2. Failure to dilate or failure of descent: If you get into the active phase of labor (when your cervix is dilated 4 cm or more) but you then have no change in your cervix for two hours with adequate contractions (measured by a small catheter placed through the vagina and into the uterus), you are experiencing what is called "failure to dilate" and you may need a c-section. If you are completely dilated and the baby is not delivered after one or two hours, this is known as "failure of descent." Generally, this means that your baby's head is too big to fit through your pelvis (known as cephalo-pelvic disproportion or "CPD"). If the baby's head is accessible, your doctor may perform an "assisted" vaginal delivery with forceps or a vacuum. If the head is not accessible or your doctor feels it is unsafe to assist the delivery, a c-section is required. Lastly, if your labor is being induced artificially and your cervix is closed after 18-24 hours of attempted induction, a c-section is often needed.
3. Fetal Distress: A c-section is usually performed if the baby needs immediate attention but the cervix is not yet sufficiently dilated. For example, if the fetus' heart rate suddenly drops and doesn't return to normal within about five minutes, a c-section is often performed. Also, if the fetal heart rate slows after the peak of each contraction and doesn't return to normal until after the contraction has ended, a c-section may be required. Prior to performing a c-section, your doctor will likely try a change in your position, administration of oxygen by face-mask, intravenous fluids, and turning off any medication being used to induce contractions, if you are receiving it. If these methods fail, a c-section will be required.
4. Large baby: If your doctor feels that your baby is too large to fit through the birth canal you may require a c-section. Your doctor may order an ultrasound to help asses the size of your baby. Unfortunately, using an ultrasound to estimate fetal size in the third trimester is not always accurate so it is a difficult test to rely on. Your doctor will use her or his judgment. Usually a baby is considered too big at 4500 grams (roughly 10 pounds), or 4000-4250 grams (roughly 9-9.5 pounds) in the diabetic patient.
5. Previous cesarean section or other previous uterine surgeries: If you have had one previous c-section and the incision was horizontal on the uterus (not the skin) then it is usually safe to have a vaginal delivery. If, however, the incision on your uterus was vertical, you should not labor and will require a repeat c-section. If you have had more than one c-section, it is between you and your doctor to decide if labor is safe in your current pregnancy. If you have had previous uterine surgery (such as fibroid removal) and the cavity of the uterus was entered, a c-section should be performed. It is up to your doctor to review the report from any previous surgeries to determine whether or not it is safe for you to have a vaginal delivery.
6. Abnormalities in the placenta: In a condition known as placenta previa, the placenta covers the cervical opening. When this happens, the placenta blocks the fetus from passing through the cervix. In all cases where the placenta completely covers the cervix, a c-section is required.
7. Previous fractured pelvis, hip replacement or other pelvic abnormality: In these cases, whether or not it is safe to have a vaginal delivery depends on the individual situation. Usually you will be examined to see if you are able to open your legs sufficiently for a vaginal delivery. Your obstetrician will usually consult with your orthopedist and together decide on the possibility of a safe vaginal delivery.
What Happens During a C-Section?
Preparation
Once it is determined that a c-section is required, you will usually be asked to sign a consent form giving the obstetrician permission to perform the operation. Often you sign this form upon your arrival at the hospital, just in case you require an emergency c-section during your labor.
You will then be asked to change into a hospital gown and a nurse will start an intravenous line to give you fluids for hydration. Usually, the nurse will draw blood at the same time for routine laboratory tests. You will then be taken to the operating room, which will be brightly lit and have a sterile appearance. The anesthesiologist will explain the type of anesthesia she or he is planning to give you and it will be administered.
Next, a nurse will prepare your abdomen for the surgery. She or he will first shave the upper portion of your pubic hair. Your legs will be placed in the "frog leg" position (bent at the knee with your heels touching and your knees apart) and a catheter will be placed through the urethra into the bladder. This will drain your urine during the procedure and usually will remain in place until the next day. Your legs are then straightened and your belly will be scrubbed with a sterile solution. A blue drape will be placed over your belly and attached to two poles at either side of you at the level of your shoulders, creating a barrier between your head and the surgical field (your belly).
At this time you can expect your doctor and her or his assistant to be scrubbing their hands and you will hear paper rustling and metal clanking as the nurses count all the sponges and instruments. The doctors will re-enter the room wearing surgical caps and masks. They will dry their hands and don sterile gowns and gloves. It is at this time that your husband or the person who is accompanying you is asked to enter the room unless there are emergency circumstances, in which case visitors may not be permitted.
The Operation
Now it is time for the operation. An incision is made on the skin of the abdomen. The most common is a small, horizontal incision called a Pfannensteil incision or "bikini cut" because the scar is usually hidden when a woman wears a bikini. There are rare cases in which your doctor may need to make a vertical incision that may extend up to the navel (and thus, may be visible at the beach). This may occur if: 1) you have had previous surgery and your doctor is using the old incision, 2) you have a condition requiring another operation to be conducted at the same time as your c-section such as removal of a large ovarian mass, or 3) there is an emergency with your baby and the doctor feels that, based on her or his experience and expertise, the fastest way to get to the baby is via a larger, vertical incision.
Your doctor will go through the several layers of tissue that comprise your abdominal wall and finally will make an incision on the uterus. Most incisions on the uterus are made in a horizontal fashion, though there are some cases that require a vertical incision. An example would be if your baby is in an abnormal delivery position (for example, with its back facing down). . Once the uterus is entered, the amniotic fluid sac (bag of waters) is broken and your baby is delivered.
To assist your doctor in delivering the baby, the assistant presses on your belly to help push the baby out. You will not feel pain but may experience a sensation of pulling and tugging. The umbilical cord will be cut and your baby has now entered the world. Depending on the circumstances surrounding your delivery, the baby will be either handed to a pediatrician who may be waiting in attendance or to the nurse.
After the Delivery
If there is an emergency situation the pediatrician may need to take your baby to the nursery immediately. In this case, you may only see the baby briefly or not until later. Most often it is not an emergency and your doctor may hold the baby higher than the drape momentarily for you to see and then the baby will be dried off and weighed by the nurse. You will then be given your baby to hold across your chest. In many cases, you will need help holding the baby because of weakness or light-headedness that may be caused by the anesthesia.
As you are bonding with your baby, the obstetrician is delivering the placenta (or afterbirth) and closing the incision on your uterus and your skin. The total surgery takes between thirty and sixty minutes to complete. Once the procedure is completed, the drapes will be removed and the nurse will clean off your belly (which is now much smaller!). Next, you'll be off to the recovery room for an hour or two and then to your hospital room where you will spend the next few days.
Will It Hurt?
Cesarean sections are performed under anesthesia. Therefore YOU WILL NOT FEEL PAIN during the operation. In certain circumstances, general anesthesia will be used (such as in emergencies) and you will be asleep during the operation. Most often a regional anesthetic is used so that you will be numb over your entire belly and parts of your legs. One type of regional anesthesia, called "spinal" anesthesia, involves injecting medication into your back near the spinal cord. Another type of regional anesthesia is called epidural anesthesia. Instead of a single injection of medication, a tiny catheter is inserted through your back into a space that surrounds your spinal cord and anesthesia is administered through the catheter. In both procedures, the spinal cord is not involved directly and you will not become paralyzed from regional anesthetic administration. Epidural anesthesia is preferable to spinal anesthesia if a longer procedure is expected to take place. Many women already have an epidural in place for labor pain when the decision is made to do a c-section, making the choice of anesthesia an easy one.
Most patients are awake and alert throughout the operation. While you will not feel pain, you will feel pressure and tugging sensations that most patients describe as "weird" but not painful. If at any time you do feel pain during your operation, tell the anesthesiologist who will immediately adjust your medication dosage accordingly.
Are There Risks To Me Or The Baby?
A Cesarean Section is a surgical procedure and carries with it the same risks as any other surgery. These risks are minor and usually all goes well for mother and child. For the mother, the risks include:
1) Bleeding, which may be severe enough to require a blood transfusion or even a hysterectomy.
2) Infection (though the operation is performed under sterile conditions and prophylactic antibiotics are usually given during the operation), which may require a lengthened hospital stay for intravenous antibiotics
3) Damage to adjacent organs including but not limited to bladder, bowel, ureter (the tube connecting the kidney to bladder), fallopian tubes and ovaries. This may produce urinary or fecal incontinence or sterility
4) Complications from anesthesia.
Cesarean delivery also carries a small risk of injury to the fetus. One rare risk for the baby is getting a cut on the shoulder or head from the scalpel upon entry to the uterus. Additionally, the risks we try to avoid by not allowing a vaginal delivery of a large baby, such as bone fractures and nerve trauma, are not always completely in cesarean delivery. Usually a c-section is performed for the benefit of the baby and the baby is not at significant risk from the procedure. It should be emphasized that although a c-section is not without risk, complications are rare and the majority of c-sections are performed with no problem whatsoever.
How Long Will It Take To Recover?
You can expect to be in the hospital for 2-4 days. You should be able to eat, walk and urinate without difficulty by the second post-operative day. You may not have a bowel movement before you leave the hospital but you should pass gas from the rectum. You should not do any heavy lifting (more than 10lbs) or driving for two weeks. You should not put anything in the vagina for four weeks (no douching, tampons or intercourse). After four weeks you can resume your normal activities including slowly resuming your prior exercise regimen. In the hospital, you will be taking prescription pain-killers. Many women require these medications at home for up to a week after the operation. Usually non-prescription ibuprofen is used next, and most women stop requiring medicine after two weeks. Remember, be patient and take it slowly; a c-section is a major surgery.
If I Have One C-Section Does That Mean I Will Always Have to Have C-Sections?
Most certainly not! As mentioned before, if you get a low transverse incision on the uterus (horizontal incision) it may be safe for you to go through labor and have a vaginal delivery in the future. The main risk of vaginal birth after a cesarean section is uterine rupture or a separation of the previous scar on the uterus. In low transverse incisions the risk is very small -- approximately 0.4%. In this case, it is safe to attempt a vaginal delivery. There are some obstetricians who will give you the choice of an elective repeat c-section or trial of labor. You will not be offered this choice unless the obstetrician feels it is safe for you to attempt a vaginal delivery. Remember that the recovery period is shorter and the risks are fewer with a vaginal delivery. If the previous c-section incision on the uterus is vertical, the risk of uterine rupture rises to an unacceptable 4-5% and a repeat c-section will be required.
Summary
In conclusion, if you need to have a c-section, you will have one! Your obstetrician will not recommend a c-section unless it is needed for the health of the mother or baby. There are some risks to the procedure, but overall, mother and child leave the hospital within 2-4 days, happy and healthy.
Best of luck, health and happiness to you and your family during this very special time.
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