While there are reasons that a cesarean section may be planned before labor begins, for most first-time mothers or women who have not had a previous cesarean, the decision to have a surgical birth will be made in labor. Most of these cesareans are not emergencies but are simply unplanned until the course of labor says otherwise.
Reasons for a Cesarean Birth
A cesarean section might be performed for a number of reasons, including:
Placenta previa: Part of the placenta covers the cervix, the opening where the baby exits the uterus. A breech baby: The baby is not in a head-down position; instead, they are feet or bottom first. Fetal distress: The baby is not tolerating labor or is having a complication in pregnancy that might necessitate an immediate delivery. Higher order multiples (triplets, quadruplets, etc.) Other maternal or fetal complications
Talking to your practitioner before labor about why a cesarean may be necessary for you can give you specific information particular to your pregnancy. You should also ask your doctor or midwife about their specific rates for cesarean section, even if you do not think that you will have a cesarean. Be sure to ask about their low-risk cesarean rate. This is based on the number of women who fall into a category called NTSV (nulliparous term singleton vertex), or first-time mothers at term with one head-down baby. The NTSV cesarean rate is more accurate in determining your risks of needing a cesarean. The NTSV or low-risk cesarean rate is calculated per provider and potentially for the practice in which your doctor or midwife provides care. You may also ask at the hospital where you are planning to give birth. Understand that your provider may not know this information right off the bat and may need to find out and get back to you. You should also be able to call and ask the practice manager for this information. The national target is lower than the total number of cesarean births and takes into account the increased need for some women to have a cesarean birth and separates that from low-risk women, who are much less likely to need surgery to birth safely.
Risks
A cesarean section is major abdominal surgery. In cases where there is an obvious need for the surgery as a life-saving tool, it is easier to weigh the benefits versus the risks. What is harder to define is when are these added risks not acceptable. This will vary from practitioner to practitioner and family to family. There are a few major categories of risks: to the mother, to the baby, and to future pregnancies. The risks to the mother include:
InfectionBlood clotsSurgical injury to the urinary tract or the gastrointestinal tractBleeding too much (hemorrhage)Needing a hysterectomy (removal of the uterus)A very small risk of dying
There are also risks to the baby, though some risks are difficult to tease out if the added risk is due to the reason a cesarean is needed, particularly in the case of fetal distress. These risks include:
Breathing difficultiesBeing in the neonatal intensive care unit (NICU)Iatrogenic prematurity (accidental prematurity due to when the surgery was performed)Breastfeeding difficultiesBeing injured or cut during the surgery
There are also potential risks to future pregnancies. These risks include:
Uterine rupture (where the scar separates during pregnancy or in labor)Abnormal placental placement, including placenta previa Emergency surgery for hysterectomyNot being allowed to attempt a vaginal birth, even if the mother is an appropriate candidate, due to hospital policiesPlacental abruption (where the placenta prematurely separates from the uterine wall)Fertility issues, miscarriage, or stillbirth
While there are additional risks from a cesarean birth, it should also be noted that this is the most common surgical procedure in the United States, with well over 1.3 million surgeries performed every year. This means that there is constant work and improvement, when possible, to reduce these risks on all fronts.
Childbirth Classes
Taking a childbirth class can also give you more information about cesareans and when they might be needed, how to avoid an unnecessary cesarean, and information about recovery. This can also help you formulate questions to ask of your practitioner and during tours of hospitals or birth centers.
Why would you have an unplanned cesarean? Why would you need to schedule a cesarean? What are the risks of a cesarean section?
C-Section Procedure
There are two basic ways that the decision is made to perform a cesarean. One is when the decision is made after labor has begun, so you are already checked into the hospital and probably in labor. You may also already have an epidural in place. The other scenario is when you schedule a cesarean prior to labor and check into the hospital, specifically for the purpose of having your baby by c-section. You will normally check into the hospital either in labor or before a scheduled c-section. From there they will do blood work to ensure they have information to help you find the right medications and treatments. You will be given medications to help neutralize the acid in your stomach and you will be given an IV. You may also have part of your pubic hair trimmed, not shaved. If you do not already have an epidural in place, you will be given an epidural or spinal anesthesia, or more rarely, general anesthesia (which puts you to “sleep” for the surgery). After anesthesia, you will have the surgery for the birth of your baby. The surgery starts with scrubbing your abdomen and preparing the instruments. There will be a lot of drapes and curtains placed to prevent infection and prevent you from having to watch the surgery if you’re not inclined to do so. Your arms will usually be placed on boards that stick out, away from your body. They may or may not be strapped onto these boards. (You can let your preference be known. Many mothers prefer to have at least one arm free.) The surgery will start by checking to ensure you’re completely numb in the area where the incision will be made. Then, the different layers will be cut and dissected. These layers include your skin, fat, muscle, fascia (fibrous connective tissue), peritoneum, uterus, and amniotic sac. This part of the surgery is usually fairly quick compared to the overall length of surgery, five to 10 minutes. It may take longer to get to the baby if you have a history of abdominal surgery, particularly a previous cesarean, due to scar tissue. There are also other things happening during this portion, including your bladder being protected and bleeding blood vessels are being cauterized to prevent additional blood loss. This is one of the reasons that your obstetrician will use a second person to assist them. This may be another doctor, your nurse midwife, or an operating room assistant (a physician assistant, advanced registered nurse practitioner, etc.). When it comes time for the actual birth, you may feel pressure and tugging. Your doctor will remind you of this and prepare you for it. Some mothers say that for a minute, they feel very nauseated from the pressure. It is typically very brief. The anesthesiologist or anesthetist is by your side and will help you cope with this and anything else you may potentially feel during the c-section (which should not be pain). You may actually be able to witness the moment of birth if you choose. Some facilities offer clear drapes that allow you to see the baby being lifted from your abdomen. You can also ask that a non-clear drape is lowered for a moment. And there is also a possibility of using a mirror that is placed near your side, face down and parallel to the floor to watch. Your partner and/or doula are usually by your head. They can also watch. If your baby is healthy, you will be able to have your baby placed skin to skin on your chest with warm blankets covering both of you. Your partner, doula, nurse and/or anesthesiologist can help facilitate this for you. Some babies will even latch on and nurse in the operating room. Other babies require some assistance at first and that will usually happen in the operating room. Your partner may be asked to come over to the warmer while your baby is evaluated. When possible, they will bring the baby back to you after the evaluation. While all of this was going on, your obstetrician is finishing your surgery. The placenta is either expressed or removed manually. The uterus is inspected and cleaned. It is sutured and the process begins of sewing and repairing the various layers. This takes longer than the original part of the surgery.
Birth Plans and Options
Having a cesarean birth might make you think that you have no options. That’s not true. There are still plenty of options for you to decide upon before you are done giving birth, including some that will help you have a safer cesarean birth. This is true whether you are having a scheduled cesarean or unplanned cesarean. Some of these options might include:
Who can go to the operating room with you for the surgery/birth Whether you use a doula to support you and/or your partner during or after the birth Whether you have music played Whether you use a mirror or some other option to watch the baby emerging Whether your baby can be given directly to you for skin-to-skin care in the OR or the recovery room Whether you or your support partner can take photos
Talk to your doctor to see what options they routinely offer. If there is something that you don’t hear but are interested in, be sure to ask. Your doctor wants you to have a safe birth, but will usually accommodate as much of your personal preference as possible, without compromising safety. You may also ask to see samples of cesarean birth plans.
Recovery
Immediately after the birth, you will recover in a special area of the hospital called a recovery room. Most hospitals have a separate recovery room for women who have just given birth surgically, but it is usually a room with the potential of more than one person at a time. This means that the number of people you are allowed to see is fewer than if you had had a vaginal birth. After the initial hour, you will usually head to your regular postpartum room for less intensive monitoring. Here you can have more visitors, depending on hospital policy. One of the best things you can do to speed your recovery is to get up and move. Many women can do this once the numbness wears off, with some support from the staff and physician approval. This movement helps you heal and lowers the risk of some complications, like blood clots. You will be given special boots, sometimes prior to the surgery, to wear on your lower legs that squeeze. This is to try to prevent blood clots forming from inactivity.
Pain Medications
You will be given pain medication to help you recover from the pain of the surgery. Many women are initially given medication through the epidural catheter to help ease the pain during the first hours to almost day after birth. This can be supplemented with oral medication like narcotics. Narcotic medications are used by mouth after the first few hours after surgery. You may need these for a while after giving birth, but some women are able to transition to over-the-counter or non-narcotic medications within a few days. Good pain control is very important to your recovery. You should not skip pain medication. It is safe for you to take while breastfeeding and an important part of your recovery. Since a c-section is a surgery, your recovery will usually be longer than that of a vaginal birth. Your incision will be sore and most women say that walking the first few times after birth is very painful. Remember that walking is actually a good thing as it speeds healing. For the first few weeks, rest as much as you can and carry nothing heavier than the baby.
Cesarean Scar
You will have a scar where your surgeon cut. It is usually about 4 inches long and located just above your pubic hairline. Sometimes, you will have a scar that is in a different location or direction. Your incision is closed with staples, suture materials, or glue, depending on what your surgeon felt was best. After a few days, you may have any remaining stitches or staples removed. This may or may not be after you leave the hospital. You should ask your postpartum nurse about how to care for your incision. Ask what is normal and what is not. For example, a bit of oozing the first few days is normal.
Six-Week Postpartum Visit
Your scar will change how it looks drastically within six weeks. And six months after you have given birth, it will look even more different. You may notice that after the pain from giving birth is gone, your scar may be itchy and/or numb. This is fairly common, but certainly something you can ask about either at your six-week check-up or by phone if needed. About six weeks after you give birth, you will have a visit with your doctor or midwife. This is a chance to talk about your recovery, and also your labor and/or birth, birth control, and future births. If you have questions, write them down and bring them. This visit usually includes a physical exam, including a pelvic exam. You may also be given a prescription for birth control at this time if you want it. Once you are declared healed, you are usually given the green light for sex. Remember, this is a physical clearance. Sometimes, you’re not emotionally ready and that’s okay too. Talk to your partner about your desires, their desires, and what you can do to become ready or while you’re waiting.
Breastfeeding
Breastfeeding after a cesarean is possible, though studies and mothers tell us that sometimes it’s harder. Sometimes it is because of initial separation after birth or a delayed initiation of breastfeeding. When possible, preventing these delays and planning ahead can be helpful. You may also want to use different positions in the first days after your birth. Many mothers find that using a football hold position for breastfeeding helps protect their scar area. Be sure to ask for help if you’re having issues with breastfeeding, or simply want some tips from a pro on how to breastfeed after giving birth by cesarean.
Future Birth Plans
The majority of women who have a cesarean birth for one pregnancy can have a vaginal birth with subsequent babies. This is called a vaginal birth after cesarean or VBAC (pronounced vee-back). Discuss this with your practitioner. It will usually depend on the reason for the first cesarean and the type of incision on your uterus. Having previously had a cesarean, there are added risks for a future pregnancy. Some of these are inherent to simply being pregnant again, though some are slightly increased in labor. There has been a lot of research on whether or not having another baby vaginally is the best option and the answer is that for the vast majority of mothers and babies, having a VBAC is the best option. This is ultimately a decision made between you, your family, and your practitioner.
Avoiding a Cesarean Section
There are some women who really want to do what they can to prevent an unnecessary cesarean. Cesareans done for true medical emergencies cannot and should not be avoided. Some practitioners will do cesareans before turning to other alternatives, including waiting for labor to take its course, trying other alternatives like using Pitocin to speed or augment a slower labor, or even using a vacuum or forceps to assist with the delivery of the baby. As long as the mother and baby are healthy, a conversation between you and your practitioner is usually helpful in avoiding unwanted cesareans. It is also the perfect discussion to have with your practitioner prior to labor. There are also ways to encourage a vaginal birth, namely making sure that your practitioner has a lower cesarean rate.
