The Truth About C-Sections
November 10, 2017
If you’re like many women whose pregnancy is progressing steadily toward a vaginal birth, there’s one area of your birth plan you’re probably not fleshing out: What happens in the event of a c-section? No one wants to dwell too deeply on the circumstances that call for surgery. But given that 1 in 3 births today are via c-section—most of which occur well after vaginal labor is underway—it’s best to know a little bit about what the procedure entails, just in case. Trust me, I’ve been there. After hours of laboring, when you see your OB suddenly rip off her white jacket and call for an anesthesiologist and OR prep, some information about what you’re getting into can really help dissipate the confusion.
Most women give birth to their baby vaginally—but when problems arise, either during pregnancy or labor and delivery, a c-section procedure may be in order. A cesarean section, aka c-section, is a surgical procedure used to deliver baby through incisions made in a mother’s abdomen and uterus. It’s considered to be major surgery, so a c-section can potentially lead to more complications for you and baby than a vaginal birth. But if your health or the health of your child is at risk during childbirth, a c-section may be the safest way to bring baby into the world.
Julius Caesar was not the first to be born from a c-section procedure (if the legend is to be believed in the first place). There are many references to cesarean sections in ancient folklore from around the world, from China to India to Europe, according to the US National Library of Medicine. At the time of Caesar’s birth, the surgery was primarily used on mothers who were dead or dying, though Caesar’s mother lived to hear about her son’s invasion of Britain. Fortunately, we’ve since come a long way, and today a c-section is used for a range of reasons to make sure mom and baby come out of the OR alive and healthy.
C-sections come in three types: unplanned, emergency and scheduled.
• Unplanned c-section. OBs employ an unplanned c-section to skirt serious harm to a mother or baby after labor is already underway but for one or more reasons has stalled. Either the baby is too big to pass through the mother’s pelvis, her contractions aren’t strong enough to open the cervix so her baby can descend or the baby is facing the wrong way. OBs will also decide on a c-section if the placenta is covering part or all of the mother’s cervix, otherwise known as placenta previa. “Babies don’t have a lot of blood they can afford to lose,” says Carla Weisman, MD, an OB with Sinai OB/GYN Associates in Baltimore. If they do a c-section due to bleeding from an unresolved placenta previa, that’s considered an emergency c-section (see below).
• Emergency c-section. An emergency c-section happens when baby is in distress during labor. For instance, “if a baby’s heart rate drops precipitously below the normal range and isn’t coming back up, if the umbilical cord comes out the vagina [before imminent delivery], or if a mother has had a c-section previously and her old scar ruptures when she’s trying to have a vaginal birth,” Weisman says. While uterine rupture is very rare—12 in 36,000 births, according to one study—it can be hard to detect and could result in heavy bleeding, fetal distress, ejection of the fetus and/or placenta into the mother’s stomach, and a hysterectomy.
• Scheduled c-section. A smaller percentage of c-sections are ones that first-time mothers and their OBs schedule ahead of time, before labor begins, mostly due to the way the baby is positioned—either transverse (sideways) or breech (buttocks or feet first). “The training today is not so profound that the random OB knows how to [deliver a breech baby vaginally],” says William Schweizer, an ob-gyn at NYU Langone Health in New York City. “I’m old; I finished my residency in 1987 and I was taught how to do one, but a resident today has no experience with this, and I would question a mother saying, ‘I want to deliver vaginally.’”
Mothers delivering multiple babies also have a high rate of scheduled c-sections, especially if the babies need to be delivered prematurely or if they aren’t ideally positioned. Lastly, the majority of women who have had previous c-sections tend to plan c-sections for subsequent births rather than going the VBAC (vaginal birth after cesarean) route, especially if their scar runs vertically, which increases the risk of uterine rupture.
Can you request a c-section?
Yes, first-time mothers can—and do—request a scheduled c-section, usually because they fear the pain of childbirth and the incontinence that can follow some vaginal births. “It’s not very common,” says Robert Atlas, MD, chair of obstetrics and gynecology at Mercy Medical Center in Baltimore. “And of course we’ll discuss with them why they should or shouldn’t opt for one.”
Like any major surgery, a c-section procedure comes with a basket of risks and complications that mothers must sign off on. “Every time I open someone up, there is chance of adhesion—the bowels can get stuck to the abdominal wall,” Schweizer says. “The bladder can also get pushed up.” In addition, he notes that the risks increase with multiple c-sections. “The chances of the placenta being abnormal is greater,” he says. In rare instances, you could end up with complications that require a hysterectomy.
Many complications, though, can be treated quickly in the OR:
- Blood loss
- Blood clots in the legs
- Injury to internal organs
- Fluid in baby’s lungs
- Bad reaction to anesthesia or other medications used
Some of these c-section risks may be intensified if the mother has had previous surgeries in her midsection, because of the presence of scar tissue, Weisman notes.
Once your OB makes the c-section call, things move pretty quickly. You’ll get an IV inserted into your hand or arm if you haven’t had one already, you’re moved into the OR and your stomach gets scrubbed down. You’ll probably get an epidural or spinal block—or a combination of the two—which numbs your lower body. General anesthesia (when a mother is put completely to sleep) is rarely used—except in the case of true emergencies when complications arise that require more time than what a spinal block allots, Schweizer says.
The staff will then drape a curtain just below your chest so you don’t have to watch the surgery. Some hospitals perform gentle c-sections, which may include a transparent cellophane curtain that allows mothers to see the baby when he’s lifted out and to do skin-to-skin contact almost immediately afterward.
Once your OB is certain you’re numb—you won’t feel any pain—she makes two incisions: one to open your skin and one across the lower part of your uterus. Usually the incisions are horizontal—a bikini cut—although vertical cuts, which offer more room to extract the baby, are used when the baby is sideways, premature or when the mother is obese.
The infant is then pulled out through the incisions. (With a gentle c-section, the practitioner hands the baby immediately to your partner before cutting the umbilical cord and pulling out the placenta.) Once the baby is checked out by the pediatrician, you can request skin-to-skin time or even the first breastfeeding session, though there might only be time for a quick cheek nuzzle before you get stitched up.
If all goes well, a c-section procedure lasts roughly 45 minutes to an hour. Add 15 to 20 minutes if you require more medication and need to wait for it to take effect. And if things get complicated—there are adhesions of your body parts that require additional surgical techniques or you’re bleeding excessively (which, if every effort to stop the bleeding fails, may require a hysterectomy)—you might have to be put under general anesthesia to allow for another hour or two under the knife.
There really isn’t any pain during a c-section. Once the searing prick of the epidural and/or spinal block is over, the sensations are strange. You may shiver involuntarily from the medicine and you’ll definitely feel cold, thanks to your short sleeves in the chilled OR. There’s a lot of pressure on your abdomen as the c-section procedure starts and as your doctor pushes on your belly to help deliver the baby.
“Depending on the surgeon, the uterus is taken out and put on top of the mom’s belly so we have better visualization and exposure while closing the uterine incision,” Weisman says. “It’s sometimes uncomfortable for the patient to have the uterus on the abdomen, because it stretches the peritoneal lining and may cause nausea.”
During my c-section, I was nauseated and felt almost intoxicated because of the medication. It was extremely uncomfortable lying flat without a pillow and with my arms extended down to my sides. Everything dissipated once I heard and then felt my baby, though. Then he was whisked away for further testing, and I endured being stitched up—no pain, just lots of tugging below my chest and a strange quiet in a room full of people—for about 15 to 20 minutes.
The first 12 hours after a c-section procedure can be excruciating, though not necessarily pain-wise. If you had an epidural, your OB can administer narcotics for the next day or so before switching you to oral ibuprofen or acetaminophen. All you’ll want to do is sleep off the impact of the anesthesia, but if you’re breastfeeding, you’ll get woken up every couple of hours to feed baby. “The best thing is to get whatever help you can,” Weisman says. “That may mean sending your baby to the nursery for a while, and you shouldn’t feel guilty about that.”
Once you’re no longer numb, practitioners will get you up and out of bed for a quick walk to the bathroom or around your room, which “decreases your risks of breathing problems, improves your pain tolerance and helps to avoid developing blood clots in your lower extremities,” says Yvonne Butler Tobah, MD, an ob-gyn affiliated with the Mayo Clinic in Rochester, Minnesota. Walking around soon after a c-section should also open up your bowels a little faster. To that end, Schweizer recommends chewing peppermint gum as soon as you can after surgery, which he says helps.
You’ll feel sore and have cramping and also see bleeding, which are symptoms that your uterus is shrinking and healing. Most c-section patients spend an average of two to three nights in the hospital before they can go home; this is mostly so your practitioners can closely watch your incision for signs of infection and make sure you’re healing throughout. (And believe me, spending a little more time in the capable hands of nurses as you get acquainted with baby can help gradually build up your self-confidence, which you’ll need when you return home.)
While the general consensus is that it takes longer for your body to feel whole again after a c-section procedure than it does with a vaginal birth, there are experts trying to streamline the process—healthily, of course—for mothers who have been through it more than once: For women who have had a repeat c-section and who have breastfed with prior children, Schweizer is piloting a trial project at NYU Langone to get them back home within 48 hours.
“The idea is that these women who understand what c-section pain is like and who have other children at home—they want to get home,” he says, noting that educating new mothers on breastfeeding makes up the bulk of what they need to learn before returning home. “Hospitals can be dangerous places for falls and infections. We want to get you out quickly to the advantages of home.”
As you adapt to your new normal with baby, you’ll need to manage the pain in your c-section incision, cramping (especially while breastfeeding) and continued bleeding. You’ll also have a checkup with your OB at two weeks and six weeks. With the right strategies and care at home, your body should feel like itself again (albeit on minimal sleep) in four to six weeks.
Updated October 2017