A Caesarean section (also C-section, Cesarean section) is a surgical procedure in which one or more

incisions are made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more
babies, or, rarely, to remove a dead fetus. A late-term abortion using Caesarean section procedures is termed a
hysterotomy abortion and is very rarely performed. The first modern Caesarean section was performed by
German gynecologist Ferdinand Adolf Kehrer in 1881.
A Caesarean section is usually performed when a vaginal delivery would put the baby's or mother's life or
health at risk, although in recent times it has also been performed upon request for childbirths that could
otherwise have been vaginal
Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby.
Elective caesarean section should not be scheduled before 39 weeks gestational age unless there is a medical
indication to do so.[10] Some medical indications are below. Not all of the listed conditions represent a
mandatory indication, and in many cases the obstetrician must use discretion to decide whether a Caesarean is
necessary.
Complications of labor and factors impeding vaginal delivery, such as:
prolonged labour or a failure to progress (dystocia)
fetal distress
cord prolapse
uterine rupture
increased blood pressure (hypertension) in the mother or baby after amniotic rupture
increased heart rate (tachycardia) in the mother or baby after amniotic rupture
placental problems (placenta praevia, placental abruption or placenta accreta)
abnormal presentation (breech or transversepositions)
failed labour induction
failed instrumental delivery (by forceps or ventouse (Sometimes a trial of forceps/ventouse delivery is
attempted, and if unsuccessful, it will be switched to a Caesarean section.)
large baby weighing >4000g (macrosomia)
umbilical cord abnormalities (vasa previa, multilobate including bilobate and succenturiate-lobed
placentas, velamentous insertion)
Other complications of pregnancy, pre-existing conditions and concomitant disease, such as:
pre-eclampsia
[11]
hypertension
previous (high risk) fetus
HIV infection of the mother
Sexually transmitted diseases, such as genital herpes (which can be passed on to the baby if the baby is
born vaginally (but can usually be treated in with medication and do not require a Caesarean section)
previous classical (longitudinal) Caesarean section
previous uterine rupture
prior problems with the healing of the perineum (from previous childbirth orCrohn's disease)
Bicornuate uterus
Rare cases of posthumous birth after the death of the mother
Other
Lack of obstetric skill - obstetricians not being skilled in performing breech births, multiple births, etc.
(In most situations, women can birth vaginally under these circumstances. However, obstetricians are
not always trained in proper procedures)[12]
[12][13]
Improper Use of Technology (Electric Fetal Monitoring [EFM])
Risk
Women who delivered their first child by Caesarean delivery had increased risks for malpresentation,placenta previa,
antepartum hemorrhage, placenta accreta, prolonged labor,uterine rupture, preterm birth, low birth weight, and
stillbirth in their second deliveries.

Types
There are several types of Caesarean section (CS). An important distinction lies in the type of incision
(longitudinal or latitudinal) made on the uterus, apart from the incision on the skin.
The classical Caesarean section involves a midline longitudinal incision which allows a larger space to
deliver the baby. However, it is rarely performed today, as it is more prone to complications.
The lower uterine segment section is the procedure most commonly used today; it involves a transverse
cut just above the edge of the bladder and results in less blood loss and is easier to repair.
An unplanned Caesarean section is performed once labour has commenced due to unexpected labor
complications.
A crash/emergent/emergency Caesarean section is performed in an obstetric emergency, where
complications of pregnancy onset suddenly during the process of labour, and swift action is required to
prevent the deaths of mother, child(ren) or both.
A planned caesarean (or elective/scheduled caesarean), arranged ahead of time, is most commonly
arranged for medical reasons and ideally as close to the due date as possible.
A Caesarean hysterectomy consists of a Caesarean section followed by the removal of the uterus. This
may be done in cases of intractable bleeding or when the placenta cannot be separated from the uterus.
Traditionally, other forms of Caesarean section have been used, such as extraperitoneal Caesarean
section or Porro Caesarean section.
A repeat Caesarean section is one that is done when a patient had a previous Caesarean section.
Labor is slow and hard or stops completely.
The baby shows signs of distress, such as a very fast or slow heart rate.
A problem with the placenta or umbilical cord puts the baby at risk.
The baby is too big to be delivered vaginally.
USES:
When doctors know about a problem ahead of time, they may schedule a C-section. Reasons you might have a
planned C-section include:
The baby is not in a head-down position close to your due date.
You have a problem such as heart disease that could be made worse by the stress of labor.
You have an infection that you could pass to the baby during a vaginal birth.
You are carrying more than one baby (multiple pregnancy).
You had a C-section before, and you have the same problems this time or your doctor thinks labor might
cause your scar to tear (uterine rupture).
In some cases, a woman who had a C-section in the past may be able to deliver her next baby through the birth
canal. This is called vaginal birth after cesarean (VBAC). If you have had a previous C-section, ask your doctor
if VBAC might be an option this time.
In the past 40 years, the rate of cesarean deliveries has jumped from about 1 out of 20 births to about 1 out of 4
births.1 This trend has caused experts to worry that C-section is being done more often than it is needed.
Because of the risks, experts feel that C-section should only be done for medical reasons.
What are the risks of C-section?

Most mothers and babies do well after C-section. But it is major surgery, so it carries more risk than a normal
vaginal delivery. Some possible risks of C-section include:

Infection of the incision or the uterus.

Heavy blood loss.
Blood clots in the mother's legs or lungs.
Injury to the mother or baby.
Problems from the anesthesia, such as nausea, vomiting, and severe headache.
Breathing problems in the baby if it was delivered before its due date.

When would I need a cesarean section?

A cesarean delivery might be planned advance if a medical reason calls for it, or it might be unplanned and take
place during your labor if certain problems arise.

You might need to have a planned cesarean delivery if any of the following conditions exist:

Cephalopelvic disproportion (CPD) CPD is a term that means that the babys head or body is too large to pass
safely through the mothers pelvis, or the mothers pelvis is too small to deliver a normal-sized baby.
Previous cesarean birth Although it is possible to have a vaginal birth after a previous cesarean, it is not an
option for all women. Factors that can affect whether a cesarean is needed include the type of uterine incision
used in the previous cesarean and the risk of rupturing the uterus with a vaginal birth.
Multiple pregnancy Although twins can often be delivered vaginally, two or more babies might require a
cesarean delivery.
Placenta previa In this condition, the placenta is attached too low in the uterine wall and blocks the babys
exit through the cervix.
Transverse lie The baby is in a horizontal, or sideways, position in the uterus. In this condition, a cesarean
delivery is always used.
Breech presentation In a breech presentation, or breech birth, the baby is positioned to deliver feet or
bottom first. If your doctor determines that the baby cannot be turned through abdominal manipulation, you
will need to have a cesarean delivery.

An unplanned cesarean delivery might be needed if any of the following conditions arise during your labor:

Failure of labor to progress In this condition, the cervix begins to dilate and stops before the woman is fully
dilated, or the baby stops moving down the birth canal.
Cord compression The umbilical cord is looped around the babys neck or body, or caught between the
babys head and the mothers pelvis.
Prolapsed cord The umbilical cord comes out of the cervix before the baby does.
Abruptio placentae The placenta separates from the wall of the uterus before the baby is born.
Fetal distress During labor, the baby might begin to develop problems that cause an irregular heart rate. Your
doctor might decide that the baby can no longer tolerate labor and that a cesarean delivery is necessary.

What can I expect before the cesarean?

If the cesarean delivery is not an emergency, the following procedures will take place.

You will be asked if you consent to the procedure, and in some hospitals, you might be asked to sign a consent
form.
The anesthesiologist will discuss the type of anesthesia to be used.
Your blood pressure, pulse and temperature will be taken.
A shave will be done around the incision area.
A catheter will be inserted to keep your bladder empty.
Medicine will be put directly into your vein.
You will have heart and blood pressure monitors applied.

What is the procedure for a cesarean?

At the start of the procedure, the anesthesia will be administered, and a screen or sterile drape will be used to
prevent you from watching the surgery. Your abdomen will then be cleaned with an antiseptic, and you might
have an oxygen mask placed over your mouth and nose to increase oxygen to the baby.
The doctor will then make an incision through your skin and into the wall of the abdomen. The doctor might use
either a vertical or transverse incision. (A horizontal incision is also called a bikini incision, because it is placed
beneath the belly button.) Next, a 3- to 4-inch incision is then made in the wall of the uterus, and the doctor
removes the baby through the incisions. The umbilical cord is then cut, the placenta is removed and the
incisions are closed.
How long does the procedure take?

If the cesarean is an emergency, the time from incision to delivery takes about two minutes. In a nonemergency, a cesarean birth can take 10 to 15 minutes, with an additional 45 minutes for the delivery of the
placenta and suturing of the incisions.

What happens after the delivery?

Because the cesarean is major surgery, it will take you longer to recover from this type of delivery than it would
from a vaginal delivery. Depending on your condition, you will probably stay in the hospital from 3 to 4 days.
Once the anesthesia wears off, you will begin to feel the pain from the incisions, so be sure to ask for pain
medicine. You might also experience gas pains and have trouble taking deep breaths. You will also have a
vaginal discharge after the surgery due to the shedding of the uterine wall. The discharge will be red at first and
then gradually change to yellow. Be sure to call your health care provider if you experience heavy bleeding or a
foul odor from the vaginal discharge.
Can I have a baby vaginally after a cesarean delivery?

The majority of women who have had a cesarean delivery might be able to deliver vaginally in a subsequent
pregnancy. If you meet the following criteria, your chances of vaginal birth after cesarean (VBAC) are greatly
increased:

A low transverse incision was made into your uterus during your cesarean.
Your pelvis is not too small to accommodate a normal-sized baby.
You are not having a multiple pregnancy.
Your first cesarean was performed for breech presentation of the baby.

When you go home

It takes about four to six weeks for a C-section incision to heal. Fatigue and discomfort are common. While
you're recovering:

Take it easy. Rest when possible. Try to keep everything that you and your baby might need within reach. For
the first few weeks, avoid lifting from a squatting position or lifting anything heavier than your baby.
Support your abdomen. Use good posture when you stand and walk. Hold your abdomen near the incision
during sudden movements, such as coughing, sneezing or laughing. Use pillows or rolled up towels for extra
support while breast-feeding.
Drink plenty of fluids. Drinking water and other fluids can help replace the fluid lost during delivery and breastfeeding, as well as prevent constipation.
Take medication as needed. Your health care provider might recommend acetaminophen (Tylenol, others) or
other medications to relieve pain. Most pain relief medications are safe for women who are breast-feeding.
Avoid sex. Don't have sex until your health care provider gives you the green light often four to six weeks
after surgery. You don't have to give up on intimacy in the meantime, though. Spend time with your partner,
even if it's just a few minutes in the morning or after the baby goes to sleep at night.

It's also important to know when to contact your health care provider. Make the call if you experience:

Any signs of infection such as a fever higher than 100.4 F (38 C), severe pain in your abdomen, or redness,
swelling and discharge at your incision site
Breast pain accompanied by redness or fever
Foul-smelling vaginal discharge
Painful urination
Bleeding that soaks a sanitary napkin within an hour or contains large clots
Leg pain or swelling

Postpartum depression which can cause severe mood swings, loss of appetite, overwhelming fatigue and lack
of joy in life is sometimes a concern as well. Contact your health care provider if you suspect that you're
depressed. It's especially important to seek help if your signs and symptoms don't fade on their own, you have
trouble caring for your baby or completing daily tasks, or you have thoughts of harming yourself or your baby.

3. Vistaril 25-50 mg IM every 3-4 hours prn

II. Management: Acute
1. Transfer to postpartum ward when stable
4. Later analgesia
2. Vital Signs q15 minutes for 1 hour, then q4 hours
1. Ibuprofen 800 mg PO tid prn
3. Monitor intakes and outputs every 4 hours for 24
2. Tylenol #3 1-2 mg PO every 4-6 hours prn
hours
5. Other Medications
4. Activity:
1. Iron Sulfate dosing based on Postpartum
1. Bed rest
Anemia
2. Supine for 8 hours after spinal anesthetic
2. Prenatal Vitamin po qd
3. Incentive Spirometry every 1 hour while
3. Colace 100 mg PO bid OR 200 mg PO at
awake
bedtime
5. Standard Diet
4. Mylicon 80 mg PO qid prn bloating
1. Nothing by mouth for 8 hours after
5. Milk of Magnesia
cesarean section
IV. Labs
2. Sips of water after 8 hour window
1. Complete Blood Count in morning
3. Advance to clear liquids as tolerated
2. Maternal Blood Type Indications for Cord Blood
4. Advance to Regular diet when flatus or
1. Mother Rh Negative
Bowel Movement
V. Rounds
1. Assess
6. Early Solid Diet Protocol
1. Abdominal and perineal Pain
1. Solid food within 8 hours of C-Section
2. Lochia
2. Well tolerated
3. Flatus or Bowel Movement
3. Resulted in faster bowel function return
2. Examine
4. Shortened hospital stay by 24 hours
1. Cardiopulmonary exam
5. Patolia (2001) Obstet Gynecol 98:113-6
2. Abdominal examination
7. Intravenous fluids
1. Fundal height
1. D5LR OR D51/2NS at 125 cc/hour
2. Uterine tenderness
2. Foley to gravity
3. Bowel sounds
8. Contact physician for
4. Incision clean and dry
1. Temperature > 100.4
3. Extremity exam
2. Systolic Blood Pressure <90 mmHg or >140
1. Calf tenderness
mmHg
2. Homan's sign
3. Diastolic Blood Pressure >90 mmHg or <50
3. Intravenous Access discontinuation
mmHg
1. Patient taking adequate fluids
4. Heart Rate >130 or <60
2. No signs of Postpartum Hemorrhage
5. Respiratory Rate >32 or <8
4. Discontinue Foley Catheter when no longer
6. Urine output
needed
1. Foley Catheter in place: <60 cc in 2
5. Administer Rubella shot id mother not immune
hours
1. RubellaVaccine 0.5 cc SQ at Discharge
2. Intermittent Urine collection: <300
6.
Mother
Rh Negative
cc per shift
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1. Blood Type and Indirect Coombs
III. Medications:
2. Cord blood sent to lab
1. Antibiotics if patient labored before cesarean
3. RhoGAM indicated for Rh Positive infant
section
VI. Disposition
1. Cefoxitin 2 grams IV every 4 hours for 3
1. Staple Removal
doses or
1. Horizontal incision
2. Ancef 1 gram IVPB every 8 hours for 3
1. Remove staples on Day 3-4 and
doses
place steri-strips
2. Nausea
2. Vertical incision
1. Inapsine 1.25 mg IM/IV every 4-6 hours
1. Remove staples on Day 4-5
prn Nausea
2. Follow-up in clinic
3. Initial Analgesia
1. Status post Cesarean Section at 2 weeks
1. Demerol 50-75 mg IM every 3-4 hours prn
2. Postpartum visit at 6 weeks
2. Morphine 10 mg IM every 3-4 hours prn