Caesarean section, or C-section as it is commonly known, is a surgical method of delivery of a baby through an incision made in the mother’s abdomen and into the uterus instead of delivery through the vagina. It has been in practice for centuries throughout the world.

The Centers for Disease Control and Prevention (CDC) report that C-sections accounted for about 29 percent of all deliveries in the United States during 2004 – the highest rate ever reported. This number includes women who have a C-section for the first time and those who have a repeat procedure with a second or third child.

Some health experts believe that this form of delivery is overused, often because the patient requests a Caesarean that is not medically necessary. Such “Caesarean on demand” procedures place the mother and her baby at unnecessary risk for surgical or delivery-related complications. The World Health Organization recommends that Caesarean rates should be no higher than 10 to 15 percent in any country.

There are many reasons for an obstetrician to recommend the use of a Caesarean delivery. Most reasons are related to the status of the baby, while others have to do with the mother. Some of the most common reasons include abnormal presentation (such as when the baby is in the breech position), fetal distress (the baby’s heart rate is too slow or too rapid), multiple births, prolonged or ineffective labor, or maternal health. Unlike a vaginal delivery, a Caesarean section is considered major abdominal surgery. This entire procedure normally lasts 45 minutes to an hour, although the baby is typically born in the first five to 10 minutes.

A hospital stay of three to five days following the C-section is normally required. It may take the mother as much as four to six weeks to fully resume normal activities.

As with any surgical procedure, there are certain risks to having a C-section and the recovery time is longer than with vaginal birth. However, serious complications are rare for mother and baby.

Caesarean section, or C-section as it is commonly known, is a method of delivering a baby through an incision made in the mother’s lower abdominal wall and uterus instead of delivery through the vagina. The origins of the name are unclear. Although widely believed to be named for Julius Caesar, it is unlikely that this surgical procedure was used at the time of his birth. It may have been so named because of a law, enacted under Julius Caesar’s rule, which required this form of birth when a mother was sick or dying.

According to the Centers for Disease Control and Prevention (CDC), there are more than 700,000 first-time C-sections and 400,000 repeat Caesarean deliveries each year. The total number of C-sections accounted for approximately 29 percent of all births during 2004, the highest rate ever reported in the United States. The following table shows a further breakdown of each type of delivery:

Source: CDC’s National Center for Health Statistics

Caesarean delivery has generated a great deal of debate. Some experts believe that this form of delivery is overused and places the mother and baby at unnecessary risk for surgical or delivery-related complications. According to the CDC, C-section rates have been rising since 1996, and in 2004 the highest percentage of C-sections ever in the United States were performed. In a study conducted by the U.S. Agency for Healthcare Research, C-section was determined to be the most common hospital procedure in the United States. The surgeries were estimated to cost a total of 14.6 billion dollars in 2003.

In many cases, it is the patient who requests a Caesarean section. A growing number of expectant mothers are choosing a C-section in an effort to avoid future pelvic support or sexual dysfunction problems, as well as for other reasons. Between 2001 and 2003, the rate of C-sections performed due to patient-choice increased by nearly twice as much as those performed between 1999 and 2001.

A physician is said to be ethically justified in performing the procedure, called “patient choice Caesarean” or “Caesarean on demand,” as long as it poses no additional risk to the mother or her unborn child, according to the American College of Obstetricians and Gynecologists (ACOG). However, if the procedure would not promote the overall health and welfare of the patient and her fetus, then the physician is ethically obligated to abstain from the procedure.

In most cases, the Caesarean section is used only after the obstetrician has carefully considered the patient’s individual condition in relation to the pregnancy and has determined that it is medically necessary. This determination may be made at any time during the patient’s prenatal visits, but most often is evident only after labor begins.

There are many reasons that an obstetrician may determine that a Caesarean delivery is advisable for a healthy and safe delivery. Most reasons are related to the status of the baby, while others have more to do with the mother. In general, the most common reasons for a C-section include:

Reasons related to the baby:

• Abnormal presentation. This includes situations such as when a baby is breech (entering the birth canal upside down – either feet or buttocks first) or transverse (shoulders or side first). Some breech babies can be manually turned to the head down position by the obstetrician (a process called external cephalic version).
  
  
• Prolapsed umbilical cord. When the umbilical cord enters the vagina before the baby during labor it creates a risk of strangulation or possibly block the progress of a vaginal delivery.
  
  
• Placenta previa. At times, the placenta (organ that connects the mother and her baby) drops so low in the uterus that there is a risk that it can block the cervix and keep the baby from passing easily through the birth canal. Placenta previa can also lead to hemorrhaging (severe bleeding). This condition is more common among expectant mothers who smoke, use cocaine or are over the age of 35 years. In addition, the scar created by the surgical incision during a C-section can increase the risk of placenta previa in future pregnancies.
  
  
• Placenta abruptio. At times, it is possible for the placenta to disengage from the uterine wall just before delivery, which can cause the baby to have an abnormal heart rate and the mother to hemorrhage. New research also finds a link between C-section deliveries and placenta abruptio in later pregnancies. In addition, the risk of both placenta previa and placenta abruptio is greater if a second pregnancy occurs within a year of a Caesarean delivery.
  
  
• Developmental abnormalities. In the case of a baby that has birth defects, such as hydrocephalus (a condition where cerebrospinal fluid collects on the brain and may result in an enlarged head) or spina bifida, a C-section may be indicated.
  
  
• Fetal distress. When the baby has an abnormal heart rate pattern – either too slow or too rapid.
  
  
• Multiple births. In the case of twins or triplets (or more), a Caesarean section is often considered a safer method of delivery.

Reasons related to the mother:

• Maternal illness. Certain diseases and conditions in the mother may indicate the need for a C-section. Some examples include:
  
• • High blood pressure (hypertension)
    
    
  • Heart disease
    
    
  • Preeclampsia or eclampsia
    
    
  • Gestational diabetes
    
    
  • Genital herpes outbreak at the time of delivery
    
    
  • Maternal HIV infection
    
    
  • Ovarian or uterine cysts or tumors
    
    
  • Previous Caesarean delivery. Previous surgery in the uterus, including C-section and myomectomy. However, a woman who has had a C-section may still be able to deliver vaginally for subsequent pregnancies.
    
    
• Placenta accreta. Rarely, the placenta will attach deeply to the wall of the uterus. This condition is dangerous to the health of the mother. A history of multiple Caesarean deliveries increases the risk. This condition frequently remains undiagnosed before delivery and, although rare, can result in excessive bleeding and the need for a hysterectomy to be performed at the time of delivery.
  
  
• Prolonged or ineffective labor. A C-section may be performed in the case of prolonged or arrested labor, such as insufficient contractions of the uterus or if the cervix does not dilate sufficiently. Physicians’ opinions differ in the determination of what constitutes a prolonged or ineffective labor.
  
  
• Cephalopelvic disproportion. This is a condition in which the baby’s head is too large or the mother’s birth canal or pelvis is not large enough to ensure a safe vaginal delivery.
  
  
• Polyhydramnios. This condition is characterized as a pregnant woman having too much amniotic fluid. In many cases, polyhydramnios will go away by itself. When that does not occur, women with this condition are more likely to have a C-section.
  
  
• Oligohydramnios. This condition is characterized as a pregnant woman having too little amniotic fluid. In some cases where this condition is causing fetal distress, a C-section may be necessary.

Prior to surgery, the obstetrician will take a medical history and perform a physical examination to evaluate the overall physical health of the patient as part of her prenatal care, especially if the Caesarean section is planned in advance. During the presurgical consultation, the surgical technique, the type of anesthesia to be used and the patient’s expectations are normally discussed.

If the C-section was planned, the expecting mother will most likely meet with an anesthesiologist prior to the procedure. This meeting is an opportunity to discuss the options for anesthesia. It is also a good time to discuss any concerns or known disorders with the anesthesiologist including coagulopathy (clotting disorder), obesity, any abnormalities of the spine, as well as a personal history of cardiovascular or respiratory diseases.

The type of anesthesia will be determined based on the condition of the mother and her baby. It will also depend on the reasons for the Caesarean delivery (e.g., in emergencies general anesthesia may be necessary). The three most common options include:

• Spinal anesthetic. This form of anesthesia is administered at the subarachnoid space in the lower back, which contains the cerebrospinal fluid. This causes total numbness, but the mother is still awake.
  
  
• Epidural anesthesia. When this type of anesthesia is used, the medication is injected in the epidural space that surrounds the fluid-filled sac around the spine. This form of anesthesia numbs the mother’s abdomen and legs.
  
  
• General anesthesia. This form, which keeps the mother asleep during the entire procedure, is used less often.

Patients may be asked to donate blood in case a transfusion later becomes necessary, although it is unlikely. Patients are typically asked to refrain from eating or drinking for eight to 12 hours prior to surgery.

Before the procedure, the patient will be prepared for surgery. This includes the abdomen being prepped with special antiseptic solutions and occasionally shaved. A catheter (small tube) is also placed in the bladder, allowing urine to empty into it. Other preparations will include a small tube being placed in the vein of the patient’s arm to allow for fluids and medications, including possibly anesthesia, during surgery.

Prior to the procedure, the woman’s arms are often secured to the table for her own safety. Depending on the standard procedures of the individual physician, the patient may be given an oral dose of an antacid to lower the amount of acid in the stomach. It is also possible that the patient will be given medication to decrease the amount of secretions of the mouth and nose.

Shortly before the anesthesia is administered, a curtain is hung across the woman’s chest to prevent any adverse reaction by the patient or her spouse in viewing the procedure, and to maintain a sterile operating field. At all times, the patient’s blood pressure, heart rate and rhythm and blood oxygen level are monitored closely.

After the woman is anesthetized, an incision is made in the abdomen. There are two types of incisions that can be used for a Caesarean delivery:

• Vertical or longitudinal incision. This incision starts at the navel and extends down to the pubic hairline. The advantage of this type of incision is that the surgeon can have fast access to the abdominal cavity and reduce the amount of time the woman is under anesthesia. There is also less blood loss associated with this particular type of incision.
  
  
• Transverse or horizontal incision. The transverse incision is commonly referred to as the “bikini cut” because the incision’s scar is often hidden beneath a woman’s bikini bathing suit. This incision runs across the pubic hairline or sometimes slightly above it. After the first incision in the abdomen, the surgeon often makes a horizontal incision in the lower part of the uterus. The advantage of this type of incision is that the woman experiences less postoperative pain during recovery. Additionally, there is a lower rate of medical complications, such as the incision separating.

For women who have epidurals and are thus awake during the procedure, it is possible to feel some pulling, tugging or even some pressure in the abdominal area. After the incision is made, the obstetrician will gently remove the baby and the placenta (organ that connects the mother and her baby) from the uterus. Many times the baby will be taken out manually, but occasionally forceps or a vacuum extractor will be used.

Once the baby is removed, fluids are cleared from the baby’s nose and mouth using suction. The umbilical cord is then clamped and cut.

Finally, the uterus is stitched securely back together using stitches that will dissolve on their own. The abdomen is then closed using either stitches, staples, a combination of the two or a type of skin glue.

Approximately six to eight hours after delivery, the catheter is removed from the urethra and the new mother will be encouraged to get out of bed and walk around (with aid). Starting to walk after a C-section can be challenging and painful. Also, a significant amount of gas may accumulate in the abdomen following this type of surgery. The gas and pain both begin to decrease after the patient becomes mobile.

After the procedure, the new mother is typically given antibiotics to reduce the risk of infection. In addition, the mother will be given necessary pain medication. Patients are monitored closely for 24 hours following delivery to ensure there are no problems, including excessive bleeding and difficulties with urination and bowel movements.

Unlike a vaginal delivery, a Caesarean is considered major abdominal surgery even though the entire procedure normally lasts only about 45 minutes to an hour. This procedure normally requires a hospital stay of three to five days.

After the woman is discharged from the hospital, she should expect her abdomen to take a few weeks to heal. During the recovery period, mild cramping, pain at the site of the incision, vaginal bleeding or discharge for four to six weeks and bleeding with clots and cramps are all normal.

To reduce the possibility of infection, women are advised not to place anything in their vagina, including tampons, for several weeks. Resuming sexual intimacy should also wait several weeks. It may take the mother as much as four to six weeks to resume normal activities.

Although Caesarean section is considered a relatively safe procedure, it is still surgery and therefore has risks. There is less risk for the baby than there is for the mother as this procedure is often performed for the benefit of the unborn child.

The risks associated with a Caesarean delivery include those from anesthesia, those related to surgery and those that are specific to this procedure. Caesarean births are more painful, more expensive and have a longer recuperation period than vaginal births. Some of the most common potential risks associated with a Caesarean delivery include:

For the mother:

• Reactions to the anesthesia
• Difficulty breathing from the medications
• Increased bleeding
• Blood clots in the legs, pelvic organs and sometimes the lungs
• Infection at the wound site
• Bladder, vaginal or uterine infection
• Placenta previa, placenta accreta and placenta abruptio (in later pregnancies)
• Injury to the urinary tract or bowel

For the baby:

• Injury or trauma to the baby due to the use of surgical or obstetrical devices to remove the baby from the womb (rare)
  
  
• Premature delivery or low birth weight (if the due date is not calculated accurately)
  
  
• Transient respiratory problems due to lung fluid not being reabsorbed by the fetus unless the baby passes through the birth canal

Newborns who are delivered via planned C-section also may be more likely to be transferred to a neonatal intensive care unit (NICU) and to experience lung disorders compared with those infants who are delivered via planned natural (vaginal) childbirth, according to a new study. More research is needed to establish this link.

In addition to the risks during the procedure, there are sometimes difficulties with the mother having a vaginal birth after a C-section. According to the National Institutes of Health (NIH), about two-thirds of women who attempt a vaginal birth after Caesarean (VBAC) are successful. When a woman chooses to have VBAC, it is recommended that the birth take place in a hospital and not a birthing center to ensure adequate care in case of complications.

Reports from the Centers for Disease Control and Prevention (CDC) indicate that VBACs have declined by 67 percent between 1996 and 2004 in the United States. According to the CDC, the total number of VBACs now account for slightly more than 9 percent of all deliveries. Those who do elect to have a VBAC should be aware of a slight risk of uterine rupture, which can be dangerous to both the mother and baby. This risk is reduced if the type of incision made in the uterus during the initial C-section was placed horizontally across the lowest part of the uterus (low transverse incision). Many hospitals now have stricter protocols that set the guidelines for allowing VBACs to labor normally because of the increased potential risks and liability.

In addition to these risks, C-sections also require additional recuperation time compared to a vaginal delivery. The average hospital stay following a C-section is three to five days. This is much longer than that of a natural (vaginal) birth. There is also a considerable amount of pain from this surgery, but it usually can be controlled with oral medications.

For women who have had two or more Caesarean deliveries, it is possible for a significant amount of scar tissue to develop in and around the uterus. Scar tissue development increases the risk of the mother developing chronic pelvic pain. In addition, it makes each successive C-section increasingly more complicated. For example, the risk of placenta previa (where the placenta covers the cervix), placenta accreta (the placenta grows too deeply into the uterus and adheres too tightly) and placenta abruptio increases with the number of Caesareans a woman has.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions regarding Caesarean delivery:

1. How many of the pregnancies in your practice result in Caesarean deliveries?
   
   
2. What do you consider to be a normal progression of labor?
   
   
3. What does surgery for Caesarean delivery involve?
   
   
4. When would it be decided that I need a C-section?
   
   
5. Is there anything I can do to avoid having a Caesarean delivery?
   
   
6. What are the disadvantages involved in Caesarean delivery?
   
   
7. What risks does C-section present for my baby and myself?
   
   
8. How would I prepare for this type of delivery?
   
   
9. What are my anesthesia options with a C-section?
   
   
10. What type of incision will be made in my abdomen and uterus?
    
    
11. How long will it take to deliver my baby by C-section?
    
    
12. Will my partner be able to participate in the delivery?
    
    
13. How long will it take for me to recover?
    
    
14. What activities will be restricted following C-section?
    
    
15. What are the chances that I can deliver vaginally in subsequent pregnancies?