Cesarean sections

Every pregnant woman hopes for a short labor and delivery with no complications — manageable contractions, some pushing, then a beautiful baby — but it doesn't always work out that way.

These days, almost 30% of all babies in the United States are delivered via cesarean section (C-section). In fact, there's a lot of debate and concern about their increasing number, with some health professionals wondering how many are medically necessary. Federal officials have even set a goal of reducing the cesarean rate to 15% by the year 2010.

Still, many C-sections are justified and unavoidable. Even if you're envisioning a traditional vaginal birth, it may help to ease some fears to learn why and how C-sections are performed, just in case everything doesn't go as planned.

What Is a C-Section?

A C-section is the surgical delivery of a baby that involves making incisions in the mother's abdominal wall and uterus. Generally considered safe, C-sections do have more risks than vaginal births. There's far less chance of infection and severe bleeding with a vaginal delivery than with a C-section. Plus, you can come home sooner and recover quicker after a vaginal delivery.

C-sections are worth avoiding, if possible. However, these common surgical deliveries can help women with high-risk pregnancies avoid dangerous delivery-room complications and can save the life of the mother and/or baby in emergency situations.

Who Performs Them?

C-sections are done by obstetricians (doctors who care for pregnant women before, during, and after birth) and some family physicians. Although more and more women are choosing midwives to deliver their babies, midwives of any licensing degree cannot perform C-sections.

Why Are C-Sections Done?

Some C-sections are scheduled if the doctor is aware of certain factors that would make a vaginal birth risky. That means some women know ahead of time that they will be delivering via C-section and are able to schedule their baby's "birth day" well in advance. This allows them to prepare themselves emotionally and mentally for the birth — which can help to lessen the feelings of disappointment that many mothers who are unable to deliver vaginally experience.

So what determines if a woman is scheduled for a C-section? A doctor may schedule one if:

• the baby is in breech (feet- or bottom-first) or transverse (sideways) position in the womb (although some babies can be turned before labor begins or delivered vaginally using forceps and anesthesia)
• the baby has certain birth defects (such as spina bifida)
• the mother has problems with the placenta, such as placenta previa (when the placenta sits too low in the uterus and covers the cervix)
• the mother has a medical condition that could make a vaginal delivery risky for herself or the baby (such as HIV or an active case of genital herpes)
• some multiple pregnancies
• the mother previously had surgery on her uterus or a C-section (although many such women can safely have a vaginal birth after a C-section, called a VBAC)

Some C-sections are unexpected emergency deliveries performed when complications arise with the mother and/or baby during pregnancy or labor. An emergency C-section might be required if:

• labor stops or isn't progressing as it should (and medications aren't helping)
• the placenta separates from the uterine wall too soon (called placental abruption)
• the baby's shoulders are stuck in the birth canal
• the umbilical cord becomes pinched (which could affect the baby's oxygen supply) or enters the birth canal before the baby (called umbilical cord prolapse)
• the baby is in fetal distress — the heart rate drops, doesn't change at all, or is too fast or too slow
• the baby's head or entire body is too big to fit through the birth canal (which is rare)

Of course, each woman's pregnancy is different. If your doctor has recommended a C-section and it's not an emergency, you can ask for a second opinion. In the end, you most often need to rely on the judgment of the doctors.

How Is a C-Section Done?

The thought of having surgery can be unnerving for any woman. Here's a quick look at what usually happens during a scheduled C-section, according to the American College of Obstetricians and Gynecologists (ACOG).

Your labor coach can be right by your side, clad in a surgical mask and gown, during the entire delivery (although partners may not be allowed to stay during emergency C-sections). Before the procedure begins, an anesthesiologist will discuss your options.

To prepare for the delivery, you'll probably have:

• various monitors in place to keep an eye on your heart rate, breathing, and blood pressure
• your mouth and nose covered with an oxygen mask or a tube placed in your nostrils to give you oxygen
• a catheter (a thin tube) inserted into your bladder through your urethra (which may be uncomfortable when it is placed, but should not be painful)
• an IV in your arm or hand
• your belly washed and any hair between the bellybutton and pubic bone shaved
• a privacy screen put around your belly

After being given anesthesia, the doctor makes an incision on the skin of the abdomen — either vertically (from the bellybutton down to the pubic hair line) or horizontally (1-2 inches above the pubic hairline, sometimes called "the bikini cut").

The doctor then gently parts the abdominal muscles to get to the uterus, where he or she will make another incision in the uterus itself. This incision can also be vertical or horizontal. Doctors usually use a horizontal incision, also called transverse, which heals better and makes a VBAC much more possible.

Once the uterine incision is made, the baby is gently pulled out. The doctor suctions the baby's mouth and nose, then clamps and cuts the umbilical cord. As with a vaginal birth, you should be able to see your baby right away. Then, the little one is handed over to the nurses and a pediatrician or other doctor who will be taking care of your newborn for a few minutes (or longer, if there are concerns).

The obstetrician then removes the placenta from the uterus, closes the uterus with dissolvable stitches, and closes the abdominal incision with stitches or surgical staples that are usually removed, painlessly, a few days later.

If the baby is OK, you can hold and/or nurse your newborn in the recovery room by lying on your side (since holding your baby will put too much pressure on your abdomen).

What Will It Feel Like?

You won't feel any pain during the C-section, although you may feel sensations like pulling and pressure. With a planned C-section, the anesthesiologist will give you the option to be unconscious (or "asleep") during the delivery using general anesthesia or awake and simply numbed from the waist down using regional anesthesia (an epidural and/or a spinal block).

Many women want to be awake to see and hear their baby being born. A curtain will be over your abdomen during the surgery, but you can take a peek as your baby is being delivered from your belly.

However, women who need to have an emergency C-section occasionally require general anesthesia, so they're unconscious during the delivery and won't remember anything or feel any pain.

What Are the Risks?

C-sections today are, in general, safe for both mother and baby. However, there are risks with any kind of surgery. Potential C-section risks include:

• increased bleeding (that could, though rarely, result in a blood transfusion)
• infection (antibiotics are usually given to help prevent infection)
• bladder or bowel injury
• reactions to medications
• blood clots
• death (very rare)
• possible injury to the baby

Some of the regional anesthetic used during a C-section does reach the baby, but it's much less than what the newborn would get if the mother received general anesthesia (which sedates the baby as well as the mother). Babies born by C-section sometimes have breathing problems (transient tachypnea of the newborn) after birth since labor hasn't jump-started the clearance of fluid from their lungs. This usually gets better on its own within the first day or two of life.

Having a C-section may — or may not — affect future pregnancies and deliveries. Many women can have a successful and safe vaginal birth after cesarean but, in some cases, future births may have to be C-sections, especially if the incision on the uterus was vertical rather than horizontal. A C-section can also put a woman at increased risk of possible problems with the placenta during future pregnancies.

In the case of emergency C-sections, the benefits usually far outweigh the risks. A C-section could save your life or your baby's.

What Will I Feel Like Afterwards?

As with any surgery, there's usually some degree of pain and discomfort after a C-section. The recovery period is also a little longer than for vaginal births. Women who've had C-sections usually remain in the hospital for about 3 or 4 days and need to stay in bed for at least a day after the delivery.

Right after, you may feel itchy, sick to your stomach, and sore — these are all normal reactions to the anesthesia and surgery. If you needed general anesthesia for an emergency C-section, you may feel groggy, confused, chilly, scared, alarmed, or even sad. Your doctor can give you medications to ease any discomfort or pain.

For the first few days and even weeks, you might:

• feel tired
• have soreness around the incision (the doctor can prescribe medications and/or recommend over-the-counter pain relievers that are safe to take if you're breastfeeding.)
• be constipated and gassy
• have a hard time getting around and/or lifting your baby

After about 6 to 8 weeks, the uterus is usually healed and you can probably get back to your normal routine. In the meantime, you'll need to avoid driving or lifting anything heavy so that you don't put any unnecessary pressure on your incision. And as with a vaginal delivery, you should refrain from having sex until about 6 weeks after delivery and your doctor has given you the go-ahead.

Frequent walking may help ease some post-cesarean pains and discomfort. Among other things, it can help prevent blood clots and keep your bowels moving. But don't push yourself — take it easy and have someone help you get around, especially up and down stairs. Enlist friends, family, and neighbors to lend a helping hand with meals and housework for a while, especially if you have other children.

Although breastfeeding may also be a little painful at first, lying on your side to nurse or using the clutch (or football) hold can take the pressure off your abdomen.

Also, C-sections scars fade over time. They'll start to decrease in size and become a natural skin color in the weeks and months after delivery. And because incisions are often made in the "bikini" area, many C-section scars aren't even noticeable.

Call your doctor if you have:

• fever
• signs of infection around your incision (swelling, redness, warmth, or pus)
• pain around your incision or in your abdomen that comes on suddenly or gets worse
• foul-smelling vaginal discharge
• heavy vaginal bleeding
• leg pains
• difficulty breathing or chest pain
• feelings of depression

Emotionally, you may feel a little disappointed if you'd been hoping for a vaginal birth or had gone through labor that ended in a C-section. Although it can be disheartening when the traditional way doesn't work for your delivery, having a C-section does not make the birth of your baby any less special or your efforts any less amazing. After all, you went through major surgery to deliver your baby! It might not be the birth experience you'd imagined, but you can finally meet the little one you've been nurturing all this time!