Reasons to Have a Cesarean Section

Today we are joined by Dr. Florencia Polite, an Ob/Gyn, who discusses with us reasons for having a C-section. 

We answer the following questions: 

1. What is a cesarean section?
   • A cesarean section, or C-section, as many people call it, is a type of abdominal surgery that allows your doctor to get the baby out from the womb through an incision or cut on your belly--often near your bikini line. It is very common -- about 30% of babies in the United States are born via C-section.
   • While most people recover very well from a C-section, and it is overall a very safe procedure, it still means that there can be complications, like heavy bleeding, infection, and complications from the wound. The risks for these are still higher than in a vaginal delivery. It is why we encourage everyone to have a vaginal delivery if it is possible for them.
2. What happens during a C-section?

• • In a scheduled C-section, you would have talked to your doctor beforehand, and you will be scheduled for a C-section on a specific date. You will be asked not to eat or drink anything beforehand, for about 8 hours. You can still have clear liquids like black coffee or water up to 2 hours beforehand. You will have your blood drawn, and you will meet with an anesthesiologist right before to talk about expectations for anesthesia. 
  • After, you will be taken to the operating room. Most patients will get what is called “spinal anesthesia.” For more information about that, please listen to the anesthesia podcast, which is part of this series. Your anesthesiologist will also test the anesthesia before we get started.
  • After you receive your anesthesia, you will be numb from your waist down. You will not be able to move your legs very well or be able to feel if you need to pee. Because of that, your nurse will put a catheter in your bladder.
  • Your doctor will then come in and wash off your belly with a special soap. After that, we will put a big blue drape on your belly to maintain sterility. Then, once everything is set up, we can bring your support person in to be with us.
  • Then, the surgery will start. There will usually be multiple doctors there to help with the surgery, and there will also be doctors and nurses there from the pediatric team to help take care of the baby. Usually, getting the baby out takes anywhere between five to twenty minutes, depending on how many previous C-sections you have had.

  • Just like anywhere else on your body, if you get injured there, you can have a scar. When you have a C-section, your body will also create a scar. That scar is not just on your skin. It can actually scar all the way down to your uterus. Sometimes, when you have scarring inside your belly, it can cause different things inside your belly to stick together in ways that wouldn’t happen without having surgery. So for example, it could cause your bladder to be stuck to your uterus. Because of this, every C-section you have can make your next surgery harder, because it will change the normal anatomy around. Your surgeon has to be very careful, which can make your second, third, or fourth C-section take longer.

  • For every single C-section, the pediatricians are there to assess the baby. If everything looks ok with the baby, sometimes we can bring your support person to see the baby or even bring the baby over to you. However, it may take another thirty minutes to an hour for your surgeon to sew everything back together. It takes that much longer because we want to make sure that we are putting everything back together correctly. Once we are done there, we will bring you and your support person to the recovery area.

3. What are the different types of C-section?

• • Now, most patients will have something called a “low transverse” C-section. This means the cut that we make on the uterus, not on the skin! Most people will have a “bikini cut” or a cut that goes very low on the belly that is slightly curved and horizontal. The “low transverse” means that you also have a low, horizontal cut on the uterus on the inside.

    There are other types of cuts that can be made on the uterus. These are not as common, but may need to be done to help get the baby out. Some words that you may hear are things like “classical” C-section, which is a vertical cut on the uterus. You may also hear “T-incision,” which means that the incision on the uterus looks like an upside down T.

  • We would try to do a low-transverse incision if possible. However, sometimes, if babies are premature and very small, it is not safe to make a low-transverse incision to get the baby out. These patients may need a “classical” C-section. A T-incision is only made if we really need room to get a baby out.

  • The main difference is that if you have had one previous low transverse incision (or even two, depending on certain things) you could have a trial of labor with your next pregnancy. Of course, you should talk to your provider about this to see if it is the right decision for you. However, if you have a classical or T-incision on your uterus, you should not labor again, because there is a higher risk that that inside incision could open up, which would be very dangerous for you and your baby.

4. Why is a C-section necessary?

• • For a scheduled C-section, we already talked about one of the reasons, which is a previous C-section with one of those scars: a T-incision or classical C-section. Another reason would be if you have had three or more C-sections. We do not recommend that you labor after that many C-sections. Patients can also, of course, decide that they have an elective C-section, which means that they choose to have a C-section. Some patients may also have medical problems that make having a vaginal delivery unsafe, but your doctor would let you know if that is the case. And finally, one of the most common reasons is if the baby is not head down.

  • There are some studies that show that if a baby is breech (or butt down), that there can be some increased risk for babies if they are born vaginally, like getting stuck. There are even more risks if the baby is in a different position, like if the feet are coming first, or if the baby is transverse, or lying horizontally. We really do not recommend having a vaginal delivery if baby is not head down. If your baby is not head down, though, your doctor can also talk to you about other options about trying to turn the baby,  but we won’t discuss that here

  • Most of the time, if we are doing an urgent or emergent C-section during labor, it is either for mom or for baby. In terms of baby, most of the time it is because we think that the baby is not getting enough oxygen and is in distress.

  • While labor and birth are both very natural things, sometimes things can go in a way that we don’t plan. During labor, the uterus contracts a lot to open the cervix to allow for a baby to come down into the birth canal so that they can be born. These contractions can be stressful for both mom and baby. While we understand that contractions are very uncomfortable for mom, it can cause a different kind of stress for baby.  Some babies just don’t tolerate these contractions very well, and they show us signs that they may not  be getting  enough oxygen during labor. We can detect signs of that on the labor monitor, which we put on almost every mom and baby. Of course, these monitors are not foolproof, but if the baby is telling us that they may not be getting enough oxygen, we may talk about a C-section with you to get the baby out as soon as possible. Not having enough oxygen for a baby could mean something very bad, like brain damage or death.

  • There are lots of other reasons. We also talked about reasons for mom. One of the more common ones could be that mom reaches full dilation of her cervix, but is not able to push the baby out. Sometimes, some babies are just too big for certain moms’ pelvises. If that baby is not able to come out of the vagina, then that is another reason for a C-section.

    Another reason is if mom has been in labor for a long time, but her cervix is not changing. Usually, that by itself is not a reason for us to do a C-section, and we can sometimes give medication to give mom more powerful contractions to change the cervix. But if her cervix is not changing for many hours that might be a reason why we talk to you about a C-section.

    When this happens, this is usually an unplanned C-section. While the surgery itself is usually the same as a planned C-section, some of the things we do to prepare for the surgery is different. For example, if it is an emergency and you don’t have an epidural, the anesthesiologists may have to put you to sleep so that you don’t feel the C-section. But if you already have an epidural, usually the anesthesiologists can use that to give you more medicine so you don’t feel the C-section.