C-section

14April 2023

What is C-section?

A C-section is a surgerydone to deliver the baby by performing an incision on the uterus and the abdomen. This surgical procedure is performed when vaginal delivery is not the safest option.

It is a major surgery in obstetric practice and its prevalence has drastically increased all over the worldin the last few decades from 6.7% in 1990 to 19.1% 2014.

Most common reasons for C-section

Also known as Cesarean deliveryor Cesarean section, the goal is to minimize the risk for the mother and child therebyreducing:

Maternal mortality
Prenatal mortality

ACesarean delivery might be planned –in the early stages of pregnancy,either for medical or non-medical reasons. It can also be unplanned and performed in an emergency due to complications that may come up during labor.

Planned Cesarean delivery is recommended for medical reasons, if:

Previous Cesarean birth: If you have had a C-section previously, it is highly likely that for future pregnancies a C-section will be recommended to you. However,whether your doctor will suggest a VBAC (vaginal birth after Cesarean) or a Cesarean delivery for your future pregnanciesdepends on many factors, such as:
Uterine incision type used previously.
Risk of uterine rupture.
Baby is in an abnormal position: During pregnancy, babies regularly change their position. Generally, they move to the head-first position by the time labor begins. However, if that doesn’t happen then the baby may be lying in a:
breech position (bottom first or feet first)
transverse position (lying sideways or shoulder first)

At 36 weeks of pregnancy, the doctors try to turn the baby from a breech position or transverse position to the head-first position. They do this by applying gentle pressure on the mother’s abdomen. However, if this doesn’t work,Cesareans are usually planned from the 39^th week of pregnancy.

Cephalopelvic Disproportion (CPD): CPD refers to a situation wherein either:
The size of the baby’s head or body is too large: therefore the baby cannot pass through the mother’s pelvis, or;
The sizeof the mother’s pelvis is too small: therefore, the delivery of a normal-sized baby is not possible.
Vaginal Bleeding: With progress in pregnancy, the mother’s womb expands. This expansion affects the position of the placenta. If the placenta stays too low in the uterine, the baby’s exit through the cervix is blocked. This condition is called Placenta Previa and it might also lead to vaginal bleeding, thereby putting both the mother and the baby at risk.
Twin Pregnancy: Twins can be delivered vaginally. However, twin pregnancies often result in prenatal mortality due to prematurity. To avoid such complications, your healthcare provider may recommend aCesarean section.

Unplanned Cesarean delivery is recommended during labor, if:

Stalled labor:If the baby’s movement down the birth canal stops or the cervix starts to dilate but stops before the mother is fully dilated,the doctor might resort to Cesarean delivery.
Abruptio Placentae: In this condition, during labor, the placenta separates from the lining of the uterus before the second stage of labor. This rare but serious complication puts both the mother and the fetus at risk.
Prolapsed cord: a loop of umbilical cord drops through your open cervix. The umbilical cord may slip into the vagina ahead of your baby. This could reduce the oxygen supply to the baby and may lead to stillbirth.
Baby’s health is in danger: Many things can negatively affect the baby’s well-being and such conditions may precipitate the need for an early delivery through a C-section. Some of the events that may compel your healthcare provider to recommend a Cesarean delivery include:
Baby is getting insufficient amounts of oxygen and nutrients.
Changes in the baby’s heartbeat.
The mother might have untreated HIV or an active genital herpes infection occurring at a later stage of pregnancy.
The umbilical cord may wrap around the baby’s neck or body. It may also come between the baby’s head and the mother’s pelvis.

Can I have Elective Cesarean?

Elective Cesarean, for non-medical reasons, is no longer a marginalized idea. Due to improved technology, the risk-benefit calculus has considerably improved in favour of elective Cesarean. However, a Cesarean is a major surgery,hence one rule fits all scenariosare challenging to confirm.

Therefore, if you are considering getting an elective Cesarean, consult your health care provider to know how your body and the baby would respond to a C-section. Your doctor can compare andoutline the risk and benefits of vaginal delivery versusCesarean delivery that apply to you.

How is a Cesarean section performed?

Cesarean delivery is performed under spinal or epidural anesthetic. The mother is awake but the lower part of her body is numb, so she feels no pain. Typically the duration of Cesarean delivery is 30-45 minutes. However, in case of an emergency during the delivery, a baby could be delivered using a C-section in as little as 15 to 20 minutes.

For Cesarean delivery, you will need to stay in the hospital for 3 or 4 days on average.

Preoperative appointment

In the case of a planned Cesarean, you will have a preoperative appointment with your obstetrician. Generally, this appointment is scheduled a week before the surgery.

At this appointment:

Your blood pressure, pulse and temperature measurements will be taken.
You may also get to know about the type of anesthesia to be used.
You will undergo a blood test to check the red blood cells.
You will be given some medicines that you need to take before the procedure. These generally include
- Antibiotics
- Anti-emetics (anti-sickness medicine)
- Antacids (to reduce the acidity of your stomach acid)
To give your consent to the procedure, you will have to sign a consent form.

The operation

Preparation

Your doctor will ask you to fast a few hours before the surgery.
You will be asked to change into a hospital gown on the day you arrive at the hospital.
The anesthesia will be administered to numb the lower part of the body.
A small area of pubic hair is also trimmed, if necessary.
A catheter – thin, flexible tube will be inserted into your bladder to keep it empty while you are underanesthetic.
You’ll be awake at the time of the delivery and you can see and hold your baby right away.
When you are awake (spinal or epidural anesthetic) – your birth partner is present with you. However, when you’re asleep (generalanesthetic) – your birth partner usually is not present with you.

What is the step by step procedure for a C-Section:

You lie down on a slightly tilted operating table.
A screen or sterile drape is placed across your abdomen. This is done so that you cannot see what is going on and to protect the incision site.
The doctor makes a 10 to 20 cm long incision through the skin across your abdomen and uterus. The two types of incision are:
Vertical incision:
Transverse incision: also known as horizontal or bikini incisionis made beneath the belly button.
The baby is delivered through the opening – it generally takes 5 to 10 minutes and you might feel some tugging at this point.
The doctor clears the fluids from the nose and the mouth of the baby and then cuts the umbilical cord.
The placenta is removed from your uterus and the womb is closed with dissolvable stitches.
Once your baby is born, you’re given an injection of the hormone oxytocin. This will encourage your womb to contract and reduce blood loss.

After the procedure:

Post-delivery your doctor will stitch the uterus and close the incision in your abdomen.
Once the procedure is over, you will be moved from an operating room to a recovery room.

After a successful C-section you’ll be offered:

Painkillers to relieve any discomfort
Treatment to reduce the risk of blood clots- this may include compression stockings or injections of blood-thinning medicine or both.

The catheter is usually removed from your bladder around 12 to 18 hours after the operation. By this time, you should be able to walk around.

Cesarean section recovery

Cesareandelivery is a major surgical procedure. Therefore its recovery period is usually more extended than vaginal birth. However, there are exceptions to this rule. For instance, if a woman has had strenuous labor while undergoing vaginal delivery, she may need a longer recovery period than a C-Section. The average stay in the hospital after a Cesareanis 3 to 4 days, whereas, for vaginal delivery, this period is usually 1 or 2 days.

After the effect of anesthesia wears off,and you start recovering from the surgery you may experience:

Discomfort and pain from the incision.
Gaspains
Difficulty in breathing.
Vaginal discharge- referred to as lochia, because the uterine lining starts shedding. The colour of this discharge changes from red to yellow. Inform your doctor if there is heavy bleeding or a foul odour in the vaginal discharge.

Alert: Immediately consult your doctor if you consistently experience the following symptoms:

Breast pain associated with fever
Pain while passing urine
A fever greater than 100°F
Foul smelling discharge

Consult your doctor for painkillers to take care of the pain and the discomfort.

Do’s and dont’s after C-section:

Take it easy: Avoid stressful activities such as driving or lifting anything heavier than your baby. Rest as much as possible until your postnatal check-up.
Look after your wound: Take advice from your doctor on how to take proper care of the wound. The suggestions from the doctor might include:
- Cleaning and drying the wound everyday. Take good care of your C-section incision.
- Wearing cotton underwear and loose and comfortable clothing.
- Look out for signs of infection.
- Take painkillers as per your doctor’s recommendation for sore wounds.
Avoid sex: The rules for sex after pregnancy are the same for vaginal delivery and Cesarean delivery. Your doctor will most likely recommend you to avoid sex for 6 weeks after the surgery. This is because it will take about 6 weeks for the cervix to close completely.

The non-dissolvable stitches or staples are taken out after 5-7 days by your midwife.

Risk of a Cesarean

The benefit-risk ratio for the Cesarean section has considerably improved over time. This has been possible because of improvement in techniques for surgery,anesthesia, infection control and blood banking. However, any major surgery comes with its share of risks. Therefore it is crucial to learn about what risks are involved in Cesarean delivery.

The potential risks include:

An infection could develop at the lining of the uterus (endometritis)
Blood clots
Extreme bleeding
Damage to neighbouring areas, such as the bladder.
Temporary breathing difficulties in your baby.
Problems in future pregnancies because of the abnormal behaviour of the placenta.

Future pregnancies after a C-section

Despite having a Cesarean delivery, you can deliver vaginally in future pregnancies.

If your answer to the following questionsis a ‘yes’, then you can expect a VBAC (vaginal birth after Cesarean):

Are you having a singlet pregnancy(only one baby)?
Did you have a C-section because the baby was in a breech position?
Do you have a normal-sized pelvis to accommodate a normal-sized baby?
Did you have a vertical incision during your Cesarean?

The choice of the procedure depends on what is the safest option for the baby and the mother.

Reference:

By -
Dr. Ruchika Singh

14-April-2023

C-section

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