Definition
Cesarean delivery — also known as
a C-section — is a surgical procedure used to deliver a baby through incisions
in the mother's abdomen and uterus.
A C-section might be planned
ahead of time if you develop pregnancy complications or you've had a previous
C-section and aren't considering vaginal birth after cesarean (VBAC). Often,
however, the need for a first-time C-section doesn't become obvious until labor
is underway.
If you're pregnant, knowing what
to expect during a C-section — both during the procedure and afterward — can
help you prepare.
Uses
A
7-week old Caesarean sectionscar and linea nigra visible on a 31-year-old mother.
Caesarean section is recommended when vaginal delivery might pose a risk to the
mother or baby. C-sections are also carried out for personal and social
reasons. Systematic reviews have found no strong evidence about the impact of
caesareans for non-medical reasons. Recommendations
encourage counseling to identify the reasons for the request, addressing
anxieties and information, and encouraging vaginal birth. Elective caesareans at 38 weeks showed
increased health complications in the newborn. For this reason, planned caesarean sections (also known as elective caesarean
sections) should not be scheduled before 39 weeks gestational age unless there
is very good medical reason to do so.
Medical uses
Some medical indications are below. Not
all of the listed conditions represent a mandatory indication, and in many
cases the obstetrician must use discretion to decide whether a Caesarean is
necessary. This decision is a complex one and many factors need to be taken
into account.
Complications
of labor and factors increasing the risk associated with vaginal delivery, such
as:
·
abnormal presentation (breech or transverse
positions)
·
uterine
rupture or an elevated
risk thereof
·
increased blood pressure (hypertension)
in the mother or baby after amniotic
rupture (the waters
breaking)
·
increased heart rate (tachycardia)
in the mother or baby after amniotic rupture (the waters breaking)
·
placental problems (placenta
praevia, placental abruption or placenta
accreta)
·
failed labour
induction
·
large baby weighing >4000g (macrosomia)
·
umbilical cord abnormalities (vasa previa,
multilobate including bilobate and succenturiate-lobed placentas, velamentous
insertion)
Other
complications of pregnancy, pre-existing conditions and concomitant disease,
such as:
·
previous (high risk) fetus
·
HIV infection of the mother with a high
viral load (HIV with a low maternal viral load is not necessarily an indication
for caesarean section)
·
Sexually transmitted diseases, such as a
first outbreak of genital herpes very recently before the onset of labour
(which can cause infection in the baby if the baby is born vaginally)
·
previous classical (longitudinal)
Caesarean section
·
previous uterine rupture
·
prior problems with the healing of the perineum (from previous childbirth or Crohn's
disease)
·
Rare cases of posthumous
birth after the death
of the mother
Other
·
Decreasing experience of accoucheurs
with management of the breech presentation — since the publication of the Term
Breech Trial it is clear that planned caesarean section in women presenting at
term in their first pregnancy with a breech presentation has a lower risk of
infant death than planned vaginal breech delivery. Although obstetricians and midwives
are extensively trained in proper procedures for such deliveries using
simulation mannequins, there is decreasing experience with actual vaginal
breech delivery which may increase the risk further.)
Prevention
It is generally agreed that the
prevalence of caesarean section is higher than needed in many countries and
physicians are encouraged to actively lower the rate. Some of these efforts
include: emphasizing that a long latent phase of
labor is not abnormal and thus not a justification for C-section a new
definition of the start of active labor from a cervical dilatation of 4 cm
to a dilatation of 6 cm; and allowing at least 2 hours of pushing for
women who have previously given birth and 3 hours of pushing for women who have
not previously given birth before labor arrest is considered. Physical exercise during pregnancy also decreases the
risk.
Risks
Recovery from a C-section takes longer than does recovery
from a vaginal birth. And like other types of major surgery, C-sections also
carry risks.
Risks to your baby include:
·
Breathing problems. Babies
born by scheduled C-section are more likely to develop transient tachypnea — a
breathing problem marked by abnormally fast breathing during the first few days
after birth. C-sections done before 39 weeks of pregnancy or without proof of
the baby's lung maturity might increase the risk of other breathing problems,
including respiratory distress syndrome — a condition that makes it difficult
for the baby to breathe.
·
Surgical injury. Although
rare, accidental nicks to the baby's skin can occur during surgery.
Risks to you include:
·
Inflammation and infection of the membrane lining the uterus. This
condition — known as endometritis — can cause fever, foul-smelling vaginal
discharge and uterine pain.
·
Increased bleeding. You're
likely to lose more blood with a C-section than with a vaginal birth. However,
transfusions are rarely needed.
·
Reactions to anesthesia. Adverse
reactions to any type of anesthesia are possible. After a spinal block or
combined epidural-spinal anesthesia — common types of anesthesia for C-sections
— it's rare, but possible, to experience a severe headache when you're upright
in the days after delivery.
·
Blood clots. The
risk of developing a blood clot inside a vein — especially in the legs or
pelvic organs — is greater after a C-section than after a vaginal delivery. If
a blood clot travels to your lungs (pulmonary embolism), the damage can be
life-threatening. Your health care team will take steps to prevent blood clots.
You can help, too, by walking frequently soon after surgery.
·
Wound infection. Infections
are more common with C-sections compared to vaginal deliveries. C-section
infections are generally found around the incision site or within the uterus.
·
Surgical injury. Although
rare, surgical injuries to nearby organs — such as the bladder — can occur
during a C-section. Surgical injuries are more common if you have multiple
C-sections. If there is a surgical injury during your C-section additional
surgery might be needed.
·
Increased risks during future pregnancies. After
a C-section, you face a higher risk of potentially serious complications in a
subsequent pregnancy — including problems with the placenta — than you would
after a vaginal delivery. The risk of uterine rupture, when the uterus tears
open along the scar line from a prior C-section, is also higher if you attempt
vaginal birth after C-section (VBAC).
Classification
Caesarean
sections have been classified in various ways by different perspectives. One way to discuss all classification
systems is to group them by their focus either on the urgency of the procedure,
characteristics of the mother, or as a group based on other, less commonly
discussed factors.
It is most
common to classify caesarean sections by the urgency of performing them.
By urgency
Conventionally, caesarean sections are
classified as being either an elective surgery or an emergency operation. Classification is used to help
communication between the obstetric, midwifery and anaesthetic team for
discussion of the most appropriate method of anaesthesia. The decision whether
to perform general anesthesia or regional anesthesia (spinal or epidural anaesthetic) is
important and is based on many indications, including how urgent the delivery
needs to be as well as the medical and obstetric history of the woman. Regional anaesthetic is almost always
safer for the woman and the baby but sometimes general anaesthetic is safer for
one or both, and the classification of urgency of the delivery is an important
issue affecting this decision.
A planned caesarean (or
elective/scheduled caesarean), arranged ahead of time, is most commonly
arranged for medical indications which have developed before or during the
pregnancy, and ideally after 39 weeks of gestation. In the UK this is
classified as a 'grade 4' section (delivery timed to suit the needs of the
service) since there is no rush in these situations. Emergency caesarean
sections (those where vaginal delivery has been planned beforehand, and the
indication for section has developed since this plan was agreed, usually after
assessment by a healthcare professional) are classified in the UK as grade
3(delivery within 4 hours of the decision, no maternal or fetal compromise),
grade 2 (delivery required within 90 minutes of the decision but no immediate
threat to the life of the woman or the fetus) or grade 1 (delivery required
within 30 minutes of the decision: immediate threat to the life of the mother
or the baby)
Elective caesarean sections may be
performed on the basis of an obstetrical or medical indication, or because of a
medically non-indicated maternal request. Among
women in the United Kingdom, Sweden and Australian about 7% preferred caesarean
section as a method of delivery. In
cases without medical indications the American Congress of
Obstetricians and Gynecologists and
the UK Royal College of Obstetricians and Gynaecologists recommend a planned
vaginal delivery. The National Institute
for Health and Care Excellence recommends
that if after a women has been provided information on the risk of a planned
caesarean section and she still insists on the procedure it should be provided. If provided this should be done at 39
weeks of gestation or later.
By characteristics of the mother
Caesarean delivery on maternal
request
Caesarean delivery on maternal request
(CDMR) is a medically unnecessary caesarean section, where the conduct of a childbirth via a caesarean section is requested
by the pregnant patient even though there is not a
medical indication to
have the surgery.
After previous Caesarean
Mothers who have previously had a
caesarean section are more likely to have a caesarean section for future
pregnancies than mothers who have never had a caesarean section. There is
discussion about the circumstances under which women should have a vaginal
birth after a previous caesarean.
Vaginal birth after caesarean (VBAC) is
the practice of birthing a baby vaginally after a previous baby has
been delivered by caesarean section (surgically). According to The American Congress
of Obstetricians and Gynecologists (ACOG),
successful VBAC is associated with decreased maternal morbidity and a decreased
risk of complications in future pregnancies. According
to the American Pregnancy Association, 90% of women who have undergone
caesarean deliveries are candidates for VBAC. Approximately
60-80% of women opting for VBAC will successfully give birth vaginally, which
is comparable to the overall vaginal delivery rate in the United States in
2010.
Twins
For otherwise healthy twin pregnancies
where both twins are head down a trial of vaginal delivery is recommended at
between 37 and 38 weeks.[8][29] Vaginal delivery in this case does not
worsen the outcome for either infant as compared with caesarean section. There is controversy on the best
method of delivery where the first twin is head first and the second is not. When
the first twin is not head down at the point of labour starting, a caesarean
section should be recommended. Although the second twin typically has a higher
frequency of problems, it is not known if a planned caesarean section affects
this. It is estimated that 75% of
twin pregnancies in the United States were delivered by caesarean section in
2008.
Breech birth
A breech birth is the birth of a baby from a breech presentation, in which the baby exits the
pelvis with the buttocks or feet first as opposed to the normal head-first presentation. In breech
presentation, fetal heart sounds are heard just above the umbilicus.
The bottom-down position presents some
hazards to the baby during the process of birth, and the mode of
delivery (vaginal versus caesarean) is controversial in the fields of obstetrics and midwifery.
Though vaginal birth is possible for the breech baby,
certain fetal and maternal factors influence the safety of vaginal breech
birth. The majority of breech babies born in the United States and the UK are
delivered by caesarean section as studies have shown increased risks of
morbidity and mortality for vaginal breech delivery, and most obstetricians
counsel against planned vaginal breech birth for this reason. As a result of
reduced numbers of actual vaginal breech deliveries, obstetricians and midwives
are at risk of de-skilling in this important skill. All those involved in
delivery of obstetric and midwifery care in the UK undergo mandatory training
in conducting breech deliveries in the simulation environment (using dummy
pelvises and mannequins to allow practice of this important skill) and this
training is carried out regularly to keep skills up to date.
Resuscitative hysterotomy
A resuscitative hysterotomy,
also known as a peri-mortem caesarean delivery, is an emergency caesarean
delivery carried out where maternal cardiac arrest has occurred, to assist in resuscitation of the mother by removing the aortocaval compression generated by the gravid uterus. Unlike
other forms of caesarean section, the welfare of the fetus is a secondary
priority only, and the procedure may be performed even prior to the limit of fetal viability if it is judged to be of benefit to
the mother.
Other ways, including by surgery
technique
There are several types of caesarean
section (CS). An important distinction lies in the type of incision
(longitudinal or transverse) made on the uterus,
apart from the incision on the skin: the vast majority of skin incisions are a
transverse suprapubic approach known as a Pfannenstiel incision but there is no way of knowing from
the skin scar which way the uterine incision was conducted.
·
The classical caesarean section involves
a midline incision on the uterus longitudinal incision which allows a larger space to deliver
the baby. It is performed at very early gestations where the lower segment of
the uterus is unformed as it is safer in this situation for the baby: but it is
rarely performed other than at these early gestations, as the operation is more
prone to complications than a low transverse uterine incision. Any woman who
has had a classical section will be recommended to have an elective repeat
section in subsequent pregnancies as the vertical incision is much more likely
to rupture in labour than the transverse incision.
·
The lower uterine segment section is the procedure most commonly used
today; it involves a transverse
cut just above the
edge of the bladder.
It results in lessblood loss and
has fewer early and late complications for the mother, as well as allowing her
to consider a vaginal birth in the next pregnancy.
·
A caesarean hysterectomy consists of a caesarean section
followed by the removal of the uterus.
This may be done in cases of intractable bleeding or when theplacenta cannot be separated from the uterus.
The EXIT procedure is a specialized surgical delivery
procedure used to deliver babies who have airway compression.
The Misgav Ladach method is a modified
caesarean section which has been used nearly all over the world since the
1990s. It was described by Michael Stark, the president of the New European
Surgical Academy, at the time he was the director of Misgav Ladach,
a general hospital in Jerusalem. The method was presented during a FIGO
conference in Montréal in 1994 and
then distributed by the University of Uppsala, Sweden, in more than 100
countries. This method is based on minimalistic principles. He examined all
steps in caesarean sections in use, analyzed them for their necessity and, if
found necessary, for their optimal way of performance. For the abdominal
incision he used the modified Joel Cohen incision and compared the longitudinal
abdominal structures to strings on musical instruments. As blood vessels and
muscles have lateral sway, it is possible to stretch rather than cut them. The
peritoneum is opened by repeat stretching, no abdominal swabs are used, the
uterus is closed in one layer with a big needle to reduce the amount of foreign
body as much as possible, the peritoneal layers remain unsutured and the
abdomen is closed with two layers only. Women undergoing this operation recover
quickly and can look after the newborns soon after surgery. There are many
publications showing the advantages over traditional caesarean section methods.
However, there is an increased risk of abruptio placenta and uterine rupture in
subsequent pregnancies for women who underwent this method in prior deliveries.
What you can expect
During the procedure
While the process can vary, depending on why the procedure is
being done, most C-sections involve these steps:
·
At home. While
research suggests the benefit is unclear, you might be asked to bathe with an
antiseptic soap before your C-section to reduce the risk of infection. Don't
shave your pubic hair. This can increase the risk of surgical site infection.
If your pubic hair needs to be removed, it will be trimmed just before surgery.
·
At the hospital. Before
your C-section, your abdomen will be cleansed. A tube (catheter) will likely be
placed into your bladder to collect urine. Intravenous (IV) lines will be
placed in a vein in your hand or arm to provide fluid and medication. You might
be given an antacid to reduce the risk of an upset stomach during the
procedure.
·
Anesthesia. Most
C-sections are done under regional anesthesia, which numbs only the lower part
of your body — allowing you to remain awake during the procedure. A common
choice is a spinal block, in which pain medication is injected directly into
the sac surrounding your spinal cord. In an emergency, general anesthesia is
sometimes needed. With general anesthesia, you won't be able to see, feel or
hear anything during the birth.
·
Abdominal incision. The
doctor will make an incision through your abdominal wall. It's usually done
horizontally near the pubic hairline (bikini incision). If a large incision is
needed or your baby must be delivered very quickly, the doctor might make a
vertical incision from just below the navel to just above the pubic bone. Your
doctor will then make incisions – layer by layer – through your fatty tissue
and connective tissue and separate the abdominal muscle to access your
abdominal cavity.
·
Uterine incision. The
uterine incision is then made — usually horizontally across the lower part of
the uterus (low transverse incision). Other types of uterine incisions might be
used depending on the baby's position within your uterus and whether you have
complications, such as placenta previa — when the placenta partially or
completely blocks the uterus.
·
Delivery. The
baby will be delivered through the incisions. The doctor will clear your baby's
mouth and nose of fluids, then clamp and cut the umbilical cord. The placenta will
be removed from your uterus, and the incisions will be closed with sutures.
If you have regional anesthesia, you'll be able to hear and
see the baby right after delivery.
After the procedure
After a
C-section, most mothers and babies stay in the hospital for two to three days.
To control pain as the anesthesia wears off, you might use a pump that allows
you to adjust the dose of intravenous (IV) pain medication.
Soon after
your C-section, you'll be encouraged to get up and walk. Moving around can
speed your recovery and help prevent constipation and potentially dangerous
blood clots.
While you're
in the hospital, your health care team will monitor your incision for signs of
infection. They'll also monitor your movement, how much fluid you're drinking,
and bladder and bowel function.
You will be
able to start breast-feeding as soon as you feel up to it. Ask your nurse or a
lactation consultant to teach you how to position yourself and support your
baby so that you're comfortable. Your health care team will select medications
for your post-surgical pain with breast-feeding in mind. Continuing to take the
medication shouldn't interfere with breast-feeding. Pain control is important
since pain interferes with the release of oxytocin, a hormone that helps your
milk flow.
Before you
leave the hospital, talk with your health care provider about any preventive
care you might need, including vaccinations. Making sure your vaccinations are
current can help protect your health and your baby's health.
When you go home
While you're
recovering:
·
Take it easy. Rest when possible. Try to keep everything that you and your
baby might need within reach. For the first few weeks, avoid lifting from a
squatting position or lifting anything heavier than your baby.
·
Support your abdomen. Use pillows for extra support while breast-feeding. A pregnancy
belt might provide additional support.
·
Drink plenty of fluids. Drinking water and other fluids can help replace the fluid lost
during delivery and breast-feeding, as well as prevent constipation.
·
Take medication as needed. Your health care provider might recommend acetaminophen
(Tylenol, others) or other medications to relieve pain. Most pain relief
medications are safe for women who are breast-feeding.
·
Avoid sex. Don't have sex until your health care provider gives you the
green light — often four to six weeks after surgery. You don't have to give up
on intimacy in the meantime, though. Spend time with your partner, even if it's
just a few minutes in the morning or after the baby goes to sleep at night.
Contact your
health care provider if you experience:
·
Any signs of infection —
such as a fever higher than 100.4 F (38 C), severe pain in your abdomen, or
redness, swelling and discharge at your incision site
·
Breast pain accompanied by
redness or fever
·
Foul-smelling vaginal
discharge
·
Painful urination
·
Heavy bleeding that soaks
a sanitary napkin within an hour or bleeding that continues longer than eight
weeks after delivery
Postpartum
depression — which can cause severe mood swings, loss of appetite, overwhelming
fatigue and lack of joy in life — is sometimes a concern as well. Contact your
health care provider if you suspect that you're depressed. It's especially
important to seek help if your signs and symptoms don't fade on their own, you have
trouble caring for your baby or completing daily tasks, or you have thoughts of
harming yourself or your baby.
Recovery
Abdominal, wound and back pain can
continue for months after a caesarean section, with some evidence that non-steroidal anti-inflammatory drugs are helpful. Women who have had a
caesarean are more likely to experience pain that interferes with their usual
activities than women who have vaginal births, although by six months there is
generally no longer a difference. However,
pain during sexual intercourse is less likely than after vaginal birth,
although again, by six months there is no difference.
There may be a somewhat higher incidence
of postnatal depression in the first weeks after childbirth for women who have
caesarean sections, but this difference does not persist. Some women who have had caesarean
sections, especially emergency caesareans, experience post-traumatic stress disorder.
Trying To
Avoid A Cesarean
Key Factors In Considering Cesarean Birth:
Several
key factors can influence the choice of a cesarean vs. vaginal delivery.
These factors include:
- Choice of health
care provider and their philosophy regarding cesarean birth
- Birth setting
- Access to labor
support
- Medical
interventions during labor
Steps For Avoiding Cesarean
Birth:
- Find a health care
provider and birth setting with low rates of intervention
- Ask the health
care provider about their philosophy on cesareans and their cesarean rate
(rates vary between 10-50%1 nationally)
- Create a flexible birth plan and discuss the plan with your
health care provider
- Become more
educated about birth by taking child birth classes, reading books, and asking
lots of questions.
- Arrange for
continuous labor support from a professional, like a doula. (Studies show
that women with continuous labor support are 26% less likely to have a
cesarean2).
- Explore options
for coping with pain
- Ask your health
care provider about how long you can delay going to the hospital once
labor begins. A common reason forces are and is prolonged labor at the hospital.
- Avoid continuous
electric fetal monitoring during labor. Studies show that EFM can increase
the chance of cesarean by up to one-third.
- Avoid epidural analgesia if possible.
- Ask for
recommendations on turning a breech baby, and actively attempt these if
necessary.
- Avoid induction if
possible.
- When in labor,
find laboring and pushing positions that work for you to help labor
progress.
Thanks for sharing this blog about csection. Good work.
উত্তরমুছুনBorn c-section baby