Cesarean delivery: planned, unplanned

According to a Euro-Peristat study dated 2015 and published in Bjog:  An International Journal of Obstetrics and Gynecology,  caesarean delivery rates in Europe range from 52% in Cyprus to 14.8% in Iceland. In Italy the rate fluctuates between 36 and 38%. 

According to our Ministry of Health, there is an increasing tendency to transform childbirth, which is a natural event, into a surgical problem.

More and more often especially in Italy, today many women give birth by caesarean section without a real reason that is related to health.

However, being a surgical intervention, only in the case of an appropriate medical indication is this type of birth able to guarantee benefits that exceed the potential risks that any surgical intervention inevitably entails.

Why is a cesarean delivery performed? The cut can be an intervention scheduled before or, during the birth if the conditions of the fetus or those of the mother impose it. Let us examine these two cases separately.

The unscheduled caesarean section

A doctor may recommend this procedure before the pregnancy ends. Here are some of the conditions that may require a C-section:

  • Certain medical conditions.  If you have certain chronic conditions such as heart conditions, diabetes, high blood pressure, or kidney disease that are likely to make a vaginal birth dangerously stressful for your body, a C-section may be the safest option.
  • Some infections . If you are HIV positive or have active genital herpes, a caesarean section should be scheduled because both of these viruses can be passed on to your baby during delivery.
  • The health of the child . An illness or congenital condition could make your baby’s already difficult journey through the birth canal even more treacherous.
  • A too big baby.  Sometimes the baby may be too large (macro, if the fetus weighs 4.5 kg or more) to move smoothly through the birth canal, especially if you have gained more weight than recommended in pregnancy.
  • The weight of the woman . Being obese significantly increases the odds of having to have a C-section, in part because of the other risk factors that often accompany obesity (such as  gestational diabetes ), and in part because obese women tend to go into labor longer: the longer it is, the greater the risk of having to end up on the operating table.
  • Her age.  While getting older doesn’t necessarily mean you need to have a C-section, your chances of needing one increase as you get older.
  • The baby’s breech presentation . When your baby is positioned with his feet or bottom towards the exit of the birth canal, it means that his presentation is breech: and if you are unable to turn him in the right direction, your doctor may decide to perform a Caesarean section.
  • A multiple pregnancy.  The likelihood of having the C-section procedure increases with the  number of babies you are carrying .
  • Some placental problems . If the placenta is partially or completely blocking the opening of the cervix (placenta previa); or she separated from the uterine wall (placental abruption), a C-section is probably the safest thing for you and your baby.
  • Other complications.  In the case of pregnancy-induced hypertension or eclampsia (a rare development of preeclampsia that affects the central nervous system causing seizures) and in the case of treatments that are not having an effect, your doctor may opt for a caesarean section to to protect you and your baby.

Urgent cesarean section

Much more frequently the need for a C-section is not certain until a woman is in full labour.

Some of the most common reasons for this condition are given by:

  • Labor that doesn’t start . Your doctor may opt for surgery if your labor doesn’t seem to want to start despite contractions: the cervix isn’t dilating after 24 to 25 hours for a new mother, and after fewer hours for subsequent deliveries.
  • Labor that stops.  You may go through the early stages of labor (up to 3cm dilation) only to come to a stop. While it’s possible that oxytocin, or other substances that stimulate labor, can restart contractions, a C-section may be necessary if the problem is that your baby’s head is too large to fit through your pelvis (a which happens in about half of the cases).
  • Fetal exhaustion or distress . If your doctor decides you’re exhausted, or if the fetal monitor shows any signs of your baby’s distress, they may opt for a C-section.
  • The prolapse of the umbilical cord.  If the  umbilical cord  slips into the birth canal before the baby, it will be compressed by the passage of the fetus, a complication that would cut off its oxygen supply.
  • A uterine rupture.  If your uterus tears, a  C-section is needed .

How does a cesarean birth happen?

  1. In preparation for the surgery, an intravenous cannula is placed in the woman’s arm or hand to give her the fluids and medicines needed during the operation.
  2. His abdomen is cleaned and his pubic hair may be trimmed or shaved.
  3. A catheter is placed in the woman’s bladder to remove her urine, and it will be left there for a day after surgery.
  4. Local anesthesia is usually done by epidural or spinal. Both of these types of anesthesia desensitize the lower half of the body but allow the woman to be awake when her baby is born. This operation tends to be safer than general anesthesia, in which the woman would remain totally asleep during delivery.
  5. The gynecologist will use a scalpel to make a horizontal incision in the skin and abdominal wall, usually along the pubic line, i.e. low enough that it can later be covered by underwear or bikini. Some women may experience a vertical or inverted V-shaped incision.
  6. After the abdomen has been opened, the uterus is incised. “Typically” a horizontal cut is made, which breaks the amniotic sac that surrounds the fetus.
  7. Once this protective membrane has been broken, the baby is removed from the uterus; the umbilical cord is cut, and the placenta is removed.
  8. The baby is examined and then given to the mother to encourage contact.

How the cut is made to the mother’s uterine wall is important, because how the scar heals will affect her ability to have vaginal deliveries in the future.

Once delivery and postpartum have been completed, the incisions in the mother’s uterus are stitched up with stitches that will later dissolve under the skin.

The skin of the abdomen is closed with stitches or staples, which are then removed before the woman leaves the hospital.

A cesarean delivery in the operating room usually lasts between 60 to 120 minutes. The exact duration depends on any complications that may arise during delivery.

After the surgery, the woman will be taken to the maternity ward of the hospital to recover.

Recovery after cesarean delivery

Recovery after a cesarean delivery usually takes longer than after a vaginal birth.

All of this translates into a longer stay in the hospital. Any pain may make it necessary for the mother to take painkillers.

Upon returning home, the mother may need to rest for a few weeks.

A red scar will remain on the belly of new mothers, which will change color over time and become more and more invisible.

If you’ve already had a C-section, that doesn’t mean any subsequent deliveries have to happen the same way.

Most women who have had a cesarean delivery are subsequently able to have a vaginal birth.

Only in particular situations, both for their own safety and that of their child, could it be advised to opt for caesarean section also for any future deliveries. 

Katherine Johnson, M.D., is a board-certified obstetrician-gynecologist with clinical expertise in general obstetrics and gynecology, family planning, women’s health, and gynecology.

She is affiliated with the Obstetrics and Gynecology division at an undisclosed healthcare institution and the online platform, Maternicity.com.

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