Definition

A cesarean section (also referred to as c-section) is the birth of a fetus accomplished

by performing a surgical incision through the maternal abdomen and uterus. It is one
of the oldest surgical procedures known throughout history.

Purpose

Ads by Google
Infant with Heart Defect?
Free, confidential case evaluation
from national injury law firm.
www.LieffCabraser.com

5 Ways to Help Baby Sleep

Tear-free tips to help baby sleep
No obligation, privacy guaranteed
www.SleepThroughNight.com

How to Get Pregnant Fast

I Stopped these common mistakes and
got Pregnant almost Immediately!
www.MaximumFertility.com/

Summit Doppler
Leading Manufacturer of Ultrasound
Dopplers for Fetal/Vascular Monitor
www.summitdoppler.com

Although Healthy People 2010 established a goal of a 15 percent rate for c-sections in
the United States, the ideal rate has not been established. As of 2004, the average c-
section rate is one out of every four births or approximately 26 percent of all births. A
c-section allows safe and quick delivery of a baby when a vaginal delivery is not
possible. The surgery is performed in the presence of a variety of maternal and fetal
conditions with the most commonly accepted indications being complete placenta
previa, cephalopelvic disproportion (CPD), placental abruption, active genital herpes,
umbilical cord prolapse, failure to progress in labor or dystocia, proven
nonreassuring fetal status, and benign and malignant tumors that obstruct the birth
canal. Indications that are more controversial include breech presentation, previous
c-section, major congenital anomalies, cervical cerclage, and severe Rh
isoimmunization. C-sections have a higher maternal mortality rate than vaginal
births with approximately 5.8 women per 100,000 live births dying, and half of these
deaths are ascribed to the operation and a coexisting medical condition. Perinatal
morbidity is associated with infections, reactions to anesthesia agents, blood clots,
and bleeding.

Description

According to the United States Public Health Service, 35 percent of all c-sections are
performed because the woman has had a previous c-section. The skin incision for a c-
section is either transverse (Pfannenstiel) or vertical and does not indicate the type of
incision made into the uterus. "Once a cesarean, always a cesarean," is a rule that
originated with the classical, vertical uterine incision. It was believed that the
resulting scar weakened the uterus wall and was at risk of rupture in subsequent
deliveries. As of 2004, the incision is almost always made horizontally across the
lower uterine segment, called a low transverse incision. This results in reduced blood
loss and a decreased chance of rupture. This kind of incision allows many women to
have a vaginal birth after a cesarean (VBAC).

Failure to progress and/or dystocia is the second most common reason for a c-
section and represents about 30 percent of all cases. Uterine contractions may be
weak or irregular, the cervix may not be dilating, or the mother's pelvic structure may
not allow adequate passage for birth. When the baby's head is too large to fit through
the pelvis, the condition is called cephalopelvic disproportion (CPD). Failure to
progress, however, can only be diagnosed with documentation of adequate
contraction strength. The force of the contractions can be measured with an
intrauterine pressure catheter (IUPC), which is a catheter that can be placed through
the cervix into the uterus to measure uterine pressure during labor. Calculation of
this force is determined by subtracting the baseline (resting) pressure from the peak
pressure recorded for all contractions in a ten-minute period. This pressure
calculation results in a force termed Montevideo units. A minimum of 200
Montevideo units are required before the forces of labor can be considered adequate.
If the Montevideo units are less than this ten-minute sum and the fetal heart rate is
reassuring, augmentation of labor with pitocin may be necessary.

Breech presentation occurs in about 3 percent of all births, and approximately 12

percent of c-sections are performed to deliver a baby in a breech presentation:
buttocks or feet first. Breech presentations were still delivered vaginally in the 1970s,
but with the advent of the malpractice climate, many doctors shied away from this
practice, opting to perform a c-section. As a result, physicians who were being
trained during that time period never learned how to manage a breech vaginal
delivery. There was some change in this approach in the 1990s, and doctors are once
again learning how to manage this situation; however, it is still uncertain whether
this knowledge will be used in their practice.

Fetal distress or the more appropriate term, nonreassuring fetal heart rate, accounts
for almost 9 percent of c-sections. With the introduction of electronic fetal
monitoring (EFM) in the 1970s, doctors had more information for assessing fetal
well-being. It was assumed that fetal monitoring would transmit signals of distress,
thus, the EFM tracing became a legal document. There is still considerable debate as
to what a non-reassuring FHR really is, but there are other parameters available to
assist in this interpretation. When a fetus experiences stress, (oxygen deprivation) in
utero, it may pass meconium (feces) into the amniotic fluid. The appearance of
meconium in the fluid along with a questionable EFM tracing may indicate that a
fetus is becoming compromised. At this point, if a woman is in early labor, a c-
section may have to be performed. If, however, she is close to delivery, a vaginal
delivery is often quicker. Oxygen deprivation may also be determined by testing the
pH of a blood sample taken from the baby's scalp: a pH of 7.25-7.35 is normal;
between 7.2 and 7.25 is suspicious; and below 7.2 is a sign of trouble. If the sample is
equivocal, it can be repeated every 20 to 30 minutes.

The remaining 14 percent of c-sections occur secondary to other emergency

situations, including the following:

 Umbilical cord prolapse: This situation occurs when the cord is the presenting
part from the vagina. It becomes compressed and cuts off blood flow to the
 baby. The birth attendant must insert a hand into the vagina and relieve
pressure on the cord until a c-section is performed.
 Placental abruption: The placenta separates from the uterine wall before the
baby is born. If it is a complete abruption, the baby's blood flow will be cut off
completely. The mother experiences severe pain , possible bleeding, and her
abdomen feels rock hard. This situation demands an immediate c-section.
Partial abruptions can occur without endangering the mother or the baby, but
they need to be closely monitored. The risk of placental abruption is higher in
multiple births and in women with high blood pressure.
 Placenta previa: With a complete previa, the placenta covers the cervix
completely, and the mother may experience painless bleeding. With a
complete previa, a c-section is mandatory as cervical dilation would cause
bleeding. The baby is often in a transverse position in this case, which means
it is lying horizontally across the pelvis. Women with partial previas will
usually need a c-section due to bleeding problems, but those with marginal
previas can often deliver vaginally.
 Active genital herpes: Any active herpetic lesions in the vaginal area can infect
the baby as it passes through the birth canal. This is especially true for those
with a primary outbreak, a first-time exposure.
 Mother's health status: A c-section may be necessary in women with pre-
existing diseases, such as diabetes,hypertension , pregnancy induced
hypertension (preeclampsia), autoimmune diseases such as lupus
erythematosus, and blood incompatibilities. Each case must be evaluated on
an individual basis in these instances to achieve the optimal outcome for baby
and mother.

Precautions

There are some precautions any pregnant woman can follow to enhance her chances
of preventing a c-section. These include the following:

 She should check her doctor's c-section rate to see if it is unnecessarily high.
She can ask what his/her rate is and verify it by checking with the labor and
delivery nurses at the hospital or with a childbirth educator.
 She should not stay on her back during labor. She can walk, rock, or use a hot
shower or whirlpool.
  From the beginning, she should discuss with her doctor that she wants to
avoid having a c-section if at all possible and enlist his opinion on how to
achieve it.
 Studies show that women who go to the hospital early have a higher c-section
rate than those who do not. Therefore, when labor starts, the woman should
stay home for as long as she safely can. She should not go in if contractions are
further apart than four to five minutes.
 She should use a midwife since studies show that they have a higher
percentage of natural childbirths without surgical intervention than
obstetricians do.
 She should hire a doula to assist during labor birth. Doulas have a lower c-
section rate and can offer massage, different positions, and support
alternatives during the difficult phases of labor.
 She should gather as much information as possible on hospital policies to
educate herself and then discuss this information with her doctor or midwife.
She should keep an open mind and stay informed.

Preparation

There is no perfect anesthesia for a c-section because every choice has its advantages
and disadvantages. When a c-section becomes necessary and if it is not an
emergency, the mother and her significant other should take part in the choice of
anesthetic by being informed of risks and side effects. The anesthesia is usually a
regional anesthetic (epidural or spinal), which makes her numb from below her
breasts to her toes. In some cases, a general anesthetic will be administered if the
regional does not work or if it is an emergency c-section. Every effort should be made
to include the significant other in the preparations and recovery as well as the
surgery if at all possible. An informed consent needs to be signed, and the physician
should explain the surgery at that time. The mother may already have an intravenous
(IV) line of fluid running into a vein in her arm. A catheter is inserted into her
bladder to keep it drained and out of the way during surgery and the upper pubic
area is usually shaved. Antacids are frequently administered to reduce the likelihood
of damage to the lungs should aspiration of gastric contents occur. The abdominal
area is then scrubbed and painted with betadine or another antiseptic solution.
Drapes are placed over the surgical area to block a direct view of the procedure.
The type of skin incision, transverse or vertical, is determined by time factor,
preference of mother, or physician preference. Two major locations of uterine
incisions are the lower uterine segment and the upper segment of the body of the
uterus (classical incision). The most common lower uterine segment incision is a
transverse incision because the lower segment is the

To remove a baby by cesarean section, an incision is made into the

abdomen, usually just above the pubic hairline (A). The uterus is located
and divided (B), allowing for delivery of the baby (C). After all the
contents of the uterus are removed, the uterus is repaired and the rest of
the layers of the abdominal wall are closed (D).
(Illustration by GGS Information Services.)
thinnest part of the pregnant uterus and involves less blood loss. It is also easier to
repair, heals well, is less likely to rupture during subsequent pregnancies and makes
it possible for a woman to attempt a vaginal delivery in the future. The classical
incision provides a larger opening than a low transverse incision and is used in
emergency situations, such as placenta previa, preterm and macrosomic fetuses,
abnormal presentation, and multiple births. With the classical incision, there is more
bleeding and a greater risk of abdominal infection. This incision also creates a
weaker scar, which places the woman at risk for uterine rupture in subsequent
pregnancies.

Once the uterus is opened, the amniotic sac is ruptured and the baby is delivered.
The time from the initial incision to birth is typically five to ten minutes. The
umbilical cord is clamped and cut, and the newborn is given to the nursery personnel
for evaluation. Cord blood is normally obtained for analysis of the infant's blood type
and pH. The placenta is removed from the mother and her uterus is closed with
suture. The abdominal area may be closed with suture or surgical staple. The time
from birth through suturing may take 30 to 40 minutes. The entire surgical
procedure may be performed in less than one hour. Physical contact or

holding of the newborn may take place briefly while the mother is on the operating
table if the baby is stable. The significant other can go with the baby to the nursery
for the remainder of the operation.

Aftercare

Immediate postpartal care after a c-section is similar to post-operative care with the
exception of palpating the fundus (top of the uterus) for firmness. If an epidural or
spinal were used, Duramorph (a pain medication similar to morphine) is often
administered through these catheters just prior to completion of surgery. It does very
well in controlling pain but may causeitching , which can be managed. During
recovery the mother is encouraged to turn, cough , and deep breathe to keep her
lungs clear, and the neonate is usually brought to the mother to breastfeed if she so
desires. The mother will be encouraged to get out of bed about eight to 24 hours after
surgery. Walking stimulates the circulation to avoid formation of blood clots and
promotes bowel movement. Once discharged home, the mother should limit stair
climbing to once a day, and she should avoid lifting anything heavier than the baby.
It is important to nap as often as the baby does and make arrangements for help with
the housework, meals, and care of other children. Driving may be resumed after two
weeks, although some doctors recommend waiting for six weeks, which is the typical
recovery period from major surgery.

Risks
The maternal death rate for c-section is less than 0.02 percent (5.8 per 100,000 live
births), but that is four times the maternal death rate associated with vaginal
delivery. The mother is at risk for increased bleeding from two incision sites and a c-
section usually has twice as much blood loss as a vaginal delivery during surgery.
Complications occur in less than 10 percent of cases, but these complications can
include an infection of the incision, urinary tract, or tissue lining the uterus
(endometritis). Less commonly, injury can occur to the surrounding organs, i.e., the
bladder and bowel.

Normal results

The after-effects of a c-section vary, depending on the woman's age, physical fitness,
and overall health. Following this procedure, a woman commonly experiences gas
pains, incision pain, and uterine contractions, which are also common with vaginal
delivery. The hospital stay may be three to four days. Breastfeeding the baby is
encouraged, taking care that it is in a position that keeps the baby from resting on the
mother's incision. As the woman heals, she may gradually increase appropriate
exercises to regain abdominal tone. Full recovery may be seen in four to six weeks.

The prognosis for a successful vaginal birth after a cesarean (VBAC) may be at least
75 percent, especially when the c-section involved a low transverse incision in the
uterus, and there were no complications during or after delivery.

Of the hundreds of thousands of women in the United States who undergo a c-

section each year, about 500 die from serious infections, hemorrhaging, or other
complications. These deaths may be related to the health conditions that made the
operation necessary and not simply to the operation itself.

Parental concerns

Undergoing a c-section may inflict psychological distress on the mother, beyond

hormonal mood swings and postpartum depression. The woman may feel
disappointment and a sense of failure for not experiencing a vaginal delivery. She
may feel isolated if the father or birthing coach is not with her in the operating room
or if she is treated by an unfamiliar doctor rather than by her own doctor or midwife.
She may feel helpless from a loss of control over labor and delivery with no
opportunity to actively participate. To overcome these feelings, the woman needs to
understand why the c-section was crucial. It is important that she be able to verbalize
an understanding that she could not control the events that made the c-section
necessary and recognize the importance of preserving the health and safety of both
herself and her child. Women who undergo a c-section should be encouraged to
share their feelings with others. Hospitals can often recommend support groups for
such mothers. Women should also be encouraged to seek professional help if
negative emotions persist.

KEY TERMS

Breech presentation —The condition in which the baby enters the birth canal with
its buttocks or feet first.

Cephalopelvic disproportion —The condition in which the baby's head is too

large to fit through the mother's pelvis.

Cervical cerclage —A procedure in which the cervix of the uterus is sewn closed, it
is used in cases when the cervix starts to dilate too early in a pregnancy to allow the
birth of a healthy baby.

Doula —A doula is someone who undergoes special training to enable them to

support women during childbirth and into the postpartum period.

Dystocia —Failure to progress in labor, either because the cervix will not dilate
(expand) further or because the head does not descend through the mother's pelvis
after full dilation of the cervix.

Genital herpes —A life-long, recurrent sexually transmitted infection caused by the

herpes simplex virus (HSV).

Perinatal —Referring to the period of time surrounding an infant's birth, from the

last two months of pregnancy through the first 28 days of life.

Pitocin —A synthetic hormone that produces uterine contractions.

Placenta previa —A condition in which the placenta totally or partially covers the
cervix, preventing vaginal delivery.
Placental abruption —An abnormal separation of the placenta from the uterus
before the birth of the baby, with subsequent heavy uterine bleeding. Normally, the
baby is born first and then the placenta is delivered within a half hour.

Postpartal —The six-week period following childbirth.

Rh blood incompatibility —Incompatibility between the blood of a mother and

her baby due the absence of the Rh antigen in the red blood cells of one and its
presence in the red blood cells of the other.

Umbilical cord prolapse —A birth situation in which the umbilical cord, the
structure that connects the placenta to the umbilicus of the fetus to deliver oxygen
and nutrients, falls out of the uterus and becomes compressed, thus preventing the
delivery of oxygen.

See also Apgar testing ; Electronic fetal monitoring .

Resources

BOOKS

Olds, Sally et al. Maternal-Newborn Nursing & Women's Health Care , 7th ed.
Saddle River, NJ: Prentice Hall, 2004.

ORGANIZATIONS

Association of Women's Health, Obstetric and Neonatal Nursing. 2000 L Street,

NW, Suite 740, Washington, DC 20036. Web site: http://www.awhonn.org.

International Childbirth Education Association Inc. (ICEA). PO Box 20048,

Minneapolis, MN 55420. Web site: http://www.icea.org/info.htm.

WEB SITES

"Cesarean Section." MedlinePlus. Available online at

http://www.nlm.nih.gov/medlineplus/cesareansection.html (accessed December 7,
2004).
"Cesarean Section Homepage." Childbirth. Available online at
http://www.childbirth.org/section/section.html (accessed December 7, 2004).

"C-Section." March of Dimes. Available online at

http://www.marchofdimes.com/pnhec/240_1031.asp (accessed December 7, 2004).

Linda K. Bennington, RNC, MSN, CNS