Most women that I care for during pregnancy discuss their birth plan at some point. Many will only ask questions related to aspects they did not understand, such as “what is an episiotomy?” Others have very detailed plans down to the ambiance of the room such as “I want low lighting, do not say the words pain or contraction in the room, and do not ask me if I want an epidural” Some women ask about the c section rates of my practice, and a very few ask for an elective scheduled c section. However, I have never been asked by a patient what I think her individual c-section risk is. This is a hard topic to broach by obstetricians as we are living in a time in our culture where there is a push for “natural” delivery, which means different things to different people, and there are women posting on social media about their doctors being aggressive and forcing them into a c-section or not providing patient centered care where the woman felt there was an adequate discussion centering her desires. This has created a difficult balance where I want to talk to my patients more about c-section however I do not want them to think I am overly prone to take my patients to the operating room. The delivery of a child is analogous to the wedding day for many women and they do not want their wedding planner focusing on what to do if there is a hurricane the day of.
According to CDC birth data from 2019, approximately 30% of babies in the United States are born via cesarean section. Of women who are 1. Nulliparous (having their first baby), 2. Term (37+ weeks at time of birth), 3. Singleton (no twins or greater multiples) and 4. Vertex (head is the presenting part in the pelvis), or NTSV for short, approximately 25% will have a c-section. A 2018 study out of Texas looked at risk factors for c-section in a cohort of women who were NTSV. The greatest risk factor for c-section was obesity. Other risk factors such as diabetes, hypertension, preeclampsia, and IVF pregnancy also contributed to c-section rate. Another important factor shown to contribute to c-section risk was age, with women over the age of 40 having a c-section rate of 50%. Racial disparities were noted with 33% of non-hispanic black women having c sections compared with non-hispanic white women at 25%. Nearly 50% of women with c-section had at least one maternal risk factor. Black non-hispanic women had the highest rate of associated risk factors with 54% having at least one risk factor. The greater the number of risk factors, the higher the rate of c-section. Women with no risk factors had a 20% risk of c- section. Women with 3 risk factors had a 54% chance of c-section.
I am not talking about the risk of c section to scare moms to be, nor am I talking about it to justify doing c-sections. I am not an aggressive physician when it comes to labor inductions, augmentations or c-section recommendations. When I am on call I am in the hospital for the full 24 hours, so as I tell my patients it does not matter to me whether you deliver at 2pm or 2am. I also follow the guidelines from the American College of OB/GYN and only recommend c- sections for failed induction, arrest of dilation, or arrest of descent when my patients meet criteria as long as there is no sign of fetal distress. I am talking about c-sections because I have seen so many women who are not just disappointed when they do not have a vaginal delivery but are in shock, denial, have PTSD, depression, or a combination of the aforementioned responses. We know from studying patient reported experience measures (PREM scores) that patients are most likely to be unhappy with their experience when their experiences does not match their expectations. It is great to prefer a vaginal delivery, but even if this is your plan as with everything else in being a parent you can plan and prepare as much as possible and still not get your desired outcome. I want moms to understand that any time you are delivering a baby there's a chance you may need a cesarean delivery. I want women and their support system to understand what happens when they have a c-section so that they can be more prepared if the doctor recommends a c-section, or there is fetal distress and they have an urgent c section which is very scary for moms especially when they had not processed the possibility of a c-section prior. It is so much better when you are able to understand and process what happens during a c-section before you are heading to the OR.
A cesarean section is typically done with regional anesthesia such as an epidural, spinal, or both. If a patient has been in labor and has an epidural then that is used and a stronger dose of medication is given for the surgery. If you have not been in labor then either a spinal or a combined spinal epidural is performed. If there is an emergency and there is no time for regional anesthesia, or if a patient has a medical condition for which regional anesthesia is not an option, general anesthesia is used and the patient is intubated and asleep for the surgery. With regional anesthesia it is very common to have shaking, nausea, low blood pressure, and feel very cold. When my epidural was dosed for c section I felt as if my lower body had been dumped into ice cold water and I was shaking uncontrollably.
A cesarean section involves delivery of the baby through an abdominal incision. Most of the time it is a small, approximately 12 cm, incision across the lower abdomen below the bikini line. Occasionally the incision is made up and down from around the belly button down to the pubic bone- this may be done on certain occasions based on if the lower abdominal incision seems unsafe for mom and baby. If you are not asleep for your surgery then you will know what is going on- you will hear everyone talking in the room and feel touching, pressure, and pulling. You should not feel anything sharp and your obstetrician and the anesthesiologist will make sure the anesthesia is working properly before making the incision by testing if you feel pain. From the start of the surgery until the baby is out is typically only a few minutes for a first c-section. If you have had prior c-sections or other surgery on your abdomen you may have some scar tissue which means the procedure will take longer as the surgeons must safely get to the uterus without damaging anything else that is stuck where it would not naturally be.
Risks of a c-section include pain, bleeding, infection, damage to surrounding structures such as your uterus, bladder, and bowl, need for hysterectomy or blood transfusion, risk of permanent injury or death to mom and baby. This is not to scare you. These are risks discussed with every patient prior to obtaining informed consent. Some patients are at higher risk for different complications and you can ask your doctor specifically. For instance, being in labor for a long time, fibroids, and history of prior abdominal surgery put you at increased risk for bleeding. Obesity, infection in labor, and stat surgery where there is not time for a complete abdominal prep put you at increased risk for infection. Prior abdominal surgery and stat c-sections put you at higher risk for damage to surrounding structures. The other risks are very low but we do have to discuss everything that has even a remote possibility.
When your baby delivers you will feel a lot of pressure. The baby is handed off to a nurse or pediatrician to be evaluated as sometimes the baby gets fluid in their lungs when not squeezed through the birth canal. Babies that are premature or were stressed may need extra resuscitation from the pediatricians to help them breathe and transition to the outside world. There are different protocols in every hospital for if the baby can go to the support person in the room with mom once cleared by the pediatricians or if the baby stays in the warmer. This typically depends on staffing as there needs to be someone who can supervise the baby and the support person if the baby is not left in the warmer
After the baby is delivered the surgeons will close up all of the layers they had to open to deliver your baby. The part of the surgery after delivery typically takes much longer than the part going in. This is because we want to make sure everything goes back the way we found it!
When you leave the OR you will be brought to the recovery room. This is so you can be monitored closely for the first few hours and make sure your vital signs and urine output are normal and that you do not have any concerning symptoms. You will have frequent checks by the labor and delivery team to make sure your uterus is staying firm and your lochia (vaginal bleeding) is not too heavy. Afterwards you will be transferred to a postpartum (after delivery) room where you will stay until you are discharged from the hospital.
You may be put on blood thinners to help prevent blood clots. This is a relatively common practice and means that you will have some extra bruising on your abdomen and perhaps at your incision line. You may also have a very large dressing over your incision for the first couple of days- don’t worry, your incision is not as big as the bandage. You may have an epidural in place initially for pain control or you may receive intravenous (IV) and oral pain medications. There are different protocols at every hospital. You will be woken up a lot over night for the nurse to check on you and give you medication. Most importantly, you will feel like you had major surgery. Although c sections are the most common abdominal surgery it is still major abdominal surgery. For those considering an elective c-section or those who are in labor but just want to “get it over with” please remember to weigh the risks of major abdominal surgery and the necessary recovery time against your other options before making this decision. No one however should feel shamed or judged for having a c-section no matter if it was an elective decision or necessary due to labor complications. The American College of OB/GYN states that it is reasonable for women to request an elective c-section and after discussing all of the options, risks, and benefits I always make sure to let my patients know that I support them in their decision. And no matter how your baby comes into the world, you still created, nourished, and delivered a new human being so you should never feel like less of a woman or mom if you do not have a “natural” birth!
You will be in the hospital for two or more nights depending on how your recovery goes, as well as considering that moms typically want to stay the maximum nights allowed by insurance when their baby is admitted in the NICU (yes, NICU stays happen as well- this is a whole topic for another post) When you go home you should be able to walk around, your pain should be pain controlled with oral medication, you should be able to pee and pass gas (no bowel movement required), and able to eat regular food. If you are breastfeeding you should be comfortable with the latch and be assured that your baby is feeding, hydrated, and not losing too much weight. This does not mean that you will feel amazing and 100% ready to return to the normal world outside of the hospital. You will need help sitting up and standing up to avoid active engagement of your core initially while the sutures heal and should not be lifting anything heavier than the baby for the first 6 weeks. You also will need to allow your body to heal the full six weeks and have clearance from your doctor before returning to exercise, lifting heavier than the baby, and having intercourse (don’t worry- just because you are cleared at six weeks does not mean you are automatically expected to want to have your libido back and the energy to want to engage in sex!) Your doctor will typically schedule a visit 1-2 weeks after surgery and another at 6 weeks and you should definitely call them with any concerns in between visits.
The part about recovery that I can not stress enough is that this is major surgery on top of having just created and carried a full human being at a time when your body is already going through major physical, emotional, and mental changes. You will not feel like yourself, you will not look like yourself, and you need to be able to take a deep breath and treat yourself and your body with compassion. So many women come back with complaints that they are still swollen, puffy, the scar doesn’t look great yet, they have a little pouch in their lower abdomen, and numerous other self critiques. We should anticipate that no matter how we labor and deliver our bodies and minds are changing drastically throughout this process so we need to learn to show some grace and less self criticism. I always tell women it will take at least a year before they look and feel like their old selves, and even then there will be some changes that you have to learn to accept. As you heal and recover please think about how you would encourage a friend going through this process and say those same kind words and positive affirmations to yourself.
For an amazing resources on post c-section recovery that you can even start while still in the hospital please check out Joanie Johnson’s Strong Mom Society