problem. If the mother's or baby's health is at risk, then a c-section might become the immediate alternative for saving lives. So, you may go into the delivery room anticipating a "normal" delivery and suddenly find that you're going to have a C-section. It's impossible to tell when this will occur, but some of the circumstances that might precipitate this decision on the part of your doctor are listed below.

Maternal Indications for a C-Section
There are several conditions in the mother that would necessitate a C-section (or in doctor jargon, absolute indications – in other words, the doctor would always suggest or resort to a C-section in these cases). If these conditions are noted in advance, chances are good that you'll be scheduled for a C-section when your baby is at term. These health conditions include the following:

Fetal Indications for a C-Section
In addition, there are conditions related to the baby's health that would prompt the doctor to suggest a C-section over a vaginal delivery. These conditions may not be known in advance of the baby's birth. They include the following: Possible But Not Absolute Indicators for a C-Section
Then there are conditions that occur where the doctor has the option for a C-section, but may or may not decide to perform one. These are the cases where it helps to trust your doctors and have confidence in their decisions. Remember, these conditions can go either way – meaning, the doctor may or may not decide to perform a C-section, but one could be warranted. Make sure your doctor discusses it with you or your partner first. (However, if the condition is life threatening, there may not be enough time.) These conditions include the following: Elective C-Sections (for the Convenience of the Patient)
Having a C-section just because it's more convenient (meaning you can schedule your child's birth) is a very controversial issue today, especially for first-time mothers. It's especially controversial if there are no known maternal or fetal issues indicating that the C-section is necessary. Traditionally, the thought process was that C-sections were riskier for both mother and baby compared to vaginal deliveries. Traditionalists say that C-sections put the mother at risk unnecessarily, and doctors and patients alike have to deal with the problems of repeat C-sections, which are not a trivial matter.

Proponents of voluntary C-sections argue that it is a woman's right to choose her type of delivery option and that even though the risk is increased, the overall risk is low. According to Dr. John, this is not a settled issue in the OB field, but it is being addressed in various forms, both from the patient safety standpoint and also from an ethical, moral standpoint.

Dr. John feels that it is helpful to address the reasons why the patient might want a C-section when discussing elective surgery. He's found that often the reason might be related to the patient's fears – the fear of unknown pain that might be experienced in labor being the most common. In counseling the patient and addressing the pain issue, Dr. John's patients have usually reconsidered having an elective C-section and opted for a vaginal delivery instead. "I've never had to do an elective primary C-section after I talked to my patient and relieved her concerns," he said.

What Is a Classical C-Section?
The classical C-section has been used by physicians as the standard way of performing a C-section, but recently it has been superceded in use by the Low-Transverse uterine incision (see next section).

In a classical C-section, the physician makes an incision or cut in the upper or contractile portion of the uterus. This gives much more access to the baby. It traditionally has been done under emergency circumstances, so many doctors thought this was the quickest and easiest way to deliver the baby. However, as doctors discovered later, this type of incision subjected both the mother and baby to additional risks, as will be discussed later.

While we're on the subject, don't confuse the way your skin is cut and the way your uterus is cut. We're talking about the cutting of the uterus here, not the incision in the skin that you see – confusing, but important differences. Just because a doctor cuts your outer skin up and down or a bikini cut (sideways) doesn't mean that he cuts your uterus that same way. You can't tell from the outer skin incision how your uterus was cut, and it does matter later if you plan on having subsequent births.

The old dictum was once a C-section, always a C-section, which usually applied to the classical Cesarean section and meant that you always had to have C-sections for later deliveries. However, that dictum does not always apply to a low-transverse C-section.

Risks of a Classical C-Section
When a classical C-section is performed, the area that is cut tends to be muscular so that when a scar forms, the scar is found to be weaker when laboring with a future pregnancy. This does not bode well for a mother's attempt at a vaginal delivery in subsequent births, for fear that the scar might tear while in labor. Thus, there is a risk in future deliveries for the uterus to rupture.

If a rupture occurs, the mother could bleed internally, and the baby could work its way through the previous incision or scar. In that case, the placenta would be compromised, and the baby could die. The mother could also die. The overall risk of a uterine rupture occurring is less than one percent in women who have never had surgery of the uterus (for example, a previous baby born by this type of C-section).

However, in women who have had a classical C-section in a previous birth, the risk for rupture elevates to 20-25 percent in subsequent pregnancies and births attempted vaginally. For this reason, most doctors recommend that subsequent births also be delivered via C-section.

In contrast, the risk for rupture in subsequent pregnancies for a woman with one low-transverse C-section is less than one percent. And that's the real reason that OBs prefer the low-transverse C-section procedure.

Uncovering Statistics
How did doctors figure this out? Dr. John said that there is an unfounded story that the difference between these two types of C-sections in subsequent births was first noticed in the UCLA parking lot, of all places! One day the parking lot was literally full of women having babies at the County Hospital because the hospital was full, and there weren't enough rooms. Because many of the women were Hispanic and possibly there weren't enough interpreters or time to get full histories or data before the births, it wasn't until after the births occurred that doctors discovered that many of the women were having a third or fourth child delivered vaginally, but they had previously had low-transverse incisions and C-sections. Bells started ringing and people started asking questions. The result: The discovery that low-transverse incisions are safer for vaginal deliveries after C-sections. (Hey, it's a good story whether it's true or not.)

Low Transverse C-Section
In a low transverse C-section (LTCS), the doctor cuts through the lower uterine segment of the uterus, which typically doesn't involve the same tissue as a classical C-section. This region of the uterus has less muscular fiber, and is less easy to tear or rupture with future labors.

There are still risks with a LTCS, but they seem to be fewer in nature. The uterine scar will tear less easily, as we already suggested. However, even though many women can deliver subsequent babies vaginally after this procedure, many doctors still advise going the C-section route with subsequent babies, just to be on the safe side.

What Happens During a Planned C-section?
In a planned C-section (make note of the word "planned" because procedures might work differently in an emergency), the doctor will review the patient's history, make recommendations, and schedule a certain day and time for the surgery.

Before the Surgery
On the day prior to the surgery, the patient is asked not to eat or drink anything after midnight because she should ideally have an empty stomach in order to keep from aspirating. Aspiration occurs when the patient vomits the contents of her stomach, the contents go back into her throat, and then possibly fall back down the windpipe and into her lungs. This is obviously not a good thing and could be life-threatening. The doctor will ask the patient to show up at the hospital at a specific time. (Dr. John stresses how important it is to be on time. Even though it is several hours before your surgery, there is a lot of prep work that has to be done.) The patient will also be informed of any requisite postoperative restrictions, as well as ensuring that she has adequate help after the surgery.

On the morning of the surgery, the nurse will evaluate the baby's heart rate and mother's contraction pattern by using external monitors placed around the mother's abdomen. In addition, the nurse will check the mother's vital signs. The nurse, doctor, and anesthesiologist will review the records again to evaluate any medical complications. Consent forms will be signed and witnessed. The surgeon will ask the mother if she has any questions and will explain what will happen, if that has not already occurred.

Once everything is set, the patient will be taken to the operating room (OR). The nurse may or may not do a shave of the pubic area, depending on the physician's preference. A Foley bladder catheter is inserted to drain the bladder so that it is not in the way of the operating field (basically, they deflate it). At this point, the anesthesiologist takes over. If the indication is not urgent, the patient will receive a regional anesthetic (most likely a spinal) so she stays awake, but the region being worked on is numb. In this way, the patient does not have to be intubated as she is breathing on her own. This is considered to be much safer than a general anesthetic where the patient is put under and is not conscious. (Much nicer to be conscious for your baby's birth.)

If the baby has been continuously monitored up to this point, the monitors are taken away so that the abdomen can be prepared for surgery. The preparation consists of applying sterilizing solutions to kill all the germs on the surface of the skin. Many times it is an iodine solution. If you're allergic to iodine, let the doctor know earlier. Also, let them know if you're allergic to latex.

Before the surgery begins, a hip roll is placed beneath the patient's right hip, to tilt her slightly to the left. They do this for the same reason that the doctors don't want you sleeping on your back during the latter stages of pregnancy – because the uterus being heavy can rest on the vena cava, which can restrict the blood flow to the baby.

The patient is then draped, and the surgeons take their places on either side of the patient. Often, there is a second surgeon (who might be a resident) assisting the primary surgeon (your doctor). Obviously, the primary surgeon will be the person performing the operation.

At this point, the surgeon will check with the anesthesiologist to verify that the anesthesia is adequate – in other words, they will do a test to make sure the patient can't feel anything in the appropriate area and therefore is ready for surgery. Now the father or significant other is allowed into the operating room. That person will be draped in a gown and facemask to preserve the sterile environment, and he (or she) will be positioned at the head of the bed next to you.

The drape is elevated above the patient's chest so that her face is shielded from the operative field. This is done for two reasons: Doctors want to keep the patient's face shielded from anything that could splatter on it; they also don't want her seeing the trauma of her innards coming out. Let's face it – that would be a disgusting thing to witness. So, it's a combination of emotional and physical safety issues.

Next, the doctor makes the incision in the skin. Typically, it's called a Pfannenstiel skin incision (otherwise known as a bikini cut), which is a horizontal incision just above the pubic hairline. Several layers of tissue are cut before the surgeon is inside reaching the uterus.

From the patient's perspective, all she should feel is a little bit of pressure or tugging and pulling, but she shouldn't feel any sharpness or pain.

After the surgeon reaches the uterus, he will study the anatomy to decide where the baby is lying and where to make the cut to optimize getting the baby out. There will be some gentle dissection behind the bladder in order to create a space to expose the incision site on the uterus. The reason the surgeon takes so much care is that he is trying to preserve the mother's option of having a baby vaginally in the future.

The physician will make a low-transverse uterine incision. The incision will be large enough to pull the baby out, possibly 8-10 centimeters (the doctor can stretch it more with his hands). The surgeon will go slowly before the next cut, with the assistant suctioning away the blood that obscures the surgeon's vision. There is lots of blood pouring into the hole he is cutting, so he must trust his tactile feel to reduce injury to the baby. Once the doctor feels that he is inside the uterus, he will stretch open the incision and put one hand inside to protect and deliver the baby's head. Usually, he will be aided by an assistant who is applying pressure on the top of the uterus to push the baby forward.

The baby's head can't be pulled out until it's actually peeking out. The surgeon will use a little force to push the mother's uterus down, thereby squeezing the baby out of the incision.

From the mother's perspective, she'll feel tugging and a lot of pressure. She will not be asked to push, but she will definitely be aware of the tugging and pulling.

The Baby Delivered by C-Section
When the baby is delivered, there tends to be a lot of amniotic fluid that comes out, so the doctor will suction the baby's mouth and nose to aid the baby's breathing efforts. He'll clamp the umbilical cord, cut the cord between two clamps, and one of the doctors will hand the baby to a nurse so that the baby can go immediately to a warmer. (The doctor might show you the baby briefly, but don't count on it. The immediate concern is to get the baby evaluated.) After the baby is on the warmer, the neonatal resuscitative team (NNR) will work on the baby and make sure that it is progressing as it should.

The way the staff handles a baby delivered by Cesarean is different than the way they handle a vaginal birth because of the increased risk to both mother and baby in a C-section. For example, the baby may have more of an adjustment or transition period from intrauterine to extrauterine life by being delivered from a C-section. In a vaginal delivery, the squeezing of going through the birth canal pushes the fluid in the baby's lungs out and can facilitate breathing of the baby once it's delivered. However, in a C-section, depending upon whether labor occurred or not, much of this fluid may still remain in the baby's lungs, so the baby is often given oxygen and the baby's back is massaged (palpation) to increase the expulsion of fluid.

The Surgery Continues...
Once the baby is out, the OB will focus his attention back on the mother (his primary patient) because she is still bleeding from the uterus, which must be controlled immediately. The placenta is delivered next. The surgeon places his hand inside the uterus and peels the placenta off the uterine wall. Simultaneously, the anesthesiologist administers Pitocin, which will help the uterus squeeze down upon itself to cut down on the blood loss. Typically, if the patient hasn't received antibiotics up to this point, she will receive them now. Antibiotics are a key factor because they will reduce the chances of infection, since virtually all the contents of the uterus have spilled into the patient's abdominal cavity , including lots of bacteria (not to be too graphic here, but yeech – I'm beginning to notice that doctors get a kick out of describing gross stuff).

Once the placenta is out, the doctor focuses on closing the incision he made. There tends to be a lot of bleeding at this juncture, so visualization is a challenge. The team uses a combination of suction and gauze sponges to find out where they need to sew. They start at one end of the uterine incision and work across to the other side, closing the incision site. Often, the OB will perform a second layer of closure on top of the first one. Some doctors feel that this is helpful to prevent a uterine rupture in the future.

Next, the surgeon will look for any signs of bleeding that haven't been addressed yet and cauterize those areas. The pelvic region may be irrigated with sterile water or saline. The doctor will remove any large clots and begin the closure of the various layers of incisions that were previously incised, including the skin. The skin may be closed with suture materials or staples.

From the Doctor's Perspective...
Studies show that the healing rates from using either staples or suture material are the same. Dr. John, however, likes sutures better because they are dissolvable. "With staples, you have to remove them in three days, say the morning of going home. Sutures don't have to be removed since they dissolve on their own. Some doctors think it's faster to work with staples, but I still prefer sutures."

The Pitfalls of Surgery
Compared to a vaginal delivery, the risk for the mother in a C-section is generally twice that of a vaginal birth for bleeding, infection, and other complications. Having said that, the overall risk of having a complication is one to three percent.

The mother could also have injury to other organs, including the bladder and intestines. In rare cases, the uterus may continue to bleed despite conservative efforts to stop the bleeding. In those situations, it's possible that a hysterectomy might have to be performed. This would be done as a last resort to save a woman's life. The decision is never taken lightly. With any surgery, there is also the risk of scar tissue or adhesions, which could cause pain later.

One of the obvious risks for the baby is that the doctor could cut the baby's skin with the scalpel. Because the baby's head or face is pressed against the uterus, the doctor has to go very slowly and carefully when incising the uterus, clearing away blood before making his every cut. That is where experience and touch come into play for the surgeon, who is often blinded by the extensive amount of blood. Other injuries the baby could suffer might be a neck injury, as it is being pulled out.

Post-Op and Recovery
After the woman is all stitched up, she is transported (referred to as towed in the Navy) to the recovery room for at least an hour. There her vital signs are monitored to make sure there are no significant complications from surgery that would require her to go back to the OR. If the baby is doing fine, she may see the baby at this point, or she may have to wait until she goes to her room. Sometimes, it's hard for family members to visit in the recovery room due to privacy issues with other patients, so don't expect a lot of visitors.

Typically, your OB will sit down and explain how the surgery went and answer any questions. Afterwards, the patient is transferred to a recovery room or a postpartum room, where she will stay until she is discharged, which will probably be in two or three days, barring complications.

The Day of the Surgery
The day of the surgery, if you're the patient, you will feel pretty tired and have some pain issues. You will be required to rest a lot. The catheter will stay in place so that you don't have to get out of bed to go to the bathroom. Pain medicines will be administered through an IV. You will not be allowed to eat at first, although fluids are provided. Mostly, you'll just want to rest (and see your baby, of course).

The First Day Post-Op
By the first day after surgery (post-operative Day 1), the doctor will evaluate you to make sure you're stable. The bandage will be removed so the doctor can look at the incision, and then it will be left uncovered. The Foley catheter is removed. The patient is asked to begin walking, if she hasn't already done so.

Walking will be a little bit challenging at first, but with effort, the majority of women find they can walk pretty well by the end of the first day. Dr. John always asks patients to sit up for a few minutes first to make sure they aren't dizzy, and then stand up with a hand close to the bed to give themselves another minute before they walk around the room.

You will still have an IV with fluid flowing. You should sit in a chair if you're tired but don't feel like sleeping. If you're tired, use the bed to sleep, but if you're not tired, doctors prefer that you try to use the chair. Sitting and walking not only restores confidence, but also helps prevent clots from forming in the legs. You'll be asked to increase your walking daily.

It's time for food, if you feel like eating. The first meal you will eat will be a soft diet of easily chewed foods. If those are tolerated well, you'll advance to eating regular foods.

The Second Day Post-Op
On the second day, the hospital staff and your doctor will evaluate your progress and take a blood test to make sure you haven't lost too much blood. You'll continue to walk the hallways, obviously more than the day before. In some instances, patients may recover so well that they can be discharged at the end of the day, but this is usually reserved for post-op Day 3.

The Third Day Post-Op
On post-op Day 3, you'll be examined, the staples will be removed if necessary, and you'll be given instructions on how to take care of yourself at home. Things to watch out for include fevers, increased vaginal bleeding (more than a period), and pain that is not responding to pain meds that could indicate complications from surgery. The doctor will recommend that you don't lift anything heavier than your baby.

Home Care
For six weeks, you should watch for all of the above (fever, vaginal bleeding, and pain), but precautions also should include not placing anything inside the vagina (this means no tampons, douching, or sexual intercourse). Some doctors recommend driving restrictions (meaning don't drive) from three to four weeks or longer.

Don't forget to make a follow-up appointment with the OB who delivered your baby. Make the appointment within four to six weeks after the delivery (that means you'll have to call for an appointment as soon as you get home – you know how these doctors are with their schedules). If you have any questions regarding your recovery, however, always call your doctor ASAP.

As far as wound care goes, you can take a shower, but don't rub the incision while showering. Let the water run over it and take a bar of antibacterial soap, make a dollop of suds in your hands and apply it gently to the incision, let the suds sit for a minute, and then rinse them off. Use a clean towel and pat the incision dry, don't rub it. If you want to use Bacitracin or Neosporin ointment and rub it on, it might reduce scarring. (But, first make sure you're not allergic to either of those products.) Taking a bath is acceptable once your bleeding has decreased significantly. Be careful not to slip while getting out of the tub. For the first couple of weeks, a shower is preferable.

For painkillers, the majority of women can take Motrin or Ibuprofen. Make sure you take any medicine with food or milk, assuming that there are no contraindications to that. Take medicine regularly for the first couple of days after surgery. Most doctors will also provide a narcotic-based medicine as well. Dr. John recommends trying the Ibuprofen first and then the narcotics – the reason being, Ibuprofen is an anti-inflammatory, which will address the cause of the problem, whereas the narcotic simply masks the pain. Be aware that the Ibuprofen might have gastro-intestinal side effects. The narcotics also have side effects, including drowsiness, which could increase your chances for clotting and constipation if you're sleeping and not walking (unless, of course, you sleepwalk). Instead, try taking the narcotic at night if you're going to take it.

For the six weeks after surgery, use walking as your main source of exercise. Avoid setups or crunches or anything that could weaken or tear the incision.

The Unexpected C-Section
Obviously, if you have an unexpected c-section, then it is probably an emergency situation. Many of the same procedures will be followed, but probably faster – OK, possibly at lightning or warp speed on the part of the hospital staff. The father or significant other may or may not be allowed in the operating room. It will depend on the severity of the situation.

The Absolute Minimum
There is no getting around the fact that a c-section is an operation that requires cutting, and as such, it can be dangerous. Fortunately, with the advent of antibiotics and improvements in surgical techniques, it is a relatively normal procedure that is performed routinely and successfully every day around the world. Still, be aware of what it entails and ask questions before you get to the point where you need a c-section.

Reproduced from Absolute Beginner's Guide to Pregnancy, by John Adams and Marta Justak, by permission of Pearson Education. Copyright © 2005 by Que Publishing. Please visit Amazon to order your own copy.

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