One in every four babies in the United States is delivered surgically via Caesarean section (C-section), and the numbers are increasing. The primary reason for the increase in C-section rates is that newborns today tend to be larger than in years past. Newborns' increased size can be attributed to several factors: mothers are older, and older women tend to have bigger babies; fewer women are smoking; more women take vitamins, are better nourished, and receive prenatal care; and fewer babies are delivered prematurely.
Approximately half of all C-sections are performed on an emergency basis;
the other half are planned. Today, C-sections are safer than ever before.
The technique has been refined, and risks related to infection or anesthesia
are extremely unlikely.
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Emergency C-sections
The most common reason for an emergency C-section is the inability of
the baby to fit through the pelvic canal. In these cases, labor is unsuccessful
in delivering the baby vaginally. There's no reliable test to predetermine
whether a baby will be too large for a vaginal delivery, but guidelines
recommend a C-section if the pelvis is normal and a physical exam or a
sonogram determines that the baby weighs 10 pounds or more.
Fetal stress is another common reason for an emergency C-section. A typical and serious cause of fetal stress is placental abruption - the placenta disconnects from the wall of the uterus prior to delivery, depriving the baby of oxygen before birth. Other causes of fetal stress include an umbilical cord that becomes wrapped around the baby's arm, leg, or neck; a hole in the amniotic membrane; an overlong pregnancy; squeezing of the baby's head as it comes through the pelvic canal; or diminished amniotic fluid. Babies can also exhibit signs of stress for no apparent reason.
Malpresentation - when labor begins with the baby in a position that will likely make delivery more difficult and dangerous for both mother and baby -- is yet another reason for an emergency Cesarean. The most common malpresentation is breech birth, in which the baby is positioned to deliver feet first rather than head first. Other examples of malpresentations include a baby that is turned sideways or upwards, or has an arm or shoulder extending through the pelvic canal.
Planned C-sections
Planned C-sections are most common among women who have previously delivered
a baby via C-section. However, in many situations, it's safe for women
who have delivered via C-section to try a vaginal delivery for a subsequent
pregnancy. In assessing the risk, the most important consideration is
the reason for the initial C-section. If the first baby didn't fit through
the woman's pelvic canal, chances are the second one won't either. In
fact, with each subsequent pregnancy, the baby tends to be a little larger.
But if the first baby was a breech and the second is positioned head first,
the woman might want to try a vaginal delivery.
For women who are diabetic; or developed a fever or an infection; or experienced a prolonged difficult recovery, excessive bleeding, or anemia following their first C-section delivery, it would be safer to consider an elective repeat C-section. Finally, in evaluating the safety of attempting a vaginal delivery in a woman who has already had a C-section the obstetrician also has to consider the small risk that the pre-existing C-section scar may cause the uterus to rupture in labor, resulting in injury to the baby.
Multiple pregnancies are another reason for planned C-sections. Pregnancies involving three or more babies should always be delivered via C-section. If a vaginal delivery is attempted, by the time the second baby has been delivered the third will be in stress. The majority of twins can be delivered vaginally. Mothers carrying twins frequently go into labor before their due date, so the babies are generally smaller and easier to deliver. But twins should be delivered via C-section if one baby is a breech or if one baby is too big.
Some women plan C-sections because of a traumatic first delivery that caused damage or pain. But they should be aware that second babies come much more easily than first ones.
Then there are women who elect to have a Cesarean for personal reasons. Patient choice, once a controversial issue, has been endorsed by the American College of Obstetricians and Gynecologists. If there is informed consent and the patient refuses to consider a vaginal delivery, doctors may ethically offer a patient the choice of a Cesarean.
What to Expect
If you have a C-section, here's what you can expect. After the anesthesiologist
administers anesthesia (usually a spinal), the obstetrician makes an incision,
opening the uterus, without cutting muscle fibers. Four to five minutes
later, the baby is delivered through the incision. You will be awake throughout
the procedure, and can watch the delivery on a mirror if you wish. Most
fathers are present in the delivery room, but the support person can be
anyone close to you.
The closing is done in a criss-cross to enhance strength - a technique called Phannenstiel, which leaves a small horizontal scar, known as a bikini cut, above the pubic bone. This incision is very unlikely to open.
Spinal anesthesia lasts about 24 hours, so pain is not a big factor on the first day after the surgery. You'll be able to get out of bed, eat, walk around, shower, and care for your baby. You may have some pain the next day but it won't be disabling, and you'll probably go home on the third day after delivery.
At home, you can expect to function normally although you may be hesitant on stairs and experience fatigue, which is a normal part of the childbirth process. You should be cognizant of postpartum depression, a hormonal condition that can occur after either a vaginal or cesarean delivery. Speak to your physician if you have unclear thoughts and feelings of guilt, sadness, or crying.
If complications requiring a C-section should occur, it helps to understand what is involved. In considering a planned C-section, you and your physician should discuss the risk of not performing the procedure. Keep in mind that a scheduled Cesarean is easier than a prolonged, difficult vaginal delivery.