Cesarean Delivery

(Cesarean Section, C-section, Cesarean Birth)

Procedure overview

What is a cesarean delivery?

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Cesarean delivery (also called a cesarean section or C-section) is the surgical delivery of a baby by an incision through the mother's abdomen and uterus. This procedure is performed when it is determined to be a safer method than a vaginal delivery for the mother, baby, or both.

In a cesarean delivery, an incision is made in the skin and into the uterus at the lower part of the mother’s abdomen. The incision in the skin may be vertical (longitudinal) or transverse (horizontal), and the incision in the uterus may be vertical or transverse.

A transverse incision extends across the pubic hairline, whereas, a vertical incision extends from the navel to the pubic hairline. A transverse uterine incision is used most often, because it heals well and there is less bleeding. Transverse uterine incisions also increase the chance for vaginal birth in a future pregnancy. However, the type of incision is determined by conditions of the mother and the fetus.

Reasons for the procedure

If a woman is unable to deliver vaginally, the fetus is delivered surgically by performing a cesarean delivery. Some cesarean deliveries are planned and scheduled accordingly, while others may be performed as a result of complications that occur during labor.

There are several conditions which may make a cesarean delivery more likely. These include, but are not limited to, the following:

• Abnormal fetal heart rate. The fetal heart rate during labor is a good indicator of how well the fetus is handling the contractions of labor. The heart rate is usually monitored electronically during labor, with the normal range varying between 120 to 160 beats per minute. If the fetal heart rate indicates a problem, immediate action can be taken, such as giving the mother oxygen, increasing fluids, and changing the mother's position. A cesarean delivery may be necessary.
• Abnormal position of the fetus during birth. The normal position for the fetus during birth is head-down, facing the mother's back. However, sometimes a fetus is not in the right position, making delivery more difficult through the birth canal.
• Labor that fails to progress or does not progress normally
• Baby is too large to be delivered vaginally
• Placental complications (e.g., placenta previa, in which the placenta blocks the cervix and presents the risk of becoming detached prematurely from the fetus)
• Certain maternal medical conditions (e.g., diabetes, high blood pressure, or human immunodeficiency virus [HIV] infection)
• Active herpes lesions in the mother’s vagina or cervix
• Twins or other multiples
• Previous cesarean delivery

There may be other reasons for your physician to recommend a cesarean delivery.

Risks of the procedure

As with any surgical procedure, complications may occur. Some possible complications of a cesarean delivery may include, but are not limited to, the following:

• Bleeding
• Abnormal separation of the placenta, especially in women with previous cesarean delivery
• Injury to the bladder or bowel
• Infection in the uterus
• Wound infection
• Difficulty urinating and/or urinary tract infection
• Delayed return of bowel function
• Blood clots

A woman may or may not be able to have a vaginal birth with a future pregnancy, called a vaginal birth after cesarean (VBAC). Depending on the type of uterine incision used for the cesarean birth, the scar may not be strong enough to hold together during labor contractions.

There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.

Before the procedure

• Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear. If you want to have a tubal ligation (a permanent method of birth control in which the fallopian tubes are cut, cauterized, or banded to prevent the egg from being transported to the uterus) as part of your surgery, you must sign a consent form for this procedure.
• You will be asked when you last had anything to eat or drink. If your cesarean delivery is a planned procedure and requires general, spinal, or epidural anesthesia, you will be asked to fast for eight hours before the procedure, generally after midnight.
• Notify your physician if you are sensitive to or are allergic to any medications, latex, iodine, tape, and anesthetic agents (local and general).
• Notify your physician of all medications (prescription and over-the-counter) and herbal supplements that you are taking.
• Notify your physician if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
• You may be given medication to decrease the acid in your stomach and to help dry the secretions in your mouth and breathing passages.
• Plan to have someone stay with you after a cesarean delivery. You may have pain in the first few days and will need help with the baby.
• Based upon your medical condition, your physician may request other specific preparation.

During the procedure

A cesarean delivery may be performed in an operating room or a designated delivery room. Procedures may vary depending on your condition and your physician’s practices.

In most cases, you will be awake for a cesarean delivery. Only in rare situations will a mother require general anesthesia (you will be asleep) for this type of birth. Most cesarean deliveries today are performed with a regional anesthesia such as an epidural or spinal. With these types of anesthesia, you will have no feeling from your waist down, and you will be awake and able to hear and see your baby as soon as he/she is born.

Generally, a cesarean delivery follows this process:

1. You will be asked to undress completely and put on a hospital gown.
2. You will be positioned on an operating or examination table.
3. A urinary catheter may be inserted if it was not inserted before coming to the operating room.
4. An intravenous (IV) line may be started in your arm or hand.
5. For safety reasons, straps will be placed over your legs to secure your position on the table.
6. Hair around the surgical site may be clipped and the skin will be cleansed with an antiseptic solution.
7. Your abdomen will be draped with sterile material. A drape will also be placed above your chest to screen the surgical site.
8. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the procedure.
9. Once the anesthesia has taken effect, an abdominal incision will be made above the pubic bone, either transverse or vertical. You may hear the sounds of an electrocautery machine that is used to seal off bleeding.
10. Deeper incisions will be made through the tissues and muscle until the uterine wall is reached. A final incision will be made in the uterus. This incision is either transverse or vertical.
11. The amniotic sac will be opened, and the baby will be delivered through the opening. You may feel some pressure and/or a pulling sensation.
12. The umbilical cord will be cut.
13. Medication to help the uterus contract and expel the placenta will be given in your IV.
14. The placenta will be removed.
15. The uterus will be examined for any tears or remaining pieces of placenta.
16. Sutures will be used to close the incision in the uterine muscle and the uterus will be repositioned in the pelvic cavity.
17. The muscle and tissue layers will be closed with sutures and the skin incision will be closed with sutures or surgical staples.
18. A sterile bandage/dressing will be applied.

After the procedure

In the hospital

You will be taken to the recovery room for observation. Nurses will monitor your blood pressure, breathing, pulse, bleeding, and the firmness of your uterus.

Usually, your baby can be brought to you while you are in the recovery area after surgery. In some cases, babies born by cesarean will first need to be monitored in the nursery for a short time. Breastfeeding can begin in the recovery area, just as with a vaginal delivery.

After about one to two hours in the recovery area, you will be moved to your room for the rest of your hospital stay.

As your anesthesia wears off, you may receive pain medication as needed, either by a nurse or by administering it yourself through a device connected to your intravenous line. In some cases, pain medication may be given through the epidural catheter until it is removed.

In addition to the soreness of your abdomen, you may also have gas pains as the intestinal tract begins working again after surgery. You will be encouraged to get out of bed. Moving around and walking are helpful in relieving gas pains. Your physician may also recommend medication for this. You may also feel some uterine contractions called after-pains for a few days. The uterus continues to contract and get smaller over several weeks.

Your urinary catheter will be removed usually by the next day after surgery.

Depending on your situation, you may be given liquids to drink a few hours after surgery. Your diet may be gradually advanced to more solid foods as tolerated.

You may be given antibiotics in your IV while in the hospital and a prescription to continue the antibiotics at home.

At home

You will need to wear a sanitary pad for bleeding. It is normal to have vaginal bleeding for several days after birth, followed by a discharge that changes from dark red/brown to a lighter color over several weeks.

You should not douche, use tampons, or have intercourse until the time recommended by your physician. You may also have other restrictions on your activity, including no strenuous activity, driving, or heavy lifting.

Take a pain reliever as recommended by your physician. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications.

Arrangements will be made for a follow-up visit with your physician, usually two to three weeks after the procedure.

Notify your physician if you have any of the following:

• Heavy bleeding
• Foul-smelling drainage from your vagina
• Fever and/or chills
• Severe abdominal pain
• Increased pain, redness, swelling, or bleeding or other drainage from the incision site
• Leg pain

Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.