- A caesarean section (C/S) is an operation performed to deliver a baby when vaginal birth is impossible or unsafe.
- The doctor makes a cut in the mother's abdomen and uterus to remove the baby.
- A C/S may be scheduled before labour begins if there are medical reasons for not going through labour or vaginal delivery; a C/S may also be performed during labour if certain problems arise.
- When a C/S is necessary, it can be a life-saving technique for both mother and child.
- A C/S does pose certain documented medical risks.
Alternative namescaesarean, caesar, C-section; C/S
What is a caesarean section? A caesarean section (C/S) is an operation performed to deliver a baby when vaginal delivery (normal birth) is impossible or unsafe. The doctor makes a cut in the mother's abdomen and uterus (womb) to remove the baby.
When is it used? A caesarean section may be performed before labour begins if there are medical reasons for not going through labour and vaginal delivery. The health of the mother or baby may be in danger, or vaginal delivery may be impossible. A C/S may also be performed during labour if certain problems arise.
The following are some of the medical circumstances in which a C/S may be performed:
- Incomplete dilatation of the cervix. Sometimes during labour, the cervix (the cylindrical lower part of the uterus that leads into the vagina) does not dilate fully, making vaginal delivery difficult or impossible.
- A woman may have full cervical dilatation, but be unable to push the baby through the birth canal. This may occur because the baby is too large for the birth canal. For example, with cephalo-pelvic disproportion (CPD), the baby's head is too large to fit through the pelvis, or the pelvis is too small for even a normal size baby. Disproportion can also develop if the baby´s head is positioned wrongly.
- Prolapsed cord: the umbilical cord descends before the baby does. (The umbilical cord connects the foetus with the placenta (afterbirth), the blood-rich structure in the uterus that provides the fetus with nourishment.
- Placental abruption: the placenta separates before birth.
- Placenta praevia: the placenta is situated in front of the baby in the lower segment of the uterus and partially or completely covers the cervix.
- Fetal malpresentation or malposition: at the time of delivery the baby is not correctly positioned for normal vaginal birth. For example, if the baby's face or forehead (malposition) or the baby´s shoulder or buttocks (malpresentation) are located lowest instead of the baby´s back of the head, a C/S may be necessary.
- Maternal medical conditions, such as pre-eclampsia, severe hypertension or diabetes. However, having these conditions does not imply that a C/S is always necessary.
- Foetal distress: a baby may become distressed during labour, usually due to insufficient oxygen supply from the placenta, that causes its heartbeat to slow down. This may indicate that the baby cannot tolerate further labour.
- Maternal exhaustion, often from prolonged labour.
- Uterine scar: a woman who has had a C/S previously or a scar in her uterus from a previous operation (for example: removal of fibroids). However, recent studies have shown that a large percentage of women have a good chance for vvaginal bbirth after a ccaesarean (VBAC). One of the main concerns about going through labour and vaginal birth after having previously had a C/S is that the scar could tear causing a ruptured uterus. This is why an attempt for VBAC is always performed at a hospital where the labour process with the “trial of scar” can be interrupted anytime and a C/S proceeded with if there is inadequate progress of labour or signs of threatening uterine rupture. An expecting mother with a previous C/S will be advised by her obstetrician whether or not she can undergo a trial of scar. This depends on the obstetrical circumstances which have led to the previous C/S and whether the indication is repetitive. If, for example, the previous C/S was due to a placenta praevia or an umbilical cord prolapse, which are unlikely to recur, a VBAC can be attempted. On the other hand, if the C/S was done for CPD because of a narrow pelvis, the obstetrician may decide to perform an “elective” C/S, which means the C/S will be done at 38 weeks´ gestation without the woman going into labour.
How could one prepare for a caesarean section? A caesarean section is major abdominal surgery. If an expecting mother knows she is going to need a C/S, it is a good idea to plan for care and recovery after hospitalisation.
The instructions provided by the doctor should be followed. If the C/S will be performed under general anaesthesia, one should eat only a light meal the night before the operation. No food (including tea, coffee or water) should be taken after midnight and in the morning before the procedure.
After being discharged from the hospital, there should be time to rest and one should try to find people beforehand to help with day-to-day activities.
What happens during a caesarean section?
Pre-operative procedureBefore the operation, a catheter will be inserted into the bladder enabling free flow of urine after the C/S. An intravenous line (drip) will be inserted into a vein to allow fluids and drugs to be given directly into the blood before and during the operation. Monitoring leads will be set up to measure the heart beat and blood pressure. The abdomen will also be swabbed with an anti-bacterial wash.
Pain reliefThe patient will be given a regional or general anaesthesia. A regional anaesthetic block prevents the sensation of pain in a particular part of the body, while the patient remains awake. General anaesthesia prevents any pain sensation and relaxes the muscles while being asleep for the duration of the operation.
In the case of a scheduled C/S, or if the patient has not already received regional anaesthesia for labour, an epidural or a spinal block will probably be given. General anaesthesia will usually be given in the case of an emergency C/S. An emergency C/S may be performed when there is a sudden, serious threat to the mother´s or baby's health.
After the birth, the regional anaesthetic block will help to keep the patient pain-free for a few hours, after which some other type of pain medication will be prescribed.
The caesarean sectionThe doctor makes an incision into the skin below the navel, enters through the abdominal wall and opens the lower part of the uterus. The most common kind of skin incision used is the transverse incision which goes across from left to right just above the pubic hair, also known as bikini cut. In the case of an emergency C/S, a sub-umbilical mid-line incision may be made which goes from just below the navel down to the pubic area allowing for faster access to the womb to save time. After having opened the uterus, the doctor removes the baby by hand or, rarely, by forceps and clamps, and cuts the umbilical cord after which the baby is handed over to the paediatrician. Then, the placenta (afterbirth) and membranes of the birth sac are removed. The doctor repairs the uterus and closes the abdominal incision with sutures. The edges of the skin wound are sutured or stapled together.
It generally takes about five minutes from the time the initial incision is made until the baby is delivered. The rest of the surgery will take between 30 and 40 minutes, including repair.
Afterwards, the patient will be moved to the recovery room. Depending on the circumstance, the baby will join the mother or be moved to the nursery or to a neonatal intensive care unit.
How can the partner help during a caesarean? A number of hospitals will allow the partner to go into the operating room unless it is an emergency caesarean section. By simply being there and telling the patient what is happening, the partner can provide comfort and support while the patient is undergoing the operation. Most men, in fact, do not faint in the operating room. However, if the partner feels anxious about the operating theatre atmosphere, he should rather wait outside. The patient will be screened off with a drape to block the view of the surgery from her and her partner. Sometimes, the doctor will allow the partner to hold the baby and to take photographs, but it is always better to make sure about this before the surgery.
What happens after caesarean section? Each person's recovery will be different, depending on the medical and obstetrical circumstances and general health of the patient. In all cases, however, it is important to remember that a C/S is major abdominal surgery and that a new baby has been born which all means that one has to take things slowly. Hospitalisation may take anything from two to ten days and depends on the recovery of the patient and the condition of the baby.
To prevent patients from feeling postoperative pain from the incision, analgesic drugs (pain killers) will be prescribed which can be administered at regular intervals according to the degree of discomfort. The mother may also experience uterine contractions (the uterus will contract, particularly when breast feeding is started).
The catheter will be removed the next day, and the staples and/or stitches are usually taken out somewhere between day five and eight after the C/S. The patient will be encouraged to get out of bed early which will speed up recovery and prevent the development of thrombosis (blood clots in the veins).
When the mother is discharged from hospital, she should try to get help with her daily activities, taking care of her newborn baby and looking after her other children. She should avoid to lift heavy objects for six weeks because this may cause complications with the healing of the abdominal wound. Some doctors allow patients to drive a car after about two weeks, while others recommend to wait until a full six weeks.
By the end of the sixth week, the mother should be fully recovered and be able to resume most of her activities. The doctor should be asked about beginning an exercise programme to regain abdominal muscle tone and when to return for a postnatal check-up.
Emotional changesMost first-time mothers go through emotional changes when their baby is born. This can be due to a number of factors, including hormonal changes and stress. However, mothers who are also recovering from caesarean section may have more pronounced emotional changes. Many women who had a C/S say they feel a range of emotions. They can feel happy or relieved that their baby is safe, disappointed that they did not achieve a normal birth, annoyed at the circumstances or some people, or disconnected from the baby.
What are the benefits of caesarean section? When a caesarean section is necessary, it can be a life-saving operation for both mother and child. In addition, some of the pain of labour may be avoided, and it may be possible to schedule the time of the delivery. The latter is particularly important, if the baby needs to be born before the due date when there is placental insufficiency (insufficient supply of oxygen and nourishment from the placenta to the baby). Often, labour will be induced by means of drugs administered through a drip. If there is a good response of the uterus with adequate contractions and good labour progress, the baby may be born vaginally. If, however, labour is not progressing sufficiently or the baby develops foetal distress, a caesarean section may be necessary.
What are the risks of caesarean section? A caesarean section poses certain medical risks to the health of both mother and baby. An elective (scheduled rather than an emergency) C/S before the due date increases the risk of foetal prematurity and respiratory distress syndrome (in which a premature infant has impaired oxygen intake).
Prematurity and respiratory distress syndrome are associated with several complications, which may necessitate intensive care for the newborn baby with added financial costs. These complications need to be balanced against the potential risks for the baby if a C/S is not done, and only an experienced obstetrician (sometimes together with a paediatrician and a neonatologist) will be able to make the right decision.
Risks to the mother include:
- Anaesthesia complications. A regional anaesthetic block may not numb the area sufficiently and the patient may feel some minor discomfort. Also, in rare cases, an allergic reaction to the anaesthetic drug may occur. In most cases, regional anaesthesia is considered safer than general anaesthesia, which always carries certain risks in any operation. The anaesthetist will advise the patient about these.
- Haemorrhage. Some of the blood vessels which were cut and later sutured again during the operation, may open up and cause internal bleeding.
- Thrombosis and embolism. Due to the spontaneous activation of clotting factors in the blood during the operation, a blood clot may form on the inner wall inside one of the veins of the legs or pelvis (thrombosis). The clot may even break off and go through the bloodstream into the lungs (pulmonary embolism).
- The cut in the wall of the uterus may result in a weakness in that part of the wall.
- Any future children may need to be delivered by C/S, depending on the indication for the C/S, how the operation was done and its outcome.
- Injury to other organs.
- Psychological complications. C/S can delay interaction and bonding between the mother and newborn baby. (Also see emotional changes.)
- Maternal mortality is two to four times greater than for a vaginal birth.
The doctor should be asked about the chances for complications and the various risks.
When to call the doctor A mother who has recently had a caesarean section, should call her doctor immediately if she:
- Develops fever.
- Becomes dizzy or faint.
- Experiences nausea and vomiting.
- Becomes short of breath.
(Reviewed by Prof Bert Schaetzing, University of Stellenbosch)