Nearly one out of three pregnant woman deliver via cesarean section. With numbers like these, expectant moms ought to know the procedure, risks and reasons for this surgery. Here are expert opinions about its place in obstetrics. Caesarean section, also known as C-section or caesarean delivery, is the use of surgery to deliver one or more babies.
A caesarean section is often necessary when a vaginal delivery would put the baby or mother at risk. This may include obstructed labour, twin pregnancy, high blood pressure in the mother, breech birth, problems with the placenta or umbilical cord. A caesarean delivery may be performed based upon the shape of the mother’s pelvis or history of a previous C-section.
A trial of vaginal birth after C-section, may be possible.The World Health Organization recommends that Caesarean section be performed when there is a medical need as in many cases it is lifesaving for the mother and baby. However, some C-sections are performed without a medical reason, upon request by someone, usually the mother.
A C-section typically takes 45 minutes to an hour. It may be done with a spinal block where the woman is awake or under general anesthesia. A urinary catheter is used to drain the bladder and the skin of the abdomen is then cleaned with an antiseptic. An incision of about 15 cm (6 inches) is then typically made through the mother’s lower abdomen. The uterus is then opened with a second incision and the baby delivered.
The incisions are then stitched closed. A woman can typically begin breastfeeding as soon as she is awake and out of the operating room. Often a number of days are required in hospital to recover sufficiently to return home.
C-sections result in a small overall increase in poor outcomes in low risk pregnancies. They also typically take longer to heal from, about six weeks, than vaginal birth. The increased risks include breathing problems in the baby and amniotic fluid embolism and postpartum bleeding in the mother.Established guidelines recommend that caesarean sections not be used before 39 weeks of pregnancy without a medical reason. The method of delivery does not appear to have an effect on subsequent sexual function.
The rate of cesarean section in this country has never been higher. Reasons for the drastic increase (50 percent in the past decade) are: greater monitoring in the delivery room (which increased the cesarean rate 40 percent with no significant drop in delivery-rated problems); higher medical malpractice premiums and higher rates of obesity. It seems that physicians are quicker to suggest and perform a cesarean, particularly in fist-time mothers. Since the trend these days is for women who have had one cesarean to deliver all subsequent babies the same way, the rate will likely continue climbing.
Overall estimates are that up to 18 percent of cesarean deliveries in the United States are electiveâ€”that is, performed without a clear medical need. It’s important to know the facts about elective cesareans: Women and their babies are more likely to have birth-related complications than women who have vaginal births. They are also more likely to deliver babies too early. Regardless, there are times when a cesarean is necessary for women experiencing complications that make a vaginal birth unlikely or dangerous.
During a cesarean, the baby is delivered through an incision in the abdominal wall and uterus.
Other things you should know:
- Anesthesia. Unless there is no time, you are usually given an epidural or spinal as anesthesia for a cesarean. That means you can stay awake for the delivery, although the doctor will screen the surgical field from view. If things are going too fast for an epidural, you may need general anesthesia.
- Recovery. A cesarean section is major surgery; expect a longer hospital stay and recovery time.
- Blood loss. You lose more blood during a cesarean section than with a vaginal delivery. You may require a transfusion, although the risk that you’ll need one is approximately 2 percent. At the very least, the blood loss may leave you tireder than if you’d had a vaginal delivery.
- Scar tissue. You may have scar tissue form in the pelvic region from the surgery that may affect future pregnancies and deliveries.
- The baby. The baby may have some breathing problems because it did not come through the birth canal. It may also have low APGAR scores (a way of evaluating its health right after birth) because of anesthesia or problems during labor and delivery. But don’t worry; the delivery room staff will rub the baby to restore color and movement and/or provide some supplemental oxygen to help it pink up.
Why Are C-Sections So Common?
We don’t tend to think of childbirth as dangerous, but it’s never been risk free. “Just a relatively short time ago, women and babies died in labor due to infection or prolonged, dysfunctional labor,” says Angela King, MD, an ob-gyn in Fort Collins, Colorado. “Thankfully, medicine has improved to where that very rarely happens in the U.S.” The option of a c-section is part of that improvement.
If problems arise during labor, your doctor might decide that an emergency c-section (one that’s unplanned) would be safer than a vaginal birth. For instance, the baby’s oxygen supply might be in jeopardy due to pressure on the umbilical cord. Maybe the fetal monitor signals trouble with the baby’s heart rate. Or perhaps the baby just isn’t budging, which puts the mother at risk for infection.
When facing a difficult delivery, doctors have traditionally resorted to extracting the baby with forceps or a vacuum. But many younger physicians don’t have the same experience with these techniques as previous generations of ob’s have, so they consider them to be riskier than surgery.
For another range of reasons, scheduled c-sections are on the rise as well. An ultrasound might show that the baby is breech (bottom first), and efforts to turn her in the womb aren’t working. Prior health issues (such as hypertension or diabetes) can also lead to pregnancy complications that require a c-section. And if a woman has had a previous uterine operation, she may opt for surgery to avoid the risk of rupturing her uterus during a vaginal birth.
An increase in multiple births has also inched up the c-section rate, especially for women expecting triplets. “With 40 percent of twins, labor is not a problem, as long as their heads are down,” says John P. Elliott, MD, director of maternal fetal medicine at Banner Good Samaritan Medical Center, in Phoenix. When Courtney Hall, of Fort Worth, went into preterm labor at 33 weeks, she welcomed the option of delivering her twins by c-section. “I was glad that it happened that way,” she says. “I trusted that it would be okay because doctors perform so many c-sections.”
Finally, as c-sections become more common, there’s a small but growing trend to choose this form of childbirth. Some women want to avoid the possibility of prolonged labor pain or vaginal tearing. Others like the convenience of scheduling the birth. “I call them designer deliveries,” says Dr. Elliott. “A woman will say, ‘I’d like to deliver my baby next Tuesday.
My mother is flying in.'” So she’ll opt either to induce labor (which raises the odds of emergency c-section) or to schedule an elective c-section (one performed without a medical reason). The surgery is generally done at or shortly after 39 weeks’ gestation, which is the earliest time sanctioned by the American College of Obstetricians and Gynecologists.
Elective c-sections also give doctors a measure of control. Obstetrics, in general, is unpredictable, and can require that an ob is on call for 24 to 48 hours at the hospital, says Kenneth Johnson, a doctor of osteopathic medicine who practices obstetrics in Fort Lauderdale. A scheduled 25-minute c-section, on the other hand, is more predictable.
What Are the Risks and Complications?
Cesarean section is considered relatively safe. But it does pose a higher risk of some complications than does a vaginal delivery. If you have a cesarean section, expect a longer recovery time than you would have after a vaginal delivery.
The trend is not without its critics. “It’s still a major operation,” says Dr. Elliott, and surgery puts the mom at a greater risk for complications such as infection, blood clots, or excessive bleeding. “Mother Nature has been doing this way longer than I have,” says Dr. King. “I need a very good reason to intervene — not just a tee time.”
Scheduling the c-section before 39 weeks might jeopardize the baby’s health too. Premature babies have a greater risk of having breathing difficulties, due to underdeveloped lungs, as well as delayed brain development.
Women who want to try a vaginal birth after a c-section (VBAC) run the risk of bursting their incision during labor. In subsequent pregnancies, a woman with a cesarean scar on her uterus also runs a higher risk for a condition called placenta accreta; the placenta implants low in the uterus and grows into the scar where the previous incision was made. The risk rises with each c-section, and it can be life-threatening for the mother.
On the other hand, Dr. Elliott says, the baby is better off in a c-section than in a vaginal delivery, under most circumstances. Your child could avoid potential trauma from a vacuum or forceps or the loss of oxygen from a compressed umbilical cord. And the majority of mothers do make it through their c-sections just fine.
Is There a Right Way to Have a Baby?
Many women feel disappointed about having an “irregular” birth experience. “I tell my patients who are upset about having a c-section that it’s my job to deliver a healthy baby and to get Mom through the process healthy and well too,” says Dr. King. “Whether it happens by a vaginal delivery, by forceps, or by c-section doesn’t matter to me.”
Betsy Brown, of Raleigh, North Carolina, was initially upset about her c-section, but when she thinks of her daughter, Miller, now, she feels differently: “No matter how she got here, she’s a wonder. And I should just pipe down and love her, no matter how she got out.”
What Is the C-Section Procedure?
A c-section generally starts with a visit from an anesthesiologist, who discusses your pain-relief options. In most cases, you’ll have either an epidural (a catheter inserted in your spine, which delivers a steady stream of anesthesia) or a spinal block (a single injection of anesthesia).
The physician begins by making a 5- to 6-inch incision in the skin above your pubic bone. Cutting through the underlying tissue, he then makes a horizontal incision through the lower part of the uterus, just above the bladder. Generally, you’re alert but numb, and a curtain is draped across your chest, blocking your view of the surgery.
The doctor then reaches in and pulls the baby out. “My ob said, ‘It’s a girl,’ and held her up in the air for me to see,” says Anne Negrin Reis, of Queens, New York, when her daughter, Lindsey Stella, was born. “My husband got to hold her, and then they weighed her and took her to the nursery.” Meanwhile, the doctor continues the surgery, removing the placenta and stitching up the incisions, layer by layer. The surgery lasts about 25 to 60 minutes.
When it’s over, you’re wheeled into a recovery room where you’re reunited with your infant, provided you’re both well. “Within an hour after she was born, I was nursing her,” says Trista Blouin of Pensacola, Florida, whose first child, Sophia, was born via a planned c-section.
While many women share this experience, c-section moms are statistically less likely to breastfeed their babies than women with vaginal deliveries. A number of factors, such as pain from the incision, keep these moms from establishing a breastfeeding routine early on.
Your hospital stay typically lasts three to four days, as opposed to two days for a vaginal birth. Once you leave the hospital, reduce activity for about six weeks, Dr. King recommends. “I limit my patients to carrying only the baby, nothing heavier,” she says. “Stairs and walking are fine. No baths for at least two weeks, but showers are okay.”
How painful is the recovery? That’s hard to predict because different moms experience different levels of postoperative soreness.
After cesarean section, the most common complications for the mother are:
- Heavy blood loss.
- A blood clot in the legs or lungs.
- Nausea, vomiting, and severe headache after the delivery (related to anesthesia and the abdominal procedure).
- Bowel problems, such as constipation or when the intestines stop moving waste material normally (ileus).
- Injury to another organ (such as the bladder). This can occur during surgery.
- Maternal death (very rare). About 2 in 100,000 cesareans result in maternal death.
Cesarean risks for the infant include:
- Injury during the delivery.
- Need for special care in the neonatal intensive care unit (NICU).
- Immature lungs and breathing problems, if the due date has been miscalculated or the infant is delivered before 39 weeks of gestation.
While most women recover from both cesarean and vaginal births without complications, it takes more time and special care to heal from cesarean section, which is a major surgery. Women who have a cesarean section without complications spend about 3 days in the hospital, compared with about 2 days for women who deliver vaginally. Full recovery after a cesarean delivery takes 4 to 6 weeks. Full recovery after a vaginal delivery takes about 1 to 2 weeks.
Long-term risks of cesarean section
Women who have a uterine cesarean scar have slightly higher long-term risks. These risks, which increase with each additional cesarean delivery, include:
- Breaking open of the incision scar during a later pregnancy or labor (uterine rupture). For more information, see the topic Vaginal Birth After Cesarean (VBAC).
- Placenta previa, the growth of the placenta low in the uterus, blocking the cervix.
- Placenta accreta, placenta increta, placenta percreta (least to most severe). These problems occur when the placenta grows deeper into the uterine wall than normal, which can lead to severe bleeding after childbirth, and sometimes may require a hysterectomy.
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