Cesarean section

What is a cesarean section?#

A cesarean section (also called a c-section or simply a cesarean) is a surgical procedure in which a baby is born through an incision made in the mother’s abdominal wall and the wall of the uterus (womb). A baby is born this way when there are problems that prevent a safe vaginal birth.

A cesarean may be planned (elective) when there are signs that a vaginal birth would be risky, or unplanned (emergency) when problems arise during labor.

If there are no serious problems with the pregnancy or labor, a vaginal birth is usually the safest way for a baby to be born. Most women have vaginal births.

Your right to be involved in decisions#

A cesarean can only be performed with your written permission. If you are unable to give it, your partner or next of kin can do so on your behalf. You and your obstetrician may decide together on a planned cesarean for several reasons.

These can include:

• You have had a previous cesarean section.
• Your baby is in a breech position (bottom or feet first) and cannot be turned.
• Your baby is lying sideways (transverse) and cannot be turned.
• You have a twin pregnancy with the first baby positioned bottom or feet first.
• You are expecting three or more babies.
• The cervix (opening to the womb) is blocked by the placenta (placenta praevia).

Not every woman in these situations has or needs a cesarean. The decision is based on your particular circumstances and, in some cases, your own preferences.

Reasons for an unplanned (emergency) cesarean can include:

• Your baby’s head does not move down or fit through your pelvis during labor.
• Labor does not progress because contractions are not strong enough and the cervix opens too slowly or not at all.
• Your baby shows signs of distress.
• The umbilical cord, which carries nutrients and oxygenated blood to the baby, has slipped down (prolapsed) through the cervix and into the vagina after the waters have broken.
• A health problem, such as high blood pressure, is making labor riskier for you or your baby.

Things to discuss before a cesarean#

Before a cesarean, talk to your doctor or obstetrician about:

• Your general health, including any health problems, as some conditions can affect decisions about surgery and anesthetics.
• Any bleeding problems or whether you bruise easily.
• Any allergies or medication you are taking.
• Your blood type, so that blood can be made available if you need it during or after the operation.
• Blood tests, including a check for anemia.

Some hospitals offer enhanced recovery programs for planned cesareans. These aim to help women manage pain better, eat and drink sooner, move around earlier, care for their baby more easily and go home sooner. You will be told when booking your cesarean whether your hospital offers this type of care.

Anesthetic for a cesarean section#

There are three types of anesthetic that may be used so that you do not feel pain during the operation.

Spinal anesthetic#

This is the most common anesthetic for a planned cesarean. A needle is inserted between the bones of your spine and local anesthetic is injected through it, blocking pain from the chest downwards. You stay awake and breathe normally. As your baby is born you may feel tugging and pulling sensations, but no pain. In some cases a pain-relieving medicine (morphine) is given at the same time. This can last for the next 24 hours and aids recovery, as you are less drowsy and able to eat, drink and walk around sooner. Ask your doctor whether this is offered.

Epidural anesthetic#

An epidural is often used to ease the pain of labor. If you already have a working epidural during labor, it can be topped up for an emergency cesarean. A thin plastic tube is inserted into a space around the lining of the spine and local anesthetic is injected through it, blocking pain from the waist down. You stay awake and breathe normally, and may feel tugging and pulling as your baby is born, but no pain.

General anesthetic#

A general anesthetic may be used if your baby needs to be born very quickly. You breathe oxygen through a mask and are given medicine through a drip that makes you drowsy and puts you to sleep, so you sleep through the birth.

Types of cesarean sections#

Cesarean sections differ in where the incision is made on the uterus. After your cesarean, ask the obstetrician what kind of cut was used, as this is useful information for future births. The two types are:

• Lower segment incision – used wherever possible. This is a horizontal cut through the abdomen and a horizontal cut through the lower part of the uterus, sometimes called a “bikini line” incision. These cuts heal better, are less visible and are less likely to cause problems in future pregnancies.
• Classical incision – a vertical cut on the uterus, with a horizontal or vertical cut on the abdomen. This is usually only used in extreme emergencies or particular situations, such as when the placenta is lying very low, the baby is lying sideways or the baby is very small. It can increase the chance of problems in later pregnancies and births.

Preparing for a cesarean section#

You will need to fast before a planned cesarean, which usually means no food or drink, including water, for up to 6 hours beforehand. In some cases you can drink clear fluids until 2 hours before admission. Your doctor will advise you about the fasting time needed for your operation. For an emergency cesarean, the doctor will ask when you last ate or drank so they know how to proceed.

You may have a support person with you unless there are serious complications or you need a general anesthetic. It is generally possible for someone to take photos of the birth, so ask your support person to bring a camera. Do not be afraid to ask questions or to tell the doctors or midwives if you feel worried. If you have any special preferences, talk to your doctor or midwife beforehand so they can try to support your choices. Some doctors offer “maternal assisted” cesareans, where you can be directly involved in the birth — ask whether this option is available.

If you are at increased risk of blood clots, you may be measured for compression stockings to wear during the operation. The theater team will clean your abdomen with antiseptic and cover it with sterile cloths to reduce the risk of infection. In many hospitals the hair around the area is shaved so it is easier to clean. A catheter (thin tube) will be inserted into your bladder so that it stays empty during the operation.

During a cesarean section#

The operation usually takes between 30 and 60 minutes. The doctor makes a cut in your abdomen and uterus (both about 10 cm long), and your baby is lifted out through the cut. Sometimes the doctor uses forceps to help lift out the baby’s head. Your baby is then carefully checked.

You should be able to hold your baby soon afterwards. Skin-to-skin contact can strengthen your early bond and make breastfeeding easier. If you cannot hold your baby in the operating theater, your support person usually can.

The umbilical cord is cut and the placenta removed. An injection is usually given to make the uterus contract and reduce bleeding, and antibiotics are given to lower the risk of infection. The layers of muscle, fat and skin are stitched back together and a dressing is applied over the wound.

After a cesarean section#

You will be cared for in the recovery room until you are ready to move to the ward. If you had a general anesthetic, you will most likely wake up there and should be able to see your baby once you are awake.

Breastfeeding#

You will be encouraged to breastfeed. The earlier you start, the easier it tends to be for you and your baby. Having a cesarean can make breastfeeding harder to begin, so ask for all the support you need — breastmilk is excellent food to help your baby grow healthy and strong, and the midwives are there to help. Some hospitals encourage women to breastfeed in the recovery room if a midwife is available to assist.

Pain relief and recovery#

Tell your midwife or doctor when you feel pain so they can give you something to ease it. Pain-relieving medication may make you a little drowsy. You may have a drip for the first 24 hours or so until you recover from the anesthetic, and you can start drinking as soon as you feel able. The midwife or doctor will tell you when you can eat again. In some cases early eating and drinking is encouraged, and chewing gum may be offered to help with your appetite.

Your catheter stays in until the anesthetic has worn off and you have normal sensation in your legs to walk safely to the toilet, which may not be until the next day. Walking around helps recovery and can prevent blood clots and swelling in your legs. A midwife will help you the first time you get out of bed, and you may have an injection to prevent blood clots. You may also need antibiotics after the operation.

You may have trouble with bowel movements for a short time. It helps to drink plenty of water and eat high-fiber food, and the doctor or midwife can give you more advice. When the dressing is removed, you will be told to keep the wound clean and dry to help it heal faster and reduce the risk of infection.

Special care for your baby#

Some babies born by cesarean are more likely to have breathing problems and may need to spend time in the special care nursery, though they are usually ready to go home when you are. If there are no complications requiring an earlier birth, a planned cesarean is usually carried out around 39 weeks of pregnancy. If your baby needs to be born earlier, your doctor may recommend a steroid injection to reduce the risk of breathing problems.

If your baby is premature or unwell, they may need to go to the special care nursery, and your partner or support person can usually go with them. When you are well enough, the midwife or nurse will help you to see your baby and can help you express breastmilk.

Risks and complications#

A cesarean section is a common and relatively safe procedure, but it is still major surgery. As with all surgery, there are risks for both you and your baby. More common risks and complications include:

• Above-average blood loss
• Blood clots in the legs
• Infection in the lining of the uterus
• A longer stay in hospital
• Pain around the wound (you will be given pain relief)
• Problems with future attempts at vaginal birth, or the need for a cesarean in future births
• Complications from the anesthetic

Some women develop serious problems after a cesarean. Always tell your midwife or doctor about any problems so they can assess whether they are serious and provide the treatment you need. Things to look out for include:

• Pain in your abdomen or wound that is getting worse or does not ease after pain-relieving medication
• Ongoing or new back pain, especially where you had the epidural or spinal injection (muscular aches and pains are normal)
• Wound edges pulling apart or looking infected
• Pain or burning when passing urine, or being unable to pass urine
• Leaking urine, constipation, or being unable to pass wind or bowel motions
• Increased vaginal blood loss or bad-smelling discharge from the vagina
• Coughing or shortness of breath
• Swelling or pain in your calf

The first 6 weeks#

After a cesarean, women usually stay in hospital for a few days, though this varies between hospitals and depends on your recovery. Home visits by a midwife after the birth may be available, and some hospitals offer a “hospital in the home” option for women who go home early. Ask the nurse or midwife what your hospital offers.

Tips to help recovery in the first 6 weeks include:

• Rest as much as you can. Ask family or friends to help, or organize paid help if you can afford it. One useful way for others to help is by preparing meals that can be frozen and reheated. If you need extra support at home, talk with your doctor, midwife or child health nurse.
• Avoid heavy lifting. Do not lift anything heavier than your baby, take care of your back, and avoid lifting anything that causes pain.
• Take a gentle walk every day. This can have physical and emotional health benefits.
• Do your pelvic floor exercises. Whatever type of birth you have had, your lower abdominal and pelvic floor muscles will have weakened during pregnancy and need strengthening. A physiotherapist can teach you how.
• Eat a healthy, high-fiber diet and drink plenty of water every day to avoid constipation.
• Use warmth on your wound. Warmth can be soothing — try a wheat bag or hot water bottle.
• Take pain-relieving medication regularly to begin with to prevent pain, following your midwife’s or doctor’s instructions. If you are breastfeeding, check that any medication is safe for your baby too.
• Keep your wound clean and dry, and watch for signs of infection such as redness, pain, swelling or bad-smelling discharge. Report these to your doctor or midwife.
• Consider abdominal support. Some women prefer firm, high-waisted compression underwear or control briefs, which can reduce pain and be worn for comfort for the first 6 weeks.
• Avoid sex until you feel comfortable. It is quite normal for this to take weeks or even months. Numbness or itching around the scar is also normal and can last a long time.
• Look after your emotional health. Some women feel very positive about having a cesarean, while others feel disappointed or sad. Talking through these feelings with your partner, family, friends and carers can help, and a nurse or midwife can refer you for counseling if you are feeling very low. Joining a new mothers’ group can also help. Be kind to yourself — recovery may take a few weeks or longer, particularly if you had complications.

Avoid driving until your wound has healed, usually about 6 weeks, and talk with your doctor about when it is safe to start again.

Long-term outlook and future births#

It is unlikely you will have the same problem again in future pregnancies, but having had a cesarean can create different considerations for future births. If you become pregnant again, talk to your doctor about whether your next birth should be a cesarean or a vaginal birth.

Many women who have previously had a cesarean can safely give birth vaginally — this is known as vaginal birth after cesarean (VBAC). The benefits of VBAC include:

• Avoiding the risks associated with surgery, such as infection, deep vein thrombosis and increased blood loss
• A faster recovery
• A lower risk of complications than with a repeat elective cesarean
• Generally less risk for the baby (for example, a lower chance of being admitted to a special care nursery for breathing problems)

One risk of VBAC is rupture of the uterine scar. About one in every 200 attempted VBACs results in a scar rupture, and for those women there is an increased risk of hysterectomy and stillbirth.

If you have had a previous cesarean, to make an informed decision it helps to discuss and clarify the information with your doctor or midwife, and to ask what types of care and support your hospital offers for women choosing VBAC.

Key points#

• A health problem, such as high blood pressure, can make labor riskier for you and your baby.
• Lower segment (bikini line) cuts heal better, are less visible and are less likely to cause problems in future pregnancies.
• The theater team will clean your abdomen with antiseptic and cover it with sterile cloths to reduce the risk of infection.
• A catheter is inserted into your bladder so that it stays empty during the operation.
• Antibiotics are given to reduce the risk of infection.

Where to get help#