Cesarean section delivery

​​What is a Cesarean Section? 

A cesarean section, also called a C-section or LSCS (lower segment cesarean section), is an operation to deliver the baby through the tummy when it is not possible or not advisable to deliver the baby through the vagina​. A cesarean section can be planned in advance (elective), or it can be an emergency. 

Will I need a Cesarean Section? 

A cesarean section is performed either for the safety of the mother or baby or both. Below are some common conditions which may require a cesarean delivery: 

• ​​Cephalo-pelvic disproportion — The baby is too large for the birth canal and is unable to undergo a vaginal birth. 
• Non-reassuring fetal status — If the fetal heart rate is persistently abnormal and worrying and threatening the wellbeing of the baby, a cesarean section will be required if vaginal delivery is not imminent. 
• Certain types of previous surgery on the uterus (womb) — Prior removal of large or multiple uterine fibroids from the womb or multiple cesarean sections (two or more) in the past can weaken the walls of the uterus. A cesarean section is necessary to prevent the tearing of the old wound (uterine rupture) during the labouring process. 
• Placenta previa — The placenta is low-lying, partially or completely covering the opening into the birth canal, mechanically preventing a vaginal birth (Figure 40.1). 
• Placental abruption (abruptio) — This is an obstetric emergency where there is an early separation of the placenta from the uterine wall before the baby is born. This condition can be sudden and unexpected, potentially endangering the lives of both mother and baby. When abruptio occurs, the mother will often present with a sudden onset of intense and unremitting abdominal pain. This may or may not be associated with bleeding from the vagina. This condition may be very difficult to diagnose in some cases (Figure 40.2). 
• Cord prolapse — This can occur when there is rupture of the membranes (i.e. “water bag bursts”). The umbilical cord can sometimes slip downwards, below the baby’s head, into the vagina. Due to compression by the baby’s head, as well as the sudden temperature change, the umbilical cord can constrict, cutting off the blood supply to the baby. This is an obstetric emergency and requires immediate delivery of the baby (Figure 40.3). 
• Malpresentation — This happens when the baby is in an abnormal position in the womb such that a vaginal delivery is not possible or unsafe. Examples would include a breech (buttock down) or transverse position (horizontal) of the baby. Malpresentation has the danger of cord prolapse when the woman goes into labour and the forewater membranes are broken. 
• Certain maternal conditions — Some medical diseases may require a cesarean section for various reasons. In maternal HIV (Human Immunodeficiency Virus) or active genital herpes infection, a cesarean delivery will reduce the chance of transmission to the baby. In some uncontrolled medical conditions, e.g. hypertension​, a cesarean section is needed to expedite the delivery so that the underlying medical problem can be treated immediately. 

What Type of Anesthesia will I be Having? 

There are 2 types of anesthesia used for cesarean section: 

• ​​Regional anesthesia (spinal or epidural) — You will be awake during the operation but there will be no sensation of pain from the waist downwards. 
• General anesthesia — You will be asleep during the operation. ​
  

If you are in labour, you can opt for epidural pain relief (analgesia). Should you be unable to have a vaginal delivery and require an emergency C-section, this can be carried out under the epidural as well (read the article on L​abour Pain Relief). 

What does a Cesarean Section Involve? 

• ​Pre​-operative — In an elective setting, you should be fasted for at least six hours. You will be also be given some medicine to take before surgery to prevent stomach acid reflux. Your pubic hair at the lower abdomen will be shaved. Just before the surgery, a urinary catheter will be inserted into your bladder to drain the urine. 
  
• ​Operative details (simplified description of a cesarean section) — The most common skin incision is a horizontal cut made low on the tummy, near the pubic hairline. This skin incision is often called the “bikini cut” or pfannenstiel incision. The tummy is opened in layers until the uterus (womb) is reached. The uterine wall is then opened, the membranes ruptured and the baby delivered. The umbilical cord is cut, the placenta removed and the uterine wall closed. 
  
• Post-operative care — Depending on your condition, you may be allowed to drink some fluids within a few hours after the operation. Your urinary tubing will usually be removed the next day. You can breastfeed as soon as you are awake and back in the ward. Pain relief will be given so that you can be comfortable after surgery. You will experience some cramps in your lower abdomen as the womb contracts after delivery. For the same reason you will also have some bleeding from the vagina. This is known as lochia. Depending on the type of stitches used, you may or may not need to have them removed later. After a cesarean section, mothers are advised to do gradual bending and stretching of their legs to prevent deep vein thrombosis (‘economy class syndrome’). They are also advised to sit out of bed and start ambulation the next day. In some cases, a leg stocking (TEDs) and/or an anticoagulant to prevent blood clots in the legs may be prescribed. You will need to stay about 2–3 days in hospital after a cesarean section. ​

Types of Uterine Incisions 

• ​Lower segment incision — This is an incision made in the lower part of the womb, and is most commonly performed as it has been shown to have the lowest risk of complications (Figure 40.8). 
• Classical incision — This is an incision made vertically in the uterus, extending from the lower segment into the upper segment (Figure 40.9). This type of incision may be required for delivery of baby in patients with anterior placenta previa whereby the placenta is implanted into the front part of the lower uterine segment. This incision may also be necessary if there is a large fibroid in the lower segment of the uterus. Such incision is less commonly used as it is associated with greater blood loss, post-operative adhesions and infections as well as a higher incidence of uterine rupture in subsequent pregnancies. 

What are the Dangers with a Cesarean Section? 

• ​​​​​​​​​​You are at risk of vomiting during the operation. If this happens, fluid and food particles from your stomach may pass into your lungs (this is known as aspiration) and can cause potentially serious inflammation (known as aspiration pneumonitis). Eating during labour may increase the amount of food and fluid in your stomach, and this may increase the risk of aspiration if you have an emergency cesarean section. 
• Though rare, surgical risks are higher than with a vaginal delivery. These include: 
• ​Increased infection or pain in the abdomen (tummy). 
• Injury to the bladder or to the tube that connects the bladder to your kidneys (ureter). 
• Removal of the womb as a result of uncontrollable and massive bleeding that occurred during the surgery. (This risk is higher if you have a low-lying placenta or placenta previa.) 
• Developing a blood clot in the legs that may be potentially life threatening (deep vein thrombosis). 
• Problems, such as the placenta covering the opening of the womb (placenta previa) or the tearing of the womb, can be higher in future pregnancies. 
• Other considerations — Women usually spend a longer time in hospital after a cesarean section (on average, 3–4 days) than after a vaginal birth (on average, 1–2 days). 
• Women who have a cesarean section are more likely to have a repeat cesarean section in the future. ​​

Should I Request for an Elective Cesarean Section? 

There is now an increasing trend of mothers requesting for an elective cesarean section in order to avoid undergoing labour. Some do it out of fear of a​ vaginal delivery, while others do it to prevent any perineal or vaginal trauma. 

In addition to the possible complications as mentioned above, there are other issues to consider as well. They include: 

• ​​A higher incidence of chronic pelvic pain, infertility and dyspareunia (pain during intercourse) after the operation. 
• A higher risk of antenatal complications in subsequent pregnancies such as abnormal placenta implantation and scar rupture. 
• An increased risk of baby problems such as lacerations and respiratory problems. 

In all, research clearly shows that elective primary cesarean section poses much greater risks to both mother and child in the short term, long term and future pregnancies compared to a normal vaginal birth. 

What is An Emergency Cesarean Section? 

An emergency cesarean section will be advised if it is deemed that you will not be able to deliver the baby safely through the vagina. The common reasons for an emergency cesarean section include: 

1. ​​A non-reassuring fetal status arising during the course of labour and it is deemed safer for the baby if you undergo a cesarean section. A fetal monitor attached to your abdomen may help detect suspicious patterns of the baby’s heart rate. 
2. A failure to progress in terms of cervical dilation and descent of the baby’s head. The team of doctors in the delivery suite will monitor the labour progress by regular vaginal examination of your labour progress. Unfortunately in most cases, the failure to progress is often difficult to predict before labour starts. 
3. Other special clinical circumstances where it is felt that a successful vaginal delivery cannot be completed safely. In rare circumstances, when an attempt at instrumental delivery is unsuccessful, a cesarean section may be advised. 

Frequently Asked Questions

1. If I had a cesarean section before, will I need another one in the next pregnancy? 

There are pros and cons to a repeat cesarean section and it is discussed in greater detail in the next chapter​. However, women who have a cesarean section are more likely to have one again in the future. 

2. Should I undergo an instrumental delivery​ instead of cesarean section in the second stage of labour? 

The cesarean section will be performed if it is deemed that you will not be able to deliver vaginally safely. Therefore, your obstetrician will advise on the most appropriate method based on the clinical situation.

3. Will I be able to breastfeed after a cesarean section? 

After a cesarean section, women are less likely to start breastfeeding in the first hour after the birth, but if they do start they are just as likely to continue breastfeeding as those who have a vaginal delivery. 

4. When is it safe for me to conceive after a cesarean section? 

The cut in the womb will heal after six weeks and the womb returns to its pre-pregnancy state. Thus, theoretically, it will be safe to conceive after six months to a year after the cesarean section. However, do take into account the physical and emotional stress of coping with a newborn. Thus, conceive again only when you are ready for the next child. ​

Acknowledgement

Source: Dr TAN Thiam Chye, Dr TAN Kim Teng, Dr TAN Heng Hao, Dr TEE Chee Seng John, The New Art and Science of Pregnancy and Childbirth, World Scientific 2008.

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