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Cesarean Section

What Is It?

A Cesarean section, also called a C-section, is surgery to deliver a baby through the abdomen when it is impossible or not advised to deliver the baby through the vagina. A Cesarean section sometimes is scheduled in advance, but it also may be done in an emergency.

Between 25% and 30% of all births in the United States are delivered by Cesarean section. The procedure is done less often in some other countries. Cesarean sections are done in 10% of births in the Netherlands and 15% to 20% in England, Wales and Canada.

What It's Used For

Cesarean sections often are done because the mother previously delivered by Cesarean section and the doctor has advised her to have another Cesarean section, or the mother prefers to have another Cesarean section.

When and whether a Cesarean delivery is necessary continues to be a matter of much controversy. "Once a Cesarean, always a Cesarean" used to be standard advice, and doctors rarely considered allowing a woman to go through labor and have a vaginal birth. For the last 20 years, however, obstetricians have been more willing to consider trying labor. Many, but not all, women can have a safe vaginal delivery after a Cesarean. The American College of Obstetricians and Gynecologists encourages vaginal birth after Cesarean, called VBAC, but they offer a series of guidelines to better identify those women who are likely to have success and to reduce the possible complications of VBAC, such as uterine rupture. About one-third of women who attempt a VBAC will need a Cesarean section.

Recently, some experts have questioned whether a Cesarean section should be done when a mother requests it but there is no accepted medical or surgical justification for the surgery. Cesarean section generally is safe, but the risk of major complication and death during Cesarean delivery is three to five times higher than with vaginal birth. Vaginal birth still is preferred over Cesarean unless there is a compelling reason to have a Cesarean section.

A number of organizations are focusing on reducing the number of Cesarean surgeries done in the United States. The U.S. Department of Health and Human Services encourages reducing first-time Cesarean deliveries to 15.5% of all deliveries by the year 2010. Although this recommendation is controversial, it is widely recognized that not all Cesarean sections are absolutely necessary and that vaginal birth offers a number of benefits to both mother and child when the pregnancy is low risk. However, the use of Cesarean sections for higher-risk pregnancies has made delivery dramatically safer for both mother and child.

Conditions that create a higher-risk pregnancy and may require Cesarean delivery include:

It is important that every woman is assessed to determine whether Cesarean delivery is needed. Although each of the problems listed above is a reason to consider a Cesarean section, every situation is different. Some breech babies are positioned in a way that may allow safe vaginal delivery, whereas others aren't. Placenta previa does not always interfere with vaginal delivery if the cervical opening is covered only partially.

Preparation

Preparation for Cesarean section can vary depending on whether the Cesarean section is scheduled or is being done as an emergency and on whether regional or general anesthesia is used.

Usually, women undergoing a scheduled Cesarean section are not allowed to have anything to eat or drink after midnight the day before surgery.

To reduce stomach acids, you will be given antacids to take before surgery because pregnant women are more likely to have acid reflux. You will also be given a dose of antibiotic just after delivery of the baby to reduce the risk of infection.

An enema is rarely, if ever, given before Cesarean delivery but can be arranged if you are severely and unusually constipated.

Just before surgery, an intravenous line (IV) will be placed into a vein. It will be used to deliver medications, fluids and, if needed, a blood transfusion during surgery. Wires connected to heart-monitoring equipment will be attached to your chest, and a blood pressure cuff will be placed on your upper arm. You will be given extra oxygen to breath through a mask and an oxygen monitoring device will be placed on your finger.

A flexible tube, called a Foley catheter, will be inserted into your bladder to drain urine and keep your bladder as empty as possible during the surgery. Your abdomen and pubic area will be washed with an antiseptic or antibacterial soap. It may be necessary to shave the hair in the area where the incision will be.

Doctors usually prefer to use regional anesthesia for Cesarean sections. Regional anesthesia means that you remain awake while an area of your body is made numb for your surgery.

Regional anesthesia for Cesarean section can be a spinal, an epidural or a combination of the two. Spinal anesthesia is given by injecting anesthesia into and around the nerves of your spinal column near the middle to lower back. This gives a rapid and complete numbing sensation, relaxing all the muscles of your legs and abdomen. Surgery can be started soon after the anesthesia is given because the effect begins quickly. Epidural anesthesia requires a little more time and is given by inserting a small catheter into the space around the spinal column, called the epidural space. The epidural catheter is used to keep constant levels of anesthetic medication in the space around the nerves. The extent of numbing in the legs and abdomen and the length of time you are numbed can be controlled and adjusted as needed to prevent pain. A combined spinal/epidural, called CSE, provides both the spinal's immediate pain relief and the epidural's control, which is needed for more extensive surgery. A CSE is preferred when the Cesarean operation is expected to be more difficult or require more time to finish.

Regional anesthesia allows the mother to be awake and alert during the baby's birth and to breathe naturally on her own. Some women worry that they will have pain with regional anesthesia. However, regional anesthesia numbs from the mid-chest down to the toes, and its effects last for a short time after the Cesarean is completed.

General anesthesia usually is reserved for emergency Cesarean sections. If general anesthesia is used, the woman receives anesthetic medication through an IV. After she is asleep, a plastic tube called an endotracheal tube will be placed in her throat and into her trachea. The trachea, or windpipe, connects the throat to the airways of the lungs. When the endotracheal tube is in place, the anesthesiologist can manage breathing for the mother while she is unconscious.

How It's Done

A low, horizontal skin incision, is made in the abdomen at or just above the pubic hairline. Sometimes a vertical incision is required, especially if an emergency Cesarean surgery is done.

After the abdomen is opened, the bladder is protected and the uterus is opened. The incision in the uterus also may be horizontal and low in the uterus, or it may be vertical. A vertical incision is preferred when a larger uterine incision is needed. For example, this may be required for twins, a large baby, or for a baby in a breech position. The bag of waters is broken, the baby is removed, and the umbilical cord is clamped and cut. The time from the beginning of surgery to delivery of the baby generally is less than 10 minutes. Once the baby is delivered, it can take another 30 to 40 minutes to remove the placenta and close the uterus and abdomen with stitches or staples. The entire surgery usually takes just under an hour.

Follow-Up

The bladder catheter will usually be removed within several hours of delivery and you will be encouraged to walk and begin to drink fluids. If staples were used to close the incision, they generally are removed within one week. Stitches may either dissolve on their own or need to be removed within a week. During the first few weeks after a Cesarean section, you will be told not to carry anything heavier than the baby. Breastfeeding can be started as soon as surgery is completed and the mother is awake in the recovery room. Holding the baby in the "football hold," with the baby's body under your arm and the head near your breast, can help keep the weight of the baby off the incision.

Risks

The most common problems following Cesarean delivery are heavy bleeding (hemorrhage); endometritis (infection of the uterus); bladder injury, and blood clots in the large veins of the legs, pelvis or lungs. Risks to the baby include skin cuts made during the uterine incision and a delay in absorbing amniotic fluid from the lungs.

Possible complications from anesthesia depend on whether general or regional was used for the surgery. General anesthesia provides deep, total relaxation of the body, which can lead to stomach acids flowing into the woman's lungs. This is a rare complication. The after-effects of general anesthesia can also make the mother and baby sleepy and delay mother-infant bonding. Headache may occur after regional anesthesia.

The most serious and rare complication of Cesarean section is the death of the mother, which is three to five times more likely with Cesarean section than with vaginal delivery. However, it is uncommon, with 7.5 deaths per 100,000 live births. That makes this surgery relatively safe.

When To Call A Professional

After surgery, you should contact a health care professional if you develop:

Additional Info

American Academy of Family Physicians (AAFP)11400 Tomahawk Creek ParkwayLeawood, KS 66211-2672Phone: (913) 906-6000Toll-Free: (800) 274-2237http://www.familydoctor.org/

American College of Obstetricians and Gynecologists409 12th St., SWP.O. Box 96920Washington, DC 20090-6920Phone: (202) 863-2518http://www.acog.org/




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