According to a study by the World Health Organization (WHO), one in five (21%) deliveries worldwide is by caesarean section. The operation can be elective or emergency.
What is a cesarean section?
Abdominal delivery, or cesarean section, is an operation in which an obstetrician-gynecologist extracts the baby through incisions in the abdominal wall and uterus of the woman in labor. It is believed that the name of the procedure comes from the Latin word “Caesar” (‘king’, “lord”) and is associated with the birth of the ancient Roman emperor Julius Caesar. According to legend, his mother died of labor, and her abdomen was opened to extract the baby for separate burial. However, the baby turned out to be alive.
According to another version, the name of the operation “Caesarean section” comes from the law “Lex Caesarea” (“imperial law”) that existed in the Roman Empire. It obliged doctors to use all available methods to save the babies of dying mothers.
When is an elective cesarean section scheduled?
A planned caesarean section is scheduled in advance if there are medical indications for the woman or the fetus. The decision on the operation is made by a consilium of doctors. Other indications for elective caesarean section:
- transverse positioning of the fetus;
- breech or transverse positioning of one of the fetuses in a multiple pregnancy;
- placenta previa (attachment of the placenta in the lower part of the uterus rather than the upper part of the uterus);
- monoamniotic twins (development of the fetuses in one fetal sac);
- delayed development of one of the fetuses in a multiple pregnancy;
- estimated baby weight more than 4500 g in case of diabetes mellitus in a woman;
- fusion of twins;
- multiple intrauterine blood transfusion in case of mother-fetus Rh conflict;
- scar on the uterus (after previous abdominal deliveries, gynecological surgery, uterine rupture in the anamnesis);
- genital herpes six weeks or less before delivery;
- cardiovascular diseases in a woman (aortic dilatation, pulmonary arterial hypertension, severe aortic stenosis, heart attack, heart failure);
- prolonged use of anticoagulants by the pregnant woman;
- pathologies of the respiratory system in a woman (pneumothorax, pulmonary hemorrhage four weeks before delivery);
- diseases of the nervous system in a pregnant woman (intracerebral tumors, history of stroke);
- pathologies of the visual analyzer (acute glaucoma attack, perforated corneal ulcer, hemorrhagic retinopathy, penetrating wound of the eyeball);
- hepatitis C in combination with human immunodeficiency virus (HIV);
- HIV infection with a viral load of more than 50 copies/µl;
- pelvic tumors or deformities that prevent vaginal delivery;
- cervical cancer;
- third-degree perineal laceration or history of perineal surgery;
- surgical treatment of genitourinary and intestinal-genital fistulas (fistulas).
Scheduled abdominal delivery is indicated when fetal malformations are detected during the second screening of pregnancy, which must be surgically corrected immediately after birth. These include gastroschisis (protrusion of abdominal organs due to a defect in the abdominal wall), teratomas (tumors that develop from fetal tissue), spinal dysraphia (split spine), diaphragmatic hernia (displacement of abdominal organs due to a defect in the diaphragm).
In singleton pregnancies, a planned caesarean section is performed after the full 39 weeks, and in multiple pregnancies – the full 38 weeks of gestation (carrying the fetus). In monoamniotic twins, the operation is performed at 32-33 weeks of pregnancy. Beforehand, during a consultation with a gynecologist, a woman signs a consent to the procedure, confirming her awareness of possible complications.
When is an emergency cesarean section performed?
An emergency caesarean section is performed in case of unexpected complications of pregnancy or labor. The doctor determines the urgency of the situation and decides on the timing of the operation. The first category of urgency includes cases accompanied by a significant threat to the life of the mother or fetus. The operation should be started within 30 minutes after the detection of complications.
The second category of urgency includes violations of the state of the mother and child without a direct threat to their lives. The third category of urgency combines cases in which the condition of the mother and fetus is not disturbed, but requires abdominal delivery. In the second and third category of urgency, the operation should be started within 75 minutes from the moment of detection of complications. Indications for urgent cesarean section:
- premature detachment of the placenta (before the onset of labor or during prolonged labor);
- genital bleeding of unclear origin in the third trimester of pregnancy or during labor;
- uterine rupture or threat of uterine rupture in late gestation;
- prolapse of pulsating umbilical cord loops;
- sudden change in fetal presentation after amniotic fluid withdrawal;
- mucus plug withdrawal in a pregnant woman accompanied by profuse bleeding from the genital organs;
- unsuccessful attempt to induce (stimulate) labor;
- delayed labor that cannot be corrected by medication;
- death of a woman with a living fetus.
Caesarean section in labor should be performed urgently in cases of fetal distress (unsatisfactory condition due to lack of oxygen). In situations where the life of the fetus and the woman is not threatened, the emergency procedure is performed with the informed consent of the patient. If the pregnant woman is unconscious or there are circumstances that threaten the life of the mother and child, the decision to perform the operation is made at an emergency consilium of doctors.
How is a cesarean section done?
To ensure sterility, quick access to surgical instruments and resuscitation equipment, cesarean sections are performed in the operating room rather than in the delivery room. Stages of surgery:
- The woman is placed on the operating table, connected to monitors to control her condition, a catheter is placed in the bladder and anesthesia (anesthesia) is administered. The incision area is treated with antiseptic.
- After the onset of anesthesia, the doctor makes a 10-centimeter transverse incision in the abdominal wall about three centimeters above the pubis. The uterus is then opened.
- The gynecologist extracts the baby and cuts the umbilical cord. The doctor examines the newborn and clears his or her airway.
- After the fetus is extracted, the doctor removes the placenta from the uterus of the woman in labor. To prevent subsequent pregnancies, tubal ligation may be performed at the woman’s request during a cesarean section.
- The integrity of the uterus is restored with a single-row or double-row continuous suture performed with self-absorbable suture material (Vicryl).
- The abdominal wall is sutured with a continuous cosmetic intradermal suture and several individual sutures according to the Donati technique.
If the abdominal wall suture is sutured with non-absorbable threads, it is removed on the fifth to seventh day after the operation. At the end of the procedure, the woman in labor is transferred to the intensive care unit.
Types of anesthesia and anesthesia for cesarean section
(spinal, epidural) anesthesia. Factors influencing the choice of anesthesia method for cesarean section:
- urgency category;
- maternal and fetal condition;
- physician’s experience;
- patient’s desire.
General anesthesia is usually used in cesarean sections of the first urgency category. In cases of second and third urgency, depending on the condition of the mother, general anesthesia or spinal anesthesia (injection of anesthetic into the area around the spinal cord) may be used. Epidural (injection of the drug into the lumbar spine) or spinal anesthesia is used for elective caesarean sections.
What kind of incision is made during a caesarean section?
A cesarean section usually involves a horizontal incision in the lower abdomen, just above the bikini line. It is the least painful and heals quickly.
Vertical incision from the navel to the pubic bone is rarely used for medical reasons (low location of the placenta, lateral position or small size of the fetus, the presence of myomas that interfere with the operation). This type of incision takes longer to heal and may cause complications in subsequent pregnancies.
Does a scar remain after a cesarean section?
Complete resorption and healing of the internal C-section suture usually occurs within one to three months. The external C-section suture heals in one to two weeks.
A scar remains at the incision site after a C-section, which becomes less noticeable over time, changing color from red to flesh-colored. The size and appearance of the scar depends on the type of incision, the method of suturing, and the individual skin’s ability to repair itself.
Scar removal can be accomplished with laser, cryotherapy (exposure of the skin to liquid nitrogen), dermabrasion (resurfacing of the top layer of skin), and botulinum toxin injections. In the presence of large scars that deform the anterior abdominal wall, a woman may be recommended abdominoplasty (abdominoplasty) after cesarean section.
How long does a cesarean section last
On average, the duration of the procedure varies from 30 minutes to one hour.
The duration of the operation may be affected by the way the incision is made, the occurrence of unforeseen complications during the procedure, the presence of tumors or scars in the woman, making it difficult to extract the fetus. Caesarean section under general anesthesia lasts longer than under regional anesthesia because of the more complicated procedures for administering the drug and waking up the patient after the operation.
Recovery after Cesarean
Recovery after a Cesarean is individualized and lasts on average from four to six weeks to several months. To prevent infection of the wound, the patient may be prescribed a course of antibiotics. In the first day after surgery, the woman in labor is shown bed rest. The midwife helps to put the baby to the breast.
A day after the procedure, a woman is helped to get out of bed. Sitting after cesarean section is recommended with pillows under the back to minimize pressure on the incision zone.
In consultation with the doctor, 48 hours after the cesarean section, you can begin to perform exercises to reduce the uterus, alternately tensing and relaxing the muscles of the perineum. Slow, short walks are allowed. More active exercises can be started after four to six weeks. During the rehabilitation period after caesarean section (up to six weeks) it is not recommended to lift anything heavier than the baby.
Nutrition in the first days after caesarean section should be fractional and easily digestible. To avoid pain in the intestines, increased gas formation and constipation, you should give preference to low-fat broths and vegetable soups, liquid porridge on water, low-fat kefir and yogurt. After four to five days, you can add boiled chicken and turkey, vegetables and fruits, whole-grain cereals to improve intestinal peristalsis. Spicy, fatty, fried foods should be avoided.
For at least six weeks after cesarean section, you can not visit swimming pools, Jacuzzis, saunas. To avoid infection of the wound, you should not swim in open bodies of water. Among the recommendations after cesarean section is abstinence from sexual intercourse for four to six weeks or until the permission of the attending physician.
Benefits of Cesarean section
The main benefit of cesarean section is that it can save the life of the mother and fetus when natural birth is medically impossible or dangerous. With the help of surgical delivery, it is possible to avoid traumatization of the baby in case of incorrect presentation, high body weight or narrowness of the mother’s pelvis. In case of unforeseen complications of pregnancy and labor (placental abruption, fetal hypoxia), the surgery allows for a quick removal of the baby, preventing possible health problems in the future.
Minuses of caesarean section surgery
The disadvantage of caesarean section is a longer and more painful recovery compared to vaginal delivery. The danger of cesarean section is the possible traumatization of organs adjacent to the uterus (bladder, rectum) during the operation. Other risks of abdominal delivery:
- massive bleeding;
- thrombosis in the veins of the lower extremities;
- risk of uterine rupture and placenta previa in the next pregnancy;
- infection in the wound and development of systemic purulent inflammatory process (sepsis);
- divergence of surgical sutures;
- menstrual irregularities;
- secondary infertility;
- chronic pelvic pain syndrome.
The disadvantage of a cesarean section for the baby is the possibility of injury when an incision is made in the uterus. The risk of injury increases when the fetus is actively moving during the operation or the uterus is contracting intensely.
Are there any contraindications to cesarean section?
There are no absolute contraindications to caesarean section. Relative contraindications include acute infectious processes in the mother’s body. Scheduled surgery can be performed after the woman has recovered to avoid worsening of her condition and infection of the baby.
The procedure is performed with caution in women who have problems with blood coagulation. Depending on the nature of the pathology, it may be necessary to administer hemostatic (coagulants) and blood-thinning (anticoagulants) drugs.
If the pregnant woman is allergic to anesthesia, an alternative drug that is safe for the patient is selected. Contraindication to epidural and spinal anesthesia for cesarean section may be dermatological diseases in the area of puncture (puncture), spinal cysts or tumors. In these cases, regional anesthesia can be replaced by general anesthesia.
How are cesareans different from regular babies?
Cesareans differ from normal babies in their increased tendency to have problems with their first breath and adaptation to atmospheric pressure. In natural childbirth, the baby’s chest compresses, which helps to remove fluid from the lungs. In abdominal deliveries, this process does not occur and fluid may be retained in the lungs.
Cesareans may have less developed gut microflora because they do not pass through the mother’s birth canal, where initial colonization with beneficial bacteria occurs. As a result, there is an increased risk of food allergies and dysbiosis.
After removing the baby from the uterus, it is recommended to organize skin-to-skin contact with the mother as soon as possible to strengthen the immune system of the newborn. If the woman in labor is in a severe or unconscious state, the infant is placed on the chest of the father or another relative accompanying the woman.
In some Caesareans, the sucking reflex, formed in the second trimester of a woman’s pregnancy, may be activated with a slight delay. In natural childbirth, there is intense stimulation of the baby’s nervous system, which helps the reflexes to start quickly. Cesareans may need additional time to adapt. Temporary weakening of reflexes can be caused by anesthesia and other medications received by the baby after the procedure.
Cesareans have a more rounded head shape because there is no physical pressure on it as there is when going through the birth canal. Their body temperature is usually lower than that of babies born naturally. Therefore, to prevent hypothermia (hypothermia), the doctor should organize regular monitoring of the newborn’s body temperature, transportation in a heated cuvette or under a warm blanket.
What are the consequences of a caesarean section?
In the first few days after a cesarean section, a woman may experience sharp pain in the area of the suture, which analgesics can help minimize. During the first two weeks, the pain from cesarean section decreases, but until the end of the recovery period, a woman may feel discomfort in the area of the suture when sneezing, coughing, sharp movements. If acute pain persists for more than two weeks, you should make an appointment with an obstetrician-gynecologist.
During four to six weeks, bloody discharge from the vagina (lochia) is observed. They are a consequence of the cleansing and healing of the uterus after the separation of the placenta. At first, the discharge has a rich red color, but over time it becomes brown and its volume decreases until it disappears completely.
After surgery, constipation is possible, and taking antibiotics to prevent infection can provoke diarrhea after cesarean section. Urination may be difficult and painful, but this is temporary and usually subsides before discharge. Other possible consequences of a cesarean section:
- anemia due to blood loss;
- nausea and vomiting after general anesthesia;
- swelling of the extremities;
- back pain after epidural or spinal anesthesia;
- urine leakage;
- increased gas and colic.
Late complications after cesarean section include adhesions (scars) between the pelvic organs, causing pain and restriction of movement. Sometimes hernias (prolapse of internal organs through weaknesses in the abdominal wall) occur shortly after cesarean section.
How to prepare for a cesarean section?
By the 30th week of pregnancy, the obstetrician-gynecologist usually gives the patient a list of things to take to the maternity hospital for a cesarean section. After receiving the list, you can start packing. Things for yourself and the baby should be packed in separate bags or bags of dense polyethylene.
A woman will need a change of underwear, a comfortable cotton nightgown, a special nursing bra, rubber slippers. You should also prepare disposable postpartum panties and urological pads, absorbent diapers, dry and wet wipes, garbage bags, towels and personal hygiene items. In agreement with the doctor, you need to take with you a postoperative bandage for the abdomen and compression stockings (if there are prerequisites for the development of varicose veins).
The list of baby things for cesarean includes cotton clothes, disposable and cloth diapers, diapers and cream under them, baby wet wipes. To prevent hypothermia (hypothermia), the newborn will need a blanket or plaid regardless of the time of year.
The doctor will also give you a list of medications for the cesarean section that will be used during the surgery. Along with medications, it may be necessary to purchase sterile absorbent cotton and bandages, drip systems, intravenous and urinary catheters, syringes, disposable surgical gloves.
Before cesarean section, the patient needs to take tests to exclude complications during the procedure. Diagnostic methods before abdominal delivery:
- fetal ultrasound;
- general urinalysis;
- coagulogram (blood clotting test);
- general blood test;
- blood group and Rh factor test;
- electrocardiography to assess heart function;
- Covid-19 antibody test (taken 48 hours before the procedure).
If the patient has diseases that can affect the course of the operation, the doctor may prescribe additional tests. Diagnostics should be done a few days before the scheduled surgery. In cases of the second and third category of urgency, the woman’s tests are taken immediately before the procedure. In cesarean section of the first category of urgency, the necessary tests are done in the operating room.
For the operation should take with them documents: the original and copies of the passport, exchange card of the pregnant woman, contract for childbirth (for private medical centers). You should be accompanied by your husband or a close relative. While the woman in labor will be under anesthesia, he will be able to decide on the further treatment of her and the newborn child in case of complications.
The accompanying person must also undergo preliminary diagnostics (take a Covid-19 test and undergo a fluorography). You should have your passport or other identification document with you. Rubber slippers (booties), a change of clothes (robe), a medical mask and a cap will be required to stay in a medical facility.
Preparation for an elective cesarean section involves the woman taking a shower on the eve of the procedure. Due to the use of anesthesia or anesthesia, the patient is advised not to eat for 8-12 hours before the operation.
How do I breastfeed after a cesarean section?
After cesarean section surgery, breast milk production in the laboring woman may be delayed. To stimulate lactation when using regional anesthesia and in the case of a satisfactory condition of the child and the mother, the first application to the breast is carried out immediately. With general anesthesia, breastfeeding after cesarean section is started in the intensive care unit after the woman regains consciousness.
Breastfeeding after surgical intervention is carried out on demand of the baby. If the baby is in a serious condition or the mother is taking medications incompatible with breastfeeding, the midwife helps to start milk decanting to preserve lactation after cesarean section. On the doctor’s recommendation, the newborn may be switched to artificial formula feeding.
