Cesarean section

Overview

Cesarean section is a surgical procedure through which a baby is delivered
after making a cut in the abdomen and uterus. It can be done electively when
there are absolute indications prior to the onset of labour, or may be required
as an emergency life saving procedure for the mother and/or the baby in
certain situations.

Here, we bring for you everything that you must know about the procedure- before, during and after- so that you are well prepared if you happen to land in a crisis.

Why is it done?

In some situations, a cesarean section is safer for you or your baby a vaginal delivery:

• The labour is not progressing. The arrest of labour is one of the most common reasons for a C-section. It can further divided into arrest of dilatation of cervix and arrest of descent of head.
• The baby is in distress. If there are persistent signs of fetal distress on CTG, a C-section might be the best option.
• If the baby is in abnormal position. In abnormal presentation of the baby such as breech presentation where the feet or buttocks enter the birth canal first or transverse presentation where the shoulder enters first, an elective C-section is the safest way to deliver the baby.
• Multiple pregnancies. In twin pregnancies where the first twin is in abnormal presentation or in triplets and higher order pregnancies, C-section has the best outcomes.
• Abnormal placentation. In placenta previa (where placenta lies over the internal os), placenta accreta / increta and percreta (where the placenta invades the uterine walls) a C-section is recommended for delivery.
• Cord prolapse. If a loop of umbilical cord slips through your cervix outside into the vagina, it causes fetal distress and is acute emergency for C-section.
• Cord prolapse. If a loop of umbilical cord slips through your cervix outside into the vagina, it causes fetal distress and is acute emergency for C-section.
• Maternal illness. C-section might be necessary if the mother has serious health issues, such as a severe heart disease or uncontrolled blood pressure or active genital herpes infection at the time of labor.
• Cephalo-pelvic disproportion. This refers to the disproportion between fetal head and maternal pelvis. Either a large baby head (hydrocephalus, macrosomia) or a small pelvis (large fibroid, pelvic fracture, contracted pelvis) may result in an obstructed labour.
• C-section in previous pregnancies.  The outcome of pregnancy depends on previous number of uterine incisions, duration since the last operation, indication for the cesarean, post-op recovery etc. vaginal birth after cesarean section (VBAC) can be tried in women with previous one C-section and favorable conditions but 2 or more previois C- sections are indications for repeat C- section.

Risks

Risks to the newborn baby include:

• Breathing problems especially transient tachypnea of newborn can be seen during first few days of life.
• Surgical injury are very very rare, but can occur.Risks to the mother:
• Postpartum hemorrhage.  Heavy bleeding can occur during and after delivery.
• Infection. There can be infection of the lining of the uterus (endometritis) or infection of the incision line on abdominal wall.
• Anesthesia risks. Adverse reactions to any type of anesthesia are possible.
• Surgical injury. Although rare, injuries to the bladder or bowel can occur during a C-section more so when there are pelvic adhesions due to previous surgeries or infections.
• Blood clots. In women with high risk factors like obesity, smoking, prolonged bed rest, prolonged surgery, history of thrombosis in family etc., there is increased risk of developing a blood clot (thrombus) inside a deep vein.). In rare cases it can travel to the lungs and blocks blood flow, which can be life-threatening.
• Future pregnancies. Potentially serious complications such as placenta previa, placenta accrete/increta/percreta and uterine rupture can increase with the number of surgeries.

Preparation

If the surgery is elective, it is well planned ahead of time. The date of surgery is discussed well in advance. Some routine blood investigations are advised and an appointment with anesthetist is fixed. We encourage you to ask questions, share your concerns and views. Also you discuss about permanent birth control measures if your family is complete and you don’t plan to deliver any more children.

What to expect

Before the procedure

• At home. We advice you to take a shower with an antiseptic soap the night before and the morning of your surgery. You must be fasting for at least 6-8 hrs. prior to the surgery.
• At the hospital. Intravenous (IV) lines are placed to provide fluid and medication. Shot of antibiotic is given to combat infections. Your abdomen and pubic hair are clean shaved. After proper aseptic measures, a foley’s catheter is placed inside the bladder to collect urine. Parts are cleaned thoroughly with antiseptic solution and properly draped.
• Anesthesia. Mostly C-sections are done under spinal anesthesia, which numbs only the lower part of your body. But, in an emergency, general anesthesia may be needed sometimes.

During the procedure

• Abdominal incision. A low-transverse incision also known as Pfannenstiel incision, which is around 10 cm, is given and the abdominal cavity is opened layer by layer. In rare situations, abdomen might be opened by midline vertical incision, extending from below the umbilicus to the pubis symphysis.
• Uterine incision. Once the uterus is reached, a horizontal incision is given across the lower part of the uterus (lower uterine segment).
• Delivery. If the baby is in cephalic presentation, the head is delivered through the incisions first followed by rest of the body. In breech and shoulder presentation, buttocks are delivered first. The cord is then clamped and cut and the placenta is removed.
• Closure. The uterine incision is closed in layers followed by the abdominal incision. Hemostasis is ensured at every step. Check is made of the instruments and gauze pieces before wound closure.

After the procedure

You are immediately shifted to the post-op care ward. If everything goes fine, you’ll probably have to stay in the hospital for 3 days. You are encouraged for breastfeeding as soon as you feel good. You will be kept fasting for around 6-8 hours after which clear fluids will be resumed. The catheter is kept for around 24 hours. Your normal diet is resumed slowly over a period of 2 days. Meanwhile, you will receive I/V fluids, antibiotics, painkillers and antacids round the clock.

Before the discharge, make sure that the baby is vaccinated.

When you go home

• Take the medicines prescribed to you at the time of discharge. They mostly are antibiotics, painkillers, laxative and probiotics.
• Rest whenever possible. Breastfeed 2 hourly at least. Avoid lifting heavy weights and doing strenuous work for the first few weeks. Also, avoid straining at stools, report immediately if you have cough and fever.
• Avoid sex. Abstinence is advised for about six weeks after your C-section to prevent infection.
• Driving is not advised until two weeks, till you are able to apply brakes comfortably.

If you develop any of these signs, report to the hospital immediately:

• Incision is red, swollen or leaking discharge
• Fever
• Heavy bleeding
• Worsening pain
• Mood swings, loss of appetite, depression.

Post-partum care is an ongoing process. You should visit the doctor within first three weeks after delivery and them within 12 weeks. During these visits, we assess your physical and emotional well-being, discuss the birth spacing methods and address any other of your concerns.