What you need to know about c-sections
Caesarean sections - are they are reasonable choice, or
the cruellest cut? Specialist obstetrician/gynaecologist Dr Anil
Sharma weighs in on the debate.
Caesarean section is a surgical procedure that is undertaken to
deliver a baby via an incision in the abdominal wall. It is either
planned (elective) or undertaken as an emergency. The emergency
ones may be "real" emergencies, meaning that they are performed
when harm may occur to the baby or mother if they are not done
quickly. They may also be carried out in a "semi-planned"
manner, such as when the baby and mother are both well, but the
chances of vaginal birth are looking low or remote as the labour is
not going well.
Around one of every four New Zealand births is via C-section, and
the rates in Auckland maternity units vary between
Reasons for having a C-section
There are scenarios in which a C-section is the only possible or
safe mode of delivery of the baby, such as:
• Failure to "progress" in labour (to "progress" means
to keep dilating and moving forwards to make vaginal birth
• Delayed descent of the baby's head once full dilation
of the cervix has occurred.
• Failed induction of labour.
• Placenta praevia (where the placenta or afterbirth is
in the lower part of the uterus or covering the opening in the
Another very important reason for a C-section is foetal
distress, due to any cause. Of course, it takes an experienced
obstetrician to diagnose foetal distress more accurately than most,
as tests to diagnose it are not exactly highly reliable. The
problem is that the only tests that exist need to be acted upon if
they are abnormal until better tests are invented.
Other foetal reasons for a C-section
• Unusual presentations such as breech, when the baby
presents to the pelvis by its buttocks or feet and not by its
• Many multiple pregnancies (twins, triplets,
• An overly large baby (macrosomia).
• Sometimes there may be evidence or a logical "hunch"
on the doctor's part that the "fit" between the baby's head and the
mother's pelvis may be poor (cephalo-pelvic disproportion), and a
C-section may be suggested.
Also, a maternal condition such as severe
high blood pressure or poor foetal growth (growth-restricted baby)
may well mean that a C-section is safer than an attempted vaginal
One or more previous C-sections with a reasonable likelihood of a
repeat being needed even if labour is attempted may lead to another
repeat C-section being offered.
Similarly, a woman with a previous
C-section may not wish to try labour this time around. A previous
classical C-section, where the uterine incision is on the upper
part of the womb (more common in some overseas countries), or,
indeed, where there has been previous surgery through the wall of
the uterus, can also lead to a C-section.
All of the above can increase the chances
of rupture of the scar during labour and this, in turn, can cause
severely negative outcomes to both the baby and mother.
A history of having had a vaginal repair
will mostly lead to a C-section being offered, as the repair will
become undone and damaged with a vaginal birth. These repairs are
usually performed after initial pelvic-floor damage due to vaginal
childbirth. Active genital infection with herpes at the time of
birth will lead to a C-section, to prevent the baby from developing
the infection also.
Maternal choice is another reason cited
for the rising rate of C-sections. This is due to informed choice
after careful consideration, fear of vaginal birth, concerns about
the safety of the baby, or, indeed, due to a previous bad
experience with postnatal post-traumatic stress disorder due to a
very difficult labour.
Complications of C-sections versus vaginal
There are several possible complications of C-sections that mothers
considering or facing this surgery should be aware of. These
include increased risks of blood loss, which is, on average, double
that of vaginal birth.
There also increased risks of
thromboembolism (blood clots in the legs that can break off and go
to the lungs and cause serious problems), wound infection, and
injuries to internal organs and structures.
There may also be increased difficulty
with bonding with the baby, not least due to being exhausted and
having to recover from a major operation.
Sometimes (depending on the reasons for
the operation), women who have had a C-section feel an emotional
and psychological sense of failure. This needs to be closely
monitored by a health professional.
What to expect when you have a
After an assessment by an obstetrician, an anaesthetic assessment
is also undertaken and consent forms are signed after discussion
and appropriate blood tests taken. Obviously, the speed of these
and other preparations is matched to the need for urgency.
Theatre can be daunting, as it is well staffed,
and often there will be around 8-10 people there. The faces will
include one or two anaesthetic team members and one or two
obstetric team members. There will also be an anaesthetic
assistant, surgical assistant and around two other theatre nurses,
a paediatric nurse or doctor (for the baby) and an orderly.
Usually no more than one support person
(such as the woman's partner) is permitted to be in theatre for
logistical reasons, and, although photography is usually
encouraged, it is not a good idea to photograph or video-record
staff without their consent, so it's sensible to ask about
Almost all C-sections are undertaken with
regional anaesthesia, which means spinal or epidural injections
near the nerves that emerge from the spinal cord. This bathes them
in local anaesthetic and removes the ability they have to carry
pain and temperature sensations to the rest of the body. Touch and
pressure sensations remain, but the legs generally feel heavy and
are difficult to move.
The anaesthetist usually uses ice to test
the nerve block, as the pain nerves and temperature nerves are the
ones that need to be blocked. After a urine catheter has been
inserted to empty the bladder to prevent the chances of it being
injured, the skin is painted with antiseptic solution and sterile
drapes are applied.
A C-section can take anywhere from around
20 minutes to an hour, depending on the circumstances, the speed of
the surgeon, and complications. The baby is delivered, then the
cord is cut and clamped, and the placenta is removed. The baby is
usually checked by a paediatrician or midwife next.
Usually a dose of antibiotic is given
intravenously to the mum in order to prevent the risk of infection
of the wound and urine. An intravenous drug that mimics the effect
of natural oxytocin to make the uterus contract and help limit
blood loss is also given. Following delivery of the placenta, the
layers of the abdomen are closed. Many women prefer to avoid
staples to close the skin layer and it is worthwhile discussing
this with your surgeon.
Afterwards, you will be transferred to the
recovery area in theatre prior to being sent back to the ward with
your baby for around a four-night stay. Early mobilisation and
eating are generally encouraged to help you get fit for new or
So which mode of delivery?
All things considered, some women (the minority) will wish to have
a C-section rather than a vaginal birth. Overall, looking at the
big collective picture, and excluding women who need a C-section
for medical indications, women are more likely to have safer
outcomes with a vaginal birth.
Furthermore, postnatal recovery (getting
on with mental and physical wellbeing and parenthood) is overall
faster after a vaginal birth than a C-section. Carers disagree as
to the actual amount of time that a C-section "sets you back"
compared to a natural birth, varying from one week to four
Nevertheless, there are women who would
prefer to have a C-section for non-medical indications. In my
opinion, these women (and their partners) should have a detailed,
informed discussion with an obstetrician on at least two occasions.
Informed discussion is not the same as being told what to do. If
they still elect to have a C-section despite all this, my view is
that this is okay, although many would disagree. Obviously, other
pre-existing medical conditions need to be borne in mind
Unfortunately, our society does seem to
readily stigmatise issues, and one of these is women who want a
C-section. My advice is to initially discuss your wishes with your
lead maternity carer, and, if you get fobbed off rather than be
offered detailed discussion, ask for someone else's opinion. I also
feel that coercion to have a C-section (if it is safe to try or
continue to try for a vaginal birth) is also clearly
Bear in mind that in the bigger picture,
New Zealand's limited health resources are not adequate for
"C-sections for all". One Auckland district health board has sought
a legal opinion, which supports the refusal of non-medically
The arguments will continue to rage about
the "correct" C-section section rate and the "right to choose". My
views on this are based on safety and maternal choice after
informed consent. It should be noted that most women (but not all)
who have had both a vaginal birth and a C-section prefer the
The other problem is that, in order of
safety, vaginal birth is first, then elective C-section, and,
finally, emergency C-section. So while a vaginal birth is overall
the safest choice, an attempted vaginal birth with a low chance of
success is not a great idea.
This means that in the absence of a
crystal ball, the advice of caregivers whom women can trust is
paramount. If you feel the need for further discussion, you may be
entitled to visit a public obstetrician and can seek advice from a
private one (if they offer secondary care).
Dr Anil Sharma is a specialist doctor in Gynaecology and
Maternity. He is very involved in lectures and updates for family
doctors and frequently takes part in debate regarding women's
health and maternity for print media and radio. He believes that
anxiety and fear can be conquered by knowledge. Anil emigrated to
New Zealand from the UK in 2001 with his wife, Rachel, and he tries
hard to be a hands-on and fun father (putting golf and cars on hold
for the time being) to their three daughters, who were all born
here. For further information about Anil's practice, visit www.dranilsharma.co.nz
As seen in OHbaby!
magazine Issue 2: 2008
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