Cesarean Section

One of the most controversial topics in modern obstetrics is cesarean section. Cesarean section refers to a major surgical procedure where a baby is removed from the uterus by making a cut into the abdomen, then into the uterus. Although in many cases a cesarean section, or c/section for short, is necessary to save the life of the baby or mother, there are other situations where women and their doctors are choosing this form of birth because they feel it is more convenient, because of fear about pain during vaginal delivery, or due to concerns about lawsuits. It is these “non medical” reasons for choosing a c/section that spark so much controversy. Education is the key to understanding this common and interesting surgical procedure, which should help women and their partners decide if this form of childbirth is appropriate for them.

Nobody is really sure where the term “cesarean section” came from, but we are fairly certain that Julius Caesar was not born by c/section. In the past, almost every woman who underwent a c/section died, and in many cases it was performed to save the baby, at the expense of the mother’s life. Julius Caesar’s mother lived after his birth, which suggests he was delivered vaginally. There are a number of fascinating historical theories to account for the origin of the term cesarean section. We do have written reports of c/sections being performed in the late 1500s, but survival of the mother and baby was not really feasible until the late 1700s and early 1800s. Infection was common from the procedure, as was hemorrhage. In fact, it was not until the 1800s that stitches were routinely used when performing a c/section! Cesarean section now accounts for about 25% of all births in the United States. The chance of dying from a c/section, which is a major abdominal surgery, is about 20 out of 100,000. Although this is not exceptionally high, it is higher than the chance of dying from a vaginal delivery.

The reason c/sections had such a high mortality rate, and the reason there can be so many complications from them, is because they involve opening up the abdomen and making an incision into the uterus. When doing a c/section an ob/gyn doctor first makes sure that the patient has adequate anesthesia. We commonly use epidural anesthesia. On unusual occasions the patient may need to have general anesthesia, which involves going completely to sleep with a tube in the throat and the use of a ventilator device. Once the patient is numb, a cut about the size of the distance from your wrist to the tip of your ring finger is made in to the skin. In most cases, this incision is made from side-to-side, just above the pubic hair line (sometimes called a “bikini cut”), while in some parts of the world, and in some emergency situations, an up-and-down cut is made from below the belly button to the top of the bikini line. (Most doctors prefer bikini cuts because they heal and look better, and cause less pain after leaving the hospital). After cutting through the skin and underlying fat cells, the doctor will make an incision through the remaining tissue, then will enter the abdominal cavity. The bladder, uterus, ovaries, tubes, and intestines are all visible and sometimes have to be moved out of the way before cutting into the uterus (womb). After entering the uterus through a cut a little larger than the baby’s head, the baby is carefully grasped, and the surgical assistant pushes on the top of the uterus to deliver the baby through the hole in the uterus. The umbilical cord is clamped and cut, and the baby is handed to the nurses or doctors who care for newborn babies. The ob/gyn will remove the placenta, stitch up the uterus, inspect the ovaries and tubes, then close the different tissue layers and put staples or stitches into the skin.

As the above description illustrates, c/sections are a pretty amazing procedure. Why is there so much controversy about them? First, c/sections are a major surgery, and major surgeries can have major complications. Some complications that can occur during or after a c/section include heavy bleeding, damage to the bladder or intestines, major infections of the uterus, kidneys, lungs, or other areas, opening up of the skin incision, blood clots around the uterus or in the leg veins or lungs, an inability of the blood to clot, and damage to the uterus that makes future childbirth more dangerous. The uterus is a large, muscular organ that has an enormous blood supply. When an incision is made into the uterus, there can be a lot of bleeding. Modern doctors have medications and stitches to stop this, but even so, there are some women who need a blood transfusion during a c/section. (Others, on rare occasions, need a hysterectomy to save their life).

Most women who undergo a c/section need to take oral iron pills, since the blood loss is at least twice as much as during a vaginal delivery. A number of women develop uterine infections, requiring extra days in the hospital and powerful antibiotics.

Another reason why many believe that vaginal delivery is preferable to a c/section is that some patients who have a c/section must always have another c/section, due to the type of cut made into the uterus. While the cut on the skin does not matter, the cut on the uterus is very important. We try to make a side-to-side cut on the uterus, called a “low transverse uterine incision,” since these are safer and have a very small chance of breaking open during later pregnancies. Since the chance of the incision breaking open during a later pregnancy is very small (probably at or under about 1%), doctors now consider it safe to try for a vaginal delivery during later pregnancies if the patient has a prior low transverse incision. This is called a “vaginal birth after cesarean” or VBAC (pronounced “V-Back”) . An up-and-down uterine cut, in contrast, has a much higher chance of breaking open, which can cause heavy internal bleeding or even stillbirth, so we consider it unsafe to try for a vaginal delivery when there is a history of a prior vertical incision. These patients should have a repeat c/section.

Babies also need special attention during a c/section. Their lungs are not compressed by the vagina during a c/section, so they often have lungs with a little extra fluid in them. Not all problems occur during a c/section; some occur later. These include pelvic pain or pain with intercourse from scar tissue (called adhesions), difficulty using “sit-up muscles,” and development of scar tissue between the afterbirth and the uterine lining in later pregnancies (which can lead to hemorrhage or emergency hysterectomy).

After reading about all the problems, one might ask “why do we do c/sections?” In some cases, the afterbirth is too close to the opening of the vagina, called a placenta previa, and vaginal delivery would lead to life-threatening bleeding. Other indications for c/section include a dangerous drop in the fetal heart rate for many minutes, a cord prolapse (where the umbilical cords falls out of the vagina and constricts the blood supply to the baby), heavy vaginal bleeding from a torn afterbirth, many (but not all) breech babies, babies that are in an awkward position in the uterus (for example, sideways), and active genital herpes. Triplets almost always require a c/section, while many twin deliveries can be safely performed vaginally. Arrested labor, where the woman only dilates to a certain amount then stops, accounts for many c/sections. Contrary to popular belief, this does not mean that the next pregnancy must end in c/section, because, just as all children are different, all pregnancies are different. Just because, for example, a 6 pound baby will not fit exactly right and needs a c/section, does not mean that the mother will need one for her next pregnancy, where the baby is 8 pounds. Each baby fits differently.
Finally, probably the least common reason for a c/section is because the baby is too big. Almost all pregnant women believe their baby is “too big,” yet this is almost never the case. Medical research has not shown that c/sections are better for most large babies. When doctors advise a c/section, they are aware that it is preferable to deliver vaginally, but that sometimes it is necessary to perform a c/section. As always, when considering which way to delivery your baby, discuss this issue with your doctor or midwife until you are sure you have enough information to make an informed decision. You may find that you have preconceived ideas about either a vaginal delivery or a c/section and that you change your mind after discussing the issue with your doctor.

Many women want to know what they should or should not do after a c/section. Basically, you will stay in the hospital from 2-4 days after a c/section, depending on your response to pain medications and your ability to walk around. Many women recover surprisingly quickly and leave after a few days. You will need to walk carefully to avoid straining your abdomen, and will probably need a little help getting up and down stairs. Driving should be avoided for a few weeks. Most doctors advise against lifting anything more than, say, 10-15 pounds for a few weeks, and most would like to see you immediately if you notice any redness or infection around the incision, pain in your calf muscles, worsening abdominal pain, fevers, or other abnormal symptoms. The uterus goes back to normal after about 6 weeks, and by that stage most women have almost completely recovered and are ready to resume normal activity.

References:

D. Ashley Hill, M.D.

Associate Director

Department of Obstetrics and Gynecology

Florida Hospital Family Practice Residency

Orlando, Florida

http://home.mpinet.net/dahmd