Cesarean section is the delivery route for about one woman in five in the United States. Given that C-section delivery is so common, questions about Cesarean often come up during prenatal visits with my patients. Here is a sampling of the most frequent questions I am asked in my practice, and their accompanying answers.
What are my chances of having a Cesarean delivery?
Cesarean section rates in the U.S. vary from year to year, and differ
among regions, generally occurring at a lower incidence in the western
and midwestern states than in other areas of the country. The rates also
are affected by the risk status of the mother and fetus. Primary C-section
rates (the chance of having a C-section, never having had one before)
in the U.S. are about 14%, and total C-section rates are approximately
21%.
Why would I need a C-section?
Most C-sections are performed for problems related to a mismatch between
the fetal head and the mom's pelvis. These are discovered when the labor
process becomes stalled after initial progress. A lack of progress may
occur in the last stage of labor, when the woman is ten centimeters and
pushing, or earlier, before the cervix is completely dilated. Other indications
for C-section involve breech presentation, placenta previa, fetal distress,
very large infants, previous uterine surgery, and medical problems or
diseases.
When will I know if I need one?
Babies that need to be born by C-section sometimes cooperate by declaring
early, such as with a breech or very large infant. Most C-sections, especially
those that are done for some degree of "not fitting", cannot be predicted
ahead of time. Labor, itself, is the test of whether or not a baby will
fit through the birth canal. In general, a two-hour lack of progress if
everything is optimal signals a C-section may be necessary.
What are the risks?
Cesarean delivery includes some risks common to any birth, such as blood
clots in the legs, uterine infection, excessive bleeding after delivery,
with or without blood transfusion, and pelvic injury. Some of these are
increased in C-section compared with vaginal delivery, particularly infection
and bleeding. Risks due to the surgery itself, such as damage to bladder
or bowel, are increased. Babies born by C-section face a greater chance
of retaining amniotic fluid in their lungs after birth than do those born
vaginally. Modern medicine has made both vaginal delivery and C-section
very low-risk, but vaginal delivery remains a bit safer.
Can I a avoid a C-section?
Most C-sections are performed for reasons beyond the patient's, or the
doctor's, control. You can maximize your chances of delivering vaginally,
though, by taking good care of yourself during your pregnancy, including
early prenatal care with testing for diabetes, sensible exercise, a balanced
diet, and avoidance of smoking and alcohol.
Can I refuse to have a Cesarean delivery?
You can legally refuse any medical treatment, including surgery. It makes
little sense, though, to trust someone with your health, and that of your
unborn child, and then refuse to follow that doctor's recommendations.
What is recovery like?
The common hospital stay after C-section is three days, not counting the
day of surgery. Limited activity is the hallmark of the first week at
home, with mild to moderate pain and discomfort in the incision. During
the following two to three weeks, most women advance to normal activities
with little pain, but with reduced stamina. Exercise and return to work
are usually allowed after six to eight weeks.
Will I always have to deliver by C-section?
The vast majority of C-section are performed using a transverse incision
low on the uterus, allowing that patient to labor in her next pregnancy.
Vaginal birth after Cesarean, or VBAC, is a common, safe, and generally
accepted practice these days. Each patient should discuss her individual
case with her doctor, however, as not all women are ideal candidates for
VBAC.
What about the incision?
There are two incisions to discuss with Cesarean births: the skin incision
and the uterine incision. The skin incision is almost always a transverse,
or "bikini", cut low on the abdomen. A few circumstances dictate the use
of a vertical skin incision in the midline from just above the pubic bone
to just below the belly button. In neither incision are the abdominal
muscles cut. Rather, the two strips of rectus muscles are only separated
in the midline and return to normal position after healing. The second
cut, the uterine incision, when done transversely (crossways) as is most
common, is the one that allows VBAC safely in the next pregnancy, regardless
of the type of skin incision that was done. A vertical incision on the
uterus, no matter the type of skin incision, requires a repeat Cesarean
section for all future deliveries, without exception. Vertical uterine
incisions are necessary in specific circumstances, such as extreme prematurity,
some cases with placenta previa, and certain unusual fetal positions in
the uterus.
Will I see or feel anything?
Epidural or spinal anesthesia, in which the woman is awake, but numb,
is the standard for C-section in the U.S. During the operation, which
lasts about 30 minutes, the patient may feel pressure or movement, but
should not experience any pain. An awake anesthetic is safer for the baby,
and permits the father of the baby to attend the delivery. Some C-sections
are performed under general anesthesia, where the woman is asleep. General
anesthetic is used for the direst emergency C-sections, or where an "awake
anesthesia" cannot be used.
Express your thoughts, fears, and preferences about C-section during your prenatal visits. You are likely to decrease your anxieties about your baby's birth if you are well-informed.