Cesarean Section: Giving Birth by C-section

A mother on her way to the operating room for a cesarean.
Photo © CJKPhoto/Getty Images

What is a Cesarean Section?

cesarean section is one way for babies to be born. This type of birth is done by a surgical incision in the abdomen and uterus to allow a baby or babies to be born safely when a vaginal birth is not the safest route. It is also commonly called a c-section. The current cesarean rate in the United States is over 32%.

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 in another birth, 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.

Why Would You Need a Cesarean Birth

You may wonder when a cesarean section might be the best course of action for you and your baby. A cesarean section might be performed for a number of reasons, including:

  • Placenta previa: Where part of the placenta covers the cervix, the opening where the baby exits the uterus.
  • A breech baby: When a baby is not in a head down position, usually feet or bottom first.
  • Fetal distress: When a baby is not tolerating labor or is having a complication in pregnancy that might necessitate an immediate delivery, skipping over induction.
  • 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 that 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 set is 23.9% of all births, which 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 separate that from low risk women, who are much less likely to need surgery to birth safely. 

Risks of Cesarean Birth

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.

The truth is that this will vary from practitioner to practitioner and family to family.

There are a few major categories of risks. There are the risks to the mother. These risks include:

  • infection
  • blood clots
  • surgical injury to the urinary tract
  • bleeding too much (hemorrhage)
  • needing a hysterectomy (losing her uterus)
  • a very small risk, it is increased, a 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:

  • an increased chance of breathing difficulties
  • an increased risk of being in the neonatal intensive care unit (NICU)
  • iatrogenic prematurity (accidental prematurity due to when the surgery was performed)
  • more likely to have breastfeeding difficulties
  • being 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)
  • increased risk of abnormal placental placement in future births, including placenta previa 
  • emergency surgery for hysterectomy
  • risk that the placenta would grow through the uterine wall
  • risk that mother would not be allowed to attempt a vaginal birth, even if an appropriate candidate due to hospital policies
  • risk of placental abruption (where the placenta prematurely separates from the uterine wall)
  • potential increased risk of fertility issues, miscarriage, 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 and Cesarean Birth

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 both of your practitioner but during your tour of hospitals or birth centers.

How is a C-Section Performed?

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 have an epidural, you will be given an epidural or spinal anesthesia, or more rarely, a 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. (This is someplace 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. And then the different layers will be cut and dissected. These layers include your skin, the muscle, fascia (fat), peritoneum, uterus, and amniotic sac. This part of the surgery is usually fairly quick compared to the overall length of surgery, 5-10 minutes. It may take longer to get to the baby if you have a history of abdominal surgery, particularly a previous cesarean, this is due to scar tissue. There are also other things happening during this portion, including your bladder being protected, 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 from the practice, your nurse midwife, or someone hired by the hospital who works as an operating room assistant (another doctor, 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 these feels and any other things you may potentially feel during the c-section, which should never be pain. They have a whole host of tricks, some of which are medications, but some are not. Express your preferences beforehand when possible.

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 be lowered for a moment. And there is also a possibility of using a mirror from Labor and Delivery that is placed near your side, mirror faced down and parallel to the floor to watch. Your partner and/or doula are usually by your head. They can also watch is wanted.

If your baby is healthy, you will be able to talk about having 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 an 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 dutifully finishing your surgery. The placenta is removed manually. The uterus is inspected and cleaned. It is the sutured and the process begins of sewing and repairing the various layers. This takes longer than the original part of the surgery. Though an average for an uncomplicated cesarean is about 35-45 minutes from start to finish, a bit longer to include you getting to the recovery room.

Cesarean 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 an unplanned cesareans.

Some of these options might include:

  • Who can go with you to the operating room with you for the surgery/birth?
  • Using a doula to support you and/or your partner either during or after the birth.
  • Will you want music played?
  • Can you use a mirror to watch the baby emerging? A mirror? Another option?
  • Will your baby be handed directly to you for skin to skin care in the OR? The recovery room?
  • Can you 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.

Cesarean Recovery

The immediate hour after 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, per 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. This movement helps you heals 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 from forming from inactivity.

A typical hospital stay after a surgical birth is about four days. Some mothers try to go home earlier, but other mothers enjoy the stay or need the stay. This is personal. There are also some mothers who medically are not cleared for release, even after four days.

Pain Medication and Cesarean Birth

You will be given pain medication to help you recover from the pain of the surgery. Many women are initially given a 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 awhile after giving birth, but some women are able to transition to over the counter medications or medications that are non-narcotic within a few days with routine administration. 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 will say that walking the first few times after birth is very painful. Remember that walking is actually a good thing as it speeds healing. The first few weeks rest and carry nothing heavier than the baby. 

Your Cesarean Scar and Six Week Postpartum Visit

You will have a scar where your surgeon cut. It is usually about four inches and located just above your pubic hair line. 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 the few days, you may have any remaining stitches or staples removed. This may or may not be after your leave the hospital.

You should ask your postpartum nurse to talk to you 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. But it should never smell foul, nor should you have red streaks. These are signs of infection, with or without fever, and should be reported immediately.

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 than it did then. 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 your give birth, you will have a visit with your doctor or midwife. This is a chance to talk about not only your recovery, but 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 and pap smear. You may also be given a prescription for birth control at this time.

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 After a Cesarean Birth

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.

Will Having a Cesarean Alter My Future Birth Plans?

The majority of women who have a cesarean birth the one pregnancy can have a vaginal birth with subsequent babies. This is called a vaginal birth after cesarean or VBAC (pronounced vee-back). This conversation is one that should be had 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 done 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.

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