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Cesarean Section
  Cesarean Section Q. What is a cesarean section (C/S)? A. A C/S is a major surgical operation performed by your doctor to deliver your baby by an incision made through your abdomen into your uterus. Q. What are the indications for a C/S? A. The most common reasons for a C/S are the following: A previous cesarean section, if indicated or desired (see VBAC) Your cervix fails to dilate completely Your pelvis is too small to allow the baby to descend through the birth canal (cephalopelvic disproportion) Fetal distress due to an inadequate supply of oxygen to your baby An abnormal fetal position- breech (butt or feet first) Placenta previa Rh disease Severe preeclampsia with an "unripe" cervix Diabetes with a large fetus (macrosomia) Uterine rupture Twins that are not both head down Triplets, quadruplets, etc. Prolapse of the umbilical cord through the dilated cervix Previous uterine surgery (e.g., removal of a fibroid tumor) Pelvic tumor obstructing the birth canal Active genital herpes or a positive herpes culture at term Elective C/S Q. Who does the C/S? A. Your doctor performs the surgery, alone or with another doctor assisting, either his or her partner or an associate. Q. What happens before I have the C/S? A. Your doctor will explain to you the reason for the C/S and the potential complications. You will then sign a consent form for the procedure. Your nurse will then prepare you for the surgery. A Foley catheter will be placed in your bladder to keep it drained; this is done to deflate it so it is not on the way during delivery through the cut in the uterus and to prevent an injury to the bladder during the surgery. You will need an I.V. for hydration before the administration of the spinal or epidural anesthesia and for some medications, if needed, during surgery. The pubic hair on your abdomen will be shaved, to clean the area where your doctor will make the incision. Blood will be taken for a CBC, blood type, and Rh titer to cross match your blood in case a blood transfusion is necessary. A test will also be performed to see that your blood clots properly. If the C/S is not a life-threatening emergency for you or your fetus, the anesthesiologist will discuss the different types of pain relief that can be used during the operation. All this is done in the LDR room. You will then be transported to the operating room, usually located in the labor and delivery room area, and moved onto the operating table. If a spinal or epidural anesthesia was selected, the anesthesiologist will place this now. If you already had an epidural for labor, more anesthetic will be given- a “C/S dose”. General anesthesia for a C/S is rarely necessary, even in most emergency situations. You will lie on your back and your legs will be strapped down to prevent them from moving during the induction of sleep, if general anesthesia is given, or from falling off the table, if a spinal or epidural was given. The anesthesiologist will monitor your blood pressure with a blood pressure cuff and your heart with electrocardiogram leads, which he or she will place on your chest. Your oxygen level in your blood will be monitored with a pulse oximeter, a small device placed on your finger. A nurse will place a pad on your leg to ground you so the doctor may use an instrument for cutting and cautery for hemostasis (stop bleeding) during the procedure. Your abdomen will then be washed and sterile drapes will be placed over your body, except for the site of the incision. Q. Can I wear my contacts or glasses in the OR? A. Yes Q. Can I wear my earrings, necklace, bracelets and watch in the OR? A. Yes as long as you are not undergoing general anesthesia. Medicolegally, the hospital does not want to be responsible for your jewelry when you are not conscience. Q. Can my partner watch the C/S? A. Most doctors and hospitals allow the partner to be present during the cesarean section. He is usually asked to sit on a stool right by your head, so that he may hold your hand and talk to you (if you are awake) during the surgery. A drape usually blocks his view of the surgery, but he can, if he chooses, stand up and watch any part of the C/S. Q. Can I watch the C/S? A. Some operating suites are equipped with mirrors and these can be set up for you to view the surgery, if you so desire. Q. Can we take pictures during the C/S? A. Absolutely Q. Can we videotape the C/S? A. Most hospitals have a no videotaping policy. Q. How is the C/S performed? A. First you have been prepped (cleaned with a type of soap) and draped. Your doctor will then test your skin for feeling. If you can feel a sharp or pinprick feeling, the anesthesiologist will administer more anesthetic if you have an epidural. If you had a spinal placed, it didn’t work and a new one will have to be done. This is rare. If you are going to have a general anesthesia, this step is not necessary. An incision is made with a scalpel (surgical knife) through the skin of the abdomen. Most commonly the “bikini cut” is performed. The incision is made in a horizontal fashion from one side of your hip to the other. The length of the wound is from 4 to 6 inches long and is made about 1 inch above your pubic bone. The next layer entered is fat and looks yellow. The fascia, a white leathery, covering is cut next and then separated from the underlying abdominal muscles. The muscles of the abdomen are separated, not cut in your midline and the peritoneum (the lining of the abdominal contents) is entered. Two metal instruments shaped like hoes are used to keep your belly open. The bladder is attached to the uterus. This attachment is cut and the bladder is pushed down away from the uterus. An incision is then made in this lower part of the uterus. Two types of uterine incisions can be made here, horizontal or vertical; the horizontal incision is more commonly made. The amniotic sac protrudes through this opening and is ruptured with a gush of amniotic fluid pouring out. Your baby’s head (or butt) is then delivered through this incision, the mouth is suctioned, and the cord is doubly clamped and cut after the cord stops pulsating (by your partner if desired). You will be shown your baby briefly and then your baby will be placed in a warmer and dried and examined by a nurse and respiratory therapist. Your baby will then be returned to you as quickly as possible so you can bond with skin to skin if desired. The placenta is delivered next. Blood is taken to test your baby. Pitocin is given through your IV to contract your uterus. The uterus is then brought out through the abdominal incision and placed on your belly. The uterus is wiped clean and then closed with suture. After noting that the incision is not bleeding, your doctor will look at your tubes and ovaries to make sure they are normal. The uterus will be replaced into your body and checked for bleeding and corrected with suture if necessary. The two sides of abdominal muscles will be sutured together and inspected for bleeding. Next the fascia and fat layers will be closed. The skin incision can be closed with a suture just under the skin (my preference) or with staples.Surgical glue (my preference) or steri strips then cover the incision. During the entire closure you will be able to hold your baby. Q. How long does a C/S take? A. The average time is about 30 to45 minutes. Your baby will be born within 5 minutes of the start of the C/S. Q. Who is in the delivery room during a C/S? A. There are quite a few people; you, your mate, one other family member or friend (to take still photos), your doctor and his or her assistant, the anesthesiologist, a scrub nurse to hand the instruments to the doctor, a labor nurse to get extra equipment, and, a nursery nurse, a respiratory therapist, and finally your new baby! Q. What are the potential complications of a C/S? A. Cesarean section has become one of the most common surgical procedures performed in this country. Over 25% of deliveries will be by C/S. Complications can and do occur, but they are extremely rare. In fact, a large recent study noted that all the types of complications from a C/S were only 17 per 1,000. Any surgical procedure may cause an infection. Infections are more common in women who were in labor for hours with ruptured membranes who then had a C-section, diabetic women and women who are obese. The incidence of infections has decreased with the use of antibiotics given before your baby is born. The three types of infections are: Bladder infections, uterine infections and wound infections. Increased blood loss may occur after a C/S especially if the mom was in labor for a long time and the uterus is too tired and doesn’t want to contract (atony) or after delivery of multiple babies or huge babies. Placenta previa or accreta can cause a large blood loss. Although it has been stated that the blood transfusion rate can be as high as 6%, the rate in private hospitals is less than 1%. Possible injury to other organ may occur in any surgical procedure, the most common is a bladder injury, which is rare. Adhesions or scar tissue may form rarely form after any surgical procedure. In the case of a C-section the scarring is usually between the uterus and bladder or uterus and the inside lining of your abdomen. Pain or discomfort from these adhesions is rare. DVT or deep vein thrombosis or a blood clot in your leg is rare and prophylactic measures, the sequential compression device is used to prevent this complication. Death of the mother is a very rare event and there are usually some other complicating factor. Q. When will my skin incision be strong? A. At 2 weeks, the wound has about 10% of its strength, by 3 weeks 20% and 50% by 4 weeks. You can take a shower and not worry the day after your C/S. Q. Is it normal to have numbness around the incision? A. Yes, some women will experience numbness which may last for up to 6 months. Q. My incision was soft but now it feels hard. Is this normal? A. Yes, the skin and underlying tissues are undergoing a repair process that takes months. During the initial phases the wound area may feel hard and swollen which will disappear over the first few months. Q. Will I form a thick (hypertrophic) scar? A. Hypertrophic scars are thick scars that grow within the boundary of the incision. Most people confuse hypertrophic scars with keloids. These scars are more common in dark skinned women or if you have one in a previous scar on your body. They usually form in the first month after surgery and may subside over years. The thickness of the scars can be decreased with pressure and silicone sheeting. Q. Will I form a keloid scar? A. A significant factor for keloid formation is a genetic predisposition. Asian women have a 50% chance; African- Americans have a 10% chance. The transverse abdominal skin incision has a less probability of keloid formation than a vertical incision. Keloids are thick scars that extend beyond the incision. Keloid formation usually develops several months after the surgery and rarely regresses. No good therapy is available. Q. When can I breast-feed my baby after a C/S? A. If an epidural or spinal block was used for anesthesia, you will be able to begin breast-feeding in the O.R. or in the recovery room. If you had general anesthesia, you will be groggy for about an hour after the surgery, but as soon as you are awake you may start breastfeeding your baby. Q. What is morphine epidural or spinal? A. A morphine epidural or spinal is a wonderful postoperative analgesic. After your baby delivers during the cesarean section, the anesthesiologist injects morphine through the catheter into the epidural space. The resultant effect is almost complete relief from pain for the ensuing 18- to 24-hour postoperative period. As the effect of the morphine wears off, the pain you will experience can usually be controlled by oral analgesics. If you have a spinal for anesthesia, the morphine is injected along with the anesthetic. The main advantage is the incredible lack of pain you will experience which allows you to bond and enjoy your baby immediately following your surgery. Q. What are the side effects of a morphine epidural or spinal? A. The side effects of the morphine epidural/spinal are minimal compared to the pain relief it affords you. You may experience nausea which may be controlled by different medications. Pruritus or itching may be present which also is usually easily treated. An oximeter must be worn for 12 hours and may go off frequently. This may be prevented by the use of nasal oxygen for the first 12 hours. Q. What happens to me after the C/S? A. That night--as with a vaginal delivery--excitement and happiness may cause insomnia. Once in the recovery room (LDR) you will be reunited with your newborn. You will remain there for about an hour. Your vital signs will be checked constantly. Once you are stable and you stop shivering, you will be transferred to your postpartum room. Chew gum. This will stimulate your intestines to work and decrease the time it will take for you to pass gas and have a bowel movement. Your diet that day will begin with fluids and if tolerated solid food. Early feeding will also improve bowel function. Start with small sips of fluids for about an hour. If you are not nauseous and now hungry, you can start eating solid food. Begin eating as if you were at a party where hor d'oeuvres are being served. Have a small bite of your food every 10 to 15 minutes. This will assure that you won’t over distend your stomach and vomit. Early feedings (along with early walking) will stimulate your intestines to work faster so you will have less gas and constipation. Your I.V. will remain in place for 18 to 24 hours. You will be allowed to shower as soon as the I.V. is removed; you may get your incision wet. The Foley catheter will be removed from your bladder on the morning of your first postoperative day. You will be asked to walk; early ambulation leads to early recovery! Your incisional pain and after pains can be controlled with a combination of narcotic pills and ibuprofen. Your abdomen may become distended with intestinal gas on the second or third postoperative day, and you will look pregnant again. The best way to prevent this is to walk. I order nightly milk of magnesia until you have a bowel movement. Most mothers have a bowel movement by the fourth postoperative' day. Skin staples, if used, will be removed on the day you leave the hospital. Q. When can I leave the hospital? A. You can leave the hospital whenever you want. You may stay for 4 nights. Stay at least 2 nights. Q. Will there be much discomfort after my C/S if I have a general anesthetic? A. If you received a general anesthetic, you may experience some intense pain in the recovery room and for approximately the next 24 hours. You have undergone a major abdominal surgery and this is painful. Of course, everyone has a different threshold for pain, and so you will hear different impressions from your friends. The pain is most severe the day of surgery. The pain is more intense in women who were in labor and then required a cesarean section. Women who undergo planned repeat or planned primary cesarean sections do much better and feel better faster. Pain relief may be given in the form of intramuscular injections or via an intravenous line by a method called PCA (patient controlled anesthesia) during the first 24 to 36 hours. Thereafter oral medication for pain relief will usually suffice. By the time you leave the hospital, if it is on the third or fourth postoperative day, you will be able to use a milder pain reliever. Q. What is PCA? A. PCA stands for patient controlled anesthesia. A type of narcotic or nonnarcotic medicine is constantly infused at a low baseline rate. As needed, at certain prescribed intervals, you may give yourself a bolus of medication for the relief of pain. The advantages of this route of delivery are you do not have to wait for a nurse to come in and give you an injection, you are not receiving intramuscular injections, you are receiving less of a dose of medication at a time, and therefore the side effects (nausea, dizziness, and somnolence) are minimized. The disadvantage is the interval of time of pain relief is quite short and if you sleep too long, you may wake up in intense pain and the bolus dose offered will not adequately relieve your pain. Q. I am scheduled for a repeat cesarean section. What should I do if I think that I am in labor? A. If you are experiencing uterine contractions every 8 to 10 minutes lasting 60 seconds, and think you are in labor, so does your doctor; go to the hospital. If you think that you broke your bag of water, don't wait for contractions; go to the hospital. Don't eat or drink before you go, you will be having a repeat cesarean soon. Q. Is there a limit to the number of cesarean sections I can have? A. Yes. The major limitation is the number of children you want to have. There is really no increased risk of uterine rupture with subsequent pregnancies and cesarean sections. There is an increased risk of placenta previa with each successive C/S. The incidence may be as high as 3% after your fourth C/S. This means 97% of the time the placenta will not be a previa. Placenta accreta is also more common with each repeat C/S but still extremely rare. There may be a small to significant amount of scar tissue between your uterus and your abdominal wall. You will be unaware of these adhesions. The incision to delivery time will be slightly delayed. Q. If I am having an elective primary or repeat cesarean section, can I donate my own blood, or can a family member or friend donate blood for me, in case I need it? A. Yes, but just remember that the risk of requiring a blood transfusion for an elective C/S is extremely rare. Some hospital blood banks now have programs where you or your family or friends may donate blood in advance of your surgical procedure. Programs such as Autologous Blood Donations or Directed Blood Donations have been implemented because of the fear of acquiring AIDS through a blood transfusion. However, the risk is exceedingly low (0.0005%) since AIDS testing of blood has been instituted. Autologous blood donations must be done within 35 days of the surgery and directed blood donations, within 3 to 5 days of the surgery. Of course, a directed blood donor must have the same blood type and Rh factor as you do. Q. Is it safe to donate my own blood during pregnancy? A. Yes. This is called autologous blood donation and having placenta previa. is probably the only indication for autologous blood donation during pregnancy. Unfortunately you will only be able to donate one unit which won’t be enough if you have had a massive hemorrhage. There are other conditions where a blood transfusion may be necessary, such as abruptio placenta, but large quantities of blood are usually needed as well. Q. How safe is blood from a voluntary blood bank? A. Banked blood is quite safe now. The risk of acquiring HIV, hepatitis B or C or syphilis from a blood transfusion is now exceedingly rare. The risk of acquiring another type of infection--bacterial, viral, or parasitic--is less than 1 in a million. Transfusion associated Lyme disease has not occurred. Q. What are the noninfectious complications of a blood transfusion? A. You may become sensitized to antigens on the red blood cells which may cause hemolytic disease of the newborn (HDN). You can become sensitized to platelet antibodies and cause a temporary bleeding problem in your baby. If you become sensitized to white blood cell antigens you may develop a high fever during or just after the blood transfusion, which is temporary. Allergic reactions, such as hives, may occur which can be prevented by antihistamines. Q. Are directed blood donations safe? A. Directed blood donations are safe, but not as safe as banked blood for many reasons. First, the directed donor, usually a close relative or friend, may have an undisclosed high-risk behavior and will either donate the blood or have to explain why he or she cannot donate blood. Second, there is an increased likelihood of immunologic reactions because your husband may be your first selection for a donor. Your husband is the worst choice you can make because you may already have been immunized by his red blood cell antigens during a previous pregnancy or his transfused blood may stimulate antibody production causing an anemia in your newborn. Third, statistically, first-time blood donors are more likely to have hepatitis. VAGINAL BIRTH AFTER CESAREAN (VBAC) Q. I had a cesarean section with my first baby. Do I need to have another cesarean section or can I try to deliver vaginally? A. The rule “once a cesarean, always a cesarean” now does not apply to everyone. If certain criteria are met, you may elect to have a trial of labor. The criteria are: The incision on the uterus was in the lower segment and made transversely. The vertical or classical incision in the uterus has a high probability of rupturing during labor (A). The reason for the previous cesarean section has not occurred in the present pregnancy (e.g., placenta previa or breech presentation). The fetus weighs under 9 pounds. Clinically adequate pelvis is listed as criteria which means that the mom has had a previous successful vaginal delivery because there is no other way to estimate whether the average woman will or will not delivery vaginally. Your doctor must be readily available throughout the active stage of your labor. Available personnel ready for possible C/S Q. Are VBAC deliveries common? A. No. The shift in recent times has been a decrease in the VBAC rate. The VBAC rate was about 9% in 2004. Q. If my first C/S was for CPD (cephalopelvic disproportion), how good are my chances of delivering vaginally in my current pregnancy? A. Your chances of having a normal delivery will be between 66%. Q. If my C/S was for a breech, what are my chances? A. Up to 90% of women will be able to deliver vaginally. Q. If my C/S was for fetal distress, what are my chances? A. From 70% to 85% will have a normal delivery. Q. What are the dangers of a VBAC? A. The major risk is rupture of the uterus. It occurs in about 1% of the time. Not too common, but if it happens the results may be catastrophic for both baby and mom. The baby could suffer from the long lasting effects of oxygen deprivation and the mom may require multiple blood transfusions. If the VBAC attempt is unsuccessful there is an increased risk of infection in both the baby and mom, low APGAR scores in your baby from decreased oxygen supply and an increased blood loss due to uterine atony (the uterus is tired and doesn’t contract fast). Q. What special procedures are done during labor in a VBAC? A. Most hospitals have special policies for VBAC, such as: The laboring patient will have an I.V. Internal monitors will be used during labor. The doctor must be in the hospital when the patient is in active labor. A consent form for C/S will be signed. Preoperative blood work will be drawn. Anesthesia coverage will be available for emergency C/S. Q. Do all doctors perform VBAC deliveries? A. No. There are many reasons why all doctors do not perform VBAC deliveries. Your doctor will not attempt a VBAC if your hospital does not have in house 24 hour anesthesiology coverage or 24 hour in house scrub tech coverage. Many doctors will not want to make the promise of the time commitment for a VBAC delivery. For example, if you had a previous breech delivery and this is your second delivery, your active phase of labor and second stage of pushing could last 6 or more hours. Honestly, not many physicians would want to be in the hospital during that time at night or on the weekends. There is no additional reimbursement for those hours spent. ELECTIVE CESAREAN SECTION Q. I want to have a C-section and may only reason or indication is that I want one. Can I have a scheduled C? A. Yes. If you want an elective C/S, you may ask for one. Your doctor will go over the pros and cons with you. You will have proper informed consent for the procedure as well. Q. What are the benefits to an elective C/S for my newborn? A. There is about a 1% chance of oxygen deprivation to your baby during labor and delivery. The risk of a non elective C/S for fetal distress accounts for about 10% of C/S deliveries. There is no risk of low oxygen problems for the baby with a planned C/S. The perinatal mortality rates are 9 times lower for elective C/S babies versus those delivered vaginally. The risk of shoulder dystocia and resultant Erb's palsy is virtually eliminated. The risk of bacterial and viral transmission is eliminated. There is absolutely no chance of a vaginal or perineal tear or laceration with resultant pelvic floor damage with an elective C-section. Elective C-sections are as safe to you as a vaginal delivery. The rates of DVT (deep vein thrombosis) and postpartum hemorrhage are the same for C/S and vaginal delivery. Q. What is the risk to my baby if I have a “maternal choice” C/S? A. Up to 2% of babies may experience transient tachypnea in the newborn (TTN). The baby may develop rapid breathing after delivery due to less surfactant in the lungs of C/S babies at term. The rapid breathing resolves within 24 hours. Treatment is not necessary. Q. What are my benefits for choosing an elective C/S? A. You do not have to have a vaginal delivery if you don’t want to. There is no risk for vaginal trauma. The studies about increased frequency of urinary incontinence, fecal incontinence and change in sexual satisfaction after a vaginal delivery or deliveries versus C/S are being compiled. Suffice it to say there is a difference which may affect each woman differently.