Cesarean section is an operation performed by an obstetrician to deliver a baby through an incision in the mother's abdomen. Cesarean deliveries are performed when normal vaginal delivery is not safe for mother and/or baby or when, for similar reasons, delivery must happen sooner rather than later. Some people feel that too many cesareans are performed in the today. At the same time, however, the ability to perform safe cesarean deliveries has without question been one of the most important advances in obstetrics during this century. Every year, cesarean deliveries save tens of thousands of babies from death or disability.
The mother is placed on an operating table. If she is going to have an epidural or spinal anesthesia for the cesarean, it is usually performed at this time. If she will be receiving general anesthesia (being put to sleep), the anesthesia is usually not administered until just before the surgeon is ready to begin the surgery; this is done to minimize the time the drugs circulate in the mother's bloodstream with the potential to reach the baby. Although these drugs are not harmful to the baby, they can make the baby somewhat slow to adapt to life and can increase the risk for respiratory distress requiring resuscitation.
The mother's arms are typically placed on boards extending directly out from her body. This allows easy access to the mother's veins, to administer medicine. It also prevents the mother from unconsciously reaching down to her belly during the surgery and contaminating the operative field, thus increasing the risk for infection.
The first step in performing a cesarean section is what doctors call "prepping" the abdomen. The abdomen is carefully washed and disinfected to reduce the amount of bacteria on the skin and the chances of infection following delivery. Next, sterile pieces of cloth are draped over the patient leaving only the abdomen exposed. This further reduces the risk of contamination of the incision site. A cloth is hung from two poles at the mother's shoulders. Although this prevents the mother from seeing the operation directly, it allows the anesthesiologist to pay close attention to the mother's nose and mouth and to administer medications without the chance of accidentally dropping something into the operative field.
Operating rooms are purposely kept cold. This is because doctors must wear surgical gowns and masks and stand under two or more high-powered lamps while performing surgery. The room is kept cold to keep the doctors from sweating and specifically to reduce the chances of sweat dripping onto the operative field. This must be balanced with the need to keep the mother warm. Sometimes these competing factors can result in heated discussion between the obstetrician and the anesthesiologist. The baby, when delivered, is placed under a warmer that monitors the baby's temperature and automatically adjusts to keep the baby's body temperature within the normal range.
The surgeon and an assistant prepare for the operation by scrubbing their hands, nails, and arms with a brush soaked in a special disinfecting solution. A nurse or surgery technician assists them in putting on sterile gowns and gloves. Surgical gloves are often made of latex; therefore, people with latex allergies should notify their physician so that a different type of glove can be used.
The doctor performing the cesarean stands on one side of the mother and the assistant stands on the other side of the operating table.
The operation begins with an incision in the skin of the abdomen (the outer layers of skin only). In most cases, the doctors perform a low transverse incision, or a bikini incision. This incision is made just above the pubic hairline and is approximately six inches long. Occasionally the doctor makes an incision called a midline incision (or an up-and-down incision ). This sort of incision is performed when the doctor suspects potential complications during the delivery and the possible need for additional surgery. The midline incision allows the surgeon more room to operate and can allow for quicker delivery; however, it produces a less cosmetically appealing scar. The majority of cesarean sections performed in the today utilize a bikini incision.
After incising the skin, the doctor cuts through the layers of fat tissues (which are present in all women, although in varying amounts) and then through a thick fibrous layer called the fascia. The doctor then makes an incision through a thin, filmy layer called the peritoneum (the sac lining the abdominal cavity and containing the organs). The uterus and bladder, among other organs, are now visible. The bladder usually sits on top of the uterus and must be carefully moved before the doctor can make the incision on the uterus and deliver the baby. After the uterus is opened, the delivery can proceed.
As with the initial skin incision into the abdomen, there are two types of incisions that can be made into the uterus. The most common type, the low transverse incision, is like the bikini cut. The second type, the vertical or classical incision, is similar to the midline incision discussed earlier. While the uterine incisions are similar to the skin incisions in appearance, the doctor's reasons for choosing between the uterine incisions are completely different. In most cases, the low transverse incision is preferred. This incision has less blood loss and generally heals better than the classical incision; it also allows a woman to consider vaginal birth in subsequent pregnancies. On the other hand, the classical incision provides more room for delivering the baby. It is generally chosen when the baby is in an unusual position and especially when the baby is very small. In such cases, a classical incision may allow a more gentle delivery. The disadvantages of the classical incision include the tendency for the mother to lose more blood and an increased risk for uterine rupture during subsequent labors. For this reason, women who have had a classical uterine incision must deliver all subsequent pregnancies by cesarean section. Of note, the type of incision made on the skin does not necessarily reflect the type of incision that is made on the uterus.
After the uterus has been opened, the amniotic sac is ruptured. It is then time for the doctor to reach into the uterus and pull the baby out. This is not as easy as it sounds. The doctor must take great care to deliver the baby gently without twisting the head, neck, body, or limbs in the process. As soon as possible the doctor suctions the amniotic fluid from the baby's mouth. This should be done before the baby's first breath; otherwise, the baby could breathe fluid into the lungs, which can result in breathing problems that can last for a day or two (called transient tachypnea of the newborn).
Even though the baby has been removed from the uterus, the baby is still attached to the mother through the umbilical cord. The doctor puts two clamps on the umbilical cord and cuts the cord between the two clamps. This prevents bleeding from either side of the cut umbilical cord. The obstetrician then passes the baby off the operating table into a sterile towel that is waiting. In this manner, the sterile operative field is not interrupted. A nurse or pediatrician then wipes off and wraps up the baby. If mom is able, she can then hold her newborn baby.
The obstetrician still has important work to do. The mother will be bleeding from the cut in the uterus. It is critical to repair the incision as soon as possible. First, however, the placenta must be removed. In most cases, the doctor reaches into the uterus and peels the placenta off of the uterine wall. On the other hand, if the bleeding is not too heavy, some doctors prefer to gently pull on the umbilical cord. In most cases as the uterus begins to contract, the placenta will fall away by itself. After the placenta is removed, the doctor wipes the inside of the uterus with a cloth (called a lap sponge) to remove any remaining pieces of placenta or membrane. It is then time to close the uterus.
The doctor sews the uterus shut with suture (surgical thread) that is absorbable and therefore does not need to be removed. Absorbable suture is very strong when it is first used and it retains its strength long enough to allow the tissues to heal. The body will gradually break down the suture so that it is completely dissolved within two to four weeks after the operation.
The bladder, which may have been lifted off of the uterus, does not need to be reattached-this will happen naturally within a few weeks. Of course, the bladder has remained attached to the kidneys and urethra, leaving bladder function intact. In a similar manner, the peritoneum (the thin lining of the abdominal cavity) also heals spontaneously.
The next step in closing the wound is repair of the fascia (the thick fibrous layer of tissue that envelops the body beneath the skin). The fascia is usually closed with absorbable suture; however, a suture that retains its strength longer than that used to close the uterus is usually used because the fascia heals a bit slower. In cases where healing is likely to be slow, the surgeon may use a permanent suture to close the fascia. This suture is made of nylon or a similar substance that does not dissolve; it will remain in place for the rest of the patient's life. Fortunately, permanent sutures generally cause no problems and most patients are completely unaware of whether a permanent or absorbable suture has been used.
After the layer of fascia has been closed, the doctor makes sure there is no bleeding in the layers beneath the skin or in the fat. In most cases, it is not necessary to close the fat layer. Occasionally, when the layer of fat is very thick, the surgeon may sew it together with absorbable suture.
There are two options for closing the skin. Today, most surgeons use staples; the staples are made of titanium that close the wound without much effort and generally yield a thin scar. The staples need to be removed three to five days after the operation. Both the staples and the special staple remover are designed for painless removal. The other option is for the surgeon to sew the skin shut with absorbable subcuticular suture. This very thin suture is sewn just beneath the surface of the skin and dissolves automatically after a few weeks when the skin is healed. While the scar left by a skin suture is no better than that left by staples, the suture does not have to be removed later. Nevertheless, most doctors have found no advantage to suture and prefer to use skin staples. Suturing also prolongs the operation and can require the entire incision to be opened if an infection develops.
Under rare circumstances, other methods of closing the skin are used. In cases of wound infection, the skin may be left open for a few days and closed later. The incision usually heals well by itself given proper care and leaves a scar that is not much different from those seen after an uncomplicated skin closure.
After a light bandage is applied to the incision, the mother is transferred from the operating table to a bed and taken to the recovery room, usually with the baby in her arms.
After the Surgery
A cesarean section is a major operation and most mothers experience considerable pain as the anesthesia wears off. Fortunately, a variety of agents are available for management of pain. If things go well, a mother can expect to be walking and eating within 24 hours of the surgery and she is usually discharged after three or four days. By this time, most mothers are able to care for their baby and themselves with little assistance. Although some pain may persist for several weeks, virtually all women are functioning normally within three or four weeks after an uncomplicated cesarean delivery.
There is no absolute limit in the number of cesarean sections a woman may have and it is not uncommon for a woman to have five or more cesareans without incident. As a general rule, the safety of a pregnancy following a cesarean section depends upon the mother's medical condition, her ability to withstand a major abdominal operation, and the condition of the uterus at the time of the most recent cesarean section. Most obstetricians have seen uteri that have healed well after six or more cesarean sections; they also have seen women in whom a previous cesarean section incision has opened before labor. Therefore, the answer to this question depends very much on your individual situation. In general, a woman will lose the desire for more children before the uterus will lose the ability to withstand another cesarean.
There is no question that the cesarean section rate has skyrocketed in the past 30 years. In the early-1970s, the national cesarean section rate was 4%. By the end of the twentieth century the cesarean section rate was about 22%. While the increase in the cesarean section rate undoubtedly contributed to improved outcomes for both mother and baby, most people feel that some unnecessary cesareans were being done.
The number of cesarean sections performed by any single obstetrician is related not only to how well she practices medicine but also to the doctor's type of practice. For example, doctors specializing exclusively in high-risk obstetrics (Maternal-Fetal medicine specialists) may justifiably have higher cesarean section rates than the national average, whereas healthcare providers of primarily low-risk patients (such as family physicians) may have very low cesarean section rates. Some researchers have suggested that for a practice consisting of a normal mixture of high- and low-risk patients, a cesarean section rate of about 15% is probably about right.
While reducing the rate of unnecessary cesarean sections is a worthy goal, the recent attempts by some insurance companies to lower cesarean section rates primarily to save money is a bad idea. Certain insurance companies do not pay for their patients to be treated by doctors whose cesarean section rates are above an arbitrary limit. Other organizations attempt to appropriately limit unnecessary cesarean sections by focusing on standard obstetrical indications for the operation and encouraging their doctors to follow good medical practice-this is a much better idea.