by Regula Elisabeth Burki, MD, FACOG
A cesarean section is the surgical delivery of the baby through an abdominal incision. Supposedly, Julius Caesar was delivered in this manner, hence the name. How is it done? After the skin is thoroughly cleansed with an aseptic solution and sterile drapes spread over the surgical field, the abdomen is entered by making an incision through all layers of the abdominal wall: the skin, the fat, and then several muscle layers and muscle sheaths (fascia). This incision can be made either vertically below the umbilicus like a zipper, or horizontally right above the pubic bone, a "bikini cut." Usually all the intestines have been pushed up into the upper abdomen by the enlarged uterus and the uterus lies directly against the abdominal wall.
Next, the incision through the muscle wall of the uterus is made and stopped just short of the amniotic sac that contains the baby. At this point, everybody gets ready for the arrival of the baby, including dad with the camera. The amniotic sac is ruptured carefully, so as not to hurt the baby, and the baby is delivered much as if she were coming out through the vagina. After the baby is dried and wrapped in soft cloths, the mom can often hold her baby, or at least touch while dad holds the baby. The time from the incision of the skin to the delivery of the baby can be less than three minutes if an emergency requires it, but usually takes about 10 minutes.
If the incision into the uterus is made horizontally in the lower part of the uterus (low transverse incision), the woman is eligible for a trial of labor in a later pregnancy. Rarely, the incision has to be made, or extended, vertically into the upper part of the uterus ("classical" incision) in order to get the baby out. After a classical incision, future labor is too much of a stress for the uterine scar -- it will burst and all subsequent pregnancies will have to be delivered by cesarean section. Rupture of the uterus during labor can occur even without a previous cesarean section but it is rare. It is life threatening to both mom and baby. Immediate surgery, however, can save both their lives (another reason not to have a home birth!).
After the baby is delivered, the placenta is removed through the same uterine incision as the baby, and the uterus and abdomen are closed layer by layer in reverse order. This takes about 15 to 20 minutes.
Generally cesarean sections are done under either a spinal or an epidural nerve block. This allows for the mother to be fully conscious and accompanied by a family member or friend. The mother has, of course, the option to request general anesthesia. The anesthesiologist then waits until the last possible moment before putting the mother under anesthesia, so the baby is still awake by the time he is being delivered. The medications take a few minutes to reach the baby.
The only other time general anesthesia is used is when an acute emergency arises requiring a cesarean section in a woman who does not already have a spinal or an epidural. When minutes can make the difference between life and death, a general anesthetic is usually faster. At such times, the family will not accompany the mother to the operating room, as the nurses and doctors are too busy saving the mom's or the baby's life to have time to instruct lay people on how not to be in the way or contaminate the surgery. Fortunately, such emergencies are rare; but all major labor and delivery floors have an OR ready to go at all times, even while the mother is laboring in a pretty birthing room with lace and ruffles.
A cesarean delivery should be performed when it is safer for the mother or the baby than a vaginal delivery. That can sometimes be determined before labor and a cesarean section will be scheduled. In this case, it is important to be very sure how far along the pregnancy is, so as not to deliver a baby prematurely.
Here are some examples of reasons for a scheduled cesarean delivery: