What is a Caesarean Section?
Caesarean section (C-section) is the delivery of a baby through
a cut in the mother’s lower abdomen and the uterus.
It was an
operation with many risks, less than a century ago.
Today, it is one of the most frequently performed
surgeries in the world. Caesarean births are more
common than most surgeries (such as gallbladder removal,
hysterectomy or tonsillectomy) due to many factors.
One factor, of course, is that nearly 50% of the world
population are women, and pregnancy is still a very
common condition! However, more important is the fact
that a Caesarean section may be life saving for the
baby, or mother (or both).
Caesarean birth is also much safer today than it was
a few decades ago. Thus ‘caesarean’ is not something
that should scare you, as the ultimate goal is a healthy
mother and healthy baby, regardless of the method
It is important to know a few things about caesarean
section in order to be prepared for a caesarean birth
if it does happen to you.
The following section will help you to understand
caesarean births better.
Caesarean section may be an emergency procedure
or an elective and hence planned procedure.
for the surgery may be done in the labour room
or in the theatre itself. This includes putting
a catheter into your bladder to drain urine, and
an intravenous line (needle) into a vein in your
hand or arm to give your body fluids and medications
You may be given an antacid
orally, or injections like Perinorm or Ranitidine
to reduce the level of acid in your stomach and
Your abdomen and pubic
hair will be shaved, and the area washed with
an antibacterial solution.
Suitable anaesthesia is given to you so that you are pain-free
during the procedure.
The doctor makes the skin
incision first. This is either a vertical incision
in the middle from below the navel up to the pubic
transverse or ‘bikinicut’ incision (called pfannesteil
incision) from side to side just above your pubic
incision is most common as it heals better and has
a shorter recovery time, besides being more cosmetically
going through the various layers of the abdominal
wall, and opening the bladder fold of peritoneum,
the lower segment of the uterus is exposed.
The incision is now made
on the uterine wall, usually horizontal (side
to side) this is preferred as it heals better
and bleeds less. However, due to certain circumstances
it may be necessary for your doctor to make a
vertical incision on the uterus.
Diagram of incision on the uterus.
The amniotic sac (bag of
water) is broken and your baby is delivered either
by hand or using forceps. At this point
if you are under regional anaesthesia, you may
feel some tugging, pulling or some pressure on
the upper abdomen.
The umbilical cord is clamped
and cut, and your baby is handed to the neonatologist
or nurse for evaluation.
The placenta is detatched from the uterine wall and removed.
The uterine incision is
closed using sutures (usually) or staples, and
bleeding is controlled.
The abdomen is now closed,
and the skin sutured. Depending on the initial
skin incision, the skin may be closed with removable
sutures, staples, or subcuticular (under the skin
surface) dissolvable sutures.
You may be given your baby
to hold if you are feeling upto it, After observing
your vital parameters (pulse, blood pressure,
etc.) for some time you may be shifted to your
complete procedure takes about 45 minutes to one
hour in an uncomplicated case. From the initial
incision to delivery of the baby takes about 5
minutes, and the remaining time is taken for repairing
your uterus and abdominal wall.
and Pain Relief
measures may be used for pain relief before, during
and after your caesarean.
you had been in labour, you may have been taking medications
for pain relief.
If an epidural is already in place, for
example when you have been in labour for a while before
you needed a caesarean section, it is usually continued
for the surgery.
anaesthesia, that is one, which acts to block the
pain only at the operative area (and below), is usually
preferred. This may be an epidural, typically being
continued from labour analgesia.
Another type of regional anaesthesia is spinal anaesthesia,
which can be given more quickly, provides better pain
relief and is usually preferred if an anaesthetic
is not already given.
The advantages of regional anaesthesia include the
fact that you are not unconscious only the lower half
of your body is numb. Hence, you are aware of when
your baby is delivered and may even see / hold the
baby before he / she is shifted out of the operating
room. More than that, some risks of general anaesthesia
like aspiration, respiratory complications and delayed
breastfeeding are also avoided.
It may be possible that a regional anaesthetic cannot
be given to you for medical reasons. Another possibility
is that, in an emergency caesarean .
There may not be enough time to give a
regional block. In such cases general anaesthesia
is given, where you will be completely unconscious
during the surgery. Some women, who are apprehensive
about the surgery may infact opt for general anaesthesia
as a personal choice. Your doctor, in conjunction
with the anaesthesiologist (doctor giving the pain
relief) will be the right person to help you decide
what is best for you.
are Caesareans Done?
Before you can understand the various causes for which caesarean
section may be required, you should know that basically
there are two broad categories of operation:
you may have been in labour for a while before the
decision is taken, or some problem develops that makes
urgent delivery necessary in the interest of your
baby, or your health.
Common indications for emergency caesarean sections
- Foetal distress .
- Dystocia or non-progress of labour .
- Bleeding from your placenta.
emergency surgery is always more risky than a planned
procedure. This may be because you are not on empty
stomach, or there are life threatening problems like
severe bleeding or rise in your blood pressure, or
complete facilities like experienced anaesthetist
/ neonatologist / operative team / blood may not be
This is one reason why your doctor may suggest a planned
or elective caesarean section to you. If there are
certain pre-existing conditions, which make it nearly
certain that you will not be able to deliver safely
vaginally, it may be better to do a planned procedure.
This could be for reasons like
- Previous 2 or more caesareans .
- Placenta praevia.
- Mal-presentations of your baby etc .
us now understand some of the reasons for which caesarean
births may occur.
or abnormal labour patterns).
causes of dystocia are many, but basically the end
result is that labour fails to progress, is prolonged
excessively, or gets arrested. .
doctor may try measures like augmenting contractions
with oxytocin, or rupturing the amniotic sac to improve
the labour pattern. If these fail, however Caesarean
section may be the only option.
baby may not be tolerating the forces of labour well,
and may show problems like irregularity or slowing
of the heart rate, or acid in the blood. Sometimes
greenish discolouration of the amniotic fluid (passage
of meconium or foetal stools in utero) may be a sign
of distress. If vaginal delivery cannot be completed
quickly, a caesarean may be the best way to serve
Unfavorable positions of the foetus in utero
can make vaginal delivery difficult, dangerous or
- Transverse lie.
- Shoulder presentation.
- Oblique lie.
- Breech presentation (buttocks first).
- Posterior face presentation.
- Face presentation
- Brow presentation
of these conditions may be corrected before the onset
of pains by a procedure called ‘external cephalic
version’, by which your doctor attempts to turn the
baby to the correct position. This may not be feasible
or safe in all cases. Though, for breech, particularly
if you have had a normal delivery earlier, it may
be possible in some cases to deliver the baby vaginally.
However, even without difficulties in delivery, breech
babies have a less favorable outcome. Hence many doctors
opt for planned caesarean. This is a problem, which
needs prior discussion with your doctor.
Placental or cord problem
placenta is the main connection between the mother
and the foetus providing nutrition, oxygen and other
essentials to the baby via the umbilical cord.
Bleeding occurring from the placenta before delivery
can be risky. It may be due to an abnormal location
of the placenta, ‘placenta praevia’ .
It may be due to early separation of a
normally located placenta called ‘abruption placenta.’.
These can endanger your life or your baby’s health.
Hence a Caesarean section may be done.
The umbilical cord may prolapse (come out) into the
vagina before the baby’s birth. This is more common
with malpresentations. Pressure on the prolapsed cord
can lead to baby’s death. Hence an emergency caesarean
section is usually required.
or mismatch between
the size of the baby and the birth passage. This may
be due to abnormalities in the bony pelvis such as:
- A small or contracted pelvis.
- Resulting from previous pelvic injury or
- A large sized baby where the baby is too
big to deliver through the pelvis.
however, that these are relative terms and can be
sometimes overdiagnosed. Proper evaluation of foetal
and pelvic relative sizes is best done after 38 weeks
or ideally at the onset of labour. Even if mild disproportion
is suspected, your doctor may suggest a ‘trial of
labour’ where a wait and watch policy is followed
to see what the forces of labour can achieve. This
may avoid unnecessary caesareans.
in the birth canal :
other conditions such as:
- A stenosed cervix.
- A thickly cervix which does not open up.
- Previous pelvic repair of a urinary or rectal
- Active herpes lesions of the genital tract.
These may be the reasons for your doctor
suggesting caesarean section.
Maternal medical conditions
is now becoming a very common indication for repeat
caesarean section. Most patients with one prior caesarean
delivery may deliver safely vaginally in the later
pregnancies. This is more likely if the prior caesarean
section was for a non-recurrent or temporary condition
of that pregnancy, such as:
- Foetal distress.
- Bleeding from the placenta.
options should be discussed by you and your doctor
prior to onset of labour. If a vaginal birth trial
is opted for certain guidelines need to
be followed discussed later in this section.
In some cases, you and your doctor may opt
for an elective or planned repeat caesarean. This
is more commonly done if you have had:
- More than one caesarean previously.
- Your baby is now larger.
- Not in a favorable presentation.
type of prior caesarean is also important, as with
an incision, the risks of attempting VBAC are more.Other
uterine surgeries done in the past such as myomectomy
or septum resection may also influence the decision
for type of delivery.
births are much safer now than they were a few decades
ago, In fact, hardly a century ago, having a caesarean
was like a death sentence for the mothers. Today,
the procedure carries a ‘risk’ of less than 1 in 2500.
Yet, this risk is 4 times more than the risk of death
after a normal vaginal delivery.
when talking about risks, one must keep in mind that
statistics show that most people die at home or in
bed. That doesn’t mean that by not staying home or
not sleeping you can escape the inevitable!
talking of risks what needs to be seen in the risk-benefit
ratio. The ultimate aim is to have a healthy mother
and healthy baby. In a given situation, if the benefits
offered by caesarean birth to the mother, the baby
or both are more than the risks; the procedure needs
to be done regardless. Individual medical conditions
like uncontrolled blood pressure or profuse bleeding
from the placenta may make a vaginal birth more dangerous
for the mother.
Post-operative infection of the uterus, or nearby
organs like the bladder may occur. Use of antibiotics
has reduced this risk.
- Increased bleeding: Some blood loss is inevitable at birth,
but it is twice as much at caesarean as compared
to a vaginal delivery.
- Complications of the anaesthesia used.
- Urinary tract: Difficulty in passing urine, urinary retention,
infection may occur. Rarely, surgical damage to
the bladder or ureters may occur, particularly in
cases of repeated surgery.
function: Post operatively, the bowel movements
may become sluggish or slow down completely. This
leads to distension, bloating and abdominal discomfort.
- Respiratory tract: Occasionally, due to aspiration of stomach
contents, pneumonia may result. This is more common
with general anaesthesia.
- Wound problems: There may be a blood clot or pocket of pus
in one or more stitches. In more severe cases there
may be infection of the whole abdominal wound, and
partial or complete dehiscence (splitting open)
of the wound.
- Blood clots: They may form in the leg veins, or collect in
the uterus. Clots in the pelvis organs or veins
may travel to the lungs causing embolism, a serious
complication. This is reduced by early ambulation.
- Delayed recovery: The hospital stay after a caesarean birth
is usually twice as long as after a vaginal birth.
In case of a ‘bikini’ incision, the average stay
is 5 days, with a vertical midline incision , it may be 7 days or more. Full recovery of daily
activities may take 4 weeks or more.
term: Increased chance of repeat Caesarean section.
The baby may have been delivered too early if there
was miscalculation of the due date. Sometimes, despite
knowing that the baby will be premature, an emergency
caesarean may be needed, such as, for bleeding from
the placenta, uncontrolled hypertension, etc, in the
mother’s best interest.
Low Apgar Score:
The baby may have depressed activity at birth,
as measured by the Apgar score.
This could be due to the anaesthesia,
other medications, or pre-existing factors. This
need not indicate any long-term problem, however.
Transient tachypnoea of the newborn (rapid or
irregular breathing) is more common with caesarean
birth. This is thought to be due to lack of the
‘squeezing out’ of lung fluid, which occurs in
vaginal births. This usually settles in a few
Foetal injury: Although this is rare, the
baby may be accidentally nicked while the surgeon
is opening the uterus. With malpresentations or
deeply engaged head (as in caesareans after a
long and difficult labour ) there may be some
trouble delivering the baby, a minor foetal bruising
the early years when caesarean births became used
more commonly, using a classical or vertical incision
on the uterus, most people followed the dictum, ‘once
a caesarean, always a caesarean’. This is no longer
the case. Vaginal births
after caesarean are possible.
If you have had a previous caesarean birth,
you are definitely at a higher risk of having a repeat
caesarean. The average caesarean section rates vary
from country to country, and within a country, from
center to center. In India, different places report
rates from 5% to 15%. In the United States, the rates
are close to 25%. The goal of US hospital is to reduce
the Caesarean rate to 15%. One way of doing this is
by increasing VBAC as nearly 1/3rd of caesareans
are done in patients with previous caesarean sections.
If the indication for the first caesarean section
was not recurrent (i.e. it was a temporary condition
of the first pregnancy) upto 70 – 80 % women may deliver
safely through the vagina, next time. Even after more
than 1 caesarean, some centres have described safe
vaginal delivery. The risks of vaginal birth after
caesarean (VBAC) and more, however, if there is more
than one scar on the uterus. If you know that
you are likely to have a repeat caesarean, you can
still do a lot to make the delivery a pleasurable
Some tips to prepare for a repeat caesarean
prepared: Discuss the issues involved with your
health care providers, read about caesareans,
attend special childbirth classes. Remember that
information only helps to clear doubts.
a Birth plan.
questions in advance: Satisfy all your queries
by detailed discussion of individual issues, such
the date for elective caesarean section. Be sure
of the due date, reconfirm by ultrasound screening,
choose a suitable time.
awaiting the onset of labour before having your
planned caesarean section.
type of skin incision: Usually a repeat caesarean
section is done through the same abdominal incision,
excising the previous scar.
type of anaesthesia: Request regional anaesthesia,
it is normally safer and helps
you to be awake during the delivery.
holding your baby and start breastfeeding as soon
as possible after the caesarean birth. If you
feel up to it, you can breastfeed immediately
after the caesarean is over.
for pain-relieving medication as and when you
need it. It is possible to receive an extra shot
of pain relieving medicine through the epidural,
if you had that for your surgery.
yourself to be up and about as soon as possible
after the surgery, definitely within 24 hours.
This will get your circulation going, make your
bowels and bladder move better, and overall reduce
arrangements for managing your house, older child
/ children in advance. You may want to ask for
help post delivery. A friend, a relative or a
trained nurse or ayah may be able to help
Birth After Caesarean (VBAC)
you have had one (or more) caesarean births, you are
more at risk for a repeat caesarean .
However, with proper planning and well-supervised
delivery, vaginal birth can be safely accompanied
in 75% or more of cases, provided the following conditions
previous uterine scar was a lower segment transverse
scar, with no extension during surgery (these details
will be on your operative notes or with your doctor)
disproportion in the size of your baby and the birth
non-recurring indication for the previous caesarean.
baby is in a cephalic presentation (head down) at
the onset of labour.
is spontaneous onset of labour pains (preferably)
with good progress.
staff and monitoring facilities are available.
and your partner are counselled, motivated and willing
for this ‘trial of scar’, keeping in mind that it
may sometimes be necessary to do an emergency caesarean
in your or your baby’s interest.
health care provider believes in VBACs, and is supportive.
If you are unsure about anything, there is no harm
in getting a second opinion.
must remember that having a VBAC takes a lot of hard
work and planning, both for you and your doctor. A
planned caesarean is sometimes an easier option, but
medical studies have shown that VBAC is usually safer
than a repeat caesareanin selected cases. Finally
the risks and benefits have been weighed against each
other in every individual case, and your health care
provider will be your best guide.
A Caesarean Section:
itself is hard work and you take time to recover from
a vaginal birth. Your body takes almost 6 weeks to
return to the pre-pregnancy state. The recovery process
is a little slower in caesarean birth, as it is after
all a major surgery.
can help yourself to recover faster by
help from others, as needed.
discharge from the hospital, if you feel up to it.
with the emotional issues is also extremely important.
You may be feeling upset, angry or disappointed especially
if you were keen on a ‘normal’ delivery. You can help
yourself to feel better by
your doctor to explain to you why you needed the
about your feelings with your partner, your doctor,
your friends – let it all out!
that the aim was to have a healthy and safer delivery
– whether it was a vaginal or caesarean birth should
not make a difference.
view caesarean birth as a failure – only as a minor
hiccup in the path to motherhood!