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Having a Cesarean Delivery

Many patients wonder whether they'll need a cesarean. Sometimes your doctor knows the answer before labor even begins — if you have placenta previa, for example, or if the baby is in a transverse lie (that is, the baby is lying sideways within the uterus rather than head-down). But most of the time, neither you nor your doctor can know whether you'll need a cesarean until you see how your labor progresses and how your baby tolerates labor.

A cesarean delivery is performed in an operating room under sterile conditions. An intravenous line must be in place and a catheter put in the bladder. After the patient's abdomen is scrubbed with antiseptic solution, sterile sheets are placed over her belly. One of the sheets is elevated to create a screen so that the expectant parents don't have to watch the procedure. (Although childbirth is usually an experience shared by both parents, a cesarean delivery is still a surgical operation. Most doctors feel that the procedure is not something that expectant parents should watch, because it involves scalpels, bleeding, and exposure of internal body tissue that's normally not seen, which is disturbing to many people.)

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The exact place on the woman's abdomen where the incision is made depends on the reason she's having the cesarean. Most often, it is low, just above the pubic bone, in a transverse direction (perpendicular to the torso). This cut is known as a Pfannensteil incision or, more commonly, a bikini cut. Less often, the incision is vertical, along the midline of the abdomen.

After the skin incision is made, the abdominal muscles are separated and the inner lining of the abdominal cavity, also called the peritoneal cavity, is opened to expose the uterus. An incision is then made in the uterus itself, through which the infant and placenta are delivered. The incision on the uterus can also be either transverse (most common) or vertical (sometimes called a classical incision), depending again on the reason for the cesarean and previous abdominal surgery. After delivery, the uterus and abdominal wall are closed with sutures, layer by layer. A cesarean delivery takes 30 to 90 minutes to perform.

Anesthesia for a cesarean delivery

The most common forms of anesthesia used for cesarean deliveries are epidural and spinal. Both kinds of anesthesia numb you from mid-chest to toes but also allow you to remain awake so that you can experience the birth of your child. You may feel some tugging and pulling during the operation, but you do not feel pain. Sometimes the anesthesiologist injects a slow-release pain medication into the epidural or spinal catheter before removing it in order to prevent or greatly minimize pain after the operation.

If the baby has to be delivered in an emergency and there's no time to place an epidural or spinal, general anesthesia may be needed. In that case, you are asleep during the cesarean and totally unaware of the procedure. Also, general anesthesia may be needed in some cases because of complications in pregnancy that make it unwise to place epidurals or spinals.

Reasons for a cesarean delivery

All surgical procedures involve risks, and cesarean delivery is no exception. Fortunately, these problems are not common. The main risks of cesarean delivery are

  • Excessive bleeding, rarely to the point of needing a blood transfusion

  • Development of an infection in the uterus, bladder, or skin incision

  • Injury to the bladder, bowel, or adjacent organs

  • Development of blood clots in the legs or pelvis after the operation

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If your practitioner feels that you need a cesarean delivery, he or she will discuss with you why it is needed. If your cesarean is elective or it's done because your labor isn't progressing normally, you and your partner have time to ask questions. In cases in which the baby is in a breech position, you and your practitioner may consider together the pros and cons of having either an elective cesarean delivery or a vaginal breech delivery. Both carry some risks, and often your practitioner asks you which risks are most acceptable to you. If the decision to perform a cesarean is due to a last-minute emergency, the discussion between you and your doctor may happen quickly, while you're being wheeled to the operating room.

Your practitioner may suggest that you have a cesarean delivery for one of many different reasons. This list describes the most common ones.

Reasons for elective cesarean delivery:

  • The baby is in an abnormal position (breech or transverse).

  • Placenta previa.

  • You've had extensive prior surgery on the uterus, including previous cesarean deliveries or removal of uterine fibroids.

  • Delivery of triplets or more.

Reasons for unplanned but nonemergency cesarean delivery:

  • The baby is too large in relation to the woman's pelvis to be delivered safely through the vagina — a condition known as cephalopelvic disproportion (CPD) — or the position of the baby's head makes vaginal delivery unlikely.

  • Signs indicate that the baby is not tolerating labor.

  • Maternal medical conditions preclude safe vaginal delivery, such as severe cardiac disease.

  • Normal labor comes to a standstill.

Reasons for emergency cesarean delivery:

  • Bleeding is excessive.

  • The baby's umbilical cord pushes through the cervix when the membranes rupture.

  • Prolonged slowing of the baby's heart rate.

Other than the fact that the baby and placenta are delivered through an incision in the uterus rather than through the vagina, a cesarean delivery for the baby is of little difference. Babies delivered by a cesarean before labor usually don't have the conehead look, but they may if you are in labor for a long time before having a cesarean.

Recovery from a cesarean delivery

After the surgery is finished, you are taken to a recovery area, where you stay for a few hours, until the hospital staff can make sure that your condition is stable. Often, you can see and hold your baby during this time.

During the first day after a cesarean, you need to spend most of the time in bed. After that, you need to gradually increase your activity, so that you can build the strength you need to take care of yourself and the baby at home. The recovery time from a cesarean delivery is usually longer than from a vaginal delivery, because the procedure is a surgical one. Typically, you stay in the hospital for two to four days — sometimes longer, if complications arise.

After you have a cesarean, you may feel pain where the incisions were made through your skin and uterus. Ask your nurse for pain medication if you need it. Your doctor usually leaves orders for pain medications, but they aren't automatically given unless you ask for them. The anesthesia needed to perform a cesarean delivery also tends to slow the bowels and to cause some bloating and abdominal discomfort. Again, medications can help. Prune juice and other juices also can help.

After a cesarean, lochia (bleeding) may come from the vagina, just like in a vaginal delivery. This discharge gradually decreases and eventually disappears.

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