A Cesarean section or a Cesarean birth is the delivery of a baby via an incision in the mother's lower abdomen/pelvic region. A Cesarean is most often an elective surgery, but is best used as a life saving operation when the mother and/or baby are at risk. When a Cesarean delivery is an emergency, the mother will be on the operating table and the baby will be delivered within a matter of minutes. Everything will be a whirlwind and move very quickly. For most surgeries, there is a little more prep time.
First the mother is given an epidural if she doesn't already have one. In an emergency, if she doesn't have an epidural placed, she will be placed under general anesthesia meaning she will be asleep for the surgery. Once the epidural is placed, she will be taken back to the operating room. The partner is given special clothes to put over their own to create a sterile environment in the OR. Once in the OR, a sterile drape is placed over the mother to lower the risk of infection. Next, her belly is swabbed at the incision site with a cleansing solution. There will be tests done to make sure that she feels no pain. Often they will touch her with an ice cube or poke her with something to see if she feels it. During the surgery, the mother will likely feel some tugging feelings, but should feel no pain. Once they are fully prepared, the doctor, usually an obstetrician, will make the incision. There are a few different types of incisions that may be made. The majority of Cesareans have a low transverse or "bikini" incision. This is very low in the pelvic cavity just above the edge of the bladder. The "classic" incision is a vertical incision higher up on the belly, closer to the belly button. This is generally reserved for emergencies or very preterm babies. There is also the low vertical incision which may be used for a baby in an awkward position. It is a vertical incision made lower than the classic incision, in the pelvic cavity rather than the abdomen.
Once the surgery has begun, the baby is generally delivered within the first 5-15 minutes. The remaining time is spent on closing the incision. Altogether a Cesarean delivery usually takes between 45-60 minutes from beginning to end. Once the surgery is complete, the mother is moved to a recovery area before being taken to her postpartum room.
There are a lot of statistics surrrounding birth that you may not be aware of. Let's take a look at some of the numbers surrounding Cesareans.
According to the Centers for Disease Control (CDC), there are more than 1,000,000 Cesareans performed every year in the United States making up 32.2% of all births.
The World Health Organization (WHO) recommends that the Cesarean rate be between 10-15% of all live births. This is between and not under because the rate of major complications is between 10-15%. This means that a Cesarean rate to match is a good sign. Any higher or lower indicates poor health care.
The rate of maternal mortality (the mother dying) is about 4 in every 100,000 vaginal deliveries, vs. 13 in every 100,000 Cesareans. This jump in risk for the mother is due in large part to a higher rate of hemorrhage (bleeding out), higher rate of infection, and complications from anesthesia during surgery.
According to the CDC, the rates of complications such as maternal transfusion, ruptured uterus, unplanned hysterectomy, and ICU admission are remarkably lower in mothers who have only given birth vaginally. The rates go up for those women having a Vaginal Birth After Cesarean (VBAC), but they are still lower than the rates of these complications for mothers going in for a primary or secondary cesarean. Check out the numbers for each intervention here.
Anecdotally, a survey in the United States found that first time mothers who gave birth via Cesarian were much more likely to report feelings of being frightened, overwhelmed, and helpless, as well as reporting not feeling capable, confident, powerful, and unafraid during birth. Again, this is anecdotal evidence reported by first time mothers about how they felt about their experience.
This is very important. If you have attempted a vaginal delivery and wound up in surgery, you have in no way failed. You have not failed your baby. You have not failed your partner. You have not failed yourself. One thing that is very common for women to feel is that they have failed. As women we are supposed to be able to give birth to our own babies, and in going into surgery, you have been unable to accomplish a task that should be a basic part of being a woman. Many women feel this way. Sometimes things happen that make it impossible or unsafe to deliver vaginally. Sometimes the placenta grows over the cervix and the baby can't get out. Sometimes the baby is sideways and won't turn. Sometimes infection can develop and we start to worry about the health of mother and baby. Sometimes a woman's blood pressure climbs dangerously high during pregnancy threatening her life and the life of the baby. Sometimes trauma or abuse has caused emotional scars that make the mere thought of going into labor unbearable. Sometimes you have been in labor for so long that your exhausted body is not able to keep going. There are a lot of good reasons to give birth surgically, and none of them are failure of the mother or the baby. There are also very bad reasons to have a Cesarean such as inaccurate estimate of size, the mother "taking too long", the doctor not wanting to work on a holiday, and so on. I consider most of the bad reasons to have surgery more a failing of the care provider and not of the mother.
Like the feeling of failure, it is very common for mothers who have had a Cesarean to feel as though they have not given birth to their baby. This can be perpetuated by language, particularly when people talk about the baby being "taken" or "removed". Surgical birth is still birth, and it can still be a very rewarding and positive experience. Unfortunately it is not always positive and can cause trauma and even postpartum post traumatic stress disorder. If you are experiencing symptoms of PTSD, there are therapists who specialize in working with depression and PTSD following birth. Please seek them out. There is no shame in getting help when you need it.
Many women may not be aware that although going into the operating room, they still have options. In an emergency, these options become fewer. When life is actually on the line, some concessions must be made. However, there are many instances where a woman may find herself going into a surgical birth that is non emergent, and in this case, she can absolutely make certain requests.
The idea of providing options to women in surgery is fairly new, and many hospitals still balk at the idea, however, an increasing number of them are providing women with a more pleasant experience even in the operating room. Many women are even opting for a procedure called a gentle cesarean. Here are some of the options that you may have in the OR:
- Lower the drape. I know this one sounds scary. No one wants to see themselves cut open and bleeding. It is important to remember that the low transverse or "bikini" incision that they make is right above your pubic bone below your pregnant belly. Your belly will block all of the gore of the surgery, and all you will see is your new baby emerging in the doctor's hands from underneath your still pregnant looking belly.
- You can request the music of your choice. The doctor may not honor your request, but if there is music that you would like to have on when your baby is born, you can always ask. The worst that can happen is they say no.
- Limit the conversation. While the doctor, nurses, and anesthesiologists perform Cesareans every day, this is the only birth that you will have for this baby, and it is important that that is honored. Occasionally we hear of doctors discussing their vacation or dinner plans during a delivery. You can request that all conversation be about the birth of your child. You can also ask for a play by play as the doctor is delivering your baby.
- Photography. Just because you are in surgery doesn't mean that you shouldn't be able to document the birth of your child. There are more and more pictures out there of new parents with their babies in the operating room. Unless there is an emergency, there should be no reason someone can't snap a few photos.
- Ease the baby out. More and more often, we are seeing surgeons who are extracting the baby more slowly. In a non-emergent situation, the doctor has time to ease the baby out and rotate them mimicking what the baby would experience if they had gone through the birth canal. This can help to work some of the mucous out of their airways, and makes for a much less stressful transition for the baby.
- Seeding. Seeding is something that I am seeing more discussion about. Seeding is when the baby is bathed in the mother's vaginal secretions following birth. This is done by swabbing the mother's vagina with gauze and applying that gauze to the baby's mouth, face, and body. It may sound like an unusual practice, but the idea behind it is interesting. When coming through the birth canal, babies are exposed to a large variety of good bacteria that can improve the function of their immune system. Babies born via Cesarean miss out on exposure to that good bacteria. By applying the vaginal fluid to the baby after delivery, the idea is that they will reap the same benefits of that good bacteria as the babies born vaginally.
The recovery from surgical birth is very different than recovery from a vaginal delivery. Here are a few of the things that you may experience after a Cesarean, some of which are also common after a vaginal delivery as well:
- Numbness and/or pain at the incision site. Many women report a variety of sensations at the incision site from pain and soreness to numbness and tingling. It is even possible to have permanent nerve damage at the incision which can lead to numbness or altered sensation many years down the line. While many people think it goes without saying that there will be different sensations after being cut open, it is still something that catches many people off guard when they actually experience it. In order to lessen the pain, avoid wearing pants. I know this may sound silly, but pants have a waistband that can put too much pressure on or dig into your incision. Wearing dresses or nightgowns can prevent that from happening. For that matter, I would also recommend that you use the mesh underwear they give you at the hospital. These are designed not to dig in for just this purpose. You can also try belly binding to provide a better kind of pressure and support.
- Carry a pillow around with you for a week or two. For many people who have abdominal surgery, Cesarean or other, experience a feeling like they are going to open up and spill out every time they cough, sneeze, or laugh. Carrying a pillow with you and pressing it gently against your incision will help to prevent that scary feeling.
- It will be hard to go to the bathroom afterward. This is something that is experienced regardless of the type of birth you have, and is also a problem after any abdominal surgery. Try a stool softener to help. If you are nervous about over the counter drugs, ask your doctor for a recommendation or prescription that you can try. You can also try putting peppermint oil in you toilet. Peppermint helps to shrink mucous membranes (like the ones lining your colon and urethra, as well as your nose). What that means is that the membrane will shrink back, creating a larger passage for things to get out. Make sure to put the peppermint oil in the toilet before sitting down. This also has the added benefit of making your bathroom smell nice after you use it. Two drops should suffice.
- For all new mothers, but especially those who have undergone surgery, it is important not to push yourself too hard. It is important that you give yourself time to recover from your birth experience. Getting up and moving around is good for you within reason. If anything feels difficult or especially painful, stop! Forcing yourself to push through the pain or discomfort will only lengthen your recovery time, and may cause additional damage. After a Cesarean, you will be instructed not to lift anything heavier than your baby. Stairs are also discouraged. Accept help where it is offered, and ask if you need it. Some mothers hire postpartum doulas or night nurses to help out. Others rely on family and friends for support. Make sure that you make healing a priority.
Delivering your baby via Cesarean Birth may have impacts on your future that you may not be aware of. When you agree to a Cesarean delivery, the doctor and anesthesiologist will come into the room with papers for you to sign and begin listing off complications and side effects. Most women are in no position to be listening to and processing this information, and are often caught unawares when these things come to fruition. Here are a few things that you may experience even years after a Cesarean Birth. These things are not experienced by every woman, but may be experienced by many.
- Increased risk of postpartum depression or post-traumatic stress disorder. Mothers who undergo a surgical birth are at increased risk of developing postpartum mood disorders due to a potentially traumatic experience leading up to the surgery or feelings of inadequacy. It is important that if you experience symptoms of a postpartum mood disorder, speak to a professional specializing in that field. It is a good idea to have someone you trust observe you and let you now if they notice behavior that is uncharacteristic of you, or that may be a sign of a disorder.
- Increased risk of difficulty breast feeding. Because many babies don't get to the breast right away following a Cesarean delivery, many mothers report difficulty with nursing. This can lead to cessation if it gets to difficult and stressful. Having baby skin to skin during closing can help with this, as well as speaking to a qualified lactation consultant.
- Decreased fertility. That's right, having a surgical delivery can slightly decrease your chances of having more children. This is due in large part to adhesions. An adhesion is scar tissue. Scar tissue on your reproductive organs can impact your ability to ovulate or conceive, and can also prevent implantation. These adhesions can also cause chronic pain, and in worst cases bowel obstruction, however the latter is much more unlikely. Seeing a practitioner, such as myself, who is trained to do scar tissue therapy can help to decrease the amount of scar tissue you have. If you have a surgery, make sure to see a qualified practitioner of postpartum massage.
- Greater likelihood of placenta previa or placenta accreta. Placentas like to attach to scar tissue. Because the scar tissue in the uterus is generally fairly low, this leads to an increased incidence of placenta previa which is where the placenta covers the cervix, thereby preventing the baby from coming out vaginally. The scar tissue also creates an increased likelihood of placenta accreta which is where the placenta essentially implants too deeply and doesn't detach after birth. This could be a potentially life threatening situation and often results in an emergency hysterectomy.
- Increased likelihood of repeat cesarean. Due to the higher likelihood of placenta previa, as well as the very slightly increased risk of uterine rupture, one Cesarean birth may lead to more. When favorable, we generally encourage women to attempt a Vaginal Birth After Cesarean (VBAC), as in most cases it is a much safer option than a repeat surgery, however many hospitals and doctors are still not on board and depending where you live, it may be difficult or impossible to find a doctor who will give you a Trial Of Labor After Cesarean (TOLAC), and let you labor. In worst cases, mothers are forced into surgery against their will and without their consent, and threatened to have their babies taken away. Luckily, a few of these cases have made the national news, so the issue is getting attention, and more people are aware of the problem.