By Dr Soumyaroop Dash, MD (Consultant Obstetrician and Gynaecologist)
Caesarean section refers to a major surgical procedure where a baby is removed from the uterus by making a cut into the abdomen, then into the uterus. Although in many cases a caesarean section, or c/section for short, is necessary to save the life of the baby or mother, there are other situations where women and their doctors are choosing this form of birth because they feel it is more convenient, because of fear about pain during vaginal delivery, or due to concerns about lawsuits.
Nobody is really sure where the term ‘cesarean section’ came from, but I am fairly certain that Julius Caesar was not born by c/section. In the past, almost every woman who underwent a c/section died, and in many cases it was performed to save the baby at the expense of the mother’s life. Julius Caesar’s mother lived after his birth, which suggests he was delivered vaginally. Caesarean section now accounts for about 25% of all births in most hospitals. The chance of dying from a c/section, which is a major abdominal surgery, is about 20 out of 100,000. Although this is not exceptionally high, it is higher than the chance of dying from a vaginal delivery.
When doing a c/section an obstetrician first makes sure that the patient has adequate anaesthesia. We commonly use spinal anaesthesia. On unusual occasions the patient may need to have general anaesthesia, which involves going completely to sleep with a tube in the throat and the use of a ventilator device. Once the patient is numb, a cut about the size of the distance from your wrist to the tip of your little finger is made on to the skin. In most cases, this incision is made from side-to-side, just above the pubic hair line (sometimes called a ‘bikini cut’), while in some parts of the world, and in some emergency situations, an up-and-down cut is made from below the belly button to the top of the bikini line. (Most obstetricians prefer bikini cuts because they heal and look better, and cause less pain after leaving the hospital.) After cutting through the skin and underlying fat cells, the doctor will make an incision through the remaining tissue, then will enter the abdominal cavity. The bladder, uterus, ovaries, tubes, and intestines are all visible and sometimes have to be moved out of the way before cutting into the uterus (womb). After entering the uterus through a cut a little larger than the baby’s head, the baby is carefully grasped, and the surgical assistant pushes on the top of the uterus to deliver the baby through the hole in the uterus. The umbilical cord is clamped and cut, and the baby is handed to the nurses or neonatologist who care for newborn babies.
While the cut on the skin does not matter, the cut on the uterus is very important. We try to make a side-to-side cut on the uterus, called a ‘low transverse uterine incision,’ since this is safer and has a very small chance of breaking open during subsequent pregnancies. Since the chance of the incision breaking open during a later pregnancy is very small (probably at or under about 1%), doctors now consider it safe to try for a vaginal delivery during later pregnancies if the patient has a prior low transverse incision. This is called a ‘vaginal birth after caesarean’ or VBAC (pronounced ‘V-Back’) . An up-and-down uterine cut, in contrast, has a much higher chance of breaking open, which can cause heavy internal bleeding or even stillbirth, so we consider it unsafe to try for a vaginal delivery when there is a history of a prior vertical incision. These patients should have a repeat c/section.
There are many reasons to do a c/section.
* In some cases, the afterbirth is too close to the opening of the vagina, called a placenta previa, and vaginal delivery would lead to life-threatening bleeding.
* Other indications for c/section include a dangerous drop in the foetal heart rate for many minutes,
* Cord prolapse (where the umbilical cord falls out of the vagina and constricts the blood supply to the baby)
* Heavy vaginal bleeding from a torn afterbirth
* Many (but not all) breech babies
* Babies that are in an awkward position in the uterus (for example, sideways)
* Active genital herpes
* Triplets almost always require a c/section, while many twin deliveries can be safely performed vaginally
* Arrested labour where the woman only dilates to a certain amount then stops, accounts for many c/sections.
Contrary to popular belief, this does not mean that the next pregnancy must end in c/section, because just as all children are different, all pregnancies are different. Just because, for example, a six-pound baby will not fit exactly right and needs a c/section, does not mean that the mother will need one for her next pregnancy, where the baby is 8 pounds. Each baby fits differently.
Finally, probably the least common reason for a c/section is because the baby is too big. Almost all pregnant women believe their baby is “too big,” yet this is almost never the case. As always, when considering which way to delivery your baby, discuss this issue with your obstetrician until you are sure you have enough information to make an informed decision. You may find that you have preconceived ideas about either a vaginal delivery or a c/section and that you change your mind after discussing the issue with your obstetrician.
Many women want to know what they should or should not do after a c/section. Basically, you will stay in the hospital from 2-4 days after a c/section, depending on your response to pain medication and your ability to walk around. Many women recover surprisingly quickly and leave after a few days. You will need to walk carefully to avoid straining your abdomen, and will probably need a little help getting up and down stairs. Driving should be avoided for a few weeks. Most doctors advise against lifting anything more than, say, 10-15 pounds for a few weeks, and most would like to see you immediately if you notice any redness or infection around the incision, pain in your calf muscles, worsening abdominal pain, fever, or other abnormal symptoms. The uterus goes back to normal after about 6 weeks, and by that stage most women have almost completely recovered and are ready to resume normal activity.
In conclusion, with advances in medical science and nursing care, caesarean section is a very safe mode to deliver a baby, when the conditions to deliver vaginally are not met with.
