Pregnancy- Ceserean Section

Delivery by Cesarean Section -a.k.a. c-section- involves performing surgery to deliver your baby through an incision or cut in your belly. There are many reasons to deliver your baby by c-section. They can be placed in 3 different classes: Emergent/Urgent, Unscheduled/Non-emergent, and Scheduled. Let's discuss them, shall we?

Emergent and Urgent- a situation where baby needs to come out now, either baby's or mom's life is in jeopardy.

  • Fetal distress- This is the main reason for primary, or first time, c-sections are performed. It is also referred to as fetal intolerance to labor. Whether your baby is going to tolerate labor is unpredictable. Depending on the severity of "distress", your doctor may recommend performing a c-section. How quickly this is done also depends on the severity.


The baby's heart rate is low, and not returning to normal- This would necessitate an emergency c-section. You would be taken to the operating room as quickly as possible. If you do not have an epidural in place, you would be put under general anesthesia. Your support person may or may not be allowed in the surgical suite in this situation. It varies on doctor preference, this includes both your OB and the anesthesiologist.

The baby's heart rate drops during contractions, but returns to normal in between- This could necessitate an urgent c-section. It depends on how deep the heart rate drops, how long it is down for, and how far dilated you are. It also depends on your physician, the facility you are at, if you have any medical conditions, or if the baby has any suspected conditions.

The baby's heart rate gets too high- Let's define too high: normal fetal heartrate is 110-160 beats per minute. We expect and want the baby's heartrate to increase suddenly with movement. These are called accelerations. We also expect several of these every hour. What I am referring to about being too high is that the baby's "normal" or baseline heartrate begins to slowly increase. What you would see is the baseline at say 140, fifteen minutes later it may be 145, then 150, and so on. We really don't worry until we see the baseline hanging around 170 or higher. This can be caused by fetal intolerance, it can also be caused by a cardiac (heart related) issue- such as an abnormal heart rhythm, but the most common cause is maternal fever. Maternal fever is related to infection. If we are unable to control fever, delivery is still suspected to be far away, or the heart rate does not settle out and continues to increase your doctor may opt to perform a c-section. If your baby is an abnormal heart rhythm, the majority of these babies go on to delivery vaginally, and the abnormal rhythm goes away at birth.

  • Cord Prolapse- A cord prolapse usually occurs when the bag of water breaks, although it can happen some time after rupture as well. What happens here is that when the water breaks, the umbilical cord is swept underneath the baby's head, where the head applies pressure to the cord and cuts off the blood supply to the baby. It does not matter how much or little of the cord comes into the vagina, this is still an emergency situation. Most of these happen while you are in the hospital, and can happen whether your water breaks on its own, or by the physician. The only course of action at this point is that whoever discovers the prolapse will keep their hand where it is, apply a little counter pressure to the head and we rush you back for an emergent c-section. Rarely, the prolapse happens at home, but it can happen. If it happens at home when your water breaks, you may or may not be able to feel it. You might "feel" the cord in your vagina, or between your legs, you might even be able to see it protruding out. This being said- DO NOT ATTEMPT TO "CHECK" FOR THE CORD IF YOUR WATER BREAKS, YOU RISK INTRODUCING INFECTION. Again, it is very rare that this would happen at home.
  • Vaginal Bleeding- I'm talking about more than bloody show here. Even heavy bloody show can be normal. However if you we discover lying in a pool of blood and clots, you have a stream of blood flowing from the vagina, or if you are passing clots, your doctor may elect to perform a c-section. How quickly or if done at all will depend on how far from delivery you are, how the baby is tolerating it, and the suspected cause. It can be caused by a separation of the placenta from the wall of the uterus (placental abruption), an actual split in the uterus (uterine rupture), and sometimes there are no identifiable reasons- even after delivery.
  • Maternal Issues- Sometimes, there is something going on with Mom that requires urgent or emergent delivery. Examples include seizure, infection, maternal injury (car accident, assault), and maternal instability. When Mom is sick, injured, or severely unstable it may be better for both Mom and Baby to get baby out. It is easier to treat and stabilize Mom when we don't have to limit treatment due to the baby, we also don't have to worry about how well baby is doing during our course of treatment. Remember, everything Mom deals with, Baby deals with too.
  • Previous C-Section- Okay, let me be more specific. If you had a previous c-section, and are not going to VBAC, if you come in to the hospital in hard labor, your scheduled c-section will become urgent.
  • Preterm Delivery- Some doctors prefer to perform cesarean deliveries on moms that are preterm between 24 and 27 weeks gestation. This stems from the thought that there is less trauma to the baby, hopefully decreasing the potential complications that premies are prone to..

Unscheduled and Non-Emergent- a situation in which that a vaginal delivery is not a feasible option, but delivery cannot wait for too long..

  • Failure to Progress- Unfortunately, sometimes despite all of our best efforts, dilation stalls and stops. Dilatation is caused by good, strong contractions. Lack of good, strong contractions would definitely cause labor to stall. This also includes failed induction of labor. But there are other reasons, and even lack of reasons for progress to stop. It can be related to fetal position- the baby's head could be turned facing the front versus the back, or maybe the head is tilted to the side just a bit. It can also indicate a big baby, or a small pelvis, and sometimes there is no identifiable reason- it just happens. These cause the baby's head to not descend appropriately which can prevent dilatation. Usually before your provider will diagnose you with a failure to progress or descend, he or she will start you on pitocin to strengthen and increase your contractions. They may also place an internal monitor to verify that your contractions are indeed strong enough to cause dilation. We will also turn you from side to side, have you sit straight up with your legs crossed under you. After the physician feels that you have had adequate contractions for an adequate time frame will you be diagnosed as a failure to progress.
  • Failure to descend- Can occur along with failure to progress, but can be a factor all on it's own. Basically this is diagnosed when the head does not come down into the pelvis. When we check for dilatation, we are also checking the "station" of the head. When labor starts, it is normal for the head to be at a -2, as labor progresses, the head should descend to a -1 then 0, to a +1, +2, and a +3 also referred to as being on the perineum. Your baby may not drop to a lower station until you are fully dilated, especially with subsequent babies. On average, when full dilation (10cm) is reached, the baby is between a station of 0 and +3. The lower the head, the more pressure you feel. We will typically allow you to start "pushing" when you are 10cm dilated, and +1 station or lower. If the station is 0 or above, we attempt to position you to allow the head to labor down, allowing your contractions to do the majority of the work for you. Of course, this is only possible if you have a well working epidural. Anyway, back to the task at hand, if your baby does not lower down into the pelvis, despite effective contractions and effective pushing, your doctor diagnose a failure to descend, and perform a c-section. Incidentally, it is not abnormal to push for close to 3 hours with first time moms, especially with an epidural.
  • Previous C-Section- Again, if you do not plan on having a VBAC, and you come to the hospital in early labor, or water broke, your doctor will go ahead and do your c-section then.
  • Fetal Presentation-If we discover during your labor progress that your baby is in a breech or transverse presentation- that is the head is not down. Your doctor will call a c-section.
  • HSV outbreak- If you have a history of genital herpes, your provider should put you on prophylaxis medication in the last weeks of your pregnancy. Even so, you can still end up with an outbreak on the meds. Sometimes we discover an initial outbreak during labor, where the patient did not know she had herpes. Either way, with an active outbreak, the baby cannot deliver vaginally. It's even dangerous to the baby just for your water to break with an active outbreak. If the baby contracts herpes during delivery it can cause neurological issue, retardation, or even death.

Scheduled- a situation when both you and doctor know long before labor starts that you require a c-section, so you get a surgical appointment time. This is typically scheduled for between 38 1/2 to 39 weeks. When you are scheduled, please please please- do not eat or drink -yes, this includes water- after midnight the night before. If you are not scheduled until late afternoon to evening, discuss with your doctor when you need to stop eating and drinking. If you are on medications for high blood pressure, diabetes, hypothyroidism, bleeding disorder, anything besides vitamins- discuss with your doctor when to stop taking these prior to surgery.

  • Previous C-section- Either you desire a repeat, or your doctor does not perform VBAC's, you are scheduled for your c-section
  • Large Baby- Many physicians will recommend a cesarean section if it is suspected that you have a "big baby" meaning estimated weight of 9lbs and above, even if you have successfully delivered a big baby before. The larger your baby is, the more risk you run of having complications during a vaginal delivery, such as a shoulder dystocia- where the infant's shoulder gets stuck on your pubic bone. But on the other hand, ultrasounds can be off on estimated weight, afterall- it is only an estimate. I have seen patients go through with a c-section expecting a 9 1/2 pounder, and the baby comes out at barely 7 pounds, but I have also seen the exact opposite, moms who are expecting a 6 1/2 pounder and end up delivering an 8 1/2 pounder. Just remember, ultimately the goal is to have a safe delivery for both you and baby.
  • Fetal Presentation- Many people know ahead of time that their baby is not head down, and therefore need a c-section. Your doctor will schedule and appointment for surgery. Most doctors will confirm the presentation the morning of surgery to make sure the baby has not flipped to a head down position, between the last time you were seen and now.
  • HSV outbreak- we talked before about the dangers of delivering vaginally with this. If your doctor discovers an active outbreak at your 40 week appointment, you will be scheduled for a cesarean delivery.
  • HIV- Okay, this one is tricky. If you are HIV positive, it does not automatically mean you need a cesarean. It really is up to your doctor and the hospital you deliver at. It also depends on your viral load. If it is down- exact number up to your doctor- you would qualify for a vaginal delivery, but if it is high, cesarean it is. This is to help prevent or decrease the exposure of the baby to the HIV virus. No matter which way you deliver though, you usually have to be at the hospital a few hours ahead of your scheduled time so that you can receive IV antivirals before delivery, again to prevent transmission from you to baby.
  • Previous Uterine Surgery- If you've had surgery on your uterus (note- not the fallopian tubes or cervix), such as a myomectomy, you are unable to labor.
  • Abnormal Uterine Shape- There are some uterine abnormalities can prevent you from laboring, such as a bicornate or heart-shaped uterus.
  • Previous Difficult Delivery-Some woman who have given birth vaginally choose to have a cesarean with the next pregnancy. Especially if they had a particularly difficulty delivery, including shoulder dystocia, traumatic laceration, extra long labor.
  • Patient Desires- Some woman choose to not give birth vaginally. Why? Well, it could be fear, fear pain, fear of having a baby come through down there, among others. Regardless, most physicians will honor their patients wishes.
  • Multiple Gestation- Yeah twins! Congrats! Oh I'm sorry, I must of heard you wrong. Triplets you say? Well, triple Congrats then! Triplets or more equals automatic cesarean. There is just too much risk to the babies and you. Twins on the other hand- well it depends. If one or both twins are not head down, the c-section it is. If both twins are head down, most physicians will allow you to labor and attempt a vaginal delivery. Frequently, however, after the birth of the first baby, the second baby turns. My experience has been that usually the doctor will attempt to turn the baby back to head down internally, there are a few that may attempt a breach delivery of the second baby. The other issue that we can run into is that sometimes the second baby stresses out when it's sibling is delivered. If it is not possible to get the baby into a deliverable position, or the second baby does not tolerate the loss of the first baby, it would result in a c-section for number 2. This is okay, because most hospitals deliver twins in the operating room because of the risk of something happening.

Having a cesarean section can be scary, but being knowledgeable ahead of time what to expect, and why you could need one helps immensely in understanding, thus reducing fear.

A couple of rules regarding C-Sections, no matter the reason.

  1. For scheduled surgery- nothing to eat or drink after midnight, if you do, your surgery will be delayed or even rescheduled for another day.
  2. You support person can't cut the cord, they will contaminate the surgical field, increasing the risk for infection.
  3. Your support person may be asked to wait in your room or special waiting area until your anesthesia is in, you are prepped and tested.
  4. Your support probably will not be allowed back if you are placed under general anesthesia (put to sleep).
  5. Your support person may not be allowed back in an emergency, or if something arises during surgery, your support person may be asked to leave.
  6. Most hospitals only allow 1 support person into the operating room.
  7. C-section patients are not generally allowed to eat regular food until the day after surgery, you will start out on clear liquids and progress from there. So please don't have relatives bring in food until the next day.
  8. You will have pain afterwards, how much is determined by the kind of anesthesia you are given. We will do everything possible to keep your pain in control, but it may not be possible to get rid of it completely. You also have a responsibility in controlling your pain, by asking for pain medication before pain is bad, before activity, and to tell us if the pain medication we give you is not working. If you get a pain pump, you have to use it. It's that simple. Sure, it could take a couple of doses to get it working, so don't assume it won't if you push the button one time and it didn't work well.
  9. You will have a tube in your bladder for several hours after surgery. This is because at first you can't get up, and then when you are allowed out of bed, getting up the first few times is a slow gruelling process. When this tube is placed- before or after anesthesia is in place is determined by how emergent your c-section is.
  10. Most facilities and doctors do not allow pictures of the actual surgery. It is okay to take pictures of the baby after it is stabilized. So NO PICTURES PLEASE :).

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