Cesarean Section

Topic Overview

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If you have had a C-section and would like information about how a cesarean affects future deliveries, see the topic Vaginal Birth After Cesarean (VBAC).

What is a cesarean section?

A cesarean section is the delivery of a baby through a cut (incision) in the mother's belly and uterus. It is often called a C-section. In most cases, a woman can be awake during the birth and be with her newborn soon afterward. See a picture of a delivery by C-section .

If you are pregnant, chances are good that you will be able to deliver your baby through the birth canal (vaginal birth). But there are cases when a C-section is needed for the safety of the mother or baby. So even if you plan on a vaginal birth, it's a good idea to learn about C-section, in case the unexpected happens.

When is a C-section needed?

A C-section may be planned or unplanned. In most cases, doctors do cesarean sections because of problems that arise during labor. Reasons you might need an unplanned C-section include:

• Labor is slow and hard or stops completely.
• The baby shows signs of distress, such as a very fast or slow heart rate.
• A problem with the placenta or umbilical cord puts the baby at risk.
• The baby is too big to be delivered vaginally.

When doctors know about a problem ahead of time, they may schedule a C-section. Reasons you might have a planned C-section include:

• The baby is not in a head-down position close to your due date.
• You have a problem such as heart disease that could be made worse by the stress of labor.
• You have an infection that you could pass to the baby during a vaginal birth.
• You are carrying more than one baby (multiple pregnancy).
• You had a C-section before, and you have the same problems this time or your doctor thinks labor might cause your scar to tear (uterine rupture).

In some cases, a woman who had a C-section in the past may be able to deliver her next baby through the birth canal. This is called vaginal birth after cesarean (VBAC). If you have had a previous C-section, ask your doctor if VBAC might be an option this time.

In the past 40 years, the rate of cesarean deliveries has jumped from about 1 out of 20 births to about 1 out of 4 births.¹ This trend has caused experts to worry that C-section is being done more often than it is needed. Because of the risks, experts feel that C-section should only be done for medical reasons.

What are the risks of C-section?

Most mothers and babies do well after C-section. But it is major surgery, so it carries more risk than a normal vaginal delivery. Some possible risks of C-section include:

• Infection of the incision or the uterus.
• Heavy blood loss.
• Blood clots in the mother's legs.
• Injury to the mother or baby.
• Problems from the anesthesia, such as nausea, vomiting, and severe headache.
• Breathing problems in the baby if it was delivered before its due date.

If she gets pregnant again, a woman with a C-section scar has a small risk of the scar tearing open during labor (uterine rupture). She also has a slightly higher risk of a problem with the placenta, such as placenta previa.

How is a C-section done?

Before a C-section, a needle called an IV is put in one of the mother's veins to give fluids and medicine (if needed) during the surgery. She will then get medicine (either epidural or spinal anesthesia) to numb her belly and legs. Fast-acting general anesthesia, which makes the mother sleep during the surgery, is only used in an emergency.

Once the anesthesia is working, the doctor makes the incision. Usually it is made low across the belly, just above the pubic hair line. This may be called a 'bikini cut.' Sometimes the incision is made from the navel down to the pubic area. See a picture of C-section incisions . After lifting the baby out, the doctor removes the placenta and closes the incision with stitches.

How long does it take to recover from a C-section?

Most women go home 3 to 5 days after a C-section, but it may take 4 weeks or longer to fully recover. By contrast, women who deliver vaginally usually go home in a day or two and are back to their normal activities in 1 to 2 weeks.

Before you go home, a nurse will tell you how to care for the incision, what to expect during recovery, and when to call the doctor. In general, if you have a C-section:

• You will need to take it easy while the incision heals. Avoid heavy lifting, intense exercise, and sit-ups. Ask family members or friends for help with housework, cooking, and shopping.
• You will have pain in your lower belly and may need pain medicine for 1 to 2 weeks.
• You can expect some vaginal bleeding for several weeks. (Use sanitary pads, not tampons.)

Call your doctor if you have any problems or signs of infection, such as a fever or red streaks or pus from your incision.

Frequently Asked Questions

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How a Cesarean Section Is Done

Surgery preparation

Most cesarean sections are performed with epidural or spinal anesthesia, used to numb sensation in the abdominal area. Only in an emergency situation or when an epidural or spinal anesthesia cannot be used or is a problem would fast-acting general anesthesia be used to make you unconscious for a cesarean birth.

The hospital may send you instructions on how to get ready for your surgery, or a nurse may call you with instructions before your surgery.

In preparation for a cesarean section, your arms are secured to the table for your safety, and a curtain is hung across your chest. A tiny intravenous (IV) tube is placed in your arm or hand; you may be given a sedative through the IV to help you relax. A catheter is inserted into your bladder to allow you to pass urine during and after the surgery. Your upper pubic area may be shaved, and the abdomen and pubic area are washed with an antibacterial solution. The incision site may be covered with an adhesive plastic sheet, or drape, to protect the surgical area.

Before, during, and after a cesarean section, your blood pressure, heart rate, heart rhythm, and blood oxygen level are closely monitored. You will also be given a dose of antibiotics to prevent infection after delivery.

Cesarean procedure and delivery

Once the anesthesia is working, a doctor makes the cesarean incision through your lower abdomen and uterus. See a picture of cesarean section incisions . You may notice an intense feeling of pressure or pulling as the baby is delivered. After delivering your newborn through the incision, the doctor then removes the placenta and closes the uterus and incision with layers of stitches.

Right after surgery, you will be taken to a recovery area where nurses will care for and observe you. You will stay in the recovery area for 1 to 4 hours, and then you will be moved to a hospital room. In addition to any special instructions from your doctor, your nurse will explain information to help you in your recovery.

Who to See

A cesarean section can be performed by a doctor with specialized training, such as:

• An obstetrician.
• A perinatologist (maternal-fetal medicine specialist).
• A family medicine doctor with cesarean section training and hospital privileges.
• A surgeon.

If your pregnancy care provider doesn't perform cesareans and foresees a possible need for a cesarean, you will be referred to a cesarean-trained doctor ahead of time. Your family medicine doctor, certified nurse-midwife, or certified professional midwife can assist with the surgery and provide your follow-up care.

Why It Is Done

Some cesarean deliveries are planned ahead of time; others are done when a quick delivery is needed to ensure the mother's and infant's well-being.

Planned cesarean

Some cesarean sections are planned when a known medical problem would make labor dangerous for the mother or baby. Medical reasons for a planned cesarean may include:

• A fetus in any position that is not head-down (including breech position). For more information, see the topic Breech Position and Breech Birth.
• Decreased blood supply to the placenta before birth, which may lead to a small baby.
• The medical need to deliver and no success with inducing labor.²
• Estimated fetal size of over 9 lb (4.1 kg) to 10 lb (4.5 kg) or more.
• A maternal disease or condition that may be worsened by the stress of labor, such as heart disease.
• A placenta that is blocking the cervix (placenta previa). For more information, see the topic Placenta Previa.
• Open sores from active genital herpes near the due date, which can be passed to the fetus during vaginal delivery.
• Infection with the human immunodeficiency virus (HIV), which can be passed to the fetus during vaginal delivery.³
• Multiple pregnancy. The direction and size of the incision depends on the position of the fetuses. In particular, cesarean delivery may be needed for multiple births involving:
  • Twins that share one amniotic sac (monoamniotic twins), because of the risk that the cords will get tangled.
  • Three fetuses or more.
  • Conjoined (Siamese) twins.
  • An overstretched uterus that cannot contract adequately during labor (uterine inertia), making labor prolonged and difficult.
  • Poorly positioned or large fetuses.

Many cesarean deliveries are planned ahead of time for women who have had a cesarean in the past. Medical reasons for a planned repeat cesarean may include:

• A current problem that has led to difficult labor and cesarean before, such as a narrow pelvis and a large fetus (cephalopelvic disproportion).
• Factors that increase the risk of uterine rupture during labor, such as having a vertical scar, three or more cesarean scars, triplets or more, or a very large fetus thought to weigh 9 lb (4.1 kg) to 10 lb (4.5 kg) or more. For more information, see the topic Vaginal Birth After Cesarean (VBAC).
• No access to constant medical supervision by a cesarean-trained doctor during active labor, or no available facilities for an emergency cesarean.

Should I have a VBAC trial of labor after a previous cesarean section?

Emergency cesarean

Some cesarean sections are done without planning, after labor has started. Medical reasons for an emergency cesarean may include:

• Fetal distress (suggested by a very rapid or very slow heart rate)
• Placenta abruptio, which can cause excessive bleeding (hemorrhage) and decreased oxygen supply to the fetus. For more information, see the topic Placenta Abruptio.
• Umbilical cord problems that decrease or cut off fetal blood supply, as when the cord has slipped into the birth canal ahead of the fetus, and the fetus moves into the birth canal and presses against the cord (cord prolapse).

Other reasons you might need a cesarean

• Difficult, slow labor (dystocia)
• Labor that has stopped completely (failure to progress)
• Cephalopelvic disproportion, a combination of the fetus having a large head and the mother having a narrow pelvic structure. This condition is often linked to failure to progress or dystocia.

Risks and Complications

Cesarean section is considered relatively safe. It does, however, pose a higher risk of some complications than does a vaginal delivery. If you have a cesarean section, expect a longer recovery time than you would have after a vaginal delivery.

After cesarean section, the most common complications for the mother are:

• Infection.
• Heavy blood loss.
• A blood clot in a vein.
• Nausea, vomiting, and severe headache after the delivery (related to anesthesia and the abdominal procedure).
• Maternal death (very rare). The risk of death for women who have a planned cesarean delivery is very low (about 6 in 100,000). For emergency cesarean deliveries, the rate is higher, though still very rare (about 18 in 100,000).¹

Cesarean risks for the infant include:

• Injury during the delivery.
• Need for special care in the neonatal intensive care unit (NICU).⁴
• Lung immaturity, if the due date has been miscalculated or the infant is delivered before 39 weeks of gestation.⁴

While most women recover from both cesarean and vaginal births without complications, it takes more time and special care to heal from cesarean section, which is a major surgery. Women who have a cesarean section without complications spend about 3 days in the hospital, compared with about 2 days for women who deliver vaginally. Full recovery after a cesarean delivery takes 4 to 6 weeks; full recovery after a vaginal delivery takes about 1 to 2 weeks.

Long-term risks of cesarean section

Women who have a uterine cesarean scar have slightly increased long-term risks. These risks, which increase further with each additional cesarean delivery, include:²

• Breaking open of the incision scar during a later pregnancy or labor (uterine rupture). For more information, see the topic Vaginal Birth After Cesarean (VBAC).
• Placenta previa, the growth of the placenta low in the uterus, blocking the cervix.
• Placenta accreta, placenta increta, placenta percreta (least to most severe), the growth of the placenta deeper into the uterine wall than normal, which can lead to severe bleeding after childbirth, sometimes requiring a hysterectomy.

What to Expect After C-Section

After a routine cesarean section, expect to be monitored closely for the next 24 hours to make sure that you don't develop any problems. You will receive pain medication and will likely be encouraged to begin walking short distances within 24 hours of surgery. Walking can help relieve gas buildup in the abdomen. It is usually very uncomfortable to begin walking, but the pain will decrease in the days after the delivery.

The typical hospital stay after a cesarean delivery is about 3 days. You can feed and care for your newborn as you feel able. Before going home, you'll receive postsurgery instructions, including warning signs of complications. It can take 4 weeks or more for a cesarean incision to heal, and it isn't unusual to have occasional pains in the area during the first year after the surgery.

For information about how a cesarean affects future deliveries, see the topic Vaginal Birth After Cesarean (VBAC).

When to call a doctor

After a cesarean section, call your doctor or midwife if:

• You use a new maxi sanitary pad for vaginal bleeding every hour for 4 to 5 hours. (If you have a past vaginal delivery to compare to, you may notice that post-cesarean bleeding is lighter.)
• Your vaginal bleeding seems to be getting heavier or is still bright red 4 days after delivery, or if you pass blood clots larger than the size of a golf ball. You may also have lower abdominal pain.
• You have signs of infection, including fever or increased redness and drainage at the incision site.
• The incision gapes open or starts bleeding.
• You feel dizzy.
• Your calves become painful and/or swollen and red, you have shortness of breath, or you have severe chest pain (these can be signs of a blood clot).
• You have signs of postpartum depression, such as:
  • Feelings of despair or hopelessness for more than a few days.
  • Troubling or dangerous thoughts or hallucinations.
• Your vaginal discharge smells bad or fishy.
• Your abdomen feels tender or full and hard.
• Your breasts are painful or red and you have a fever, which are symptoms of both breast engorgement and mastitis. For more information, see the topics Breast Engorgement and Mastitis While Breast-Feeding.

Some women feel shoulder pain for days after a cesarean section. This is referred pain, caused by trauma to the abdominal muscles during the delivery. It goes away on its own during recovery.

What to Think About

If you plan to deliver vaginally and have concerns about having an unnecessary cesarean delivery, talk to your doctor or midwife ahead of time. Ask in what types of situations cesarean section is usually used and what measures he or she takes to promote a vaginal birth.

Public health experts have urged the North American obstetric community to reduce the percentage of deliveries done by cesarean, identifying birth scenarios that may not necessarily require surgical delivery. These include:

• History of cesarean. Some women with a cesarean scar can deliver vaginally, although there are risks involved in a VBAC delivery. Some smaller hospitals no longer provide VBAC, reflecting a trend toward greater medical caution with VBAC. If you have had a previous cesarean, weigh the benefits and risks of vaginal delivery with your doctor or midwife. For more information, see the topic Vaginal Birth After Cesarean (VBAC).
• Fetal distress. Deciding whether and when a fetus with a slowing heart rate should be delivered by cesarean is a common judgment call during labor. Ultimately, a health professional will lean toward caution and deliver by cesarean to prevent harm to a newborn.
• Difficult, slow labor (dystocia). Dystocia can often be corrected with medication that restarts contractions (augmentation). For women with a cesarean scar, oxytocin must be used carefully to reduce the slight risk of the scar rupturing during labor.

Some doctors are more likely to see a need for a cesarean than others. For example, what one doctor considers a slow labor may be a normal labor to another. However, all doctors are guided by the common goal of a healthy labor and delivery for both the mother and her newborn.

Other Places To Get Help

Organizations

Related Information

• Breech Position and Breech Birth
• Gestational Diabetes
• Multiple Pregnancy: Twins or More
• Placenta Abruptio
• Placenta Previa
• Preeclampsia and High Blood Pressure During Pregnancy
• Pregnancy
• Vaginal Birth After Cesarean (VBAC)

References

Citations

1. Cunningham FG, et al. (2005). Cesarean delivery and peripartum hysterectomy. In Williams Obstetrics, 22nd ed., pp. 587-606. New York: McGraw-Hill.

2. Porter TF, Scott JR (2003). Cesarean delivery. In JR Scott et al., eds., Danforth's Obstetrics and Gynecology, 9th ed., pp. 449-460. Philadelphia: Lippincott Williams and Wilkins.

3. American College of Obstetricians and Gynecologists (2000; reaffirmed 2003). Scheduled cesarean delivery and the prevention of vertical transmission of HIV infection. ACOG Committee Opinion No. 234. Washington, DC: American College of Obstetricians and Gynecologists.

4. Kolås T, et al. (2006). Planned cesarean versus planned vaginal delivery at term: Comparison of newborn infant outcomes. American Journal of Obstetrics and Gynecology, 195(6): 1538-43.

Other Works Consulted

• Lydon-Rochelle M, et al. (2000). Association between method of delivery and maternal rehospitalization. JAMA, 283(18): 2411-2416.

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