What Is It?

A Caesarean section, also called a C-section, is surgery to deliver a baby through the abdomen when it is impossible or not advised to deliver the baby through the vagina. A Caesarean section sometimes is scheduled in advance, but also may be done in an emergency.

Between 20 percent and 25 percent of all births in the United States are delivered by Caesarean section. The procedure is done less often in some other countries. Caesarean sections are done in 10 percent of births in the Netherlands and 15 percent to 20 percent in England, Wales and Canada.

Caesarean sections often are done because the mother previously delivered by Caesarean section and the doctor has advised her to have another Caesarean section, or the mother prefers to have another Cesarean section.

When and whether a Caesarean delivery is necessary continues to be a matter of much controversy. “Once a Caesarean, always a Caesarean” used to be standard advice, and doctors rarely considered allowing a woman to go through labor and have a vaginal birth. For the last 20 years, however, obstetricians have been more willing to consider trying labor. Many, but not all, women can have a safe vaginal delivery after a Caesarean. The American College of Obstetricians and Gynecologists (ACOG) encourages vaginal birth after Caesarean, called VBAC, but they offer a series of guidelines to better identify those women who are likely to have success and to reduce the possible complications of VBAC, such as uterine rupture. About one-third of women who attempt a VBAC will need a Caesarean section.

Recently, some experts have questioned whether a Caesarean section should be done when a mother requests it but there is no accepted medical or surgical justification for the surgery. C-section generally is safe, but the risk of major complication and death during Caesarean delivery is three to five times higher than with vaginal birth. Vaginal birth still is preferred over Caesarean unless there is a compelling reason to have a C-section.

A number of organizations are focusing on reducing the number of Caesarean surgeries done in the United States. The U.S. Department of Health and Human Services encourages reducing first-time Caesarean deliveries to 15.5 percent of all deliveries by the year 2010. Although this recommendation is controversial, it is widely recognized that not all Caesarean sections are absolutely necessary, and that vaginal birth offers a number of benefits to both mother and child when the pregnancy is low risk. However, the use of Caesarean sections for higher-risk pregnancies has made delivery dramatically safer for both mother and child.

Conditions that create a higher-risk pregnancy and may require Caesarean delivery include:

• Prolapsed cord — This is an obstetrical emergency that occurs prior to or during labor in which the amniotic fluid bag (“bag of waters”) breaks and the umbilical cord drops into the vagina before the baby can be delivered. Emergency C-section is done to save the baby’s life.



• Placenta previa — The placenta partially or completely covers the cervical opening to the birth canal or vagina.



• Abruptio placentae — The placenta partially or completely tears away from the uterus before the birth of the baby.



• Cephalopelvic disproportion — The baby is either too large for the birth canal or is not aligned properly within the mother’s pelvic bones and her birth canal.



• Breech birth — The baby is positioned with the buttocks or feet first instead of the usual head-down position.



• Multiple pregnancies — Two or more babies are developing at the same time. Some twin pregnancies can be born vaginally, but C-section usually is done when three or more babies are expected.



• Previous surgery on the uterus — This includes certain types of Caesarean section, especially those involving a vertical incision, also known as a classical incision. Prior removal of large or multiple fibroids from the wall of the uterus can weaken the walls, making C-section necessary.



• Fetal distress, also known as non-reassuring fetal heart rate — This is a persistent and markedly abnormal fetal heart-rate pattern during labor, which can be life threatening to the fetus.



• Maternal illness — This includes conditions such as heart disease or diabetes.



• Preeclampsia and eclampsia (toxemia of pregnancy) — Symptoms include severe high blood pressure, protein in the urine and seizures.



• HIV or other infections in the mother — A mother with HIV or active herpes lesions who has a Caesarean section may be less likely to pass an infection to her baby. Although one study showed that Caesarean section can reduce the transmission of hepatitis C from mother to child, these results are preliminary. The U.S. Centers for Disease Control and Prevention currently does not recommend Caesarean section for women with hepatitis.

It is important that every woman is assessed to determine whether Caesarean delivery is needed. Although each of the problems listed above is a reason to consider a Caesarean section, every situation is different. Some breech babies are positioned in a way that may allow safe vaginal delivery, while others aren’t. Placenta previa does not always interfere with vaginal delivery if the cervical opening is covered only partially.

Preparation for Caesarean section can vary depending on whether the Caesarean section is scheduled or is being done as an emergency, and whether regional or general anesthesia is used.

Usually, women undergoing a scheduled Caesarean section are not allowed to have anything to eat or drink after midnight the day before surgery.

To reduce stomach acids, you will be given antacids to take before surgery because pregnant women are more likely to have acid reflux. If you have certain medical conditions, you may need to take antibiotics before surgery to minimize the risk of infection. You should discuss this with your doctor.

An enema is rarely, if ever, given before Caesarean delivery but can be arranged if you are severely and unusually constipated.

Just before surgery, an intravenous line (IV) will be placed into a vein. It will be used to deliver medications, fluids and, if needed, a blood transfusion, during surgery. Wires connected to heart-monitoring equipment will be attached to your chest, and a blood-pressure cuff will be placed on your upper arm.

A flexible tube, called a Foley catheter, will be inserted into your bladder to drain urine and keep your bladder as empty as possible during the surgery. Your abdomen and pubic area will be washed with an antiseptic or antibacterial soap. It may be necessary to shave the hair in the area where the incision will be.

Doctors usually prefer to use regional anesthesia for Caesarean sections. Regional anesthesia means that you remain awake while an area of your body is made numb for your surgery.

Regional anesthesia for C-section can be a spinal, an epidural or a combination of the two. Spinal anesthesia is given by injecting anesthesia into and around the nerves of your spinal column near the middle to lower back. This gives a rapid and complete numbing sensation, relaxing all the muscles of your legs and abdomen. Surgery can be started soon after the anesthesia is given because the effect begins quickly. Epidural anesthesia requires a little more time and is given by inserting a small catheter into the space around the spinal column, called the epidural space. The epidural catheter is used to keep constant levels of anesthetic medication in the space around the nerves. The extent of numbing in the legs and abdomen and the length of time you are numbed can be controlled and adjusted as needed to prevent pain. A combined spinal/epidural, called CSE, provides both the spinal’s immediate pain relief and the epidural’s control, which is needed for more extensive surgery. A CSE is preferred when the Caesarean operation is expected to be more difficult or require more time to finish.

Regional anesthesia allows the mother to be awake and alert during the baby’s birth, and to breathe naturally on her own. Some women worry that they will have pain with regional anesthesia. However, regional anesthesia numbs from the mid-chest down to the toes and its effects last for a short time after the Caesarean is completed.

General anesthesia usually is reserved for emergency Caesarean sections. If general anesthesia is used, the woman receives anesthetic medication through an IV. After she is asleep, a plastic tube, called an endotracheal tube, will be placed in her throat and into her trachea. The trachea, or windpipe, connects the throat to the airways of the lungs. When the endotracheal tube is in place, the anesthesiologist can manage breathing for the mother while she is unconscious.

A low, horizontal skin incision, called a bikini cut, is made in the abdomen at or just above the pubic hairline. Sometimes a vertical incision is required, especially if an emergency Caesarean surgery is performed.

After the abdomen is opened, the bladder is protected and the uterus is opened. The incision in the uterus also may be horizontal and low in the uterus or it may be vertical. A vertical incision is preferred when time is short and the baby needs to be delivered quickly. The bag of waters is broken, the baby is removed, and the umbilical cord is clamped and cut. The time from the beginning of surgery to delivery of the baby generally is less than 10 minutes. Once the baby is delivered, it can take another 30 to 40 minutes to remove the placenta and close the uterus and abdomen with stitches or staples. The entire surgery usually takes just under an hour.

If staples were used to close the incision, they generally are removed within one week. Stitches may either dissolve on their own or need to be removed within a week. During the first few weeks after a Caesarean section, you will be told not to carry anything heavier than the baby. Breast-feeding can be started as soon as surgery is completed and the mother is awake in the recovery room. Holding the baby in the “football hold,” with the baby’s body under your arm and the head near your breast, can help keep the weight of the baby off the incision.

The most common problems following Caesarean delivery are heavy bleeding (hemorrhage), endometritis (infection of the uterus) and blood clots in the large veins of the legs, pelvis or lungs. Possible complications from anesthesia depend on whether general or regional was used for the surgery. General anesthesia provides deep, total relaxation of the body, which can lead to stomach acids flowing into the woman’s lungs. This is a rare complication. Stomach acids and food particles can harm lung tissue and permanently lower oxygen levels in the bloodstream, causing a risk of serious infection, permanent brain damage and death. Aside from these rare problems, the after-effects of general anesthesia can make the mother and baby sleepy and delay mother-infant bonding.

The most serious and rare complication of Caesarean section is the death of the mother, which is three to five times more likely with C-section than with vaginal delivery. However, it is uncommon, with 7.5 deaths per 100,000 live births. That makes this surgery relatively safe.

After surgery, you should contact your health-care provider if you develop:

• A fever
• Yellowish green or bloody discharge from your wound
• Sudden worsening of pain or redness at the incision site
• Abdominal or pelvic pain
• A foul-smelling vaginal discharge or heavy bleeding
• Unusual pain or redness in your legs
• Chest pain, shortness of breath or cough

Diseases and Conditions Center

All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.