By Sujatha Rajagopal
What you should know before going under the knife
A caesarean section refers to the surgical method of delivering a child. It involves bringing baby out into the world by making an incision on your abdomen and uterus.
The caesarean section is not new. Records show that it has been practised since ancient times in both Western and non-Western cultures. In fact, some experts think that the term ‘caesarean’ is coined from the surgical birth of Julius Caesar. Others believe that the term stems from a Roman decree under Caesar to have infants cut open to save their lives. From about 1598, caesarean delivery began to be referred to as a “section”, and not an “operation”, after the publication of Jacques Guillimeau’s book on midwifery.
Like any invasive medical procedure, the C-section, as caesarean delivery is now popularly known, has both pros and cons. While it is riskier than vaginal delivery, with various disadvantages like infections, slower recovery, more postpartum pain and a longer hospital stay, it has also saved countless lives.
When is a caesarean required?
A C-section can be planned (that is, your doctor has made it clear that you need surgery before you go into labour) or unplanned.
You may need a planned C-section if:
- You have had a classical (vertical incision) C-section or more than one previous C-section. Do note that if you’ve had a previous C-section with a horizontal incision, you may still be able to have a vaginal birth after caesarean (VBAC) for this pregnancy.
- You have had some other form of uterine surgery.
- You’re having a multiple gestation, especially triplets or more.
- You’re having a large baby.
- You’re diabetic and have had a traumatic vaginal delivery or large baby prior to this one.
- Your baby is in a breech (bottom-first) or transverse (sideways) position, or presents a shoulder to the birth canal.
- You have placenta previa, where the placenta lies so dangerously low that it covers the cervix.
- Your baby has an illness or malformation that may cause grave risk during vaginal birth.
- You are HIV positive and have a high viral load nearing the end of your pregnancy.
You may need an unplanned C-section if labour should not be continued for any of these reasons:
- The cervix stops dilating or baby stops moving down the birth canal, and attempts to get contractions going again don’t work.
- Your baby’s heart rate gives concern and your doctor feels that inducing labour or continuing vaginally will be risky.
- The umbilical cord slips through the cervix (prolapsed cord) and may cut off baby’s oxygen supply.
- You have placental abruption where the placenta separates from the uterus and baby may die if not delivered right away.
- You have active genital herpes and baby might be exposed to the infection.
Recently, some arguments have surfaced that a C-section can help prevent injury to pelvic floor muscles and the anal sphincter. Damage to these areas can lead to bladder and bowel control problems for the mother. Such damage can be caused by an episiotomy or vaginal instrumental delivery (e.g. forceps). However, there is no conclusive evidence that a C-section can offer long-term protection from these problems. If your doctor suggests a planned C-section, do discuss the reasons with him or her thoroughly before you agree.
What happens during a C-section
A C-section normally takes about an hour to perform. Some of the initial steps involved in preparing you for the surgery include getting your official consent, prepping you with anaesthesia, and shaving off the top section of your pubic hair. Depending on the urgency of surgery, your husband may or may not be allowed to accompany you into the operating room.
Once the anaesthesia has taken effect, your belly will be swabbed with an antiseptic solution and your doctor will make a horizontal incision above your pubic bone. She will cut through underlying tissue layer by layer as she works her way to your uterus. Once she has reached the uterus, your doctor will either make a horizontal cut, or in rare cases, a vertical cut. Vertical cuts are usually made only if your baby is premature and your uterus wall is still not thin enough for cutting.
Once the uterus has been exposed, your doctor will reach in and pull baby out. As you would most probably have received only an epidural to numb the lower half of your body, you may actually be awake and able to witness the moment when the doctor pulls baby out!
You may then be able to see baby for a brief moment before a nurse or paediatrician takes over to examine him. Your doctor, meanwhile, will deliver the placenta. After baby has been examined, you can hold and nuzzle him while your doctor stitches you up. Closing up your belly can take a long time and once it’s done, you will be wheeled to a recovery room where you will be monitored. Depending on your health and baby’s health, you may be able to hold and even breastfeed baby in the recovery room.
After about three to four days, your stitches will be removed and if all is well, you should be able to bring baby home.
Potential risks of a C-section
While the C-section may proceed without problems, there can be short and long-term risks. Having a C-section can also affect future pregnancies.
Short-term or immediate risks include:
- More postpartum pain and longer recovery period, with some women still complaining of pain and discomfort eight weeks after delivery. This can make adapting to motherhood more stressful than is usual.
- Surgical complications, such as internal bleeding, pelvic infection or blood clots. One study of women in Washington State, USA, found that C-section patients had almost double the risk of re-admission after delivery than women who had vaginal births.
- Injury to the baby or baby born in poor condition (with a low Apgar score).
- Maternal death. A Dutch study has found that C-sections cause seven times more deaths than vaginal births.
Long-term risks include:
- Negative maternal feelings about the way baby was delivered, such as feeling the loss of a natural birthing experience. This may occur even if the mother was agreeable to the C-section prior to surgery.
- Scar tissue adhesions that can cause pelvic pain, pain during intercourse or bowel problems.
- Risks for future pregnancies. One study shows that a previous C-section leads to a 25% chance of having an ectopic pregnancy (embryo implants outside of uterus). Other complications include infertility, placenta previa, placental abruption and uterine rupture.
Many times, the need for a caesarean is based on the obstetrician’s judgment. Usually, it will be suggested only if the benefits outweigh the risks. If for some reason you require a C-section, do take comfort that while you were not able to experience giving birth naturally, your baby is safe and in good health thanks to the procedure.