C-Section (Cesarean Childbirth)

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Cesarean Childbirth (C-Section) Procedure Overview

Cesarean delivery, also known as c-section, is a major abdominal surgery involving two incisions (cuts): One is an incision through the abdominal wall, and the second is an incision involving the uterus to deliver the baby. While at times absolutely necessary, especially in emergencies or for the safety of the mother or the baby, cesarean childbirth is not a procedure to be undertaken lightly by the doctor or the expectant mother. During the surgical delivery, if not an emergency, the woman may be awake but numb from the chest to the legs.

  • History of the C-section: Legend has it that the Roman leader Julius Caesar was delivered by this operation, and the procedure was named after him. However, Caesar's mother lived many years after his birth, and at that time, the operation most likely caused death in the mother. In addition, no mention is made of this procedure prior to the Middle Ages; therefore, Caesar's contribution to the naming of this operation is practically impossible. The most likely origin for the term is in reference to a Roman law created in the 8th century BC that ordered the procedure in the last few weeks of a pregnancy in dying women to save the child's life.
  • Frequency of C-section: Over 30% of births in the United States are by cesarean delivery. Overall, with improvements in anesthesia, pain control, and antibacterial techniques, serious complications from birth through cesarean section have fallen dramatically in the last 30 years.

The Most Frequent Reasons for Performing a C-Section

The most frequent reasons for performing a cesarean delivery are discussed below.

  • Repeat cesarean delivery: There are two types of uterine incisions - a low transverse incision and a vertical uterine incision. The direction of the incision on the skin (up and down or side to side) does not necessarily match the direction of the incision made in the uterus.
    • As the name implies, the low transverse incision is a horizontal cut across the lower part of the uterus. In the United States, whenever possible, a low skin incision below or at the bikini line with a low transverse uterine incision is the approach of choice.
    • A vertical incision on the uterus may be used for delivering preterm babies, abnormally positioned placentas, pregnancies with more than one fetus, and in extreme emergencies.
    • In the last decade, studies have shown that women who have had a prior cesarean section with a low transverse incision may safely and successfully go through labor and have a vaginal delivery in later pregnancies. The same, however, cannot be said of women who have had vertical incisions on the uterus if the incision is in the higher portion of the uterus.
      • In women with high vertical uterine incisions, the uterus is at a greater risk to rupture (break open) in a subsequent pregnancy.
      • The uterus may rupture even before labor begins in half of these women.
      • Uterine rupture can be dangerous to the fetus even if delivery is accomplished immediately after a uterine rupture. Diagnosing a uterine rupture can be difficult, and signs of a rupture can include increased bleeding, increased pain, or an abnormal fetal heart rate tracing.
  • Previous cesarean deliveries: Women with a prior history of more than one low transverse cesarean section are at slightly increased risk for uterine rupture. This risk increases significantly when the woman has had three cesarean deliveries. If an abdominal delivery is planned and a trial of labor is not an option, the best time for delivery is determined when the lungs of the fetus are mature.
  • Lack of labor progression: If the woman is having adequate contractions but no change in the cervix (opening to the uterus) beyond 3 centimeters dilation or the woman is unable to deliver the fetus despite complete dilation of the cervix and "adequate" pushing for (generally for 2 to 3 hours or more), cesarean delivery may be performed.
  • Abnormal position of the fetus: In a normal delivery, the baby presents head first. This is the way it happens in most births. The smallest diameter of the human skull is presented to the pelvis in the most advantageous way. This increases the success of a vaginal delivery.
    • There are various other presentations of the fetus, which make vaginal delivery difficult, including the commonly known breech position (when the baby's buttocks are in the lower portion of the uterus). Certain forms of breech delivery have a very low increased risk to the fetus. Breech deliveries may cause more complications, including death and neurologic disability.
    • Careful counseling, analysis of the exact type of breech position, an estimate of the baby's weight, and other information are required before making any decision about an attempted vaginal delivery or delivery by cesarean section.
  • Fetal status: Although an attractive and much-used tool, the fetal heart rate monitor has not improved birth outcomes as once expected. Some believe the lack of improved outcomes is because many current practicing doctors are poorly trained in interpreting the subtleties of fetal heart rate patterns. Since the use of continuous fetal heart rate monitoring in labor was begun, however, birth experts say death of a fetus during labor is much more rare than in the past.
  • Emergency situations: If the woman is severely ill or has a life-threatening injury or illness with interruption of the normal heart or lung function, she may be a candidate for an emergency cesarean section. When performed within 6-10 minutes of the onset of cardiac arrest, the procedure may save the newborn and improve the resuscitation rate for the mother. This procedure is performed only in the most dire of circumstances.
  • Elective sterilization: A desire for elective sterilization is not an indication for cesarean delivery. Sterilization after a vaginal delivery can be performed via a tiny 3-cm incision along the lower edge of the umbilicus or as a delayed procedure 6 weeks after delivery with laparoscopic surgery or vaginal surgery.

Other Reasons for the Increased Use of C-Section

Other of the reasons for the increased use of cesarean childbirth include the following:

  • Use of heart rate monitors to evaluate the fetal heart rate pattern
  • Baby positioned in a manner other than head first
  • Woman's preference for repeat cesarean sections
  • Labor does not progress to delivery
  • Mother has an active genital herpes infection (the baby needs to avoid potential exposure through the birth canal)
  • Mother has HIV infection
  • Presence of obstructions such as benign or malignant tumors in the lower reproductive tract or pelvic anatomical abnormalities
  • Malpractice concerns
  • Birth in a private, for-profit hospital
  • Woman's higher level of education and social status
  • Increased maternal age, as more women are having babies later in life

Bleeding After C-Section: When to Seek Medical Care

Watch for complications and contact a health care professional or go to the hospital if severe problems develop.

  • If infection of the fetal tissues or the uterine lining is present, care must be taken in noting the type of discharge from the vagina (abnormal or bad smelling) and whether a fever is present.
  • Worsening abdominal pain, especially when infection of the uterus is present, may mean a worsening or new infection. Vomiting and an inability to keep down fluids associated with abdominal pain may suggest an unrecognized intestinal injury from surgery.
  • Vaginal bleeding after cesarean delivery, as with a vaginal delivery, should gradually decrease in the days following delivery. A sudden increase in vaginal bleeding should be checked by a doctor.
  • Call a doctor if urinating is difficult or painful.
  • Use home care with a surgical incision, and call a doctor if redness spreads around the wound or an abnormal discharge is coming from it; this may signal an infection.
Seek medical care at a hospital's emergency department for the following concerns:
  • Fever with abdominal pain
  • Separation of the wound edges, blood and fluid loss, or both
  • Severe increase in vaginal bleeding
  • Inability to keep down fluids
  • Abnormal, foul-smelling vaginal discharge
  • Inability to urinate

Post C-Section Recovery

A health care professional may assess the following conditions after a cesarean section:

  • Examine the surgical incision for infection.
  • Check to see if the wound has separated (possibly just on the surface).
  • Assess for infection of the uterus and abnormal amounts of vaginal bleeding.
  • Make sure the bladder or the kidneys are not infected.
  • Make sure severe anemia is not present from delivery-related blood loss.
  • Make sure there is no evidence suggesting a clot in the deep veins that is either localized or has moved to the lungs (pulmonary embolism).
  • Conduct a pelvic examination.
  • Order further evaluation with blood tests, uterine cultures, urine tests, and imaging.

C-Section Treatment

If there is concern about infection of the uterus, unrecognized damage to the bladder or intestines, a clot in the deep veins of the pelvis or the lungs, or a deep separation of the wound such that the lining of the abdomen is open, admission to the hospital for observation and appropriate intensive therapy is likely.

C-Section Self-Care at Home

Barring complications, the woman may leave the hospital usually 48 to 96 hours after a cesarean childbirth. If complications occur during surgery, the hospitalization may be longer. Once home, it is important to watch for further complications in the healing process.

Wound care can be handled at home.

  • Care of the surgical incision is relatively simple. Water can wash over the wound as long as the impact of water is not directly onto the wound. Keeping the wound clean and dry is important for adequate healing. This includes avoiding coverage by skin folds, which can lead to excessive moisture and infection.
  • Sometimes, the wound can separate at its edges, and blood or fluid or both may come out. If this happens, seek immediate medical attention.
  • If the wound edges are not closing properly, the wound may be left open at the time of discharge from the hospital. In this situation, the wound should be packed as instructed by the hospital staff 2 to 3 times a day. Open wounds will gradually heal from the base of the wound to the surface requiring less and less packing as the days go by.

C-Section Medical Treatment

If separation of the wound is superficial (near the surface), the wound will be packed appropriately, and proper wound care instructions will be given. Wound care supplies will also be given, and an appointment for appropriate follow-up care will be scheduled.

C-Section Medications

  • If the problem is simply inadequate postoperative pain control, proper pain medication will be prescribed.
  • If a simple bladder infection, an uncomplicated kidney infection, or a simple wound infection is present, appropriate antibiotics will likely be given and an appointment for a follow-up evaluation will be made.

C-Section Complications

A normal vaginal delivery in later pregnancies is often possible, depending on the type of incision that was performed and the reason the birth was performed by cesarean section.

Cesarean childbirth may have these types of complications:

Excessive bleeding: This is the most common complication of a cesarean delivery and may be caused by many different factors.

  • In short, at the time of active labor, the uterus receives 20% (up to 30% in some cases) of the blood pumped to the body by the heart. When a surgeon cuts the uterus, a certain amount of blood loss will occur.
  • On average, cesarean deliveries result in more than twice the blood loss of vaginal deliveries. Various factors contribute to this difference. Because most childbearing women are young and healthy, they tolerate the blood loss well and recover their normal blood volume within a relatively short time after delivery.
  • Women who have had multiple deliveries in quick succession, especially cesarean sections, are susceptible to significant anemia (loss of volume of red blood cells). Excessive bleeding along the incision line or from the uterus after the delivery of the infant may require the doctor to administer medications to promote contraction of the uterus and therefore control the bleeding.
  • Sometimes, an artery supplying blood to the uterus is cut. This requires stitches to control bleeding from the artery.
  • Bleeding may at times be so difficult to control that the uterus has to be removed as a means to control the bleeding. This is called a cesarean hysterectomy.

Infection: The risk of infection of the uterus is up to 20 times greater after cesarean delivery than after vaginal delivery. A number of factors contribute to infection, above and beyond the simple fact that an operation with an incision of the uterus has been performed. Generally, many conditions, such as a prolonged labor course, that often put a woman in a position of requiring a cesarean section may also make her more prone to developing infections.

  • Infection of the skin incision is much more common than infection in the incision made in the uterus, although they often occur together. The risk for infection in the skin incision can be decreased by giving antibiotics during the surgery.
  • Doctors can use certain types of skin preparations to clean the abdomen for surgery.
  • Proper wound care after the surgery is essential.

Clots: Blood clots can form in the pelvis or the leg. If a clot breaks off and travels (embolizes) to the lungs, it can cause death or disability after delivery, whether it is vaginal or cesarean. However, women who undergo cesarean childbirths are much more prone to clots than women who deliver vaginally. Therefore, it is imperative that if you deliver by cesarean section, you must get up and walk within 24 hours after the operation or wear devices to passively massage the lower legs.

Urinary function and bladder injury: Typically, a catheter is inserted into the bladder before the surgery to remove urine. Usually, the catheter is removed within 24 hours after the surgery as soon as the woman is ready to begin walking. Often, some initial pain occurs when urinating - as with vaginal deliveries. However, with a cesarean delivery, damage can occur to the bladder in the course of the surgery.

  • The frequency of this type of injury is more common in women who have had abdominal surgery or infection that results in scarring in the abdomen. Sometimes, a catheter may need to be in place for weeks after discharge from the hospital.
  • In the course of a cesarean hysterectomy, the tubes emptying urine from the kidneys to the bladder (the ureters - one ureter on each side) can be damaged. Repair of this injury usually depends on the surgeon recognizing the injury during the operation and fixing it then.

Bowel function and bowel injury: Typically, bowel function after a cesarean section returns quickly. Return of normal bowel function is usually aided if the woman is aggressive about frequent walking. Sometimes, bowel function does not return normally after cesarean delivery, even without specific damage to the bowel. This is termed postoperative ileus. The causes are many and are not completely understood. In the case of actual bowel injury, the nature and degree of complication depend on the size, severity, and location of the injury. Unrecognized bowel injury can lead to life-threatening illness with severe abdominal pain and fever (usually but not always present in such cases). The incidence of bowel injury, as with bladder injury, is increased if the woman has had other abdominal surgery or infection.

Prolonged hospital stay: After vaginal delivery, the woman is typically free to go home within 48 hours. However, observation after a cesarean section typically runs a minimum of 2 days. If infection, significant bleeding, slow return of bowel and bladder function, or injury to internal organs occurs, the hospital stay can be extended.

Anesthesia and pain medications: Anesthesia for a cesarean section can be delivered by an injection into the spinal fluid (spinal anesthesia), placed via a catheter into the space outside of the spinal canal, but surrounding the spinal column (epidural anesthesia). General anesthesia may also be given; this makes the person completely "asleep."

  • General anesthesia is typically reserved for emergency deliveries when there is not enough time to provide spinal or epidural anesthesia.
  • All of the methods can be supplemented with an injection of local anesthesia into the incision site during the surgery. After surgery, oral and injection drugs can be used to help control the pain.
  • The advantage of epidural anesthesia is that repeat doses of pain medication can be given after the surgery for pain control.
  • Properly dosed, these medications do not necessarily interfere with the woman's ability to get up and about after surgery.

C-Section Pictures

Closure of the uterine and abdominal incisions after a low transverse cesarean section. Blood loss during the average cesarean section is substantial—on the order of 500-1000 mL.
Closure of the uterine and abdominal incisions after a low transverse cesarean section. Blood loss during the average cesarean section is substantial—on the order of 500-1000 mL.. Click to view larger image.

High-risk uterine incisions have a high risk of uterine rupture with additional pregnancies. Consequently, these women are not candidates for future vaginal deliveries. Occasionally, a T-shaped incision is required. Women with a T-shaped incision carry the same risks as women with a vertical uterine incision with respect to future risk of uterine rupture.
High-risk uterine incisions have a high risk of uterine rupture with additional pregnancies. Consequently, these women are not candidates for future vaginal deliveries. Occasionally, a T-shaped incision is required. Women with a T-shaped incision carry the same risks as women with a vertical uterine incision with respect to future risk of uterine rupture. Click to view larger image.

Reviewed on 11/21/2017
Sources: References

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