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Cesarean Section

About Cesarean section
Nomenclature: Cesarean section, Classical Cesarean section, Lower Segment Cesarean Section, LSCS, Caesar, C-Section

The Latin word 'cedere' means 'to cut' and the word Cesarean probably originated from this word. 'Cesarean section' means to 'cut out'.

Delivery of a baby through an incision in the mother’s abdomen is known as cesarean section or a C-section. It is a surgical method of delivering a baby, undertaken when normal vaginal delivery is not possible or risky for the mother or baby.

Nowadays, it is performed even electively, as a procedure of choice, on the request of would-be mothers around the world.

World Health Organization, however, recommends that the procedure must be resorted to for medical reasons alone. The recommendation comes in the wake of increasing rates of Cesarean sections and despite the safety of the procedure, it poses certain risks to the mother and baby alike.

C-section is the most commonly performed surgery in the U.S.A. and approximately about 1.3 million children each year or one of every three babies are being delivered by Cesarean section.

Researchers estimate that in over 50% of instances when C-sections are performed in the U.S.A. the babies could be safely delivered vaginally. Performing a surgical procedure when it isn’t indicated poses avoidable risks to the mother and her child and also escalates the cost of care.

Cesarean Section

History of Cesarean Section & Anatomy

Cesarean section existed among ancient Hindus and Egyptians who performed it to save the baby if the mother died. In the pre-Christian era, the Jews practiced it even when the mother was alive. In the nineteenth century, European travellers have described Cesarean section being performed by African tribes, using alcohol to anaesthetize the mother and herbs for wound healing. It was established as a mode of delivery by the latter part of the 19th century.

Anatomy

The baby lies within the mother's womb usually with its head abutting against the mother's lower portion of the uterus. In majority of the deliveries, it is the head of the baby, which emerges first from the mother's womb into the world. In some cases the baby’s buttock may lie against the mother's lower portion and may emerge first during delivery, when it is referred to as a breech presentation. The baby is extracted from the womb by cutting open the lower portion of the uterus.

Types and Indications of Cesarean Sections
Cesarean sections are classified according to the technique and incision used in the procedure.

  • Classical Cesarean Section: A midline vertical incision on the abdomen and the uterus is made to deliver the baby. Owing to a large number of complications associated with the technique, it is hardly practiced any longer.
  • Lower Segment Cesarean Section (LSCS): It is the most commonly preferred method wherein a horizontal or transverse incision is made on the lower part of the abdomen to deliver the baby. It involves less blood loss and is easier to repair than other incisions employed for the purpose. The incision also is low so cosmetically more acceptable. The LSCS can further be graded depending on when it is performed
    • Emergency C Section: When there is suspected danger to the mother's or baby’s condition an emergency section is resorted to.
    • Elective Cesarean Section (Planned C-Section): The Cesarean is planned and done on a specific date chosen by the patient and the doctor after assessing the maturity of the baby.
  • Cesarean Hysterectomy - It is a life-saving procedure in which the uterus is removed after delivering the baby through a cesarean section. It is performed when bleeding cannot be controlled or when the placenta adheres to the uterine wall and it is not possible to separate it.
Types of Cesarean Section

Why is Emergency Cesarean Section performed?

Under certain condition this is indicated and includes -  

  • Fetal Distress- During the course of labor or even before the onset of labor, if a baby at or near full term, is found to have a slow or irregular heart rate, it signals distress for the baby.

    The baby may also send SOS signals by passing meconium, which becomes apparent when the amniotic fluid leaks out. This could happen due to separation of the placenta and bleeding.

    Likewise, if the umbilical cord may slip out during labor and the blood supply to the baby could be hampered. If the baby is not delivered immediately at this point of time, it could lead to death of baby. This is an emergency situation and the baby has to be delivered immediately.
  • Maternal Distress- If the mother faces any life-threatening situations during or before labor, like excess bleeding or surge of blood pressure, an emergency Cesarean has to be done to save the mother’s life.
  • Mechanical Impedance to the Progress of Labor – This can be due to the mother's birth passage being too narrow, or the baby head being oversized for the mother’s birth canal. At times there maybe  failure of the contractions of the uterus to progress and prolonged labor can endanger the baby's life necessitating Cesarean section.

What is Elective Cesarean Section?

Elective Cesarean section is most commonly being performed on request of mothers who wish to avoid labor pain.

Indications for an Elective Cesarean Section

The most common indications of a Cesarean section in the present day are -

  • Previous Cesarean section quite often becomes an indication to deliver the next child also by a Cesarean section. Concerns about previous scar on the uterus giving way during normal labor often leads to this decision.
  • Previous Classical Cesarean section also leads to a repeat Cesarean as these scars tend to be rather weak and may tear open during a normal vaginal delivery.
  • Placenta praevia grade 4
  • Abnormal position of the baby such as breech or transverse lie where the baby lies across the mother’s womb.
  • Transverse Lie - Abnormal Position of the Baby
  • Tumors within the mother's pelvic cavity, or large ovarian cysts
  • Genital herpes in the mother– Here a Cesarean is resorted to so that the mother’s infection does not pass on to the baby during its journey in the mother’s birth canal.
  • Medical problems in the mother like high blood pressure or diabetes
  • Triplets or more number of babies
  • In Vitro Fertilisation (IVF) or Intracytoplasmic Sperm Injection (ICSI) pregnancies
    • HIV infection in the mother is another instance when Cesarean section is done to prevent transmission of the infection to the baby in the course of a normal delivery.
    • Heavy and Big Baby - >4 kg in weight.
    • Uterine deformity like a bicornuate uterus which makes vaginal delivery difficult.
Preparation, Anaesthesia and Surgery for Cesarean Section
Preparation is done as for any major operation -

Blood Tests:
  • Hemoglobin, Packed cell volume
  • Blood sugar
  • Blood grouping
  • Thyroid hormone levels
Blood Typing - Blood is typed and cross-matched in case there is excess bleeding and blood transfusion is required.

Urine Test - For detection of protein and sugar in urine some of the basic tests are performed.

Further tests depending on the pregnant woman's condition is also done.
Keeping Them Fasting - The pregnant woman should not have anything to eat or drink for at least six hours prior to the surgery.

Hydration - She will be given medications to reduce the acidity of the stomach and will have an intravenous fluid infusion commenced to maintain the hydration at an optimum level.

Cleaning of Abdomen - The abdomen will be cleaned by means of an antiseptic solution.

Urinary Catheter -A soft tube is passed into the urinary bladder to help the mother to pass urine after the delivery, as she may not be able to move about for the first 24 hours.

Monitoring - The baby’s heartbeat is monitored with the fetal monitor, as are the mother’s pulse, BP and ECG.

Anesthesia

Before any operation, the patient has to be anesthetized so that she does not feel the pain and likewise for a Cesarean section, the anesthesia is administered before the operation.

The anesthesia can be of the following types:

1. General Anesthesia

2. Spinal Anesthesia

3. Epidural Anesthesia

Anesthesia Administration During Cesarean Section
  • Spinal Anesthesia is the commonest type of anesthesia used world over because of its ease of administration, safety for the mother and the baby, and early return to normal activities including feeding the baby by the mother.
  • Epidural anesthesia is used in situations when it is already in place for a painless labor, or in certain heart conditions wherein an epidural is safer than even a spinal anesthetic.
  • General Anesthesia is administered when there are bleeding or clotting problems in the woman which prevent a spinal or epidural or in cases of fetal distress, when there isn't sufficient time to administer spinal anesthesia.

Surgery of Cesarean Section

Generally, a Cesarean section takes about 45 mins to one hour to perform.

  • Once the abdomen has been disinfected by means of an antiseptic solution, it is opened via a curved incision in the lower part of the abdomen, a few centimeters above the pubic hairline. (Bikini incision)
  • The muscles over this region are incised and then the uterus is opened at its lower portion. (Hysterotomy). Before the uterus is opened, care in taken not to injure the urinary bladder, which lies very close to the uterus at this point. The bladder is pushed downward and away from the area to be operated.
  • Once the uterus has been opened, the waters surrounding the baby are sucked out and then the surgeon passes his hand into the uterus and grasps the “presenting part” of the baby. This is the lowermost part of the baby present within the uterus-it could be the baby’s head or breech, or occasionally its back.

    Once the presenting part is within the doctor’s grasp, he gently pulls the baby out. The baby’s mouth is immediately sucked to remove any water it may have swallowed.
  • The umbilical cord is then clamped and cut to free the baby from the mother. The baby is wrapped and taken under the pediatrician's care.

    The actual delivery of the baby in a Cesarean section is accomplished in about 5 minutes or less to minimize the effect of general anesthesia and surgery on the baby.
  • Meanwhile, the placenta or ‘after-birth’ is then removed from the mother's uterus. The inside of the uterus is wiped clean to remove any bits of placental membrane sticking to it. The opening in the uterus is then stitched up.
  • At this point the obstetrician may request the anesthetist to administer medicines to shrink the expanded uterus quickly in size, almost to the pre-pregnancy level. This will ensure that there is less bleeding from the uterus.
  • The abdomen is then closed and a sterile dressing is applied over the incision.
  • The mother is recovered from anesthesia and moved out of the operating theatre to the recovery room. She is allowed to commence breast-feeding as early as possible.
  • After a short stay in the recovery area the mother and baby are shifted to the ward or room.
Possible Complications & Risks of Cesarean Section
As with any other majcor surgery, Cesarean section poses certain potential risks to the mother and the baby.

Risks to the mother:
  • Injury to the nearby structures like - ureters, urinary bladder, intestines.
  • Perforation or hole in the uterus.
  • Aspiration or inhalation of the contents of the stomach into the lungs during anesthesia is the most dreaded complication of general anesthesia during a Cesarean section. This can be avoided to some extent by ensuring a minimum starvation period of six hours for solid food and milk. This precaution may have to be bypassed during an emergency
  • Amniotic fluid embolism is the entry of amniotic fluid from the mother's womb into the blood stream and then into the lungs. This complication carries a very high mortality but fortunately it is also very rare. It cannot be prevented.
  • Shock due to excess bleeding
Post-operative late complications to the mother include -
  • Bleeding
  • Infection of the wound site
  • Thrombosis or clot formation in the large veins of the leg or hips can occur. If these clots get dislodged from the leg and move into the lung, they can cause a fatal complication called pulmonary embolus
  • Ileus or paralysis of the bowels for a couple of days which then recovers.
  • Atelectasis is collapse of a portion of the lungs, which is quite common after an abdominal surgery under anesthesia.
  • Atelectasis - Post-operative Complications in Mother
  • Urinary tract infection (UTI) is also a possible complication in the post-operative period.
  • Fever can also annoy the mother occasionally.
  • Headache due to the spinal anesthesia.
  • Adhesions due to the formation of scar tissue, resulting in pain and complications in future pregnancies.
  • Death - Although the procedure is very safe in experienced hands, there is still a slightly higher risk of maternal mortality in a Cesarean section than a vaginal delivery. The WHO does not recommend this procedure when vaginal delivery is possible.
Besides these, the mother also experiences a longer stay in the hospital and a longer recovery time as compared to the one undergoing a vaginal delivery.

An increased incidence of postnatal depression is seen in women who deliver through a cesarean section, therefore emotional support must be adequately provided by the family.

Risks to the baby:
  • Prematurity - There is a risk of the baby being born prematurely if the gestational age is miscalculated.
  • Post-operative Complications to the Baby - Prematurit
  • Respiratory problems are observed more in babies born through Cesarean sections than vaginal deliveries.
  • Lower APGAR (test to assess a new born’s well-being) score has been observed in babies born through Cesarean section.
  • Injury may occur during the procedure though it is very rarely seen.
Recovery and Recuperation after a Cesarean

Recovery after a cesarean section takes longer than after a vaginal delivery. One can expect around six weeks for the body to heal completely.

Pain at the incision site and in the lower abdomen can continue for a couple of weeks and may require the use of pain-killers like NSAIDS (non-steroidal anti-inflammatory drugs) to combat the same.

The patient needs to avoid strenuous activity and intercourse for a few weeks and take adequate rest.

The incision site needs to be observed for any signs of infection like increased pain, redness or discharge.

Normally after 24 hours the mother can start moving around and can even commence on a soft diet.

The sutures are removed on the 5th day and if all is well, the mother is allowed to go home.

Each individual requires 3-4 weeks to get back to normal. The mother can resume normal activities after about a month.

Health tips for Smooth Recovery after Cesarean Section

Here are a few tips to help you recover after a cesarean section:
  • Rest- Taking plenty of rest is important as a cesarean section is a major surgery and the body needs time to heal. Ease into the routine and do not rush it.
  • Get Plenty of Rest after C section for Fast Recovery
  • Avoid strenuous activity- Do not lift heavy weights after a cesarean section. Do not engage in physical exercise that involves the abdominal muscles till your doctor tells you it is okay to.
  • Avoid sex- Take your own time to get back into the normalcy of your pre-pregnancy life, even the act of lovemaking. Your doctor will usually advise you to refrain from intercourse for around six weeks, which is how long it takes for the wound to heal and your body to feel better.
  • Eat healthy- It is the time to eat healthy and not indulge in food high in fat content as is commonly believed in some communities. Eat food rich in vitamins and omega-3 fatty acids to help in the repair process.
  • Walk- Rest is important but bed-rest is not. As soon as your doctor advises, start walking, gradually increasing the time spent doing it. Walking helps improve the bowel movement and avoids constipation, improves circulation and hastens recovery and also helps in avoiding complications like clot formation.
  • Stay calm- Childbirth in itself is a huge event, whether vaginally or through cesarean section. The emotional and physical ramification are huge. It is, therefore, important to stay calm and focus on the positive things. In case you feel you are suffering from post-partum depression, which is very common, seek professional help.
Frequently Asked Questions
1. Who performs Cesarean section?

The obstetricians perform the surgery. In some smaller rural hospitals a general surgeon too can perform the surgery.

2. Why do they call it a cesarean section?

The procedure is known as a cesarean section as it is thought that the Roman emperor, Julius Caesar was born through the same. Although there is no conclusive proof to evidence the theory, it is widely believed.

3. If my first child was born via Cesarean section, can I not undergo a normal delivery for my next child?

One can have a vaginal birth after Cesarean (VBAC) except for those cases where the first Cesarean was performed for conditions like small, deformed pelvis and so on. Your obstetrician will be best person to judge whether or not you can undergo a normal delivery.

4. How can I participate in my C-section?

Although the procedure does not require a mother’s involvement as much as a vaginal delivery does but you don’t need to feel left out. You may not see your baby being delivered but almost instantaneously hear its voice.

A ‘gentle’ Cesarean section is also being performed nowadays in which the baby is allowed to crawl out of the incision on its own. An increasing number of doctors now believe in early skin-to-skin contact and let the baby rest on the mother’s chest while the incision is being sutured. You may talk to your doctor about the options.

5. After a Cesarean section should I not lift heavy weights?

You can lead a normal life by the end of one month. Until then you can avoid doing heavy manual work

6. What is the best anesthesia to have for a Caesar?

Spinal and epidural are safe for the mother as well as the baby. General anesthesia is associated with more complications but may have to be the anesthesia of choice in certain maternal conditions

7. I have heard that a spinal or epidural can cause backache in the future -is this true?

A spinal or epidural cannot give rise to a backache which did not exist before.

Every woman who goes through pregnancy and childbirth, be it normal vaginal delivery, Cesarean section under general anesthesia or Caesar under spinal anesthesia is at a high risk category of developing backache due to the altered mechanics of the spine during pregnancy.

Weight gain, bearing extra weight of the fetus, alteration of the curve of the backbone during pregnancy, stretching of muscles of ligaments all contribute to the occurrence of backache following pregnancy. The backache cannot be attributed to the spinal or epidural anesthesia. It is therefore important to do post-natal exercises to strengthen the back and abdominal muscles and regain the lost tone to minimize the occurrence of backache.

8. My colleague who underwent a C-section for her baby’s delivery had to undergo a hysterectomy (uterus removal) at the same time. What is that due to?

Rarely the mother may bleed excessively during a c-section. At such times, when all measures to stop the massive blood loss have been tried and has failed, a hysterectomy or removal of the uterus is done as a last resort to save the mother from dying due to excess hemorrhage. This scenario is also fortunately very rare.

9. Immediately after a Cesarean section, will I be in position to feed my baby?

You may have pain in the post-operative period which can be taken care of by means of medications given either via the epidural catheter, or as a suppository or as injections and you will then be able to feed your baby.

10. Would I require a blood transfusion during C-section?

If you have lost a lot of blood, you may require a blood transfusion. If the bleeding is not easily controlled, you may require a transfusion of the clotting factors or platelet cells.

Glossary
Hysterotomy: Opening the uterine cavity.

Hysterectomy: Removing the uterus.

Placenta praevia: Placenta lying low in the uterus, sometimes covering the mouth of the uterus completely so as to prevent the baby’s passage into the birth canal.

Abruptio placentae or placental abruption: Separation of the placenta from its uterine bed, causing mild or at times life threatening bleeding in the mother, compromising the fetal well being as well.

Meconium: Sticky blackish stool that the baby passes during the newborn period.

Pulmonary embolus: This can be a life threatening complication-it is a clot that has travelled from the leg veins up into the heart and blocked the blood supply to the lungs.

Hemorrhage: Bleeding from any site-at times heavily.

Prolapse of umbilical cord: The umbilical cord drops down through the cervix into the vagina and may get entangled with the baby.

Bicornuate uterus: A deformity which results in a heart shaped uterus which is split in the middle and the two compartments are separated by a septum.

APGAR score: A scoring system used to assess the well-being of a newborn baby. It is performed after 1 minute and 5 minutes of childbirth.

References:
  1. Planned elective cesarean section: A reasonable choice for some women? - (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC343856/)
  2. Cesarean Section - (https://medlineplus.gov/cesareansection.html)
  3. /Introduction.aspx" rel=nofollow target=_blank>Cesarean section - (http://www.nhs.uk/Conditions/Cesarean-section/Pages/Introduction.aspx)
  4. What Is a C-Section? - (http://kidshealth.org/en/parents/c-sections.html)
Author: Dr. Shivani Shourie

Editor: Dr. Sunil Shroff

Technically Checked by: Lingaraj

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