CS

INTRODUCTION

A cesarean delivery (also called a surgical birth) is a surgical procedure used to deliver an
infant. It requires regional (or rarely general) anesthetic to prevent pain, and then a
vertical or horizontal incision in the lower abdomen to expose the uterus (womb).
Another incision is made in the uterus to allow removal of the baby and placenta. Other
procedures, such as tubal ligation (sterilization), may also be performed during cesarean
delivery. (See "Patient information: Permanent sterilization procedures for women".)

Cesarean deliveries may be performed because of maternal or fetal problems that arise
during labor, or they may be planned before the mother goes into labor. More than 30
percent of births in the United States occur by cesarean delivery.

REASONS FOR CESAREAN DELIVERY

Some women who intend to deliver vaginally will eventually require cesarean delivery.
Reasons for this include the following:

• Labor is not progressing as it should. This may occur if the contractions are too
weak, the baby is too big, the pelvis is too small, or the baby is in an abnormal
position. If a woman's labor does not progress normally, the first step is usually to
rupture her membranes (bag of water). In many cases, the woman will be given a
medication (Pitocin®/oxytocin) to be sure that contractions are adequate for
several hours. If labor still does not progress after several hours, a cesarean
delivery may be recommended.
• The baby's heart rate suggests that it is not tolerating labor well. This may be due
to a placental problem or compression of the umbilical cord.
• The baby is in a sideways or breech position (buttocks first) when labor begins.
• Heavy vaginal bleeding. This can occur if the placenta separates from the uterus
before the baby is delivered (called a placental abruption).
• A medical emergency threatens the life of the mother or infant (see 'Emergency
cesarean delivery' below)

PLANNING CESAREAN DELIVERY

A planned cesarean delivery is one that is recommended because of the increased risk(s)
of a vaginal delivery to the mother or her infant. Cesarean deliveries that are done
because the woman wants, but does not require, a cesarean delivery are called "maternal
request cesarean deliveries". (See 'Maternal request cesarean delivery' below.)

There are a number of medical and obstetric circumstances that a healthcare provider
would recommend scheduling a cesarean delivery in advance, including the following:
 • The mother has had a previous cesarean delivery or other surgery in which the
uterus was cut open. A vaginal delivery is possible after cesarean delivery in
some, but not all cases. (See 'Future deliveries' below.)
• There is some mechanical obstruction that prevents or complicates vaginal
delivery, such as large fibroids or a pelvic fracture.
• The infant is unusually large, especially if the mother is diabetic. (See "Patient
information: Care during pregnancy for women with type 1 or 2 diabetes
mellitus".)
• The mother has an active infection, such as herpes or HIV, that could be
transmitted to the infant during vaginal delivery. (See "Patient information:
Genital herpes" and "Patient information: HIV and pregnancy".)
• The birth involves multiple gestation (twins, triplets, or more).
• The woman has cervical cancer.
• The infant has an increased risk of bleeding.
• The placenta is covering the cervix (called placenta previa).

There is some controversy about the preferred method of delivery in certain situations.
These include some birth defects, such as spina bifida and fetal abdominal wall defects,
and some maternal medical problems.

One of the most important factors in scheduling a cesarean delivery is making certain that
the baby is ready to be delivered. In general, cesarean deliveries are not scheduled before
the 39th week of pregnancy. An amniocentesis may be recommended to determine if the
baby's lungs are fully developed, especially if cesarean is planned before 39 weeks of
pregnancy.

Most women will meet with an anesthesiologist before planned surgery to discuss the
various types of anesthesia available and the risks and benefits of each. Instructions about
how to prepare for surgery will also be given, including the need to avoid all food and
drinks for 10 to 12 hours before the surgery.

Advantages of planned cesarean — The advantages of a planned cesarean delivery

include:

• It allows parents to know exactly when the baby will be born, which makes issues
related to work, childcare, and help at home easier to address.
• It avoids some of the possible complications and risks to the baby.
• It avoids the possibility of postterm pregnancy, in which the baby is born two or
more weeks after its due date.
• It helps ensure that a pregnant woman's obstetrician will be available for the
delivery.
• It may offer a more controlled and relaxed atmosphere, with fewer unknowns
such as how long labor and delivery will last.
• It may minimize injury to the pelvic muscles and tissues and the anal sphincters.
These injuries sometimes occur during vaginal delivery, which may increase the
risk of urinary or anal incontinence.
The benefits of planned cesarean delivery must be weighed against the risks. Cesarean
delivery is a major surgery, and has associated risks.

Risks — Because cesarean delivery involves major surgery and anesthesia, there are
some disadvantages compared to vaginal delivery.

• Cesarean delivery is associated with a higher rate of injury to abdominal organs

(bladder, bowel, blood vessels), infections (wound, uterus, urinary tract), and
thromboembolic (blood clotting) complications than vaginal delivery.
• Cesarean surgery can interfere with mother-infant interaction in the delivery
room.
• Recovery takes longer than with vaginal delivery.
• Cesarean delivery is associated with a higher risk that the placenta will attach to
the uterus abnormally in subsequent pregnancies, which can lead to serious
complications.
• Cutting the uterus to deliver the baby weakens the uterus, increasing the risk of
uterine rupture in future pregnancy. This risk is small and depends upon the type
of uterine incision.

Infant risks — There are few risk of cesarean delivery for the infant. One risk is birth
trauma, which occurs in 0.4 percent of cesarean deliveries. Temporary respiratory
problems are more common after cesarean birth because the baby is not squeezed through
the mother's birth canal. This reduces the reabsorption of fluid in the infant's lungs.

Potential complications — The most common complications related to cesarean delivery

include infection, hemorrhage (excessive bleeding), injury to pelvic organs, and blood
clots.

• Infection — The risk of postoperative uterine infection (endometritis) varies

according to several factors, such as whether labor had started and whether the
water was broken. Endometritis is treated with antibiotics.

Wound infection, if it occurs, usually develops four to seven days after surgery, but
sometimes appears during the first day or two. In addition to antibiotics, wound
infections are sometimes treated by opening the wound to allow drainage, cleansing with
fluids, and removing infected tissue if needed.

• Hemorrhage — One to two percent of all women having cesarean deliveries

require a blood transfusion because of hemorrhage (excessive bleeding).
Hemorrhage usually responds to medications that cause the uterus to contract.
Sometimes surgery, such as curettage (scraping the uterine cavity) is needed. In
rare cases, when all other measures fail to stop bleeding, a hysterectomy (surgical
removal of the uterus) may be required.
• Injury to pelvic organs — Injuries to the bladder or intestinal tract occur in
approximately one percent of cesarean deliveries.
 • Blood clots — Women are at increased risk of developing blood clots in the legs
(deep vein thrombosis or DVT) or the lungs (pulmonary embolus) during
pregnancy and the postpartum period. This risk is further increased after cesarean
delivery. The risk can be reduced by using a device that gently squeezes the legs
during and after surgery, called an intermittent compression device. Women at
high risk of DVT may be given an anticoagulant (blood thinning) medication to
reduce the risk of blood clots.

MATERNAL REQUEST CESAREAN DELIVERY

The concept of requesting a cesarean delivery is relatively recent. In the United States
and most Western countries, pregnant women have the right to make choices regarding
treatment, including how they will deliver their child.

A woman who wants to request a cesarean delivery should discuss this decision with her
healthcare provider. He or she can provide information about each method of delivery
and can help to relieve common fears about pain, the expected process of labor, as well as
the woman's right to determine how she will deliver. The woman should also discuss the
risks and benefits of maternal request cesarean delivery; in general, the risks are the same
as those of a planned cesarean delivery (see 'Risks' above). The woman should also
discuss the possible need for a cesarean delivery with future pregnancies (see 'Future
deliveries' below).

Regardless of a woman's decision, it is possible to reconsider the decision at any time

based upon a change in circumstances.

EMERGENCY CESAREAN DELIVERY

In some cases, cesarean delivery is performed as an emergency surgery, after attempting

a vaginal delivery. Time may be of the essence, depending upon the situation. Cesarean
deliveries performed due to concerns about the mother's or infant's health are started as
quickly as possible.

In contrast, if a cesarean is performed because labor has not progressed normally or for
other, less serious concerns about the baby's wellbeing, the surgery is usually begun
within 30 to 60 minutes.

If an epidural was placed before the attempted vaginal delivery, it can be used to
administer anesthesia for the cesarean delivery (a larger dose is necessary for cesarean
delivery versus vaginal delivery). Otherwise, spinal anesthesia (or rarely general
anesthesia) is given. (See 'Anesthesia' below.)

PROCEDURE

After being admitted to the hospital, a woman may be given an oral dose of an antacid to
reduce the acidity of the stomach contents. Another medication may be given to reduce
the secretions in the mouth and nose. An intravenous line will be placed into the hand or
arm, and an electrolyte solution will be infused. Monitors will be placed to keep track of
blood pressure, heart rate, and blood oxygen levels.

Anesthesia — The woman is usually accompanied to an operating room before anesthesia

is administered. A spouse or partner can usually stay with the woman in the operating
room.

There are two types of anesthesia used during cesarean delivery: regional and less
commonly, general. For a planned cesarean delivery, regional anesthesia is usually
performed. Meeting with the anesthesiologist allows the woman to ask specific questions
about anesthesia, and allows the anesthesiologist to identify any medical problems that
might affect the type of anesthesia that is recommended.

• With epidural anesthesia, the anesthetic is injected into the epidural space
surrounding the fluid-filled sac (the dura) around the spine. This numbs the
abdomen and legs.
• With spinal anesthesia, the anesthetic is injected into the subarachnoid space in
the lower back. The space contains the cerebrospinal fluid, so the anesthetic
causes complete numbness, although the person is still awake.
• General anesthesia induces unconsciousness. This means that the mother will not
be awake or aware during the procedure. After the anesthesia is given, the woman
will fall asleep within 10 to 20 seconds and a tube will be placed in the throat to
assist with breathing. General anesthesia carries a greater risk of complications
because the endotracheal (breathing) tube can cause a severe change in blood
pressure and because drugs given to the mother affect the infant.

Regional anesthesia is generally preferred because it allows the mother to remain awake
during the procedure, enjoy support from staff and a family member, experience the birth,
and have immediate contact with the infant. It is usually safer than general anesthesia.
Many practitioners prefer spinal or combined spinal epidural over epidural techniques
because of more rapid onset and better blockage of pain. The effect of regional anesthesia
begins within a minute or so.

After the anesthesia is given, a catheter is placed in the bladder to allow urine to drain out
during the surgery and reduce the chance of injury to the bladder. The catheter is usually
removed within 24 hours after the procedure.

Skin incision — There are two basic types of incision: horizontal (transverse or "bikini
line") and vertical (midline). Most women have a transverse skin incision, which is made
1 to 2 inches above the pubic hair line. The advantages of this type of incision include
less pain, more rapid healing, and a lower chance that the wound will separate during
healing.
Less commonly, the woman will have a vertical ("up and down") skin incision in the
midline of the abdomen. The advantages of this type of incision include rapid access to
the uterus (eg, if the baby is in distress or if the woman is bleeding excessively).

Uterine incision — The uterine incision can also be either transverse or vertical. The type
of incision depends upon several factors, including the position and size of the fetus, the
location of the placenta, and the presence of fibroids. The main consideration is that the
incision must be large enough to allow delivery of the fetus without causing trauma.

The most common uterine incision is transverse. However, a vertical incision may be
required if the baby is breech or sideways, if the placenta is in the lower front of the
uterus, or if there are other abnormalities of the uterus.

After opening the uterus, the baby is usually removed within a minute or two. After the
baby is delivered, the umbilical cord is clamped and cut and the placenta is removed. The
abdominal skin is closed with either metal staples or reabsorbable sutures; staples are
usually removed within 3 to 7 days while reabsorbable sutures are absorbed by the body
and do not need to be removed. After the mother and baby are stable, she or her partner
may hold the baby.

POSTOPERATIVE CARE

After surgery is completed, the woman will be monitored in a recovery area. Pain
medication is given, initially through the IV line, and later with oral medications.

When the effects of anesthesia have worn off, generally within one to three hours after
surgery, the woman is transferred to a postpartum room and encouraged to move around
and begin to drink fluids and eat food.

Breastfeeding can usually begin anytime after the birth. A pediatrician will examine the
baby within the first 24 hours of the delivery. Most women are able to go home within
three to four days after delivery. (See "Patient information: Deciding to breastfeed".)

The abdominal incision will heal over the next few weeks. During this time, there may be
mild cramping, light bleeding or vaginal discharge, incisional pain, and numbness in the
skin around the incision site. For up to 6 weeks after the birth, nothing should be placed
in the vagina (eg, tampons, douches). Heavy lifting and strenuous activity should be
avoided during the first one to two weeks. Most women will feel well by six weeks
postpartum, but numbness around the incision and occasional aches and pains can last for
several months.

After going home, the woman should notify her healthcare provider if she develops a
fever (temperature greater than 100.4º F [38º C]), if pain or bleeding worsens, or there are
other concerns.