Overview of Cesarean Delivery
A cesarean delivery, often known as a C-section, is a common surgical procedure where a baby is delivered through a cut in the mother’s stomach and uterus. The first recorded C-section took place in the year 1020 and the method has improved greatly since then. It’s now the most commonly performed surgery in the U.S., with over a million women having C-sections each year.
The number of C-sections performed jumped from 5% in 1970 to nearly 32% in 2016. Several reasons contributed to this rise, such as older mothers, medical improvements that allow riskier pregnancies to continue, and changes in medical best practices. In fact, in 2022, the U.S. saw over 3.66 million births, with a majority happening through natural or induced labor. However, a C-section is often done when labor doesn’t progress as it should, referred to as “labor dystocia”. In spite of this, reducing the number of unnecessary C-sections is currently a healthcare priority in the U.S., where 32.2% of all births in 2022 were C-sections.
There have been efforts to lower the rate of C-sections by promoting natural births where possible and encouraging vaginal births after a C-section when it’s safe. However, experts believe that a significant reduction in C-section rates might take another decade. While a C-section can carry short and long-term risks, for some women it might be the safest, or the only way, to deliver a healthy baby.
Anatomy and Physiology of Cesarean Delivery
A cesarean delivery, or C-section, is a procedure where a doctor delivers a baby through a cut in the mother’s abdomen and womb, rather than through the birth canal. It’s a complex procedure that involves going through multiple layers of body tissue. Here’s a breakdown of what happens during the operation:
First, the doctor makes a cut in the skin and then cuts through a layer of fat just underneath the skin. They then reach a tough layer of tissue that covers the abs muscles that’s made up of two parts – one from a large muscle in the side of the abdomen, and another from two additional muscles.
Next, the doc separates the vertical muscles in the mum’s belly to reach the abdominal cavity. If the woman is pregnant, the womb is immediately encountered. For women who’ve had previous surgeries, there can sometimes be scar tissue involving other parts of the organs that the doctor has to work around.
Afterward, the doc identifies the uterus (womb) and locates a layer of tissue that connects the bladder to the uterus. If necessary, they have to cut this layer. It may be difficult to separate the bladder from the uterus in women who’ve had earlier C-sections.
The uterus is made of three layers – an outer layer, a muscular layer, and an inner layer, all of which the doctor needs to cut into. There are blood vessels around the uterus that the surgeon has to carefully avoid hurting when they’re making the incision. Blood flow through these vessels increases significantly during pregnancy.
Usually, C-sections are conducted when the lower part of the uterus is adequately developed to provide a safer area for the incision. In preterm deliveries, this access point may not be available, and a different type of C-section (“classical cesarean delivery”) needs to be done. This method has a higher risk of bleeding and cannot be used for future vaginal births due to the increased risk of womb rupture.
Once the doctor cuts into the womb, they might encounter the amniotic sac, which is the water bag that the baby has been living in during the pregnancy. This sac is made up of two layers, which merge early in the pregnancy. If it’s intact, it forms the final barrier between the surgeon and the baby. After the doc cuts through this, they can deliver the baby.
After the baby is delivered, the doctor can see additional structures and perform other necessary medical procedures if needed, such as removing fallopian tubes if required or removing ovarian cysts.
Why do People Need Cesarean Delivery
Sometimes a natural childbirth isn’t safe or possible, so a C-section, or cesarean delivery, might be necessary. This could be due to a number of factors, such as a previous C-section in a certain way or a past experience of a rupture in the uterus (the womb). While C-sections can have complications, they are reserved for when they are medically needed rather than for electives or inappropriate reasons. Yet, a mother’s input and decision is really important. So, if a mother requests a C-section when it isn’t medically necessary, her request may not be refused in favor of her being actively part of the decision-making process.
It’s important to try to reduce the number of C-sections when it can safely be done because once you’ve had a C-section, you’re more likely to have them for any future births too. There could be a specific reason why a mother chooses to have another C-section or it could purely be a medical decision. One such reason is that certain medicines used to ready the cervix (the lower part of the uterus) for labor aren’t advisable in certain situations, such as when the cervix isn’t in a favorable state for childbirth. This is because they can increase the chance of a rupture in the uterus happening. In first-time mothers, a C-section might be required for a number of reasons. These could include complications during labor, irregular readings in the baby’s heart rate, the baby not being in the right position for birth, carrying more than one baby or the baby being much larger than average.
There are various reasons why a mother might need a C-section:
– She’s had a C-section before
– It’s her personal preference
– She has a pelvic deformity or there’s a mismatch between the baby’s size and the mother’s pelvis
– She has been injured in the genital area before
– She’s had surgery on her pelvic, anus or rectum before
– She has a herpes simplex or HIV infection
– Heart or lung disease
– Brain aneurysms or blood vessel malformations
– A disease requiring simultaneous surgery in the abdominal area
– An emergency C-section is required when the mother is dying.
There could also be issues with the mother’s uterus or other anatomical factors:
– There’s an issue with how the placenta (which provides the baby with nourishment) is attached to the uterus, like placenta previa or placenta accreta
– Placental abruption, where the placenta detaches from the uterus
– A previous surgical cut through the full thickness of the uterus
– A past situation where a surgical cut in the uterus has come apart
– Invasive cervical cancer
– Past surgery to remove the cervix
– A large mass blocking the passage in the genital area
– A permanent reinforcement ring around the cervix.
There are also a number of reasons related to the baby:
– The baby is showing signs of being at risk, demonstrated by an umbilical cord that is not normal or a concerning fetal heart rate
– The umbilical cord has slipped down through the cervix before the baby
– A failed forceps or vacuum birth
– The baby isn’t positioned correctly
– A large for gestational age baby
– A birth defect
– Low platelet counts
– The baby has been injured during birth before.
When a Person Should Avoid Cesarean Delivery
There’s no clear-cut medical reason where a cesarean section, or C-section (which is the delivery of a baby through an incision in the mother’s abdomen), cannot be done. It’s a crucial procedure in emergency childbirth situations that call for immediate birth of the baby. Ideally, it is best to perform C-sections when there is access to anesthesia, antibiotics, and the necessary surgical tools. However, even if these elements are not available, a C-section may still happen based on urgent medical circumstances. Regardless of the resources available, doctors specializing in childbirth need to be ready to handle emergencies skillfully and promptly.
From an ethical standpoint, a C-section should not be done if the pregnant person does not agree to it. Respecting the pregnant person’s choices is always of utmost importance. Comprehensive education and counselling is vital for the person to make a well-informed decision about whether to have a C-section or not. If the person refuses to have it done, they have the right to do so. On more complex matters, a discussion involving various professionals, including risk management teams, may be required, especially if there are concerns about the pregnant person’s ability to make decisions.
There are certain situations where a C-section might not be the best option. If a pregnant person has a severe coagulopathy, a condition where the blood does not clot as it should, leading to significant bleeding risks, a natural birth might be safer. Also, if the person has undergone extensive abdominal surgery previously, a C-section might not be suitable. If the baby has passed away in the womb, doing a C-section could put the person at unnecessary risk as it won’t bring any benefits for the baby. Likewise, if the baby has severe irregularities that make it impossible for them to live outside the womb, these same cautionary measures should be considered.
Equipment used for Cesarean Delivery
The tools needed for a C-section, or cesarean delivery, can change depending on what’s happening at the time.[17] At the very least, you need something to cut with. For example, in an emergency like a car accident, a medic might be able to do a C-section with a sharp piece of broken glass. But those kinds of emergencies are really rare. Usually, doctors use a mix of one-time-use and reusable tools to keep everybody—the doctor, the mom, and the baby—safe. What tools they use depend on what’s happening in the moment.
The operating room should have a medical bed or table that can go up and down to make it more comfortable for the doctor. The table should also have armrests for the mom, a safety strap or belt to keep the mum from falling, and a tilt system to allow the lying mom to lean to her left. There should also be step stools for the doctor and their helper.
Most operating rooms have a brand of warmer to keep both the mom and the baby warm during the process. Before the operation starts, the mom will usually have a catheter— a thin tube—placed in her bladder. The room should also have strong overhead lights to let the doctor see what they’re doing clearly. You’ll typically see consumables—the tools you use once and throw away like stitches, gloves, gowns, dressings for wounds, and things to stop bleeding—during the operation.
The doctor will use a surgical drape to keep everything sterile once the mom is in the right position on the table. This drape might have holes in it around the tummy, and it usually has sides that will collect any fluid. The drape gets attached to two poles on either side of the mom’s shoulders, so she can’t see the operation. But there are also clear drapes if the mom wants to see their baby being born. Many hospitals use a standard pack for C-sections that come with the necessary drapes and other consumables.
The tools for giving anesthesia, like the monitors for vital signs, cabinets for storage, medicines for making sure the anesthesia is working, and equipment for the airway, are usually at the head of the surgical table. Even though most C-sections use regional anesthesia—which only numbs part of the body—the doctor might need to use general anesthesia, meaning it numbs the whole body, in certain situations. So, they should have all the equipment they might need ready to go.
Most hospitals use a standard surgical tray just for C-sections. This tray has the instruments they’d typically use in the procedure, but the exact contents might be different in different regions or hospitals. The tray might have various types of scissors, clamps, forceps (which are like tweezers), retractors, knife handles, needle drivers, and suction devices.
Having a standard surgical pack and instrument tray is especially helpful in emergencies because it cuts down on the time it takes to gather all the equipment. Along with the usual instrument trays for a C-section, there should also be a tray for a hysterectomy just in case. It’s really rare, but sometimes the mother’s uterus needs to be removed – a procedure called peripartum hysterectomy. In emergency surgeries, every second counts, the right tools can make a critical difference.
Who is needed to perform Cesarean Delivery?
A cesarean section, or C-section, is a surgical procedure to deliver a baby that involves trained medical professionals working together to take care of both the mother and the baby. During the procedure, from preparation to recovery, each team member has a key role to play.
The team usually includes:
- A surgeon: This could be a specialist in women’s health (an obstetrician or gynecologist), or in some rural areas, it could be a general surgeon. Sometimes, a family doctor who also does obstetrics can perform a C-section.
- A surgical assistant: This person supports the surgeon and could be another doctor, a trained nurse, or a nurse who specializes in midwifery.
- An anesthesiologist or anesthetist: They make sure you don’t feel pain during the procedure by administering pain relief medicine (called analgesia). They also closely monitor your vital signs – things like your pulse and blood pressure – and manage your airway to ensure you get enough oxygen. Active in dealing with blood loss during surgery and even measure urine output. They can give additional medications or blood products as needed, and may also take blood samples for testing.
- A surgical technician or operating room nurse: They help by giving the surgeon the necessary tools during the procedure, and can also step in to assist if needed.
- An operating room nurse: This nurse is not involved directly with the surgery. They get hold of other equipment or supplies as needed, make sure everything is documented properly, and help ensure the procedure is safe. They also help verify the count of surgical tools used during the procedure along with the surgical technician.
- A neonatal care professional: After delivery, they care for your baby. They make sure your baby is warm and checked over carefully. If your baby was born early or needs extra care, more staff may be involved, such as specialists in newborn intensive care.
All of these medical professionals work together to ensure that your cesarean section procedure is safe and successful for both you and your baby.
Preparing for Cesarean Delivery
According to improved health guidelines, when a woman is pregnant, her doctors should prepare her and her partner for the chance of a cesarean delivery. Women should have all the details about what to expect before, during, and after a cesarean. If the doctors think a cesarean might be necessary because of risks to the mother or baby, they will try to manage any of the mother’s existing health conditions, like anemia, diabetes, or high blood pressure, before the surgery.
There is a risk of breathing in stomach contents during cesarean delivery, which could lead to lung problems. To prevent these risks, doctors may give the mother antacids and histamine H2 antagonist, a type of medication that reduces stomach acid. Mothers are usually asked not to eat or drink anything for a certain period before the surgery. The latest guidelines suggest she should be allowed to drink clear liquids up to 2 hours before the surgery and avoid consuming any solid food 6 hours before the surgery. If the mother does not have diabetes, she might be offered a carbohydrate drink up to 2 hours before surgery to improve results. However, preparing the bowels by oral or mechanical methods is generally not recommended. In emergency situations, the fasting requirement might be bypassed based on risks to the mother or baby.
Preoperative gabapentin, a medicine for nerve pain, has been shown to improve pain control after a cesarean. It’s important to avoid any form of sedation before the surgery due to the risks of decreased motor function after delivery and potential risks to the baby, like trouble with temperature regulation, low Apgar scores (a quick measure of a newborn’s health), and “floppy baby syndrome” (a temporary loss of muscle tone).
Like any surgical procedure, a cesarean section carries a risk of infection. In fact, women who have a cesarean are twenty times more likely to get an infection than those who give birth naturally. To decrease the risk of infection, doctors often administer preventative antibiotics before the surgery. The type of antibiotic depends on the clinical scenario and the patient’s allergic reactions. The goal is to counter different types of bacteria that may cause an infection.
Usually, a single dose of 1 gram of cefazolin (an antibiotic) is given to women who weigh less than 80 kilograms. The amount is increased for those who weigh 80 kilograms or more. For women who are allergic to cefazolin, clindamycin and aminoglycoside are used instead. If the woman has previously had a certain type of resistant bacteria, a dose of vancomycin is also given.
Being exposed to bacteria present in the vaginal and skin flora increases infection risk during cesareans. So, for women undergoing a cesarean after labor or the rupture of membranes, an additional intravenous dose of azithromycin might be beneficial.
Topical medications, such as povidone-iodine and chlorhexidine, are commonly applied to the skin to reduce the risk of infection after a cesarean. Ideally, doctors should also consider cleaning the vaginal area. A recent review suggests that doing this could likely reduce the chance of infection in the womb after a cesarean section.
How is Cesarean Delivery performed
Properly handling tissue, ensuring good blood control, avoiding a lack of blood flow to tissues, and preventing infection are important factors to healing wounds and reducing the formation of scar tissue after surgery. Different techniques may be used to take care of each layer of tissue during surgery, and many factors can impact the surgeon’s preferred approach. As always, choices should be based on the best available scientific evidence. There are four main techniques for cesarean delivery: the Pfannenstiel-Kerr technique, the Joel-Cohen technique, the Misgav-Ladach technique, and the modified Misgav-Ladach technique.
Whether or not to remove pubic hair before a cesarean is a matter of choice. Some people believe it helps to reduce contamination and infection at the surgical site, but a review of different studies did not show a significant decrease in infection rates when hair was removed. Hair removal should be limited to cases where it helps the surgeon to see better. If hair removal is necessary, it should be done using clippers, not razors, to avoid microscopic skin breaks that increase the risk of infection. It is also recommended that patients should avoid shaving their pubic area as they approach their due date or scheduled cesarean to reduce infection risk.
The initial cut for a cesarean delivery can either be a horizontal incision above the pubic bone or a vertical midline incision. A midline vertical incision allows quicker access to the abdominal cavity and disrupts fewer layers and blood vessels, making it a preferred technique for many emergency cesarean deliveries. In some cases, a vertical incision may be chosen to provide a larger opening for the surgery, such as when removing a placenta that has attached too deeply into the uterine wall. However, in most cases, a transverse incision is preferred because it heals better and is more comfortable for the patient.
The Pfannenstiel incision is a small, curved cut positioned about 2-3 cm above the pubic bone. The Joel-Cohen incision, in contrast, is straight and located below the line connecting the hip bones, making it higher than the Pfannenstiel incision. After the initial cut is made, the surgeon will carefully make incisions in the layers beneath the skin, striving to minimize blood loss.
The surgeon will make sure to handle the thin layer of tissue covering the abdominal organs (peritoneum) carefully, in order to prevent injury to the organs inside the abdomen. A small tool can be placed to give a better view of the lower section of the uterus, or an instrument that holds the wound open may be used. A bladder flap can be created by carefully peeling the peritoneum and bladder away from the lower uterus.
At this point, with enough visualization, the surgeon can then make a cut in the uterus. The cut in the uterus can be either horizontal or vertical, but most often a low horizontal incision is preferred because it results in less bleeding, is easier to repair, and results in less scar tissue. However, sometimes a vertical incision may be necessary, such as when the baby is lying sideways or the lower part of the uterus is not developed enough.
The surgeon will assess the uterus before making the incision, to make sure that the incision is positioned in the midline and not skewed to the side to minimize the risk of complications. After the procedure, the cut is closed following the surgeon’s preferred method.
Possible Complications of Cesarean Delivery
In the U.S, about 2.2 out of every 100,000 women who deliver via cesarean section (C-section) die. This rate, although low, is higher compared to vaginal births, which see about 0.2 deaths in 100,000. Much like any other surgery, a C-section carries the risk of heavy bleeding during and after the operation. In fact, severe bleeding is a leading cause of serious health issues for mothers in the U.S. Conditions such as long labor, having a large baby or having too much amniotic fluid can increase the risk of the uterus not contracting back to its normal size, leading to serious bleeding.
During the C-section, certain factors can lead to excessive blood loss. These include the need to cut through large amounts of scar tissue from previous surgeries or if the cut into the uterus extends into the blood vessels. Severe bleeding can sometimes require a blood transfusion, which carries its own risks. Around 10% of deaths related to childbirth in the U.S are due to severe bleeding. Sheehan’s syndrome is one possible complication that can occur as a result of heavy bleeding during delivery.
Infections are another big risk after a C-section. Along with heavy bleeding after childbirth, wound infections and inflammation of the lining of the uterus are common issues post C-section. One study discovered that cleansing the vagina before surgery reduced infections of the uterus from 8.7% to 3.8%. Another research found that use of an additional antibiotic, azithromycin, lowered wound infections from 6.6% to 2.4% and major negative events from 2.9% to 1.5%. But considering that over a million women undergo C-sections every year, even these percentages point towards a large number of women dealing with infections after the procedure.
In 2010 data revealed that the risk of serious infection in planned repeat C-sections was 3.2% compared to women who were trying for a vaginal birth after previously having a C-section, which was 4.6%. The data also showed that repeat C-sections had a blood transfusion rate of 0.46%, a rate of surgical injury between 0.3% to 0.6%, and a rate of hysterectomy, or removal of the uterus, at 0.16%. Risks also include blood clots and problems with anesthesia.
Though C-sections are generally safer for the baby, there are still risks involved. The chance of the baby getting hurt during a cesarean delivery is around 1%, risks include cuts, broken collarbone or skull, facial or arm nerve damage, and blood collection outside the vessels in the baby’s head. But these risks are less compared to vaginal deliveries. However, compared to being born vaginally, babies born by C-section may face higher risks of breathing problems, asthma and allergies. In 2010, rapid breathing shortly after birth was noted in 4.2% of repeat, planned C-sections and 2.5% needed bag-and mask ventilation.
In addition to the immediate risks associated with surgery, C-sections also carry long-term risks for the mother and any future pregnancies. A vertical scar on the uterus from a C-section means that any future child would also have to be delivered by C-section. The more C-sections a woman has, the higher the surgical risks. Scar tissue can make each successive C-section more difficult and increase the risk of accidental injury. The risks of the placenta attaching wrongly to the uterus wall increase with each successive cesarean section. For a woman who has had one C-section, the risk of a condition called placenta accreta is 0.3%, however, it goes up to 6.74% for women who’ve had 5 or more C-sections. Abnormal placenta attachment can lead to significant bleeding and may cause infertility if removal of the uterus is required.
What Else Should I Know About Cesarean Delivery?
About 1.3 million women in the U.S. have cesarean sections, or C-sections, every year. This makes it the most common surgery in the country. The first known C-section, which happened in AD 1020, unfortunately ended in the patient’s death. However, we have seen great medical progress since then and this surgery is now much safer and more effective.
Doctors need a deep understanding of the risks and benefits of a C-section so they can guide pregnant women the right way. This surgery involves delivering the baby through a cut made in the mother’s stomach and uterus, rather than naturally through the birth canal.
Awareness and practice of medicine based on scientifically proven evidence can help doctors offer the best possible care and results to their patients. Sometimes, a patient may ask for a C-section even when it is not medically needed. Doctors should be ready to provide the right information in such cases, to ensure the patient can make an informed decision.
There is a growing push to reduce the number of C-sections performed. Proper knowledge about when a C-section is truly necessary can aid both doctors and patients in making better decisions. In some cases, C-sections can be life-saving for the mother, the baby, or both, but it is important to understand that like any surgery, it has risks too.