Overview of Cesarean Delivery
Cesarean delivery, also known as a C-section, is a type of surgery used to deliver a baby. It involves making a cut in the mother’s abdomen and uterus to bring the baby out. The first time a C-section was performed was in the year AD 1020, and since then, the procedure has changed a lot. Today, C-sections are the most performed surgeries in the United States. Every year, more than one million women have babies through C-section.
In 1970, only 5% of births were C-sections. But by 2016, that rate had gone up to almost 32%. There are many reasons for this increase. For example, mothers are generally older now, and scientific breakthroughs have made it possible for more complicated pregnancies to go ahead. Also, the ways doctors and nurses take care of pregnant women have changed. In 2022, the United States recorded more than 3.66 million births. Most of these were natural births or births that were induced, meaning that labor was started by doctors. But the most common reason for having to do a C-section was because labor wasn’t progressing normally. C-sections are happening more and more around the world. In the United States, it is a priority to reduce the number of C-sections that aren’t necessary. In 2022, 32.2% of all births were C-sections.
It will be challenging to lower the number of C-sections, despite efforts to encourage natural birth and vaginal births after a previous C-section when safe to do so. Experts believe that it will likely be another ten years before the rate of C-sections starts to drop significantly. While a C-section can come with risks, both right after the surgery and in the long-term, it can also be the safest or only way to deliver a healthy baby for some women.
Anatomy and Physiology of Cesarean Delivery
A cesarean delivery, or c-section, is a surgical procedure to deliver a baby. The doctor performing the surgery has to go through several layers to get to the baby. The procedure starts with a cut in the skin, followed by soft tissue underneath. The doctor then reaches the covering of a muscle in your belly, named the rectus abdominis muscles.
The doctor then separates these muscles to enter the belly. If you’re pregnant, the uterus is the first thing they meet. But if you have had previous surgeries, the doctor may stumble upon scar tissues clinging to your organs, like the lining of the belly, bowel, bladder, and the front part of the uterus.
When the doctor identifies the uterus, they focus on the vesicouterine peritoneum, a delicate membrane that connects the bladder to the uterus. If needed, this membrane is cut. In patients who’ve had c-sections before, it can be a bit more difficult to separate the bladder from the uterus.
The uterus itself has 3 layers—an outer layer (perimetrium), a muscle layer (myometrium), and an inner layer (endometrium). All 3 layers are cut to open the uterus. The arteries supplying the uterus are situated on the sides of the uterus and need to be avoided to prevent bleeding. These arteries come from the internal iliac artery and carry eight times more blood during pregnancy. They cross the tubes carrying urine and enter the uterus at a point near the cardinal ligament. They are also connected with the ovarian arteries in the broad ligament, which come from the main blood vessel, the aorta.
C-sections are ideally done at full term, because the lower part of the uterus is thin and has fewer blood vessels, making it safer for a cut. For early deliveries, particularly before 34 weeks, this point is not available and a different type of c-section, called a “classical cesarean delivery,” may be needed. This involves a vertical cut, which increases bleeding and prevents future vaginal births due to an increased risk of uterine rupture.
Upon cutting the uterus, the doctor may meet the amniotic sac if it’s still intact. The amniotic sac has 2 layers—the chorion and the amnion—that unite early in pregnancy. This sac is the last barrier to reach the baby. Once this is cut open, the baby is delivered, achieving the primary goal of the c-section. After the baby’s birth, the doctor can see other structures, especially if the uterus is taken out of the belly for repair. The doctor might check the fallopian tubes and ovaries and if needed, performs procedures like removing the fallopian tubes or removing problematic ovarian cysts.
Why do People Need Cesarean Delivery
Sometimes, there are certain factors that make a normal delivery risky, hence the need for a cesarean section, also known as a C-section. This is a surgical way of delivering a baby, usually done when a natural delivery could put the baby or mother at risk. For example, a woman who has had a previous cesarean, or her womb has ruptured in the past, may be advised to have a C-section. However, a C-section is a major surgery and can have complications, so it is usually reserved for cases where it is absolutely necessary, not just because it is a personal choice.
While some medical professionals might agree to a C-section upon request, the focus is on providing the best care for both mother and baby based on their specific health needs. This way, both parties participate in making decisions about the birthing process.
Work is being done to decrease the number of first-time C-sections because women who’ve had a C-section once often have their next babies in the same way. Some may choose this, or may not be eligible for a vaginal delivery after a C-section due to various medical reasons. It is very important to note that certain medications used for inducing labor are not advisable for women who can’t deliver easily due to the increased risk of their womb rupturing. Common reasons for having a first-time C-section can include complicated labor, issues with the baby’s heart rate, wrong positioning of the baby, having more than one baby at the same time, and a baby that is larger than normal.
A C-section delivery may be needed for several maternal reasons such as:
- Past C-section delivery
- Mother’s request
- Irregular shape or size of the pelvis
- Prior injury to the area between the vagina and anus
- Previous surgery on the pelvis or rectum
- Infections like herpes or HIV
- Heart or lung disease
- Cerebral aneurysm or arteriovenous malformation
- A need for concurrent abdominal surgery
- Emergency C-section delivery
There may also be uterine/anatomical reasons for a C-section like:
- Abnormal placement of the placenta (placenta previa and placenta accreta)
- Separation of the placenta from the uterus
- Prior classical hysterotomy
- Previous full-thickness myomectomy”
- Past history of uterine incision dehiscence
- Invasive cervical cancer
- Prior trachelectomy
- Blockage in the genital tract
- Permanent cerclage
Fetal reasons for a C-section could be:
- Nonreassuring fetal status (abnormal umbilical cord or abnormal fetal heart tracing)
- The umbilical cord comes out before the baby
- Failure of operative vaginal delivery”
- Wrong positioning of the baby
- A baby that is larger than normal
- Birth defects”
- Thrombocytopenia or low platelet count
- Past history of neonatal birth trauma
When a Person Should Avoid Cesarean Delivery
There are no hard and fast medical reasons that would absolutely prevent a cesarean delivery (generally referred to as C-section), especially in urgent situations that need the baby to be delivered immediately. Ideally, it’s best to have things like anesthesia (to manage pain), antibiotics (to prevent infections), and the right equipment available. But if these aren’t on hand and the situation is critical, a C-section can still be done. Doctors who deliver babies have to be ready to handle emergencies quickly and effectively, even when resources might be limited.
However, an important factor is the mother’s willingness to have a C-section. It’s essential to respect the patient’s freedom to make decisions about their own health. If a mother doesn’t want to have a C-section, her wishes should be respected after she has been fully informed about the procedure and its risks and benefits. Some situations might be more complicated and might need a team discussion, maybe getting input from experts who handle the risks related to patients’ choices, especially if there are worries about whether the patient is able to make a sound decision.
Certain situations might make a C-section less desirable, even though it’s not completely ruled out. These are known as relative contraindications. For instance, might be someone who has problems with their blood clotting, which means there are bigger risks with surgery. In this case, giving birth naturally (vaginally) might be safer. Or, a woman who’s had a lot of surgery on her belly might not be the best candidate for a C-section. Also, in situations where the baby has passed away before birth or has severe abnormalities that mean it won’t survive, a C-section might put the mother at needless risk since there’s no benefit for the baby.
Equipment used for Cesarean Delivery
When a cesarean delivery (or C-section) is performed, different types of tools might be needed depending on the specific circumstances. Basically, a cutting tool is a must. In an extreme emergency, like after a car crash, a doctor might have to do a C-section with whatever sharp object is available. But thankfully, those situations are really rare. Normally, a mix of disposable and reusable equipment is used to ensure safety for the doctor, the mother, and the baby. The type of equipment varies based on the situation.
The room where the cesarean delivery is performed should have a surgical bed or table that can be adjusted in height according to the doctor’s needs. The table should also have armrests and a safety strap or belt to prevent the mom from falling. A small wedge (or perhaps a rolled blanket) is used to tilt the mom slightly to the left. There should also be a step stool available for the doctor and their assistant.
To keep the mom and the newborn warm, blanket heaters are typically used. Before the surgery, a catheter is normally placed in the mom’s bladder. Strong overhead lighting is needed to light up the area where the surgery is happening. Common items that get used up during surgery include stitches, gloves, protective clothing, bandages, and substances that help stop bleeding.
A sterilized drape is used to cover the mom and mark out the clean area for surgery once the mom is in position on the surgical table. The drape might have a hole in it right over the belly. Usually, it has a couple of little pouches to collect fluids. The drape is tied down at two poles by the mom’s shoulders, blocking her view of what’s happening. Some drapes are clear, allowing the mom to see the surgery and the baby’s birth if she wants to. Many hospitals use a standard set for C-sections that includes the necessary drapes, surgical towels, a device to suction fluids, clamps for the umbilical cord, more suction tubing, and other items unique to the procedure.
The equipment for anesthesia, including monitors for vital signs, storage cabinets, medications needed for proper anesthesia, and gear for the patient’s airway, is placed at the head of the surgical table. Though C-sections are usually performed with regional anesthesia, there might be cases when general anesthesia is needed. Therefore, all the gear necessary to secure and maintain the mom’s airway should be readily available.
Many hospitals have a standard set of surgical instruments for C-sections. This might include different types of scissors (for bandages, tissues, or Mayo), clamps (Kelly, Kocher, Allis, and Babcock), forceps to hold sponges or tissues (Adson, Russian, Ferris Smith, and smooth), retractors (to move tissues/organs out of the way), handles for scalpel blades, devices for driving sutures, and suction devices (Yankauer or Poole).
Having a standard set of surgical tools for cesarean deliveries, as well as a cesarean special instrument tray, can be very helpful, particularly in emergency situations. This makes it quicker to gather the required equipment. A set of instruments for hysterectomies (removal of the uterus) should also be readily available. While it’s pretty rare to need a hysterectomy right after childbirth, the rate is going up. Having the right tools ready can help save precious time in emergencies.
Who is needed to perform Cesarean Delivery?
A cesarean section, or C-section, is a surgical procedure where a baby is delivered through a cut made in the mother’s abdomen and uterus. This surgery requires a team of well-trained medical professionals to make sure both the mom and the baby are safe and healthy. Different people in the team have important roles throughout the surgery, from getting everything ready to looking after the mom and baby after the procedure.
The main participants usually include the surgeon, a surgical assistant, an anesthesiologist or anesthetist (who’s responsible for the pain management), a surgical technician or operating room nurse, a circulating or operating room nurse, and a clinician who takes care of the newborn baby.
Before the surgery, the anesthesiologist or nurse anesthetist makes sure the patient feels no pain. Their job is to administer pain management, oversee the patient’s breathing, monitor vital signs like heartbeat and blood pressure and track surgical blood loss and urine output. They also give any necessary medicines or blood products and collect blood samples for testing if required.
The primary surgeon, who does the C-section, can vary. In many hospitals, an obstetrician or gynecologist (a doctor who specializes in women’s health and pregnancy) carries out the surgery. In rural areas, a general surgeon might do the procedure. Other healthcare providers like nurse-midwives or resident physicians may also play this role. The surgical assistant’s job is to help the surgeon, and a surgical technician provides the surgeon with the tools they need.
A circulating nurse is a healthcare professional who collects additional equipment or supplies during the surgery. This person also maintains records of critical information and helps keep the patient safe throughout the procedure. They also ensure all surgery tools, needles, and sponges are accounted for together with the surgical technician.
After the baby has been delivered, they’ll be cared for by a healthcare worker who could be a nurse, an advanced clinician, or a doctor. This person will carry out the initial checks on the baby and keep them warm. If the baby is born prematurely or requires special care, there may be additional staff on hand, like physicians from a neonatal intensive care unit. Sometimes, the surgeon or anesthesiologist might also assist in taking care of the newborn.
Preparing for Cesarean Delivery
Enhanced recovery care plans recommend that expectant mothers and their partners should be educated about the possibility of a cesarean birth. Detailed information should be provided about what will happen before, during, and after the operation. If a cesarean birth is expected due to health issues in the mother or baby, it’s recommended that any health conditions such as anemia (low iron), diabetes, high blood pressure, or obesity should be managed as effectively as possible before the operation, if possible.
A cesarean birth carries a risk of inhaling stomach contents into the lungs, which can cause inflammation. To prevent this, antacids and an H2 blocker can be given before the operation. Usually, patients are asked to not eat or drink after midnight. But if a cesarean birth is unplanned, people may be asked to not eat or drink anything for 6 hours beforehand. Some care plans let people drink clear fluids until 2 hours before the surgery, but solid food is not allowed for 6 hours before. Also, people without diabetes may be given a drink with carbohydrates 2 hours before surgery to improve their recovery. It is not recommended that people have bowel preparation.
Taking gabapentin before a cesarean birth can help manage pain afterwards. But you should not have any other drugs that make you feel drowsy before the operation, because it can affect coordination after the birth and potentially cause risks for the baby, such as low body temperature, low health rating scores and weak muscle tone.
Like any operation, a cesarean birth can cause an infection. Women who have a cesarean birth are 20 times more likely to develop an infection than those who give birth vaginally. But taking antibiotics before the operation can reduce the risk of infection by up to 70%. The best time to give these antibiotics is before the operation rather than after the baby’s cord has been clamped. The type of antibiotic chosen will depend on the situation and any allergies the patient has.
Usually, a single dose of cefazolin is given through an IV. Women who weigh less than 80 kilograms get 1 gram, while those who weigh 80 kilograms or more get 2 grams. If a woman weighs 120 kilograms or more, the cefazolin dose may be increased to 3 grams to make sure the antibiotic level in their body tissues is high enough. If a woman can’t have cefazolin due to a severe allergy, they may be given clindamycin and an aminoglycoside instead. If a woman has a history of infection with a bacteria that is resistant to many antibiotics, a single dose of vancomycin may be added.
Because a cesarean birth can increase the risk of infection from bacteria found on the skin and in the vagina, steps are taken to reduce this risk. Women who have a cesarean birth after labor or breaking of waters have a higher risk of being infected by vaginal bacteria. Recent studies suggest that for these women, adding azithromycin to the usual antibiotics can help reduce the risk of infection.
Lotions such as povidone-iodine and chlorhexidine are often used to help prevent infection after a cesarean birth. Both have been found to be effective at preparing the skin on the abdomen for surgery. Some research suggests that chlorhexidine might be better than povidone-iodine at reducing infection, but both options are considered acceptable because the research is not clear.
In addition to preparing the skin, preparing the vagina for surgery can also help reduce the risk of endometritis, a uterus infection, after a cesarean birth. Both povidone-iodine and chlorhexidine are considered acceptable choices for this.
How is Cesarean Delivery performed
When performing a cesarean section, which is commonly known as a C-section, it’s critical to handle body tissues carefully, ensure there’s minimal blood loss, prevent a decrease in blood supply to the tissues, and avoid infection. These factors are crucial for healing after surgery and reducing any possibility of internal organs sticking together. The surgeon has various methods to choose from at every stage of the operation depending on multiple factors. Their choice of method should be based on proven scientific research and facts. The four common ways of delivering a baby via C-section include the Pfannenstiel-Kerr method, the Joel-Cohen method, the Misgav-Ladach method, and the modified Misgav-Ladach method.
Some doctors may recommend removing pubic hair before a C-section to reduce the chances of infection during surgery. However, research shows this does not significantly lower the risk of infection. Therefore, hair removal should only be done if it makes it easier for the surgeon to see and work on the surgical site. The use of hair clippers is preferred over razors for this as razors can cause tiny cuts on the skin which increase the risk of infection. We therefore advise patients not to shave their pubic area as their due date draws near or before their scheduled C-section.
The surgeon can make the initial cut for a C-section either horizontally just above the pubic bone or vertically down the middle of the stomach. A vertical cut allows quicker access to the womb, disturbs fewer tissue layers and vessels, making it the preferred method in many emergency C-sections. It also improves visibility for the surgeon. However, a horizontal cut is usually preferred because it often heals better and is more comfortable for the patient. The most common technique used by doctors is making a horizontal cut just above the pubic bone, even in emergency situations.
The Pfannenstiel incision, a type of horizontal cut, is slightly curved, and is made 2 to 3 centimeters or 2 fingerbreadths above the pelvic bone. Because it falls within the hair-bearing area of the lower abdomen, hair removal is often necessary. On the other hand, the Joel-Cohen incision is straight, not curved, and is made 3 centimeters below the line connecting the bone tops on both sides of the hip. This makes it higher than the Pfannenstiel incision.
Once the skin is cut, the layer just below the skin is separated either by pulling it apart or using a scalpel. Because there are blood vessels in this layer, it’s important to control bleeding. The hard connective tissue coverings of the muscles underneath are cut in the middle with a scalpel and then gently pulled apart from the underlying muscles. Superior control must be taken not to damage the muscles. In some cases, the muscles may need to be cut to improve surgical exposure.
Once the muscles have been separated in the middle, the surgeon enters the belly by cutting or pulling apart the peritoneum, the lining of the abdominal cavity. If a sharp object is used to do this, care must be taken not to injure structures underneath, such as the bowel. After entry, the peritoneum is further pulled apart. Care must be taken not to injure the urinary bladder when the peritoneum is being pulled apart.
A retractor is usually used to make the lower womb visible. A flap from the bladder can be created If needed by separating the bladder from the lower uterus, either by using a scalpel or pulling it apart. This may be done to prevent injury to the urinary bladder. Despite this, several scientific studies have shown that not creating a flap from the urinary bladder can make the surgery faster without increasing complications. However, if there’s a high risk of the uterine incision extending below the womb, a bladder flap may still be created.
With good visibility, the incision can now be made on the womb. This incision can be either horizontally or vertically. For most C-sections, a horizontal cut is preferred due to lesser bleeding, easier repairs, and reduced chances of internal organs sticking together. However, in certain situations, a vertical incision may be required such as if the baby is lying sideways in the womb. A vertical incision can also be considered when it’s challenging to take the baby out, especially in cases where the baby is in a bottom-down position. Choosing the type of incision often needs to be adapted based on factors like the position and development stage of the baby.
Before cutting into the womb, its position should be assessed to keep the incision as central as possible, which can minimize the risk.
Possible Complications of Cesarean Delivery
In the US, around 2.2 out of every 100,000 women die from complications related to cesarean deliveries. While this number is pretty small, it’s worth noting that it’s actually quite a bit higher than the death rate for vaginal deliveries, which is about 0.2 out of every 100,000. Like any surgery, a C-section comes with some risks, with serious bleeding being one of the main causes of complications. This risk can be even higher due to factors like a long labor, a big baby, or having too much amniotic fluid.
Sometimes, during a C-section, there can be factors that cause more bleeding, such as the need to break up a lot of scar tissue or an incision extending in to blood vessels of the uterus. This can sometimes lead to a need for blood transfusions, which bring their own risks. Roughly 10% of maternal deaths in the US are due to severe bleeding during childbirth. Sheehan syndrome is a complication that can come from severe bleeding during delivery.
Infections are another big risk after C-sections. Besides bleeding, wound infections and inflammation of the uterus lining, or endometritis, are common complications. One study showed that cleaning the vagina before surgery lowered the rate of post-operative endometritis from 8.7% to 3.8%. Meanwhile, another study found that using an additional antibiotic lowered wound infections from 6.6% to 2.4%, and serious complications from 2.9% to 1.5%. Still, given how many women have C-sections each year, these percentages represent a lot of women dealing with infections after surgery.
Data from 2010 shows that the overall risk of infection in planned repeat C-sections was 3.2%, compared to 4.6% in women who tried to have a vaginal birth after a previous C-section. The data also showed that planned repeat C-sections had a blood transfusion rate of 0.46%, a rate of injury during surgery of 0.3% to 0.6%, and a rate of hysterectomy, or removal of the uterus, of 0.16%. Clots and anesthetic complications are other risks to consider.
Even though a cesarean is usually safer for the baby, it’s not risk-free for them either. Around 1% risk of the baby getting an injury, like cuts, fractures, nerve damage, and bruising or bleeding in the head. All of these risks are lower than with vaginal deliveries, but babies born through a C-section have higher chances of difficulties breathing as well as increased risk of asthma and allergies as compared to those born vaginally. In 2010, about 4.2% of babies born through planned repeat c-sections had temporary fast breathing, and 2.5% needed help breathing with a bag and mask.
Besides the immediate risks, there are some longer-term risks too. Once a woman has a C-section with a vertical uterine scar, all future pregnancies will require a C-section. Every time a woman has a C-section, the risks of the surgery go up. Scar tissue from previous surgeries can make each C-section more difficult and raise the chance of unexpected injuries. The chance of birth complications, like the placenta attaching too deeply into the uterus wall, go up with each C-section. For instance, the chance for this condition, known as placenta accreta, rises from 0.3% after one C-section to 6.74% after 5 or more. A difficult to remove placenta can increase the risk of major bleeding and might even result in the need for a hysterectomy, which would permanently take away the woman’s ability to have more children.
What Else Should I Know About Cesarean Delivery?
In the United States, about 1.3 million women have a cesarean section, also known as a C-section, each year, making it the most common surgery in the country. A C-section is an operation to deliver a baby through a cut made in the mother’s abdomen and womb. Even though the first recorded C-section, performed in AD 1020, led to the patient’s death, medical advances have greatly improved the safety and success of the procedure.
Knowing the risks and benefits of a C-section helps doctors guide pregnant women in making the right choices. The best health care is based on scientific evidence.
Sometimes, a woman might ask for a C-section even when it’s not medically necessary. Healthcare providers should be ready to give the proper knowledge to ensure the woman understands all the facts so she can make an informed choice. As there’s growing pressure to lower the number of C-sections being performed, understanding when it’s medically necessary can help both doctors and patients make well-informed choices.