Cesarean section

Definition

A cesarean section is a surgical procedure in which incisions are made through a woman's abdomen and uterus to deliver her baby.

Purpose

Cesarean sections, also called c-sections or cesarean deliveries, are performed whenever abnormal conditions complicate labor and vaginal delivery, threatening the life or health of the mother or the baby. Dystocia, or difficult labor, is the other common cause of c-sections. The procedure is performed in the United States on nearly one of every four babies delivered—more than 900,000 babies each year. The procedure is often used in cases where the mother has had a previous c-section.

The most common reason that a cesarean section is performed (in 35% of all cases, according to the United States Public Health Service) is the woman has had a previous c-section. The "once a cesarean, always a cesarean" rule originated when the uterine incision was made vertically (termed a "classical incision"); the resulting scar was weak and had a risk of rupturing in subsequent deliveries. Today, the incision is almost always made horizontally across the lower end of the uterus (called a low transverse incision), resulting in reduced blood loss and a decreased chance of rupture. This kind of incision allows many women to have a vaginal birth after a cesarean (VBAC).

The second most common reason that a c-section is performed (in 30% of all cases) is difficult childbirth due to non-progressive labor (dystocia). Difficult labor is commonly caused by one of the three following conditions: abnormalities in the mother's birth canal; abnormalities in the position of the fetus; or abnormalities in the labor, including weak or infrequent contractions. The mother's pelvic structure may not allow adequate passage for birth. When the baby's head is too large to fit through the pelvis, the condition is called cephalopelvic disproportion (CPD).

Another 12% of c-sections are performed to deliver a baby in a breech presentation (buttocks or feet first). Breech presentation is found in about 3% of all births.

In 9% of all cases, c-sections are performed in response to fetal distress, which refers to any situation that threatens the baby such as the umbilical cord wrapped around the baby's neck. This may appear on the fetal heart monitor as an abnormal heart rate or rhythm. Fetal brain damage can result from oxygen deprivation. Fetal distress is often related to abnormalities in the position of the fetus or abnormalities in the birth canal, causing reduced blood flow through the placenta.

The remaining 14% of c-sections are indicated by other serious factors. One is prolapse of the umbilical cord: the cord is pushed into the vagina ahead of the baby and becomes compressed, cutting off blood flow to the baby. Another is "placental abruption," whereby the placenta separates from the uterine wall before the baby is born, cutting off blood flow to the baby. The risk of this is especially high in multiple births (twins, triplets, or more). A third factor is "placenta previa," in which the placenta covers the cervix partially or completely, making vaginal delivery impossible. In some cases requiring c-section, the baby is in a transverse position, lying horizontally across the pelvis, perhaps with a shoulder in the birth canal.

The mother's health may make delivery by c-section the safer choice, especially in cases of maternal diabetes, hypertension, genital herpes, malignancies of the genital tract, and preeclampsia (high blood pressure related to pregnancy).

Choosing cesarean section

A 1997 survey of female obstetricians found that 31% would choose to have a c-section without trial of labor if they had an uncomplicated pregnancy. This finding mirrors a growing movement to allow women the right to choose c-section over vaginal delivery, even when no indications for c-section exist.

There are a number of reasons why a woman might choose a c-section in the absence of the usual indications. These include:

• Convenience. A scheduled c-section would allow a woman to choose the time and date of delivery to avoid conflicting with work or family obligations.
• Fear of childbirth. A woman might fear the pain of labor and delivery and feel that a scheduled c-section would allow her to circumvent it.
• Avoiding risks of vaginal delivery. Certain risks inherent to vaginal delivery (urinary or rectal incontinence, sexual dysfunction, dystocia) are avoided in a c-section.

Demographics

Women of higher socioeconomic status are more likely to have a c-section, 22.9%, compared to 13.2% of women who live in low-income families. C-section rates are highest among non-Hispanic white women (20.6%). Asian-American women have a c-section rate of 19.2%; African-American women, a rate of 18.9%, and Hispanic women, a rate of 13.9%.

Description

Regional anesthesia, either a spinal or epidural, is the preferred method of pain relief during a c-section. The benefits of regional anesthesia include allowing the mother to be awake during the surgery, avoiding the risks of general anesthesia, and allowing early contact between mother and child. Spinal anesthesia involves inserting a needle into a region between the vertebrae of the lower back and injecting numbing medications. An epidural is similar to a spinal except that a catheter is inserted so that numbing medications may be administered continuously. Some women experience a drop in blood pressure when a regional anesthetic is administered; this can be countered with fluids and/or medications.

In some instances, use of general anesthesia may be indicated. General anesthesia can be more rapidly administered in the case of an emergency (e.g., severe fetal distress). If the mother has a coagulation disorder that would be complicated by a drop in blood pressure (a risk with regional anesthesia), general anesthesia is an alternative. A major drawback of general anesthesia is that the procedure carries with it certain risks such as pulmonary aspiration and failed intubation. The baby may also be affected by the anesthetics since they cross the placenta; this effect is generally mild if delivery occurs within 10 minutes after anesthesia is administered.

Once the patient has received anesthesia, the abdomen is washed with an antibacterial solution and a portion of the pubic hair may be shaved. The first incision opens the abdomen. Infrequently, it will be vertical from just below the navel to the top of the pubic bone or, more commonly, it will be a horizontal incision across and above the pubic bone (informally called a "bikini cut").

The second incision opens the uterus. In most cases, a transverse incision is made. This is the favored type because it heals well and makes it possible for a woman to attempt a vaginal delivery in the future. The classical incision is vertical. Because it provides a larger opening

To remove a baby by cesarean section, an incision is made into the abdomen, usually just above the pubic hairline (A). The uterus is located and divided (B), allowing for delivery of the baby (C). After all the contents of the uterus are removed, the uterus is repaired, and the rest of the layers of the abdominal wall are closed (D). (

Illustration by GGS Inc.

)

Once the uterus is opened, the amniotic sac is ruptured and the baby is delivered. The time from the initial incision to birth is typically five minutes. The umbilical cord is clamped and cut, and the newborn is evaluated. The placenta is removed from the mother, and her uterus and abdomen are stitched closed (surgical staples may be used instead in closing the outermost layer of the abdominal incision). From birth through suturing may take 30–40 minutes; the entire surgical procedure may be performed in less than one hour.

Diagnosis/Preparation

There are several ways that obstetricians and other doctors diagnose conditions that may make a c-section necessary. Ultrasound testing reveals the positions of the baby and the placenta and may be used to estimate the baby's size and gestational age. Fetal heart monitors, in use since the 1970s, transmit any signals of fetal distress. Oxygen deprivation may be determined by checking the amniotic fluid for meconium (feces); a lack of oxygen may cause an unborn baby to defecate. Oxygen deprivation may also be determined by testing the pH of a blood sample taken from the baby's scalp; a pH of 7.25 or higher is normal, between 7.2 and 7.25 is suspicious, and below 7.2 is a sign of trouble.

When a c-section becomes necessary, the mother is prepped for surgery. A catheter is inserted into her bladder and an intravenous (IV) line is inserted into her arm. Leads for monitoring the mother's heart rate, rhythm, and blood pressure are attached. In the operating room , the mother is given anesthesia, usually a regional anesthetic (epidural or spinal), making her numb from below her breasts to her toes. In some cases, a general anesthetic will be administered. Surgical drapes are placed over the body, except the head; these drapes block the direct view of the procedure.

Aftercare

A woman who undergoes a c-section requires both the care given to any new mother and the care given to any patient recovering from major surgery. She should be offered pain medication that does not interfere with breastfeeding. She should be encouraged to get out of bed and walk around eight to 24 hours after surgery to stimulate circulation (thus avoiding the formation of blood clots) and bowel movement. She should limit climbing stairs to once a day, and avoid lifting anything heavier than the baby. She should nap as often as the baby sleeps, and arrange for help with the housework, meals, and care of other children. She may resume driving after two weeks, although some doctors recommend waiting for six weeks, the typical recovery period from major surgery.

Risks

Because a c-section is a surgical procedure, it carries more risk to both the mother and the baby. The maternal death rate is less than 0.02%, but that is four times the maternal death rate associated with vaginal delivery. Complications occur in less than 10% of cases.

The mother is at risk for increased bleeding (a c-section may result in twice the blood loss of a vaginal delivery) from the two incisions, the placental attachment site, and possible damage to a uterine artery. The mother may develop infection of the incision, the urinary tract, or the tissue lining the uterus (endometritis); infections occur in approximately 7% of women after having a c-section. Less commonly, she may receive injury to the surrounding organs such as the bladder and bowel. When a general anesthesia is used, she may experience complications from the anesthesia. Very rarely, she may develop a wound hematoma at the site of either incision or other blood clots leading to pelvic thrombophlebitis (inflammation of the major vein running from the pelvis into the leg) or a pulmonary embolus (a blood clot lodging in the lung).

Undergoing a c-section may also inflict psychological distress on the mother, beyond hormonal mood swings and postpartum depression ("baby blues"). The woman may feel disappointment and a sense of failure for not experiencing a vaginal delivery. She may feel isolated if the father or birthing coach is not with her in the operating room, or if an unfamiliar doctor treats her rather than her own doctor or midwife. She may feel helpless from a loss of control over labor and delivery with no opportunity to actively participate. To overcome these feelings, the woman must understand why the c-section was necessary. She must accept that she could not control the unforeseen events that made the c-section the optimum means of delivery, and recognize that preserving the health and safety of both her and her child was more important than her delivering vaginally. Women who undergo a c-section should be encouraged to share their feelings with others. Hospitals can often recommend support groups for such mothers. Women should also be encouraged to seek professional help if negative emotions persist.

Normal results

The after-effects of a c-section vary, depending on the woman's age, physical fitness, and overall health. Following this procedure, a woman commonly experiences gas pains, incision pain, and uterine contractions (also common in vaginal delivery). Her hospital stay may be two to four days. Breastfeeding the baby is encouraged, taking care that it is in a position that keeps the baby from resting on the mother's incision. As the woman heals, she may gradually increase appropriate exercises to regain abdominal tone. Full recovery may be achieved in four to six weeks.

The prognosis for a successful vaginal birth after a cesarean (VBAC) may be at least 75%, especially when the c-section involved a low transverse incision in the uterus and there were no complications during or after delivery.

Morbidity and mortality rates

Surgical injuries to the ureter or bowel occur in approximately 0.1% of c-sections. The risk of infection to the incision ranges from 2.5% to 15%. Urinary tract infections occur in 2–16% of patients post-c-section. The risk for developing a deep-vein thrombosis is three to five times higher in patients undergoing c-section than vaginal delivery.

Of the hundreds of thousands of women in the United States who undergo a c-section each year, about 500 die from serious infections, hemorrhaging, or other complications. The overall maternal mortality rate is estimated to be between six and 22 deaths per 100,000 births; approximately one-third of maternal deaths that occur after c-section can be attributed to the procedure. These deaths may be related to the health conditions that made the operation necessary, and not simply to the operation itself.

Alternatives

When a c-section is being considered because labor is not progressing, the mother should first be encouraged to walk around to stimulate labor. Labor may also be stimulated with the drug oxytocin. A woman should receive regular prenatal care and be able to alert her doctor to the first signs of trouble. Once labor begins, she should be encouraged to move around and to urinate. The doctor should be conservative in diagnosing dystocia and fetal distress, taking a position of "watchful waiting" before deciding to operate.

Approximately 3–4% of babies present at term in the breech position. Before opting to perform an elective c-section, the doctor may first attempt to reposition the baby; this is called external cephalic version. The doctor may also try a vaginal breech delivery, depending on the size of the mother's pelvis, the size of the baby, and the type of breech position the baby is in. However, a c-section is safer than a vaginal delivery when the baby is 8 lb (3.6 kg) or larger, in a breech position with the feet crossed, or in a breech position with the head hyperextended.

A vaginal birth after cesarean (VBAC) is an option for women who have had previous c-sections and are interested in a trial of labor (TOL). TOL is a purposeful attempt to deliver vaginally. The success rate for VBAC in patients who have had a prior low transverse uterine incision is approximately 70%. The most severe risk associated with TOL is uterine rupture: 0.2–1.5% of attempted VBACs among women with a low transverse uterine scar will end in uterine rupture, compared to 12% of women with a classic uterine incision. To minimize this risk, the American College of Obstetricians and Gynecologists (ACOG) recommends that VBAC be limited to women with full-term pregnancies (37–40 weeks) who have only had one previous low transverse c-section.

Resources

books

Enkin, Murray, et al. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. Oxford: Oxford University Press, 2000.

periodicals

Harer, W. Benson. "Vaginal Birth After Cesarean Delivery: Current Status." Journal of the American Medical Association 287, no. 20 (May 2002).

Murphy, Deirdre, Rachel Liebling, Lisa Verity, Rebecca Swingler, and Roshni Patel. "Early Maternal and Neonatal Morbidity Associated with Operative Delivery in Second Stage of Labour: A Cohort Study." The Lancet 358 (October 13, 2001): 1203–07.

Wagner, Marsden. "Choosing Cesarean Section." The Lancet 356 (November 11, 2000): 1677–80.

Yokoe, Deborah, et al. "Epidemiology of and Surveillance for Postpartum Infections." Emerging Infectious Diseases 7, no. 5 (2001).

organizations

American Academy of Family Physicians. 8880 Ward Parkway, Kansas City, MO 64114. (816) 333-9700. http://www.aafp.org .

American Board of Obstetrics and Gynecology. 2915 Vine Street, Dallas, TX 75204. (214) 871-1619. http://www.abog.org .

American College of Obstetricians and Gynecologists. 409 12th St., SW, PO Box 96920, Washington, DC 20090-6920. http://www.acog.org .

International Cesarean Awareness Network. 1304 Kingsdale Ave., Redondo Beach, CA 90278. (310) 542-6400. http://www.ican-online.org .

other

"Cesarean Birth." American College of Obstetricians and Gynecologists, March 1999 [cited February 26, 2003]. http://www.medem.com .

Duriseti, Ram. "Cesarean Section." eMedicine, August 29, 2001 [cited February 26, 2003]. http://www.emedicine.com/aaem/topic99.htm .

Sehdev, Harish. "Cesarean Delivery." eMedicine, February 22, 2002 [cited February 26, 2003]. http://www.emedicine.com/med/topic3283.htm .

Bethany Thivierge Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Cesarean sections are considered to be major surgery and are therefore usually performed under the strict conditions of a hospital operating room. The procedure is generally performed by an obstetrician who specializes in the areas of women's general health, pregnancy, labor and childbirth, prenatal testing, and genetics.

QUESTIONS TO ASK THE DOCTOR

• What is your medical training and how many c-sections have you performed?
• What percentage of women receive c-sections in your practice?
• If I have an elective c-section, what happens if I go into labor before the procedure is scheduled?
• What options are available to me for pain relief during and after the c-section?
• May a person of my choice remain with me during the procedure?
• When will I be able to hold/breastfeed my child?