by Regula Elisabeth Burki, MD, FACOG
What is a Cesarean Section?
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.
Anesthesia for Cesarean Sections
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.
Reasons for a Cesarean Section
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:
- Previous surgery on the uterus, such as removal of fibroids from deep in the muscle wall of the upper part of the uterus, or cesarean section with a high (classical) incision.
- Infectious conditions of the mom that could infect the baby in the birth canal -- HIV, large vaginal warts, acute herpes outbreak at the onset of labor.
- Medical conditions of the mom that make labor too great a risk for her, such as extremely high blood pressure or severe diabetes.
- The baby is too big for the size of the mom’s pelvis ("cephalopelvic disproportion"). Sometimes this is so obvious that a cesarean delivery is scheduled from the outset; sometimes the decision is made to do a "trial of labor" and see what happens and only resort to a cesarean delivery when the baby appears to be stuck ("failure to progress in labor").
- More than one baby. Risks are greatly elevated, especially for the second or third baby, because the placenta may detach from the wall of the uterus before all the babies are out.
- The exit is blocked. If a large tumor is located in the lower part of the uterus, it may block passage of the baby through the birth canal. The placenta can cover the cervix and block the exit. This is called placenta praevia.
- The baby is breech. Even though many babies can be delivered in the breech position (bottom first), the risk of complications is greatly increased because the head and shoulders are the largest parts of a newborn. Once they have stretched the birth canal and are out the rest follows automatically. When the smaller bottom end comes out first, the head may get trapped, and the umbilical cord compressed between the baby's skull and the mom's pelvic bones. The baby then does not get any oxygen because the placental blood is cut off and the head is not yet out in the air. The American College of Obstetricians and Gynecologists now recommends that an attempt should be made to turn breech babies in late pregnancy and only deliver them by cesarean section if turning them fails.
- The mom wants a cesarean section. A woman can choose to have a cesarean. She may choose this because she had one before and feels since she already has a scar, she does not want to subject her pelvis and vagina to the trauma of labor. Or she may just decide that labor is not for her (she may have problems to get her insurance company to pay in that case). Even with a previous cesarean women and their doctors have been pressured by the insurance companies to do a "trial of labor" (see section on VBAC). Sometimes the need for a cesarean section becomes apparent only during labor on a more or less emergency basis. In this case it is irrelevant if the baby is premature or not, as labor is already underway.
Here are some examples of when a cesarean delivery becomes medically advised once labor has started:
- Baby problems, possible fetal distress: During labor the baby’s heart rate, including how it responds to contractions, is followed either with a monitor or by auscultation. A non-reassuring fetal heart rate pattern can be a sign that the baby is not receiving enough oxygen. This can occur because the cord is tightly wrapped around the baby’s neck or shoulder, the placenta is separating from the uterine wall, or the baby is at risk for some other reason.
- Mom problems: Rarely, laboring women develop medical problems, such as seizures, that make it unsafe for them to continue with labor.
- Placental problems: This usually involves the placenta beginning to separate from the uterine wall (abruption placentae). Signs of this are excessive bleeding and fetal distress.
- Labor problems ("Failure to progress"): About 30% of cesarean deliveries are done for this reason. The most common reason the baby stops advancing down the birth canal is that the baby does not fit ("cephalo-pelvic disproportion"). If labor is allowed to continue indefinitely, something will eventually give—either the baby will develop fetal distress or the uterus will rupture.
Another reason for labor not to progress is that the contractions are not strong enough. If it is early in labor, before the membranes are ruptured, and the baby appears to be comfortable and doing well, there is nothing wrong with just waiting for a while. Usually, before going to a cesarean delivery, augmentation of labor with Pitocin will be attempted.
How important is it to avoid a cesarean section?
My recommendation is that women not obsess over avoiding a cesarean delivery. A mother should pick a birth professional she can trust to carefully explain why a cesarean section has become necessary, should the need for one arise, and then go with her recommendation. It is highly unlikely that an experienced doctor will bully a mother into an unnecessary cesarean section. If the whole prenatal care has been conducted in a "my way or the highway" style, the mom should not be in labor under such a person's care; but if she is, she still should go with the recommendation, because she simply does not have the medical knowledge at that point to determine if her baby's life or brain is at risk or not. Some things that lead to a cesarean delivery are outside the mother's control; others can be addressed during pregnancy and labor in hopes of lowering the risk of ending up with a cesarean delivery:
What to Do Before Labor...
- Eat well. Remember that "eating for two" in pregnancy means quality not quantity. You cannot stay healthy and grow a healthy baby on junk food. Excessive weight gain increases your risk of having a baby too large to fit your pelvis. There are many excellent guidelines on healthy nutrition in pregnancy. Follow them!
- Stay fit or get fit: If you are out of shape, you are ill prepared for a successful labor. Remember that labor means work—and it is hard work. Get yourself ready for it.
- Learn as much as you can about what to expect.
- Line up knowledgeable labor support. The last thing you will want to do in labor is explain to your support people what is going on and what you want them to do. Insist that the people you plan to have with you in labor come to prenatal classes with you, or hire a labor coach or doula.
- Pick a good birthing professional you can trust. This does not necessarily mean the doctor with the lowest C-section rate as many factors, such as patient mix, can influence a doctor's section rate. Make sure you pick a doctor or midwife who is willing to answer your questions openly and understandably. Should you end up with a cesarean section, it is crucial that you trust your doctor to be doing the right thing.
What to Do During Labor
- Keep moving as long as you can tolerate it. Walking, taking a hot shower, or rocking in a rocking chair lets gravity help guide the baby down in the birth canal and helps you keep your muscles loose. Laying flat on your back does not.
- Try to put off getting an epidural as long as possible. It is not clear from several well-conducted studies that epidurals increase your risk of a cesarean section, but they can certainly slow down your labor, especially if given too early.
- Rest when you can. Labors, especially first labors, can last many hours. You do not want to reach the home stretch when it is finally time to start pushing, totally exhausted. You may be asked to push with every contraction for two or three hours.
- Keep up your energy. Eat and drink at least in early labor, so you have enough energy to last you through to the end.
- Use all the help you can get, be that support people to help you breathe through all your contractions or an epidural when the pain gets to be more than you are willing to endure. Remember that you are the Prima Donna of this event -- let them all treat you like one!
Dr. Regula E. Burki is an OB/GYN and a Fellow of the American College of Obstetricians and Gynecologists (ACOG). Prior to entering private practice she was a Clinical Fellow in Obstetrics and Gynecology at Harvard University and completed a residency in Obstetrics and Gynecology at Massachusetts General Hospital in Boston, where she served as chief resident. She is the current Chair of the Utah section of the American College of Obstetricians and Gynecologists and a diplomat of the American Board of Obstetrics and Gynecology. She maintains a private practice in gynecology in Salt Lake City, Utah. The views Dr. Burki expresses are her personal views and not necessarily those of ACOG.
Copyright © Regula Burki. Permission to republish granted to Pregnancy.org, LLC.