CESAREAN PROCEDURE A cesarean birth happens through an incision in the abdominal wall and uterus rather than through

the vagina. There has been a gradual increase in cesarean births over the past 30 years. In November of 2005, the Centers for Disease Control and Prevention (CDC) reported the national cesarean birth rate was the highest ever at 29.1%, which is over a quarter of all deliveries. This means that over 1 in 4 women will experience a cesarean birth. What can I expect in a Cesarean procedure? The normal cesarean procedure will take an average of 45 minutes to an hour. The baby is usually delivered in the first 5-15 minutes and the remainder of time is used for closing the incision. Pre surgery: Before surgery, you will be given some type of anesthetic (general, spinal, or epidural) if you have not been given one earlier in your labor. General anesthetic is normally only used for emergency cesareans because it is effective immediately and the mother is sedated. The spinal and epidural anesthesia will numb the area from the abdomen to below the waist (sometimes the legs can be numb also), so that nothing can be felt during the procedure. You will probably receive a catheter to collect urine while your lower body is numb. Surgery: The health care provider will make an incision in the abdomen wall first. In an emergency cesarean this will most likely be a vertical incision (from the navel to the pubic area) which will allow the health care provider to deliver the baby faster. The most common incision is made horizontally (often called a bikini cut), just above the pubic bone. The muscles in your stomach will not be cut; they will be pulled apart so that the health care provider can get to the uterus. An incision will then be made into the uterus, horizontally or vertically. The same type of incision does not have to be made in both the abdomen and uterus. The classical incision made vertically, is usually reserved for complicated situations such as placenta previa, emergencies, or babies with abnormalities. A vaginal birth after cesarean (VBAC) is not recommended for women with the classical incision. Another type of incision which is rarely used is the lower segment vertical incision. This would only be used if there were problems with the uterus that would not allow another type of incision to be made. The most common incision made is the low transverse incision. This incision has fewer risks and complications than the others and allows most women to attempt a VBAC in their next pregnancy with little risk of uterine rupture. The health care provider will suction the amniotic fluid out and then will deliver the baby. Your babies head will be delivered first so that the mouth and nose can be cleaned out to allow for its first breath. Once the whole body is delivered, the baby will be lifted up so that you can meet your newborn. Most health care providers will then pass the baby on to the nurse for evaluation. The last thing to be delivered will be your placenta (you may feel some tugging) and then the surgical team will begin the close up process. After the Surgery: Once the surgery is over, you may begin to experience some nausea and trembling. This can be caused by the anesthesia, the effects of your uterus contracting, or from an adrenaline let down. This usually passes quickly and can be followed by some drowsiness. If your baby is healthy, this is usually the time when the baby can rest on your chest and you can begin breastfeeding and bonding. You and your baby will continually be monitored for any complications.

When you are discharged from the hospital you will be advised on the proper postoperative care for your incision and yourself.

What are the Reasons that Cesarean Deliveries are Performed? There are many reasons why a health care provider may feel that you need to have a cesarean delivery. Some cesareans occur in critical situations, some are used to prevent critical situations and some are elective. Placenta previa: This occurs when the placenta lies low in the uterus and partially or completely covers the cervix. 1 in every 200 pregnant women will experience placenta previa during their third trimester. The treatment involves bed rest and frequent monitoring. If a complete or partial placenta previa has been diagnosed, a cesarean is usually necessary. If a marginal placenta previa has been diagnosed, a vaginal delivery may be an option. Placental abruption: This is the separation of the placenta from the uterine lining that usually occurs in the third trimester. Approximately 1% of all pregnant women will experience placental abruption. The mother will experience bleeding from the site of the separation and pain in the uterus. This separation can interfere with oxygen getting to the baby and depending on the severity, an emergency cesarean may be performed. Uterine rupture: In approximately 1 in every 1,500 births the uterus tears during pregnancy or labor. This can lead to hemorrhaging in the mother and interfere with the babies oxygen supply. This is a reason for immediate cesarean. Breech position: When dealing with a breech baby, a cesarean delivery is often the only option, although a vaginal delivery can be done under certain circumstances. However, if the baby is in distress or has cord prolapse (which is more common in breech babies) a cesarean is necessary. A cesarean may also be done if the baby is premature. Cord prolapse: This situation does not occur often but when it does an emergency cesarean is done. A cord prolapse is when the umbilical cord slips through the cervix and protrudes from the vagina before the baby is born. When the uterus contracts it causes pressure on the umbilical cord which diminishes the blood flow to the baby. Fetal distress: The most common cause of fetal distress is lack of oxygen to the baby. If fetal monitoring detects a problem with the amount of oxygen that your baby is receiving, then an emergency cesarean may be performed. Failure to progress in labor: This can occur when the cervix has not dilated completely, labor has slowed down or stopped, or the baby is not in an optimal delivery position. This can be diagnosed correctly once the women is in the second phase (beyond 5 centimeters dilation), since the first phase of labor (0-4 centimeters dilation) is almost always slow. Repeat cesarean: You may be surprised to find out that 90% of women who have had a cesarean are candidates for a vaginal birth after cesarean for their next birth (VBAC). The biggest risk involved in a VBAC is uterine rupture, which happens in 0.2-1.5% of VBACs. However, there is a criteria you must meet in order to have a VBAC. Consult with your health care provider about your current situation and your options. Cephalopelvic Disproportion (CPD): A true diagnosis of CPD occurs when a baby's head is too large or a mother pelvis is too small to allow the baby to pass through. Active genital herpes: If the mother has an active outbreak of genital herpes (diagnosed by a positive culture or actual lesions), a cesarean may be scheduled to prevent the baby from being exposed to the virus while passing through the birth canal.

Diabetes: If you develop gestational diabetes during your pregnancy or are diabetic, you may have a large baby or other complications. This increases your chance of having a cesarean. Preeclampsia: Preeclampsia is a condition of high blood pressure during pregnancy. This condition could prevent the placenta from getting the proper amount of blood needed and decrease oxygen flow to the baby. Delivery is sometimes recommended as a treatment for this condition. Only with severe preeclampsia is a cesarean needed. Birth defects: If a baby has been diagnosed with a birth defect, a cesarean may be done to help reduce any further complications during delivery. Multiple births: Twins may be delivered vaginally depending on their positions, estimated weights and gestational age. Multiples of three or more are less likely to be delivered vaginally. Risks and Complications for the Mom: Take into account that most of the following risks are associated with any type of abdominal surgery.

Infection: Infection can occur at the incision site, in the uterus and in other pelvic organs such as the bladder. Hemorrhage or increased blood loss: There is more blood loss in a cesarean delivery than with a vaginal delivery. This can lead to anemia or a blood transfusion (1 to 6 women per 100 require a blood transfusion1). Injury to organs: Possible injury to organs such as the bowel or bladder (2 per 1002). Adhesions: Scar tissue may form inside the pelvic region causing blockage and pain. This can also lead to future pregnancy complication such as placenta previa or placental abruption3. Extended hospital stay: After a cesarean, the normal time in the hospital is 3-5 days after giving birth if there are no complications. Extended recovery time: The amount of time needed for recovery after a cesarean can extend from weeks to months, having an impact on bonding time with your baby (1 in 14 report incisional pain six months or more after surgery4). Reactions to medications: There can be a negative reaction to the anesthesia given during a cesarean or reaction to pain medication given after the procedure. Risk of additional surgeries: Such as hysterectomy, bladder repair or another cesarean. Maternal mortality: The maternal mortality rate for a cesarean is greater than with a vaginal birth. Emotional reactions: Women who have a cesarean report feeling negatively about their birth experience and may have trouble with initial bonding with their baby5.

Risks and Complications for the Baby:

Premature birth: If gestational age was not calculated correctly, a baby delivered by cesarean could be delivered too early and be low birth weight6. Breathing problems: When delivered by cesarean, a baby is more likely to have breathing and respiratory difficulties. Some studies show an increased need for assistance with breathing and immediate care after a cesarean than with a vaginal delivery7. Low APGAR scores: Low APGAR scores can be the result of anesthesia, fetal distress before the delivery or lack of stimulation during delivery (vaginal birth provides natural stimulation to the baby while in the birth canal). Babies born by cesarean are 50% more likely to have lower APGAR scores than those born vaginally8. Fetal injury: Very rarely, the baby may be nicked or cut during the incision (1 to 2 babies per 100 will be cut during the surgery9).

If your health care provider has suggested a cesarean and you are in a non-emergency situation, take the time to really discuss your options regarding the procedure.

Ask questions so that you can understand why a cesarean procedure has been recommended Ask for any alternatives that my be an option in your particular situation Have your health care provider compare all the possible risks and complications for you and your baby when having a cesarean and not having a cesarean Get information regarding the normal procedures after a cesarean (i.e., when can you hold your baby, can the newborn evaluation be done while the baby is on your chest, how soon can you try to breastfeed, are you given medication that would make you drowsy after the delivery)

The days following the birth of your baby, which is called the postpartum period, is one of the most challenging times for moms and families. This time can be even more challenging for a mom who has undergone a cesarean delivery. After all deliveries, mom needs to take time to allow her body to rest and heal, which means no housework or running after other little ones. The maternal mortality rate is the highest in the postpartum period, so special attention needs to be given to taking care of mom. If you are a single mom or your partner has to return to work right away, try to set up a support team before the birth of your child for this postpartum period. This can be done with help from family, church members, new mom support groups or a postpartum doula. Take some time to really understand the limitations and care that is needed for a new mother. Remember it is normal for a new mom to feel overwhelmed and drained. This is why open communication with your health care provider and your support team is so important. Let someone know if you are feeling discouraged or weighed down. ASK FOR HELP!! Physical Care After a Cesarean: Before leaving the hospital:

You will be encouraged to get up and try to go the bathroom within the first 24 hours after surgery. This will help start the healing process and get you used to moving around with your incision. Remember to move slowly because you may experience dizziness or shortness of breath. Urinating after the catheter is removed can sometimes be painful. Ask your nurse or attendant to suggest ways that this may be easier. If staples were used for your incision they will most likely be removed before you leave the hospital. Talk with your health care provider about dealing with pain after the surgery. If medication is something you are interested in, get a prescription and information on the side affects for you and baby (if you are breastfeeding). If you would rather avoid medications, talk with your health care provider about alternatives to coping with pain that are safe for you and the baby. Your uterus will begin the involution process, which is when it is shrinking down to its pre-pregnancy size. You will begin to experience heavy bleeding of bright red bloodthis is called lochia and it can continue for up to 6 weeks. You will need to have extra absorbent menstrual pads. The hospital should provide you with special pads used by new moms after delivery. (Do not use tampons during this time.) Gentle strolls around the hospital or rocking in a chair can help speed up recovery and help with gas that can result after abdominal surgery.

After Going Home:

Your activity level should be kept low until your health care provider has told you differently. This would include not lifting anything heavier than your baby and avoid housework. Your lochia bleeding will change over time and can increase with activity and position changes. Use this as a gauge to make sure you are not doing too much.

Lochia will change over time to pale pink or a dark red color, and then eventually to a yellowish or light color. Make sure you are getting plenty of fluids to keep you hydrated and eat healthy meals to restore energy and prevent constipation. Have changing stations and feeding supplies near you so that you do not have to get up too often. Make sure you watch for fever or pain, which can be a sign of infection.

Things to Avoid:

Sexual intercourse until your health care provider says it is safe The use of tampons or douche Avoid taking baths until your incision is healed and you are no longer bleeding Public pools and hot tubs Lifting anything heavier than your baby Repeatedly using stairs Exercise until your health care provider says its safe

Emotional Care After a Cesarean:

Take additional time daily just to sit and bond with your baby If you are having a hard time with breastfeeding after the cesarean delivery, contact a lactation consultant to help you get comfortable Realize that you may need to take time to decompress emotionally after the surgery, especially if the procedure was an emergency situation Ask to talk through the birth with your support person, so that you can deal with any negative feelings you may have toward your childbirth experience Clarify any questions you may have about your health and future pregnancies with your health care provider. This can help eliminate any feelings of anxiousness you may have about getting pregnant again. Do not be afraid to ask for help! The extra physical care required after a cesarean can sometimes leave women feeling inadequate, overwhelmed, and lonely.

Reasons to Call Your Health Care Provider Immediately:

Fever of over 100.4 F Severe headache that begins right after birth and does not let up in intensity Sudden onset of pain in the abdominal area, such as tenderness or burning Foul smell from vaginal discharge Sudden onset of pain in the incision area that can include a pus discharge Swollen, red, painful area in the leg Burning urination or blood in the urine Appearance of rash or hives Extremely heavy bleeding that soaks a maxi pad within an hour or the passing of large clots Sore, red, painful area on the breasts that may be accompanied by flu like symptoms Feeling anxious, panicky, and/or depressed

When Do You Need a Cesarean Section? Not every woman undergoes a traditional vaginal delivery with the birth of her child. Under conditions of fetal or maternal distress, or in the case of breech presentation (when a baby is turned feet first at the time of delivery), or if the woman's first baby was born by cesarean delivery, a procedure called a cesarean section may be required. Cesarian Section Procedure During a cesarean, a doctor will make either a lateral incision in the skin just above the pubic hair line, or a vertical incision below the navel.

As the incision is made, blood vessels are cauterized to slow bleeding. After cutting through the skin, fat, and muscle of the abdomen, the membrane that covers the internal organs is opened, exposing the bladder and uterus. At this time the physician will generally insert his or her hands into the pelvis in order to determine the position of the baby and the placenta. Next, an incision is made into the uterus and any remaining fluids are suctioned from the uterus. The doctor then enlarges the incision with his or her fingers. Delivering the Baby via Cesarian Section The baby's head is then grasped and gently pulled with the rest of its body from the mother's uterus. Sewing the Cesarian Section Back Together Finally, the abdominal layers are sewn together in the reverse order that they were cut. The mother is allowed to recover for approximately three to five days in the hospital. She will also be quite sore and restricted from activity for the following several weeks. Cesarian Section Risks There are several potential complications associated with this procedure that should be discussed with a doctor prior to surgery. What type of uterine incision was used for the prior C-section? Scars left from certain types of incisions have an increased risk of tearing during labor and delivery a rare but serious risk of VBAC. You can't tell what kind of uterine incision you've had just by looking at the scar on your belly. Instead, check with your doctor or review your medical records.

Low transverse incision. This is the most common uterine incision. It's made sideways across the lower part of the uterus. A low transverse incision usually bleeds less than an incision made higher on the uterus. It also forms stronger scars and presents less danger of rupture during subsequent labors between a 0.2 percent to 1.5 percent chance. If you've had one or even two of these incisions, you may be a candidate for VBAC. Low vertical incision. This type of incision is made low on the uterus, where the uterine wall is thinner. A low vertical incision may be used to deliver a baby situated in an awkward position or when there's concern that the incision may need to be extended. A low vertical incision presents a higher risk of subsequent uterine rupture 1 percent to 7 percent. If you've had a low vertical incision that doesn't extend into the upper uterus, you may still be a candidate for VBAC. However, it's sometimes difficult to determine if the scar is low enough to minimize the risk of uterine rupture. Classical incision. This type of incision, also called a high vertical incision, was once used for all C-sections. However, it carries the highest risk of bleeding during labor and of subsequent uterine rupture 4 percent to 9 percent. It's now used only in emergency situations. VBAC isn't recommended for women who've had a classical uterine incision. T-shaped, inverted T-shaped or J-shaped incision. These incisions are used only in emergencies or when problems develop. They're not planned. If you have any of these scars, VBAC isn't an option. The risk of uterine rupture is too great.

If your type of previous uterine incision can't be determined, your doctor may recommend a repeat C-section.