They Said I Need a Cesarean All about cesarean births (part 1)

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Q:	What's the difference between an emergency and elective cesarean?
A:	Cesareans are classified as elective or emergency. An elective cesarean indicates that a pre-planned decision was made during pregnancy to deliver the baby by cesarean before the onset of labor. An emergency cesarean is when a situation arises, usually in labor, that means the safest route for delivery is by cesarean section.

Is it fair to say that most doctors prefer cesarean deliveries these days?

Although the cesarean rate has risen over the years, it would be unfair to say that this is due to doctors' personal preferences; it is more likely to be due to overcaution on the part of the medical staff. Guidelines on cesareans are quite specific regarding when a cesarean should be considered and offered as an alternative to a vaginal delivery. However, since 1 in 5 women will have a cesarean, information about the procedure is included in most childbirth education classes. If a cesarean section is considered to be the most appropriate mode of delivery for you, then you should also be made aware of the benefits and the risks to you and your baby and of the possible implications on future pregnancies before you give your consent.

Are there any reasons why I might be more likely to have a cesarean?

The rate of cesarean birth has soared over the past 30 years and this has been attributed to pressure on physicians not to perform vaginal breech deliveries and midpelvic forceps deliveries, and an increasing reliance on continuous electronic monitoring of fetal heart rate and uterine contraction patterns. Cesarean-on-demand has also contributed due to concern about legal repercussions. The likelihood of cesarean increases when the pregnancy has been complicated, the mother's age is greater than 35, the mother is obese, if she is diabetic or poorly nourished, if she has had a previous cesarean or is in preterm labor, if baby is breech or in an abnormal presentation at term, or beyond 42 weeks gestation. In labor, cesarean is likely if baby shows signs of distress or if contractions are not efficient at dilating the cervix.

I've got a small pelvis; they said I may need a cesarean. Is this right?

It is always a good idea to educate yourself about the benefits and risks of cesarean but you should always be given a chance of delivering vaginally, a so-called “trial of labor.” Your pelvic size is only one issue to be considered; others are the size of the baby and the quality of your contractions as well as your emotional and psychological stamina. No one knows how you will do or how the baby will tolerate labor until the process is well under way and what situations may arise that would make a cesarean necessary.

The midwife wrote LST on my chart—what does that mean?

You've had a previous cesarean birth and it is critical to know the type of incision that was made into the uterus. Your appropriateness for a vaginal birth after cesarean (VBAC) or a trail of labor after cesarean (TOLAC) is assessed based on the uterine incision and the circumstances surrounding the previous cesarean. Most often, when you've had a “bikini cut” (Pfannenstiel incision) at your pubic hairline, the incision has been made transversely into the uterus. The surgical summary must be requested to confirm this. If your incision on the skin is longitudinal (from pubic bone to near the umbilicus), your uterine incision may be either transverse or longitudinal.

I want to be asleep during the cesarean section. Will I have that option?

If your cesarean section was planned before you went into labor, for example your baby is breech at term or you've had a previous cesarean and are requesting another, you and your physician should talk together to see what is the best choice of anesthesia for you and your baby. In most cases, spinal or epidural anesthesia is safest. Communicate your concerns and fears to your doctor and, if possible, make an appointment to speak to a nurse anesthetist or anesthesiologist at your hospital. There are also greater postoperative risks for the mother and baby with general anesthesia, including respiratory problems. If you are afraid of the surgery, talk to your midwife or doctor.

I haven't had problems, but I just don't want to go through labor. Can I opt for a cesarean?

You will be able to find an obstetrician in most communities who will accede to your request to deliver your baby by cesarean but consider the risks. This major abdominal surgery increases morbidity and mortality (the risk of illness and death) for both the mother and the baby. Cesarean section dramatically increases the risk of hemorrhage in the mother. Postpartum recovery is significantly longer after cesarean with resultant pain, disruption in breast-feeding, maternal-infant bonding, interruption in family life, and is much more expensive for the couple and for society.

After cesarean delivery women have increased risk for ectopic pregnancy, hysterectomy, and future placental complications. Babies born by cesarean section are at higher risk for readmission to the hospital due to respiratory problems.

It would help greatly to schedule an extended appointment time with your midwife or doctor to discuss your opinions and feelings about cesarean sections and become fully informed about this important decision.

I've had two cesareans and now have been advised to have an elective one. Is this necessary?

You'll need to know why you are at a higher risk with this pregnancy. Ask your doctor some questions about why this has been suggested and have him outline the risks should you opt for a trial of labor. The answer has a great deal to do with the original reason for both of your cesareans. If the uterine incision was longitudinal, or if you've had prior uterine surgery, or if your doctor has observed a weakening in the previous scar, then close monitoring of the pregnancy and a repeat cesarean delivery are appropriate this time. If your doctor's recommendation is against vaginal birth after cesarean (VBAC) just because you've had two previous surgical births, you may have some options. For example, you are more likely to have a successful vaginal delivery after cesarean if you are less than 40 years of age, if you have had a prior vaginal delivery, if your reason for the surgical delivery is nonrecurring, and if your cervix is ripe and ready for vaginal birth. Factors associated with a decreased likelihood of vaginal delivery include an increasing number of prior cesarean births, gestational age greater than 40 weeks, birthweight greater than 4000 grams (about 9 lb), and augmentation of labor with oxytocin.

I heard that cesarean babies are brighter because they don't have a traumatic birth. Is this true?

No, this is not the case at all. Full term, healthy babies are designed to cope with the stresses of a natural labor and birth and should not be affected in any way by this experience. The type of birth on its own does not affect a baby's abilities, although if a baby becomes “distressed” during the delivery, on rare occasions this can cause problems that persist into later life (although usually the baby is born healthy and well). It is true that you can help your baby by staying healthy in pregnancy, for example by eating well and not smoking or drinking.

What type of pain relief will I be given before the operation?

There are two main types of anesthesia, or pain relief, prior to a cesarean section: general and regional. A general anesthetic is the procedure whereby the mother is put to sleep before the cesarean. Although this is usually the quickest method and is relatively safe for both mother and baby, the down side is not being awake during the birth, a slight risk of aspiration (inhaling vomit), a delay in the baby's responses, and feeling “groggy” afterward. Sometimes after general anesthesia, both mother and baby sleep for an extended period of time (2–6 hours) and early opportunities for breast-feeding and face-to-face contact may be missed. A regional anesthesia is given as an epidural or a spinal block, where the anesthetic drug is injected into the fluid surrounding the spinal cord or into the spinal fluid itself. In both cases, a needle is inserted into the back and medication is given through a narrow tube to numb the abdomen downward. Although this takes longer to perform, the anesthesiologist will be very skilled at inserting the needle. He or she will use a local anesthesia to ensure you are totally numbed and the procedure will not start until the anesthesia is assured. On very rare occasions where the procedure can be felt, a general anesthetic will be given immediately. The regional option is safer and the birth experience is not missed. The choice will ultimately be yours, unless certain conditions dictate the safest option.

Who will be in the operating room?

Although it may seem like a crowd, all of the people in the operating room have a role. An anesthesiologist will be present to make sure you do not feel the procedure and he may be helped by a nurse anesthetist. The surgeon and his assistant will perform the cesarean section. A nurse and sometimes a pediatric nurse practioner will receive the baby. A scrub nurse will pass the instruments to the surgeon and another assistant will be there to help things and count the instruments. You may want to have your partner, friend, or a family member present with you, which is usually agreed with the surgeon in advance.

How will I be stitched and how long will my scar be?

If you have the most common type of cesarean incision, called a bikini cut or pfannenstiel incision, a 12–15 cm cut is made along the pubic hairline. The other, less common, type is a longitudinal incision. During a cesarean, the surgeon needs to cut through several layers of fat and tissues before making an incision in the uterus. These internal layers will then be restitched after the operation using dissolvable stitches and then the layer of skin will be stitched or stapled at the end. Clips or staples are usually removed about three days after the cesarean section, whereas stitches are left in for about five days. Removal of stitches is generally not painful.

Can my partner still cut the umbilical cord after a cesarean delivery?

It is important during a cesarean section that the procedure is done under sterile conditions. This means that all of the staff and instruments must be sterile. This is to reduce the risk of infection to the mother and baby. If your partner was allowed to cut the cord, this would mean that the same principles of sterility would apply to him. It would therefore not be practical to ensure that every partner was trained in this technique. However when the baby is being assessed and is being warmed and dried, your partner is welcome to trim the cord near to the umbilical clip at the baby's abdomen.

Will I be able to watch my cesarean section operation if I want to?

Usually the mother is fully awake for her cesarean section, with the exception of some emergency situations where it might take too long for the anesthesiologist to insert the spinal anesthetic, in which case a general anesthetic will be given. However, whether the mother would be able to literally watch the cesarean section is a different matter. During a cesarean where the mother is awake, it is usual for a drape to be placed above your head so it is impossible to observe the procedure. To see the operation, the screen would have to be taken down and you would also need to have your head raised, which would present difficulties for the surgeon since the surgery requires that the mother lies fairly flat so that the surgeon can get to the baby and the abdomen. Although the surgery itself may be interesting, you may not be thinking this when it is actually happening to you. On occasion, even a planned cesarean section can run into difficulties, and in the worst case scenario, the mother will have to be given a general anaesthetic.

Many obstetricians, however, can lower the screen if you want, at the point of your baby being delivered from the abdomen, and the parents are shown the baby so that they can see what it looks like and its gender. Then the screen is put back up until all layers are closed and staples or stitiches are placed. If you do want to watch more, you should discuss this with the surgeon and the anesthesiologist prior to the surgery. Likewise, if you don't want the screen to be lowered at all, make this clear beforehand.

What are the reasons for cesarean sections?

There are various reasons why a cesarean section might be preferred. You may be advised to have a cesarean section if the baby cannot enter the pelvis due to its size or position or the shape and size of the pelvis; if you have a low-lying placenta; for a multiple pregnancy or breech baby; if labor is not progressing normally; if you had a previous cesarean section or traumatic birth; if you have severe preeclampsia; if the baby's growth is severely reduced or excessive; if you have had heavy bleeding in pregnancy and for certain other medical conditions. Your midwife or doctor will advise you of the reasons why a cesarean may be the safest option.

Is a baby born by cesarean section any different than a baby born vaginally?

The condition of a baby following a cesarean section depends greatly on the reason for the surgery. If the cesarean birth is performed as an emergency due to fetal distress (abnormal fetal heart tracing or low fetal heart tones), the infant may be “depressed” at birth, pale in color and breathing with effort. Often baby feels the effects of rapid anesthesia. Rapid intervention by a neonatal team will see to a baby's physical needs, providing respiratory and heart support, warmth, and stimulation. Medications to counteract maternal medication may be indicated. If baby is significantly distressed, he or she will be taken immediately to the Neonatal Intensive Care Unit (NICU). If the cesarean was performed due to lack of progress, there is often time to use spinal or epidural anesthesia so baby is not depressed at the time of delivery and can be quite vigorous at birth. The head may be molded if labor was long.

Just as a vaginal birth, an Apgar score is given which assesses heart rate, respiratory effort, reflex irritability, flexion of the extremities, and color. Babies born by cesarean may have a lower Apgar score, especially if the baby was stressed at the time of birth. Since they do not have the benefit of being squeezed through the birth canal, all cesarean babies are at higher risk of respiratory difficulties (respiratory distress syndrome, RDS). Sometimes fluid is suctioned from the trachea and the stomach. Within 24 hours, with breast-feeding and skin-to-skin contact, cesarean babies will be in the same optimal condition as vaginal birth babies.

What pain relief will I be given after the cesarean?

If you have your cesarean under a spinal anesthetic, this will continue to work for an hour or two after the surgery. If you are recovering from a general anesthetic, the pain is likely to be increased and the surgeon may therefore inject a local anesthetic into the wound to reduce the pain. After the surgery, you will be offered regular pain relief, which is likely to be in the IV and often patient controlled. The IV is generally left in place for 24 hours after surgery until you are taking light meals. During that time, you may be able to administer small amounts of analgesia to yourself through an IV pump. All medications given postpartum are safe for breast-feeding and they are rapidly cleared from your system.

The best way to manage pain following a cesarean section is to inform the nursing staff as soon as you feel any pain, since the sooner your pain is controlled, the quicker you will be able to move around and this will, in itself, speed up recovery and reduce the risks of immobility such as deep vein thrombosis. Oral pain relief medications usually take the place of intravenous drugs after about 24 hours. Oxycodone combined with acetaminophen is a common analgesic. Pain medications that need to be injected, such as Demerol, are available but generally not needed.

Will I be able to hold my baby immediately after the birth?

In most hospitals and birthing centers, the nurse or pediatrician will show you your baby while on the way to the warmer for assessment. As the neonatal staff dries the baby, the Apgar score is given . Breathing, heart rate, reflexes, flexion, and color are assessed and baby is given ointment in the eyes as prevention of infection and an injection of vitamin K to assist blood clotting. At this point, your partner may be with the baby. Although it may be difficult to hold baby at this time, you can usually touch baby and your husband may be able to provide skin-to-skin contact. When you are transferred to the recovery area it is best to lie fairly flat for a few hours to prevent a spinal headache. Now is the time to touch your baby, admire her and put her to breast if you've decided to breast-feed.

How soon will I be able to go home after a cesarean section?

Only a relatively few years ago, women who had had a cesarean section were kept in the hospital for approximately five days after the delivery, and just a few years before that, seven days was the average amount of time women spent in hospital after a cesarean. Nowadays, mainly due to the recognition that women do recover much better in the comfort of their own homes—where they are likely to get much more sleep and rest because they are not being disturbed by other babies in the hospital ward—and also sometimes due to the hospital's economics, a lack of space in the hospital, and reduced maternity staffing levels, women are usually discharged from the hospital at around two or three days after their cesarean delivery.

There are of course individual circumstances when this might not be the case, for example if the mother is not managing so well after the birth, if she would be by herself at home with no other support, or if she is experiencing problems with breast-feeding her baby, then her discharge home may be delayed for a period. Also, if a baby has been admitted to the neonatal intensive care unit within the hospital, many maternity units will allow the mother to “board” at the hospital until the baby is ready to return home.