Cesarean Section

How a Cesarean Section Is Done

Surgery preparation

Most cesarean sections are done with epidural or spinal anesthesia, used to numb sensation in the abdominal area. Only in an emergency situation or when an epidural or spinal anesthesia cannot be used or is a problem would fast-acting general anesthesia be used to make you unconscious for a cesarean birth.

The hospital may send you instructions on how to get ready for your surgery, or a nurse may call you with instructions before your surgery.

In preparation for a cesarean section, your arms are secured to the table for your safety, and a curtain is hung across your chest. A tiny intravenous (IV) tube is placed in your arm or hand; you may be given a sedative through the IV to help you relax. A catheter is inserted into your bladder to allow you to pass urine during and after the surgery. Your upper pubic area may be shaved, and the abdomen and pubic area are washed with an antibacterial solution. The incision site may be covered with an adhesive plastic sheet, or drape, to protect the surgical area.

Before, during, and after a cesarean section, your blood pressure, heart rate, heart rhythm, and blood oxygen level are closely monitored. You will also be given a dose of antibiotics to prevent infection after delivery.

Cesarean procedure and delivery

After the anesthesia is working, a doctor makes the cesarean incision through your lower abdomen and uterus. See a picture of cesarean section incisions. You may notice an intense feeling of pressure or pulling as the baby is delivered. After delivering your newborn through the incision, the doctor then removes the placenta and then closes the uterus and the incision with layers of stitches.

Right after surgery, you will be taken to a recovery area where nurses will care for and observe you. You will stay in the recovery area for 1 to 4 hours, and then you will be moved to a hospital room. In addition to any special instructions from your doctor, your nurse will explain information to help you in your recovery.

Who to See

A cesarean section can be done by a doctor who has specialized training, such as:

• An obstetrician.
• A perinatologist (maternal-fetal medicine specialist).
• A family medicine doctor with cesarean section training.
• A surgeon.

If your pregnancy care provider doesn't perform cesareans and foresees a possible need for a cesarean, you will be referred to a cesarean-trained doctor ahead of time. Your family medicine doctor, certified nurse-midwife, or certified professional midwife can assist with the surgery and provide your follow-up care.

Why It Is Done

Some cesarean deliveries are planned ahead of time. Others are done when a quick delivery is needed to ensure the mother's and infant's well-being.

Planned cesarean

Some cesarean sections are planned when a known medical problem would make labor dangerous for the mother or baby. Medical reasons for a planned cesarean may include:

• A fetus in any position that is not head-down (including breech position). For more information, see the topic Breech Position and Breech Birth.
• Decreased blood supply to the placenta before birth, which may lead to a small baby.
• Your baby is thought to be very large.
• A maternal disease or condition that may be made worse by the stress of labor. One example is heart disease.
• A known health problem with the baby, such as spina bifida.
• A placenta that is blocking the cervix (placenta previa). For more information, see the topic Placenta Previa.
• Open sores from active genital herpes near the due date, which can be passed to the fetus during vaginal delivery.
• Some cases of human immunodeficiency virus (HIV), which can be passed to the fetus during vaginal delivery.^{footnote 2}
• Multiple pregnancy. The direction and size of the incision depends on the position of the babies. A cesarean section (C-section) may be needed, depending on the position and number of babies, whether they share an amniotic sac, or if you or the babies have any health problems.

Many cesarean deliveries are planned ahead of time for women who have had a cesarean in the past. Reasons for a planned repeat cesarean may include:

• Deciding not to try vaginal birth after cesarean (VBAC) after discussing the risks and benefits with your doctor.
• Factors that increase the risk of uterine rupture during labor, such as having a vertical scar, triplets or more, or a baby thought to be very large. For more information, see the topic Vaginal Birth After Cesarean (VBAC).
• No access to constant medical supervision by a cesarean-trained doctor during active labor, or no available facilities for an emergency cesarean.

• Pregnancy: Should I Try Vaginal Birth After a Past C-Section (VBAC)?

Depending on the reason for a planned C-section and the risks to you or your baby, the C-section may be scheduled near your due date or weeks before. Talk to your doctor to learn about the timing that is best for your situation.

Some women request to have a C-section even though they have never had one before and there is no medical need for it. This is called an elective primary C-section. Because of the risks of C-section, experts recommend that C-sections generally be done only for medical reasons. If you're thinking of having a C-section for personal reasons, you may want to talk to your doctor about reasons for and against an elective primary C-section.

Unplanned cesarean

Some unplanned cesareans happen when there is a problem before or during labor. Sometimes this is an emergency. Medical reasons for an unplanned cesarean may include:

• Fetal distress (suggested by a very rapid or very slow heart rate).
• Placenta abruptio, which can cause excessive bleeding (hemorrhage) and decreased oxygen supply to the fetus. For more information, see the topic Placenta Abruptio.
• Umbilical cord problems that decrease or cut off fetal blood supply, as when the cord has slipped into the birth canal ahead of the fetus, and the fetus moves into the birth canal and presses against the cord (cord prolapse).
• Difficult, slow labor.
• Labor that has stopped completely.

Risks and Complications

Cesarean section is considered relatively safe. But it does pose a higher risk of some complications than does a vaginal delivery. If you have a cesarean section, expect a longer recovery time than you would have after a vaginal delivery.

After cesarean section, the most common complications for the mother are:

• Infection.
• Heavy blood loss.
• A blood clot in the legs or lungs.
• Nausea, vomiting, and severe headache after the delivery (related to anesthesia and the abdominal procedure).
• Bowel problems, such as constipation or when the intestines stop moving waste material normally (ileus).
• Injury to another organ (such as the bladder). This can occur during surgery.
• Maternal death (very rare). About 2 in 100,000 cesareans result in maternal death.^{footnote 1}

Cesarean risks for the infant include:

• Injury during the delivery.
• Need for special care in the neonatal intensive care unit (NICU).^{footnote 3}
• Immature lungs and breathing problems, if the due date has been miscalculated or the infant is delivered before 39 weeks of gestation.^{footnote 3, footnote 4}

While most women recover from both cesarean and vaginal births without complications, it takes more time and special care to heal from cesarean section, which is a major surgery. Women who have a cesarean section without complications spend about 3 days in the hospital, compared with about 2 days for women who deliver vaginally. Full recovery after a cesarean delivery takes 4 to 6 weeks. Full recovery after a vaginal delivery takes about 1 to 2 weeks.

Long-term risks of cesarean section

Women who have a uterine cesarean scar have slightly higher long-term risks. These risks, which increase with each additional cesarean delivery, include:^{footnote 5}

• Breaking open of the incision scar during a later pregnancy or labor (uterine rupture). For more information, see the topic Vaginal Birth After Cesarean (VBAC).
• Placenta previa, the growth of the placenta low in the uterus, blocking the cervix.
• Placenta accreta, placenta increta, placenta percreta (least to most severe). These problems occur when the placenta grows deeper into the uterine wall than normal, which can lead to severe bleeding after childbirth, and sometimes may require a hysterectomy.

What to Expect After C-Section

After a routine cesarean section, expect to be monitored closely for the next 24 hours to make sure that you don't develop any problems. You will receive pain medicine and will likely be encouraged to begin walking short distances within 24 hours of surgery. Walking can help relieve gas buildup in the abdomen. It is usually very uncomfortable to begin walking, but the pain will decrease in the days after the delivery.

The typical hospital stay after a cesarean delivery is about 3 days. You can feed and care for your newborn as you feel able. Before going home, you'll receive postsurgery instructions, including warning signs of complications. It can take 4 weeks or more for a cesarean incision to heal, and it isn't unusual to have occasional pains in the area during the first year after the surgery.

It is important to take care of yourself at home while you are healing.

Activity

• Rest when you feel tired. Getting enough sleep will help you recover.
• Try to walk each day. Start by walking a little more than you did the day before. Bit by bit, increase the amount you walk. Walking boosts blood flow and helps prevent pneumonia, constipation, and blood clots.
• Avoid strenuous activities, such as bicycle riding, jogging, weightlifting, and aerobic exercise, for 6 weeks or until your doctor says it is okay.
• Until your doctor says it is okay, do not lift anything heavier than your baby.
• Do not do sit-ups or other exercises that strain the belly muscles for 6 weeks or until your doctor says it is okay.
• Hold a pillow over your incision when you cough or take deep breaths. This will support your belly and reduce your pain.
• You may shower as usual. Pat the incision dry when you are done.
• You will have some vaginal bleeding. Wear sanitary pads. Do not douche or use tampons until your doctor says it is okay.
• Ask your doctor when you can drive again.
• You will probably need to take at least 6 weeks off work. It depends on the type of work you do and how you feel.
• Ask your doctor when it is okay for you to have sex.

Diet

• You can eat the foods that are in your normal diet. If your stomach is upset, try bland, low-fat foods like plain rice, broiled chicken, toast, and yogurt.
• Drink plenty of fluids (unless your doctor tells you not to).
• You may notice that your bowel movements are not regular right after your surgery. This is common. Try to avoid constipation and straining with bowel movements. You may want to take a fiber supplement every day. If you have not had a bowel movement after a couple of days, ask your doctor about taking a mild laxative.

Incision care

• If you have strips of tape on the incision, leave the tape on for a week or until it falls off.
• Wash the area daily with warm, soapy water, and pat it dry. Other cleaning products, such as hydrogen peroxide, can make the wound heal more slowly. You may cover the area with a gauze bandage if it weeps or rubs against clothing. Change the bandage every day.
• Keep the area clean and dry.

For information about how a cesarean affects future deliveries, see the topic Vaginal Birth After Cesarean (VBAC).

When to call a doctor

Call 911 anytime you think you may need emergency care. For example, call if:

• You have thoughts of harming yourself, your baby, or another person.
• You passed out (lost consciousness).
• You have severe trouble breathing.
• You have sudden chest pain and shortness of breath, or you cough up blood.
• You have a seizure.
• You have severe pain in your belly.

Call your doctor now or seek immediate medical care if:

• You have bright red vaginal bleeding that soaks one or more pads each hour for 2 or more hours.
• Your vaginal bleeding seems to be getting heavier or is still bright red 4 days after delivery.
• You pass blood clots larger than the size of a golf ball.
• You have vaginal discharge that smells bad.
• You are sick to your stomach or cannot keep fluids down.
• You have loose stitches, or your incision comes open.
• Your belly feels tender, or full and hard.
• You have signs of infection, such as:
  • Increased pain, swelling, warmth, or redness.
  • Red streaks leading from the incision.
  • Pus draining from the incision.
  • Swollen lymph nodes in your neck, armpits, or groin.
  • A fever.
• You have signs of a blood clot, such as:
  • Pain in your calf, back of the knee, thigh, or groin.
  • Redness and swelling in your leg or groin.
• You have signs of preeclampsia, such as:
  • Sudden swelling of your face, hands, or feet.
  • New vision problems (such as dimness, blurring, or seeing spots).
  • A severe headache.
• You have trouble passing urine or stool, especially if you have pain or swelling in your lower belly.
• You feel sad, tearful, or hopeless for more than a few days, or you have troubling or dangerous thoughts.

Some women feel shoulder pain for days after a cesarean section. This is referred pain, caused by trauma to the abdominal muscles during the delivery. It goes away on its own during recovery.

What to Think About

If you plan to deliver vaginally and have concerns about having an unnecessary cesarean delivery, talk to your doctor or midwife ahead of time. Ask in what types of situations cesarean section is usually used and what steps he or she takes to promote a vaginal birth.

Public health experts have urged the North American obstetric community to reduce the percentage of deliveries done by cesarean, identifying birth scenarios that may not necessarily require surgical delivery. These include:

• History of cesarean. Some women with a cesarean scar can deliver vaginally, although there are risks involved in a VBAC delivery. Some smaller hospitals no longer provide VBAC, reflecting a trend toward greater medical caution with VBAC. If you have had a previous cesarean, weigh the benefits and risks of vaginal delivery with your doctor or midwife. For more information, see the topic Vaginal Birth After Cesarean (VBAC).
• Fetal distress. Deciding whether and when a fetus with a slowing heart rate should be delivered by cesarean is a common judgment call during labor. Ultimately, a health professional will lean toward caution and deliver by cesarean to prevent harm to a newborn.
• Difficult, slow labor (dystocia). Dystocia can often be corrected with medicine that restarts contractions (augmentation). For women with a cesarean scar, oxytocin must be used carefully to reduce the slight risk of the scar rupturing during labor.

Some doctors are more likely to see a need for a cesarean than others. For example, what one doctor considers a slow labor may be a normal labor to another. But all doctors are guided by the common goal of a healthy labor and delivery for both the mother and her newborn.