Caesarean section

• A physical obstruction that complicates vaginal delivery, such as a pelvic fracture, uterine fibroids, or the placenta covering the cervix;
• The baby is too large or the pelvis is too small for a vaginal delivery;
• There are multiple babies to be delivered, for example, twins or triplets;
• You have an infection that can be transferred to the baby during vaginal delivery (e.g. HIV or genital herpes), or;
• You have cervical cancer.

A planned caesarean section can have advantages, including knowing exactly when your baby will be born, as well as avoiding some potential risks to your baby. It also minimizes injuries to pelvic floor muscles that can occur during vaginal delivery. This can help to prevent urinary incontinence associated with childbirth.

It is possible to request a caesarean section. This means you choose to have a caesarean section even when there are no specific medical risks identified by your obstetrician. This is termed 'caesarean delivery on request' and you will need to understand the risks and benefits of this decision.

Unplanned or emergency caesarean section

In some cases, women who plan to have a vaginal delivery may unexpectedly require a delivery by caesarean section. A caesarean section may be required if:

• Your labor is not progressing as planned - for example, if the contractions are too weak or your baby's heart rate is abnormal;
• Your baby is in a breech (bottom or feet-first) or transverse (sideways) position when the labor begins;
• There is placental abruption, which occurs when the placenta separates from the uterus before the baby is born. This can cause heavy vaginal bleeding;
• The umbilical cord has fallen through (prolapsed) the cervix and into the vagina. This can be dangerous, as the umbilical cord carries oxygenated blood to your baby, which can be compromised during a prolapse, and;
• There is a medical emergency - for example, a car accident involving trauma, which forces a caesarean delivery to be performed.

What happens during the procedure?

After admission to the hospital, before the procedure begins, you will have monitoring equipment placed on you, to observe your blood pressure, heart rate and blood oxygen levels during the surgery. You will also be given an intravenous (IV) line into your arm or hand for the infusion of fluids. After the procedure, pain medication can also be infused using the IV line. A catheter will also be inserted into your bladder to collect urine.

Anesthesia

There are two main types of anesthesia that can be used for caesarean section - regional anesthesia and general anesthesia. Regional anesthesia involves an injection near the spine, causing numbing of the abdomen and legs for the duration of the procedure. The main types of regional anesthesia include spinal and epidural anesthesia. You will remain awake during the procedure and although you may feel some pushing and pulling, you will generally be pain-free. General anesthesia involves medications to induce unconsciousness during the procedure. Therefore, you will not be awake during the delivery of your baby. This may be performed if the caesarean is urgent and there is not enough time to perform regional anesthesia. There is the possibility that some of the general anesthetic may cross the placenta and temporarily affect the newborn. For these reasons, regional anesthesia is generally preferred.

Skin incision

Your abdominal skin will be washed with an antibacterial solution to help prevent infection and partial shaving of your pubic hair may be required. The operation involves a 10-15cm incision (cut), usually horizontally in the lower part of the abdomen ('bikini-line'). This provides access to the uterus. Less commonly, a vertical incision may be made, particularly if it is performed in more urgent situations.

Uterine incision

After reaching the uterus through the skin incision, the uterus is then opened with another incision. It is commonly horizontal, but a vertical incision may be required if your baby is in a breech or sideways position, or the placenta is in the lower front area of the uterus.

Your baby will be lifted out of your uterus by hand or with forceps. The umbilical cord is clamped and cut, freeing your baby from the placenta. The placenta is then delivered by hand, before the uterus and wound are stitched up and a dressing put in place. Your baby will be evaluated by a pediatrician, before being given to you to hold.

A caesarean section typically involves a horizontal cut in the abdomen. 

What happens after the procedure?

Once your surgery is complete, you will be monitored and given pain medication. After your anesthesia has worn off, which usually takes one to three hours, you will be able to move around, drink fluids and eat food. You will generally be kept in hospital for 3-5 days, for staff to closely assess your recovery and assist you in caring for your baby.

Recovery time after a caesarean section can be up to six weeks. During this time you will be unable to lift anything heavier than your baby and will need to get as much rest as possible. Getting help from partners, relatives and friends can help with rest and recovery. It is usually advisable to not drive a car during the recovery time. It is common to feel numbness around the incision and aches and pains for up to three months after the procedure.

Potential complications

As a caesarean section involves anesthesia and major surgery, there are potential risks associated with the procedure. These must be considered when comparing the procedure against a vaginal delivery.

Some potential risks to the mother include:

• A risk of injury to abdominal organs, including the bladder and bowel;
• A risk of infections to the wound site, uterus or urinary tract;
• A risk of developing blood clots in the legs (deep vein thrombosis);
• Hemorrhage, which may require blood transfusions;
• Anesthetic complications, including allergic reactions, medication side effects, even death, and;
• Increased recovery time.

Risks to the newborn include:

• Temporary breathing issues;
• Injury or death, and;
• The need for additional care in a neonatal intensive care unit.

Risks to future pregnancies include:

• The placenta abnormally attaching to or growing into the uterus wall, due to scar tissue;
• The uterus rupturing, and;
• An increased likelihood for a caesarean section in future pregnancies.

It is important to discuss the risks versus the benefits with your doctor that are specific to your own circumstances. Generally, a caesarean section will be recommended by your doctor if the potential risks to you or your baby will be greater with a vaginal delivery than with a caesarean section. If you choose to have a caesarean for reasons other than a specific medical reason, discuss the risks and benefits with your doctor so that you can make as informed a decision as possible.