Reasons for a Cesarean
  The Planned Cesarean
  Tips for the Partner
  The Surgical Procedure
  Recovering from a Cesarean

REASONS FOR A CESAREAN

During a cesarean delivery, the baby is delivered through an incision in the lower abdomen rather than through the vagina. About one in five women in every childbirth class ends up having her baby delivered by cesarean section. Some know in advance that circumstances will make it necessary, while others find out during labor.

If your doctor decides that cesarean section is best for you, you should keep in mind that it will help you deliver your baby safely. Although you may feel a sense of disappointment, take heart in the fact that you are doing what is best for your baby and for your own health.

One note: A physician will never recommend a cesarean as a means of avoiding the discomfort of labor. It is major abdominal surgery, performed under anesthesia, and it involves risks for both the mother and the child. A mother is at greater risk of infection, bleeding, pneumonia, and blood clots when a cesarean section is performed. Her baby is at greater risk for breathing disorders.

Because a cesarean section involves major surgery, recovery takes longer than does a vaginal delivery. Most mothers and babies recover without difficulty, however. Because a cesarean could become necessary during almost any birth, every couple should know in advance what to expect.
 
Medical conditions that might require a cesarean
During the course of your pregnancy or at some stage du-ring labor, your doctor may decide a cesarean will be necessary. The reason may be one of the following:

• A small pelvis: If your baby's head is larger than your pelvis, you will not be able to deliver vaginally.
• Ineffective labor: Sometimes labor does not progress as it should, and contractions are not strong enough to push the baby down the birth canal. In this case, labor may go on too long for the baby's safety.
• Fetal distress: This is a medical term that means a baby is not getting enough oxygen from the placenta. This could happen for several reasons, for example: if the placenta separates from the uterine wall before the baby is born, if the placenta will be delivered first, and in very rare cases, if the umbilical cord has been pinched, cutting off the flow of oxygen from the placenta.
• Abnonnal position in the uterus: A baby that is lying sideways in the uterus can not be delivered vaginally. A baby that is lying in the birth canal with feet first (breech) or face first (brow presentation) may also have to be delivered by cesarean section.
• Pregnancy-induced hypertension: If a mother begins to retain fluid and develops high blood pressure late in the pregnancy, the baby will have trouble getting oxygen from the placenta. If the condition is not controlled, there may be risks to both baby and mother.
• Diabetes: When a diabetic woman becomes pregnant, her disease must be managed very carefully. It may become necessary to perform a cesarean to make sure the baby is delivered safely. This could happen if the baby is especially large, if it is not getting enough oxygen from the placenta, if it does not respond well to the stress of labor, or if the effort to start labor has failed.
• Different blood types: Complications may develop when a woman who has Rh negative blood is pregnant with a baby who has Rh positive blood. The baby may develop anemia or other serious problems that make an early delivery necessary.
• Herpes: If a mother has herpes, an active outbreak at the time of birth can cause a baby to become infected with the virus if delivered vaginally. It is not possible to cure herpes, and about 50% of infants who get it will die.

The importance of the type of incision
There are two types of cesarean incisions. The classical incision is a long cut made from the belly button to the pubic bone. This type of incision provides the doctor with easier access to the baby, allowing delivery to take place more quickly. However, because the incision is long, it needs more time to heal. Women who once have this kind of incision generally always deliver their next babies by cesarean.

The smaller incision, called the bikini cut, extends like a smile low along the pubic hairline. It heals more rapidly and makes a less noticeable scar than the classical incision. Women who have had this kind of cesarean may be able to deliver vaginally later.

Even in this modem age, it is often difficult to know exactly when a baby was conceived. As a result, there is always a risk with a cesarean birth that the baby will be delivered prematurely. There are many reasons a planned cesarean is necessary. You and your doctor will discuss whether you will deliver on a particular date or wait until labor begins. If you are going to deliver by appointment, there are many tests to determine your baby's maturity. If you do go into labor, you should call your doctor as soon as labor begins. Waiting could place your baby and yourself at great risk.

Preoperative tests
A sonogram makes it possible to estimate your baby's age by measuring the size of his or her head.

Amniocentesis gives your baby's age based on the development of the lungs.

Serial estriol levels show whether the placenta is intact. This is especially important when the mother has a disorder like hypertension or diabetes, which both cause the placenta to leak before the baby is ready to be born.

Preoperative procedures
If a cesarean delivery date is set, you may enter the hospital the morning of surgery or the night before. While either is fine, you may wish to stay at home if you think you will rest better there. Once you have been admitted, you can expect the following procedures and tests:

• No eating or drinking: You will not be allowed to eat or drink anything for eight to 12 hours before surgery. It is important that you follow this rule since it will prevent serious complications in case you need general anesthesia and become nauseated during surgery.
• Blood tests: Blood will be drawn for a number of tests and to check your blood type.
• Urinalysis: This test will reveal an infection or, if you are diabetic, abnormal sugar levels.
• Chest X-ray and respiratory function tests: These are not always required, and they can also be done before you are admitted to the hospital.
• Shaving: To prepare you for surgery, part of your abdomen down to the pubic hair will be shaved.
• Enema: Your doctor may order an enema to clean out your bowels before surgery. If you prefer, you may do this at home.
• Consent form: Before you go into surgery, you will be asked to sign consent forms for the surgery and anesthesia and for the baby's circumcision, if you request one.
• Meeting with the anesthesiologist: The anesthesiologist will visit you before you go into surgery. He or she will talk with you about the medications and anesthesia you will receive. Be sure to mention any allergies or reactions to medications you have had in the past.
• Medication: If you are going to have general anesthesia, you will probably receive an injection of medication that will dry your mouth and throat.

Your choice of anesthesia
Your anesthesiologist will explain the two types of anesthesia used during a cesarean birth. One is regional and the other is general.

There are two types of regional anesthesia: the epidural and the spinal. With either type, you can remain conscious during the delivery. Regional anesthesia is usually preferred because it does not cross the placenta and affect the baby. It also allows the mother and father to be actively involved in the birth.

A regional anesthesia takes effect in 15 to 20 minutes. Unless an emergency develops, there is usually plenty of time to have this kind of anesthesia.

Both the epidural and spinal anesthesia have similar effects in numbing your body. An epidural anesthesia is usually delivered through a catheter so that the flow can be controlled to produce the level of comfort you need while you first cuddle your baby. With a spinal, the anesthesia is injected into the spinal canal. Because it is given as an injection, there is always the chance that general anesthesia will be necessary if the effects of the spinal wear off too soon.

With both types of anesthesia, you will begin to feel warm, then tingly, then finally numb. With the spinal, you won't feel anything as your baby is being born. With the epidural, you may feel pressure and a pulling sensation. If an emergency occurs, you will immediately be given general anesthesia. Because you will be completely unconscious, your partner will probably not be present during delivery.

TIPS FOR THE PARTNER

• As the doctor and mother-to-be discuss the type of anesthesia and incisions that will be used, show your support and join in the discussion.
• If you and the mother wish to watch the birth as it happens, arrange for a mirror to be in the room.  You may also ask you doctor to remove the protective screen as birth nears.
• Encourage the mother to use slow-paced breathing to relax.
• Hold her hand or massage her temples or jaw to relax her.
• Coach her to change breathing techniques if she needs to concentrate harder.  Breate with her if necessary to guide her.
• Watch for signs that she is breathing too fast because of anxiety.
• Try to distract her by signing or talking with her to make the time pass more quickly.
• After the baby is born, hold it close to her so that she can see it.

THE SURGICAL PROCEDURE

Your cesarean will probably take place in Labor and Delivery or the operating room. If your partner will be present, he must change into scrub clothes, which include a mask, scrub suit, cap, and shoe covers. While he is getting ready, you will be taken to the delivery room, and the following things will happen:

• An intravenous (IV) line will be started in one arm. Your attendants will tie your arm lightly to a small board, to keep the IV from slipping out during delivery. if your hand is free, you will be able to touch your partner and your baby.
• Anesthesia will be given to you either by injection or by catheter.
• You may be offered an oxygen mask to breathe through.
• A catheter will be inserted in your bladder to drain it. Keeping the bladder drained will prevent damage during surgery.
• A blood pressure cuff will be put on one arm, and electrocardiogram leads may be attached to your chest.
• A reddish-orange antiseptic solution will be spread on your abdomen and thighs.
• A draped screen will be set up in front of your face so that you and your partner will not contaminate the sterile field.
• At this point, your partner will be invited to enter the room and to sit next to your head.
• The surgery will then begin. Two incisions will be made: one in the skin and one in the uterus. One may be horizontal and the other vertical. The types of incisions your doctor makes will depend on the baby's position, its condition, and your wishes.
• You may feel a little tugging and pulling as your baby is born. Sometimes a doctor will press down on the top of the abdomen to assist the delivery, and you will feel this as well. Use slow chest breathing if you feel uncomfortable at this time.
• The doctor will lift your baby out by hand with forceps or with a vacuum extractor. Within moments, you will hear your baby cry.
• The umbilical cord will be clamped and cut, and your baby will be handed to a pediatrician who is also present. The pediatrician will show the baby to you. While you watch, the pediatrician will examine your baby.
• The placenta is delivered through the incisions, and you will be given oxytocin by IV to help your uterus contract.
• Your doctor will repair your uterus and abdominal muscles, peritoneum, and skin using clamps or staples. This will take about 45 minutes. If you feel nauseated, tell the anesthesiologist. While the repair is going on and if your hands are free, you may hold your baby. Otherwise, your partner may hold your baby close to your cheek.

RECOVERING FROM A CESAREAN

Your time in the recovery room
As soon as the surgery is completed, you will be taken to the recovery room. While you are there, your baby will be watched closely to make sure that he or she is all right after the surgery. If your baby was in distress at birth, the observation may take place in the intensive care nursery.

While you are in recovery letting the anesthesia wear off, a number of things will happen to you.

• The nurse will check your blood pressure, temperature, and pulse.
• She will also examine you to see how much you are bleeding from the vagina and your incision.
• Once your uterus becomes soft, the nurse may massage your abdomen to prevent bleeding. If you are uncomfortable at this time, use your relaxation and breathing techniques.
• Take some slow, deep breaths. This will help clear your lungs to prevent pneumonia. You may also be asked to cough for the same reason. If this is hard for you, hold a pillow against your stomach and "huff' a few times.
• If you had an epidural or a spinal, feeling will slowly return to your toes and feet and then up to your abdomen. If you had general anesthesia, you may feel a little groggy and nauseated when you wake up; you may also want some pain medication.

The first few days after surgery
You'll probably stay in the hospital three to four days. For the first two days, you will continue to have the IV for nourishment and the catheter to keep your bladder empty until you are able to walk to the bathroom.

At first, you should drink liquids only. Drinking enough is very important to keep your kidneys working. It will also prevent you from getting dried out and running a fever.

Keep rolling your ankles, flexing your feet, and stretching while you are in bed. Within 24 hours, you will be asked to get up and walk. This will be hard at first, but it gets easier every day. It is also very good for you. It will help prevent blood clots and reduce gas.

You will bleed just like women do who have had a vaginal delivery. You may also have some pain in your abdomen. Approximately three days'after surgery, your intestines will start working again. This may cause sharp gas pains. To relieve those pains, try this exercise:

Slowly tighten your abdominal muscles as you exhale. You may want to place your hand on your incisions to help support them. Tighten for one or two seconds at first. Slowly increase the length of time to five seconds.

This exercise will not only relieve the gas pains but also help your incision heal. Walking and moving around are also helpful.

You may ask for medication to help you become as comfortable as possible so that you can enjoy the precious time spent with your baby. Your breathing and relaxation techniques can help ease discomfort.

When you go home, take it easy. Moving around will be uncomfortable. You will need help with the house work and your baby for a few days. Don't push yourself. You will recover much faster if you get plenty of rest.

Although your body will heal very rapidly, you may not feel like yourself for two to six months. You may feel sad that you had to have a cesarean or as though you failed in some way, but keep reminding yourself of the most important thing: that you did the right thing for your baby.

Last Updated: May 15, 2002
Source: Preparing for Childbirth
St. Luke's Episcopal Hospital