Caesarean in Detail

This article gives information on Caesarean in Detail - what happens before and after a Caesarean section in New Zealand, what is involved and detail on what it feels like. For information on why you may need a Caesarean section, the risks and complications and how you can help yourself, see our article on Caesarean Section. An explanation of the terms planned, emergency or Crash caesarean are also included in this article. What follows is an outline of the Caesarean procedure and how it will feel for you.

Caesarean: Pre Op
Firstly a decision has to be made, between yourself and your health professionals (obstetrician, Lead Maternity Carer, midwives, anaesthetist) that this is the best option for you and your baby. The procedure will be explained and you will be asked to sign a consent. This is to verify that you understand the potential risks and complications of surgery and that, in the event of a complication, you are agreeing to further treatment, such as a blood transfusion. If you have not already had blood taken, this will happen now. Your haemoglobin (iron level), your bloods ability to form a clot and your blood group will all be checked. Two or three tubes of blood will be filled, via one needle, usually on the inside of your elbow. As you will need intravenous fluids, a luer (plastic tube) will be inserted into a vein in your hand or arm, which is done using a needle- then the needle is removed and the plastic tube is left in the vein and secured in place with sticky tape. This can be painful, so if you are afraid of needles ask about having a bit of local anaesthetic in your hand first. Once the needle is removed the luer will not hurt, but can feel uncomfortable - it will be removed after your operation, when you are able to eat and drink again. You will need to give information to the midwives and doctors about when you last ate and drank and any previous medical history you may have - for example previous operations and anaesthetics. You will be asked to change into a loose fitting gown for the operation and to remove contact lenses and all jewellery (a wedding band can be taped over if you do not want to remove it). At this stage you will have a shave of the top inch of your bikini line, where the scar will be hidden. The midwife will usually do this for you, using an electric razor.

One of the problems of any operation (particularly when you are pregnant) is the period of

immobility that follows - like being on a long haul flight - so you will be asked to wear antiembolic stockings to aid your leg circulation. Also, because you will not be able to get up to go to the toilet afterwards, a urinary catheter will be inserted into your bladder. This is a thin plastic tube which is gently inserted via your urethra (the passage from your bladder to the outside) and drains all urine from your bladder into a bag. This will usually stay in until the following day, when you will be up and about again.

The Caesarean Section

When you go in to the operating theatre, the first thing that may strike you is the large number of people there! This will include:
y y y y y y

The surgeon and the assistant surgeon The anaesthetist and the anaesthetic technician The scrub nurse and the assistant The midwife The paediatrician (baby doctor) And last but not least, you and your partner!

Firstly you will need an anaesthetic - usually you will stay awake and have a spinal or epidural block so that you are pain free, but awake to greet your baby. But you will still be aware that something is happening - it feels as though someone is washing up inside you! Occasionally you may be advised to have a general anaesthetic, where you are put to sleep. If so, your partner will have to wait outside, as the anaesthetist is too busy concentrating on your well-being to have extra people present. You will be laying on an operating table, tilted very slightly up - that is, your head will be slightly lower than your pelvis. There will be a cloth screen in front of you, so that you can't see the surgery, and nor can your partner, if he is staying near you (by your head). This is especially good if either of you are feeling squeamish! Your skin will be cleaned and draped, to keep the area sterile. The obstetric surgeon will check you are numb and then begin the operation, cutting through the skin, muscle and into the womb, usually taking 5-10 minutes. You may hear suction as the amniotic fluid around baby gushes out. Your baby will be lifted out by the doctor (occasionally using forceps if it is a tight squeeze) and shown to you over the drapes. After the cord has been cut, the midwife and baby doctor dry, wrap and check your baby over and bring the baby to you and your partner, where you will see and touch your baby for the first time. Meanwhile the surgeon will deliver your placenta and begin to stitch up the womb, muscle and skin layers - this takes about an hour. A simple dressing will be put over your wound and a sanitary towel placed between your legs, for any vaginal blood loss.

Post Op: After a Caesarean Section

You, your partner and your new baby will be moved to the recovery area after the operation is finished. A nurse or midwife will care for you here and you will be assisted with your babys first breast feed. As the anaesthetic block wears off you will need pain relief - usually this is a continuous infusion for the first day, often patient controlled so you can boost your pain relief as necessary. Your urinary catheter and intravenous drip stay in place until you are up and about and eating and drinking again. Initially you will not be able to lift your baby, but midwives will help you with this. After an hour or two in recovery area, you will be transferred to the postnatal ward, where most women stay with their babies for 3-5 days, following a caesarean section. After the first 24 hours you will probably need only oral pain killers and the more you get up and walk about, the quicker your recovery will be. Your full recovery period will take a minimum of 6 weeks, during which time you will be advised to lift only your baby, do gentle abdominal and leg exercises, eat well and gain plenty of rest. For many women the recovery period takes a lot longer - listen to your body, look after yourself and ask for help, to enable you to be a better, more active mum in the long run!

Preparing for Cesarean Section

The Labor and Delivery staff at Overlook Hospital would like to make sure that your upcoming stay with us is both safe and fulfilling, so weve compiled information that will come in handy before, during and after your delivery.
What is a Cesarean Section?

A Cesarean Section is the surgical procedure to deliver a baby. An incision is made through the abdomen into the uterus and the baby is lifted out.
Before your surgery

If you have not sent in your pre-registration forms, please do so now. Mark the material 6AB. If you do not have these forms, you may pick them up at your physicians office, or just call Labor and Delivery at 908-522-2333, and well be happy to send them to you.
The Night Before Your Cesarean Section

The night before your Cesarean Section you will not be allowed to eat, drink, or smoke after midnight. This includes candy, gum or water. After delivery of your baby your diet will be

adjusted to your needs. Try to get a good nights sleep. You may brush your teeth in the morning. Check with your doctor if you are taking any medication. We encourage you to take a shower before coming to the hospital. Please leave valuables at home and keep your luggage in the car until you are transferred to the postpartum unit. Space is limited in the pre-op area. Videotaping is not permitted in the operating room; however, you may take still photographs of your newborn under the warmer. You may videotape, your newborn only, in the nursery. This is to ensure confidentiality and privacy of both your family and staff.
Admission

Admission to the hospital begins approximately two hours before your scheduled Cesarean Section time. Come directly to the sixth floor where our secretary will register you. Be sure to bring your insurance card and a drivers license or some other form of identification. The preregistration form you sent in will make the registration process much more efficient.
The PRE-OP Area

In preparation for your Cesarean Section you will:

y y y y y y y

Change into a hospital gown and provide a urine sample. Have an intravenous line (IV) started in your arm or hand. Through this you will receive necessary fluids and medications as needed. Have blood drawn. You may be required to take a clear liquid medicine. This is an antacid. Have your surgical site prepared. (Shaved) Be seen by your obstetrician and anesthesiologist, and asked to sign a consent form. The nurse and /or doctor will answer any questions.

On Your Way to Having Your Baby

One support person may accompany you to the Operating Room. You will be escorted into the room first and your support person will be asked to change into his/her scrub suit, and wait outside the room. Your anesthesiologist will place the blood pressure, pulse and respiration monitors on you. He or she will then administer your anesthesia. A foley catheter will be inserted in your bladder. Your abdomen will be washed and sterile drapes will be placed over you. Your support person will be escorted in to sit next to you, and the Cesarean Section will begin. A team consisting of a pediatrician/neonatologist and one or two pediatric nurses will arrive to take care of your baby as soon as it arrives. They will stabilize your baby and then bring it over so you may see it. Your support person will then accompany them with your baby to the nursery. You will be reunited in the recovery room.

Recovery Room

Following the birth of your baby, you will be taken to the Recovery Room. Your blood pressure, pulse and respiration will be monitored closely. You may receive oxygen through a tube that fits loosely into your nostrils. You will be given time to become reacquainted with your baby. Only two visitors including the support person are permitted in the recovery area. Grandparents and significant others are welcome, but siblings are not allowed in the recovery area at any time.

What is cesarean birth?

A c-section is abdominal surgery. An incision is cut in the mothers abdomen, and the baby is delivered through the incision.

Trends in cesarean birth

How common? 31.8% of births nationwide in 2006. For women with prior cesareans, 7.6 9.5% had a VBAC (vaginal birth after cesarean). (from the Center for Disease Control) [2008 Rates for Seattle area hospitals ranged from 23 - 40%] What is the trend in cesareans? In 2000, 22.9% of women gave birth by cesarean. The cesarean rate has increased dramatically since then, reaching a new record level every year since 2000. What rate is recommended? Cesarean is a vital tool for preserving the well-being of mothers and babies in high risk situations, and is often a life-saving procedure. However, it is also major surgery, and is a tool which should be used only when necessary, and only when the benefits of the surgery outweigh the possible risks associated with it. Healthy People 2010,[i] the World Health Organization[ii], and Coalition for Improving Maternity Services[iii] recommend a primary cesarean rate of 15% or less.

Why has there been such an increase in cesareans in the U.S.? (For all the details, look here)

Changes in demographics of birthing women: more older moms, more obese moms, more multiple births

Changes in obstetrics and modern maternity care: surgery is much safer than it once was, physicians are no longer being trained in some techniques that were once safer alternatives to surgery (forceps and vaginal breech deliveries), hospitals are over-using maternity care practices known to increase cesarean rates without necessarily improving the health of mother or baby (continuous fetal monitoring, and elective induction of labor), and under-utilizing self-help practices that can increase a womans chance of vaginal birth (upright positions for labor and birth, continuous labor support, manual rotation of babies, and VBAC)

Defensive medicine and hospital policies: Physicians are very aware of the risk of malpractice lawsuits. 10-20% of their gross income goes to malpractice insurance, and 76% of obstetricians have been sued at least once. Even though most of those claims are dismissed, or found in the obs favor, fighting lawsuits still takes a lot of time and energy. This leads physicians to practice defensive medicine, saying things like the only cesarean you get sued for is the one you didnt do. A survey[iv] of physicians found that because of fear of liability: 79% order unnecessary tests, 74% make unnecessary referrals, and 51% suggest unnecessary biopsies. 14.8% of OBs report that they stopped offering VBAC because of the risk of lawsuits.[v]

Cultural perspectives: In the popular media, every birth portrayed as an emergency waiting to happen, with technology the savior for every challenge, leading many women to mistakenly believe that vaginal birth is dangerous for babies, and cesarean is guaranteed safer. In general, western culture embraces technology, women may feel more confident about surgery than they do about the unpredictability of letting labor take its natural course.

Cesarean on maternal request. There is a lot of media buzz about women choosing elective cesareans. How common is this? Depends on who you ask. In 2006, the NIH estimated 4 18% of all cesareans.[vi] National birth certificate data shows that there is an increase in cesareans for women with no indicated risk factors from 3.3% in 1991 to 5.5% in 2001.[vii] However, the data doesnt actually tell us anything about why the cesarean was done, and who initiated the decision making. In a survey of 1573 American mothers, only one woman (.06%) initiated an elective cesarean for no medical indication. Of the other women in the survey who had primary cesareans, 98% believed there was a medical reason for their surgery, 2% had scheduled cesareans for non-medical reasons that they report were initiated by a health professional. Amongst all women in the study, 9% reported feeling pressured by their care provider to have a cesarean.[viii]

Reasons a cesarean may be recommended to you

Planned cesareans for clear medical indications that the risks of vaginal delivery for the mother or the baby are greater than the risks of abdominal surgery. Caregivers agree on the benefits of c-section in these cases. [ix]
o Placenta previa or a large uterine tumor which blocks the cervix o Malformed or injured pelvis o Severe pregnancy-induced hypertension, where induction is contra-indicated, or was

attempted and failed

o Genital herpes first outbreak of herpes contracted in late pregnancy

o HIV - if viral load over 1000 copies/mL near time of delivery[1] o Transverse lie (baby is lying horizontally in the uterus) o Twins if first baby is breech. Triplets or more. o Certain birth defects, fetal problems, or maternal medical problems where the risks

of cesarean are outweighed by the risks of attempting a vaginal delivery

Planned cesarean for other medical indications (Some care providers will recommend cesarean based on these, others will not)
o Recurrent genital herpes with active lesions at onset of labor o Breech o Twins if first baby is head-down o Preterm birth, or small for gestational age o Prior cesarean or prior uterine surgery (see VBAC discussion below) o Big baby research doesnt support this as a reason to do a cesarean

Planned cesarean for no medical indication

o Fear, convenience, etc. (see below)

Unplanned cesarean for situations that arise in labor (see below)

o Failure to progress / cephalo-pelvic disproportion o Fetal heart rate variations

Emergency cesareans:
o Placental abruption happens in 1 in 200 pregnancies. o Prolapsed cord happens in 1 in 400 pregnancies. o Uterine rupture with an unscarred uterus, less than 1 in 1000 pregnancies (see

VBAC below)
o Urgent maternal or fetal health situations

What about cesarean to prevent urinary incontinence, and improve sexual function? You may have heard that some women choose cesarean for these reasons. About 3% of women have urinary incontinence (accidentally leak urine) after birth. It is unclear whether incontinence is caused by vaginal birth, or by care practices associated with vaginal birth, like: episiotomy, vacuum extractor, forceps, and forceful pushing. Studies indicate that incontinence is lower in the 6 months after elective cesarean than after vaginal birth. But over time the incontinence resolves. Cesarean is not guaranteed to prevent incontinence. Some women will be incontinent in later years regardless of whether they have ever been pregnant or ever birthed vaginally. Better options for limiting incontinence would be doing kegel exercises, quitting smoking, and maintaining a healthy body weight.

Research shows that any differences in sexual function based on route of delivery were no longer evident by 6 months postpartum. Factors that affect sexual functioning, such as changing family roles, relationship satisfaction, physical recovery or continuing morbidities, mood, and lack of sleep, have not been adequately studied. [x]

What about choosing cesarean for no medical reason? Some women ask their care providers for a cesarean for non-medical reasons, including fear of birth, desire to avoid pain, the convenience of scheduling, or the sense of being in control of the situation. In 2003, the American College of Obstetricians and Gynecologists stated that physicians are ethically justified in performing an elective cesarean if they believe it promotes the overall welfare of the woman and her fetus. In 2006, a NIH panel stated that decisions should be individualized and consistent with ethical principles. They note that maternal request cesareans are not recommended for women desiring several children, and should not be performed prior to 39 weeks or without verification of lung maturity because of the significant danger of neonatal respiratory complications.[xi] Several womens health care professionals issued responses to these statements, warning No evidence supports the idea that cesareans are as safe as vaginal births for mother or baby [xii],[xiii] There have been studies which show increased risks of cesarean. For low-risk healthy women, overall rates of severe complications were 27.3/1000 women having planned cesareans versus 9.0/1000 for women having planned vaginal births.[xiv]

If you are considering choosing cesarean, its important to first fully inform yourself about all aspects of vaginal birth and cesarean birth so you can make an informed choice. If your desire is driven by a fear of childbirth, seek counseling to address those fears, take childbirth classes, and consider hiring a doula for extra support. Taking these steps may make vaginal birth seem more manageable to you. There are some women for whom this is not enough, and a cesarean may be an appropriate tool for her psychological well-being.

How common is each reason? The most common reasons for cesarean are: failure to progress (20-30%), fetal heart rate concerns (20-25%), repeat cesareans (20%), maternal health issues, fetal health issues, breech babies. [xv] About 40% of cesareans are planned, about 60% are unplanned and arise during labor[xvi]. The indications for planned and emergency cesareans are usually things that are beyond your control. For unplanned cesareans, at the point the recommendation for cesarean is made, it often is the best option. However, there may be things that could have been done earlier on to prevent reaching that point. (See To Improve your Chances for Vaginal Birth ) For example, if a woman is stalled at 4cm after 24 hours of labor, is feverish, and has a baby with an elevated heart rate, cesarean may be a good option at that point. However, she may have been able to prevent this situation by: waiting till active labor to go to the hospital, being active throughout early labor to help baby move to a good position, and delaying epidural (having an epidural in place for many hours can lead to fever for mom and elevated heart rate for baby).

Understanding unplanned cesareans The most common reason for cesarean is failure to progress. This means that labor is taking longer than expected to progress to 10 cm dilation, or that baby is taking longer to descend through the birth canal than expected. A long labor or delivery is not in itself harmful, and if mom and baby are doing fine, is not necessarily a reason for cesarean. Using all the tips from this book will help minimize your chance of prolonged labor. (Especially important: upright positions and movement and labor coping techniques.) Sometimes failure to progress is diagnosed as CPD (cephalo-pelvic disproportion), which means that the babys head is too large to fit through the mothers pelvis. CPD is impossible to predict even if everyone has always told you that those tiny hips just werent made for birthing, or even if you have x-ray pelvimetry and ultrasounds to check the size of your pelvis and your baby. The key to bringing baby through your pelvis is getting the baby in the best possible position by being active in labor and changing positions frequently to help baby line himself up well. The diagnosis of failure to progress cannot be made reliably until the active phase of labor (after 5 centimeters dilation) since a normal latent phase (0 to 4 cm) is often very slow. If the diagnosis is made in active labor, you may ask your care provider what alternatives are available. They may include changing positions or other coping techniques for augmenting your labor, or pain medication. (Sometimes if labor is not progressing due to moms tension level, having pain medication may allow it to progress.) Another viable alternative is to keep doing what youre doing and see if things improve, as they often may. Some maternity care advocates refer to failure to progress as failure to wait long enough. However, if you have tried everything to help labor progress and nothing has changed, or if prolonged labor is not the only issue, but there are other

compounding factors such as fetal heart rate variations, or maternal exhaustion, the care provider may recommend doing a cesarean now rather than waiting. The second most common reason for cesarean is variations in fetal heart rate. Babys heart rate is one of the best clues we have about babys well-being during the labor. (more on monitoring) Particular changes in the heart rate may indicate problems for the baby, such as decreased flow of oxygenated blood to the baby. Research studies have consistently shown that a) there is huge variation in care providers interpretations of heart rate, b) that there is a high rate of false positives, where the heart rate looks concerning but baby is actually fine, and c) even though it is possible for brain damage to occur to baby during birth due to lack of oxygen, in most cases, brain damage actually takes place during pregnancy before labor begins. Cesareans cannot prevent or cure these pre-existing problems. Nevertheless, when there are significant concerns about the babys heart rate, most care providers will recommend a cesarean just in case. If your care provider recommends cesarean due to concerns about the heart rate, ask whether there are other tests that can be done to check whether baby is doing well, or whether baby is beginning to suffer from lack of oxygen. These tests might include a biophysical profile (page 82), observing the fetal heart rate response to scalp stimulation, fetal scalp blood sampling or oxygen saturation monitoring (see page 260). Whatever the reason why cesarean has been recommended to you, its important to make informed decisions about this procedure.

Risks of cesarean[xvii]

The following are things which are more likely to happen after a cesarean birth than after a vaginal birth. They are listed in order from most common side effects to rare complications. Effects on mother y y Longer hospital stay: 3-4 days vs. 1-2 for vaginal Pain in abdomen: 79% had pain after the birth. For 18%, pain persisted for 6 months or more y y y y y y y y y Increased blood loss Infection: 1 10% Re-hospitalization: 5% Admission to ICU: 10 per 1000 Hysterectomy: 8 in 1000 Injury to bowel, bladder, or ureter: 1 in 1000 Blood clots: 1 per 1000 (could lead to stroke) Rare: complications from anesthesia Maternal mortality: research indicates that women are 2 7 times more likely to die from cesarean, even when medical risk factors are controlled for. However, the chance of maternal death from any cause is still very small (13 per 100,000 women). (CDC) Effects on babies: y less immediate contact with mother

y y

lower likelihood of breastfeeding, shorter duration of breastfeeding breathing problems at birth: 35 of every 1000 babies born by cesarean, 5/1000 after vaginal

y y y y

admission to neonatal ICU for 7 or more days is twice as likely Asthma scalpel injury during surgery: 1-2% fetal death: 1.77 per 1000 for babies born by c-s to low risk women, .62/1000 for babies born vaginally to low-risk women Effects on future pregnancy and birth y y y y y y y y More likely to birth by cesarean Placenta previa: doubling of risk (NIH), 55/10,000 vs. 35/10,000 (NICE) Placental abruption: 1-10 / 1000 (CC) Ectopic pregnancy 1-10/1000 (CC) Placenta accreta Increased risk of rupture Pre-term labor and low birthweight baby Stillbirth: Twice the risk of stillbirth in subsequent pregnancies (CC)

The more cesareans a woman has, the more risks she will have for future fertility and future pregnancies.

Benefits of Cesarean:
Mother is less likely to have: y y Pain in perineum 2% with cesarean, 5% with vaginal (NICE) Urinary incontinence: 450/10000 = 4.5% with cesarean, 7.3% with vaginal (NICE) y y 3rd or 4th degree tear: .12% with unplanned cesarean, .77% with vaginal Uterine prolapse

Baby is less likely to have: y Brachial injuries, nerve injury affecting shoulder, arm, hand (rare)

The other benefits for cesarean depend on the reason why cesarean is being recommended to you.

Informed Choice
No matter what the outcome of a birth, a woman is more likely to have a satisfying birth experience if she feels like she understood what was happening and that she actively participated in the choices that had to be made, rather than feeling like the cesarean was something out of her control that happened to her. Ask the questions

you need to ask to make an informed choice about whether cesarean is the best option for you and your baby. Benefits. Ask about the benefits, and why it is being recommended. These will vary based on the reason for cesarean. You may also ask whether all care providers would make the same recommendation for your situation, or if there are other views of your options. Risks. Ask about the risks of cesarean surgery. Alternatives: Ask what alternatives you might have, and what other things you might try before deciding on the surgery. Timing: Ask How urgent is this situation and how quickly do I need to make the decision? That will help you relax and know that you have time to ask questions and adjust to this new plan for your birth. If you began labor expecting a vaginal birth, and then cesarean is recommended, it may come as a shock to you. It may feel difficult to ask questions and make informed choices while still coping with the challenges of labor. An unplanned cesarean tends to feel like an emergency to the parents, but there is usually time to explore options. You have the right to consent to a procedure that is recommended, you also have the right to refuse the procedure. And even after you have signed a consent form, you have the right to change your mind.

The Procedure
If it is a planned cesarean, you will be asked not to eat for 8 hours prior to labor (you may be allowed to have clear fluids up to 2 hours before labor.) You will usually be told to arrive at the hospital about two hours before the surgery.

If its an unplanned cesarean, heres what to expect once the decision has been made to move toward surgery.

Preparation for surgery These steps may be done in your labor room, or in a pre-op suite, or in the O.R. You will be asked to sign a consent form stating that you are aware of the potential risks involved in cesarean surgery. You will be given an antacid to drink typically bicarbonate of citrate. An IV will be started, and youll be given extra fluids to hydrate you. You may be given antibiotics at this time, or they may be given during the surgery. Your belly will be washed, and then cleaned with an antiseptic solution. They may shave any hair on your abdomen, and the top part of your pubic hair. Your support partner(s) put on scrubs, a mask, hair net or hat. You may be able to walk to the O.R. or you may ride on a gurney. Sometime before surgery, they will insert a catheter to drain the urine from your bladder, as this helps reduce the risk of injury to your bladder. You can ask that this be done after the anesthesia is in effect.

Anesthesia If you are having a planned cesarean, usually a spinal block is used, which can be administered quickly, and lasts for a few hours. If you were in labor, and already have an epidural catheter in place, they will use that catheter, and just increase the dosage of the medication to numb you completely from your chest down. In rare emergency situations, general anesthesia is used, which will render you unconscious for the surgery. Your partner may not be able to be in the room.

Both epidural and spinal blocks allow you to stay awake and alert, but will numb you so you will not feel any pain from the surgery. You may feel pressure and pulling when baby is delivered. The anesthesiologist will be right next to you throughout the surgery. Be sure to let him know if you feel any pain, nausea, or other discomforts.

In the Operating Room The staff in the O.R. will include the primary obstetrician who will lead the surgery, an assisting OB, an anesthesiologist (there may be a nurse anesthetist or anesthesia resident who will take over after the medications have taken effect), a surgical nurse who will handle all the sterile instruments, a circulating nurse who handles all the tasks that dont need to be sterile, and a nurse for baby. There may be neonatologist and other personnel if there are concerns about babys health. The anesthesiologist will be up by your head. You can ask him any questions you have. Your partner will also be up by your head. You will lie on your back on a table. Either the table will be tilted sideways a little, or you will have towels placed under one hip. This takes your weight off your major blood vessels, and reduces the chance that you will develop low blood pressure or nausea. Your arms will be spread out to your sides on arm rests, and may be restrained there to prevent tangling of the various cords. You will typically have EKG sensors on you, an oxygen sensor on your fingertip, a blood pressure cuff, and an oxygen mask, as well as the IV and bladder catheter. You will be covered with a sterile sheet, and a surgical screen will be placed across your chest at nipple level everything below that point must be kept sterile. The screen prevents you from seeing the surgery, and from reaching down and touching the surgical area. Its normal to feel some anxiety in this situation. Practice the deep breathing exercises, relaxation techniques, or visualizations you learned in childbirth class to help you remain calm and relaxed.

The Surgery First, the doctor will make an incision through your abdominal wall (your skin, fat layer, and fascia a fibrous layer of connective tissue). Typically, this is a horizontal incision, nicknamed the bikini cut, an opening about 4 to 6 inches long, and an inch above the pubic bone. Occasionally, in emergency situations or for obese women, this may be a vertical incision between the navel and your pubic bone. Then the doctor uses her hands to separate the stomach muscles which run up and down. Then she cuts or pokes through the peritoneum, which encases the abdominal cavity. The bladder is pulled back to protect it. Then an incision is made in the uterus. It is usually a low transverse incision, from side to side; occasionally a low vertical incision, or rarely a classical incision, which is a vertical cut in the upper part of the uterus (only done for placenta previa or a baby in a transverse position. The type of scar you have effects whether a vaginal birth will be an option for you in the future, so be certain to learn which you had. After a small cut is made, the physician uses her fingers to stretch the opening, or scissors to make it wide enough for babys head to fit through. To control bleeding, she may cauterize the ends of the cut blood vessels. You may smell a burning odor. Then she will break the amniotic membranes if needed, and you will hear her suction out the fluid. Then the doctor slips a hand inside the uterus, and cups it around the top of babys head (or babys feet if breech). The assisting physician will press on the top of the uterus to help push baby out. You may feel intense pulling and tugging; you shouldnt feel pinching. Babys head is lifted out first, then fluids are suction from his nose and mouth, then baby is brought up and out. The cord is clamped and then cut, then baby is held up for you to see. Baby is usually born about 5 to 15 minutes after surgery began.

Immediate baby care

Baby may be cared for at a warming table in the O.R. or may be taken to the nursery. (You may request that baby be cared for in the O.R. if at all possible.) Babys mouth and nose may need to be suctioned more to remove all the fluids. During a vaginal birth, the contractions squeeze all the fluids up out of babys lungs, but a baby born by cesarean doesnt have that same physiological advantage. Baby is evaluated with APGAR scores taken, and a newborn assessment. Other newborn procedures may also be done at this time, including antibiotic eye ointment, vitamin K shot, and height and weight measurements. If baby is having any breathing difficulties (more likely after cesarean), he may need supplemental oxygen or a ventilator, may be given surfactant treatment, which helps to keep the lungs from collapsing, making breathing easier for baby. As soon as possible after the birth, baby should be brought over close to you where your partner (or the nurse) can hold baby so you can get to know him while surgery is completed.

Repair Pitocin is injected into the IV, which helps the uterus start shrinking, which aids in the removal of the placenta and helps control bleeding. Then the placenta is manually removed and inspected. Your uterus may be lifted up out of your abdomen for repair, or the repair may be done internally which means less pain for mom without any increased risk of infection or excess bleeding. The uterus closed with stitches that will dissolve. The double suturing method is most recommended, which means suturing both the inner wall and the outer layer of the uterus to have a stronger scar, which will be less likely to rupture in future pregnancies and labors. Then the skin is closed with staples or stitches, and bandaged.

The process of repairing the uterus and completing the surgery takes about 30 45 minutes after the birth, so the total surgery procedure takes about an hour. During the surgery, you may feel nauseous. You may feel anxious or panicky. You may also be trembling all over (probably due to the anesthesia or your bodys response to the shock of surgery). Medications can help with these discomforts, but can also make you so tired you may sleep through babys first hour in the world. Before medications, you might try slow deep breathing, a cool cloth on the forehead for nausea, warm IV fluids or warm blankets for the trembling. After the surgery, you may return to the room you were laboring in, or you may return to a surgical recovery room. Then you will be transferred to a postpartum room a few hours after surgery.

Partners Role During a Cesarean Once surgery begins, you may feel relegated to the sidelines while the experts do the work. But, you still have an important role to play. Your job at this time is to be reassuring and supportive for the mother, and to be the primary caretaker for baby while surgery is completed. During surgery, you are seated up by moms head, above the sterile area. If youre interested, the doctors may allow you to look at the surgical area, but you need to remain completely out of the doctors way. During this time, stay close to mom, hold her hand, talk to her, stroke her hair, rub her shoulders; help with relaxation techniques and visualization. Sometimes the medication makes a mom feel like she cant breathe. She may say I cant breathe and may be panicky. She can breathe (if she couldnt, she couldnt talk!). Reassure her that shes OK.

Note: if you start feeling light-headed or nauseous, tell the anesthesiologist. Hell have good ideas for what you should do. When the baby is born, you may ask to be the one who announces the gender to mom. Once baby is there, you go where the mother asks you to go. Most often, she will ask you to stay with the baby, but occasionally, she will ask you to stay close by her side. (Its nice when two support people are allowed in the surgery, because then one can stay with baby and one with mom.) If you are over with the baby, be moms eyes and ears, and begin a running commentary, telling her everything you are noticing about baby. While the nurses are completing newborn procedures, you may start touching your baby. Sometimes it may feel to you only medical staff are allowed to touch the baby in the O.R. but you can too! You can usually hold the baby shortly after birth, and bring it over for the mother to see as surgery is completed. Your big goal should be to get mom and baby in touch as quickly as possible. Stand next to mom and hold baby where mom can see him and touch him. If mom falls asleep due to medication and the stress of surgery, then remember all the events so you can tell her about it later (that first diaper change!). Take lots of pictures. Think about what else you can do to make things special for her. Maybe tell everyone else (grandma and grandpa and others) that they have to wait to hold baby till after mom has her turn. Or maybe keep baby wrapped up till mom is there to count the fingers and toes. Its very important to get breastfeeding started as soon as possible after the birth. Baby often becomes very sleepy about one to two hours after the birth, so its best if the first feeding happened before that. You may need to help with getting baby latched on, and help support baby through the whole feed if mom is still feeling groggy from the medication.

Recovery

When your baby is born by cesarean, you have all the normal aspects of postpartum physical recovery and learning to care for and feed your newborn, plus youre recovering from major abdominal surgery! Heres a general overview of what to expect: Expect that for the first 24 hours, you will need help with everything: rolling over, sitting up, walking. For the first two weeks, you will be sore, youll be moving slowly, and youll need help with basic household tasks. By 6 weeks, you will probably be feeling back to normal physically. Plan on getting some extra help and support to help you through this time!

Your Hospital Stay You will probably be in the hospital for 3 4 days after a cesarean. Your nurse will be checking on you regularly: shell check your vital signs, listen for bowel sounds, ask if you are peeing and pooping, and check your incision to be sure it is healing well. Your nurse is a valuable resource to you during this time for information, advice, and assistance. Ask for her support with getting breastfeeding off to a great start.

Pain Medication In the first 24 hours, they may continue your epidural, or more likely you will have IV pain medication (possibly morphine or Demerol). You may have patient controlled analgesia which allows you to control the dose you need. You will continue to need pain medication for several days to a week, typically oral medications such as Percocet, Tylenol or ibuprofen.

Low concentrations of the medication does reach baby via your breastmilk, but the effects on your baby from the pain medication will be very slight. Take enough medication to be comfortable. If youre tense with pain, it will be hard to bond with baby, learn parenting skills, and relax for breastfeeding. Dont let medications wear off completely. Go ahead and take your next dose when it is due, even if youre not hurting yet. If your medications make you groggy, ask to have dosage decreased, or medication changed.

Sitting, standing, and walking Within six hours of the birth, they will ask you to sit up on the side of the bed. You will find it easiest to first roll onto your side, then use your arms to push yourself to a sitting position. Rest there for a moment to see if youre dizzy. With the nurses help, you can stand up: use your hands to push yourself up. Within 6-8 hours, you should be able to walk to the bathroom. When you can do this, the nurse will remove your bladder catheter. You should be walking independently within 12 hours, should be able to walk the hallways of the hospital within 24 hours. For the first week or two, try to minimize climbing stairs, as that puts a lot of pressure on your belly muscles. Moving as soon as possible after surgery improves lung function, boosts blood circulation which lowers risks of clots, and improves digestion.

Supporting your belly (Splinting)

When you first get up and walk, it can feel like insides are falling out. Also, your belly may hurt when you change positions, hurt when you cough, hurt when you laugh. Try using your hand, a pillow, or a rolled up towel pressed gently against your incision area to support it whenever needed.

Exercises / Physical Activity On day 1, try these simple exercises: Deep breathing take some nice deep breaths, all the way down to your belly. Gently exercises your abdominal muscles. Coughing hold hands over incision, take a deep breath, and let it out with a gentle huffing cough. This dislodges any accumulated mucus from respiratory system, and clears lungs of anesthesia residue. Roll from side to side in bed. Roll your ankles and do knee bends: bend your leg while sliding your heel up on the bed, then straighten that leg, and repeat with the opposite leg. These exercises help prevent blood clots. On day 2 4: While sitting: flex your feet, roll your shoulders. Do stomach pull-ins: pull your stomach in than relax it. First 2 4 weeks: Dont lift anything heavier than baby for first 2 weeks

Dont drive for 4 weeks (reaction time is slowed by meds, difficult to brake well) Limit stairs, reaching into high cabinets, laundry, vacuuming. No heavy exercise. No sex. Rest and take it easy, and dont wear yourself out entertaining too many visitors.

Gas and Elimination Abdominal surgery can sometimes lead to problems with gas, gas pains, slow bowel function, and problems with urination. For the first four hours after birth, you may just have sips of water and ice chips. Then clear liquids. After at least 6 hours and after hearing bowel sounds, the nurse will take out your IV, and you can eat something. Start with easily digested foods, and bland mild foods. Over the next few days, take the stool softeners you will be given, drink lots of water, and gradually add in high fiber foods. To minimize gas, avoid ice, iced drinks, carbonated beverages, and very hot or cold foods. Walk, change position often, and rock gently back and forth in a chair.

Incision care: Your nurses will show you how to clean area, and check for swelling or infection. Its normal to have some watery pink discharge and some itching. Avoid touching the incision without washing your hands first. Gently clean and dry the wound daily. After 24 hours, you can shower or bathe as usual, using a mild unscented soap. Dry thoroughly. Wear loose comfortable clothes.

If youre very overweight, make sure air can circulate around the incision area. Obese moms have a higher rate of infection because it is harder to keep the incision area clean and dry. If your incision is closed with tape, it will come off on its own. If it was closed with staples or stitches, these may need to be removed around day 5. Your care provider will tell you what to expect. You may notice a hard ridge along the incision. This will soften over time, especially if you massage it for a few minutes every day. Your scar shouldnt be uncomfortable after 6 weeks, though it may still feel stretched and pulled. It may feel numb for three months.

Warning signs: Call your care provider if you have any of these symptoms. Fever over 100, excessive fatigue, change in urine volume or color, vaginal bleeding increases or becomes painful, cough or shortness of breath, abdominal pain, lightheaded/dizziness, isolated pain in calf with swelling and redness. Problems with incision: Redness and pain at incision. Unusual discharge. If bleeding from incision stops, then starts again, soaks more than one dressing per hour, or turns bright red.

Breastfeeding Breastfeeding can be more challenging after cesarean, thats why after cesarean fewer moms start breastfeeding, and if they do start, they may quit sooner.

However, cesarean does not have to be a barrier to successful breastfeeding if you know about the possible challenges and work to manage them. Your first challenge may be finding a comfortable position for nursing. Some women do best with the football hold, because baby is off to your side, so isnt putting any pressure on your belly. Youll need to find just the right combination of pillows for propping baby in the right place. Some women prefer side-lying, though you may need your partners help with getting baby latched on well when youre on your side. If you use the cradle or cross-cradle hold, use pillows under baby to cushion your incision. A baby born by cesarean may be sleepier than the average baby, whether thats due to the pain medications, or just the lack of stimulation they would have had during a labor and vaginal birth. It also may take longer for your mature milk to come in. For many women, their milk supply increases dramatically on day 3. If you had labored, but birthed by cesarean, it may be day 4 for you. If you had a cesarean without labor, it may be day 5. If this happens, your baby may lose more weight than your doctor would recommend, or your baby may have an increased chance of developing jaundice. The best way to prevent and address these problems is with frequent feeds. The more often you put baby to breast, the more milk you will make. Skin-to-skin contact between mom and baby also helps. You may have more risk of thrush, a yeast infection on your nipples. You may be able to reduce the chance of thrush by minimizing sugar in your diet, and taking acidophilus supplements or eating yogurt. When youre in the hospital, ask the nurses for help with breastfeeding! Ask your partner to help you with position and latch. Find out the name of a local lactation consultant and/or breastfeeding hotline you can call when you have questions.

Helpful Tips for the first 6 weeks If you are planning a cesarean, plan ahead to have these things in place for the first 6 weeks. If you have an unexpected cesarean, here are some ideas that can help. Extra help and support: If anyone offers to help in any way, take them up on it! Its especially great if someone can help with grocery shopping, laundry and dishes, as those may be especially difficult for you. Postpartum doula services and cleaning services are great gifts to ask for at your baby shower! Set up the house so everything is nearby when you need it: If your house has more than one floor, then set up a diaper-changing station on each floor so you dont have to go up and down stairs every time you need to change a diaper. Even better, organize your house so you can live on one floor for the first couple weeks. Set up breastfeeding stations throughout the house, where you have everything you need to settle in with baby for a long feeding. Stock up on foods that are easy to prepare, and keep a small cooler packed with snacks and drinks in the room where you spend the most time. Organize kitchen, bathrooms and closets to minimize bending and stretching.