C-Section Birth – What Happens in a Cesarean

According to the World Health Organisation, c-section rates in any country should be around 10-15% – a rate which is currently double that in many countries, including the United States and Australia.

This is showing we have a huge percent of unnecessary caesareans occurring, however for some women, caesarean section is a necessary procedure to ensure the safety of mother and/or baby. Only a small percent of women are choosing elective c-sections, meaning what is going on at birth is a huge contributor of emergency c-sections – a major cause of this is induction of labour.

A caesarean section is an operation that enables your baby to be born through an incision made on your pregnant belly. You may plan an elective caesarean for medical or social reasons or you may experience an emergency caesarean when labour does not go as planned. An emergency caesarean usually occurs after labour has begun.

What Are The Most Common Reasons For An Elective C-Section?

Note: Vaginal birth is often possible in many of these situations

• Previous c-section (the most common reason – a VBAC is usually possible)
• Suspected CPD (Cephalo-Pelvic Disproportion) – This is where the baby’s head is said to be too big to fit through the mother’s pelvis. Often misdiagnosed due to the head being posterior in labour (baby facing up towards the pubic bone). See our article on CPD.
• History of big babies/difficult past deliveries with/without shoulder dystocia involved. See our article on big babies
• Gestational Diabetes may lead to extra large babies if poorly controlled. See our articles on Gestational Diabetes
• Placenta Problems, e.g. Placenta Praevia (where placenta is situated low and may cover/partially cover the cervix) or Placental Abruption (where the placenta separates a bit from the uterus)
• Foetal distress, which may occur in labour or late pregnancy when the blood supply to the placenta is reduced for any reason. May be caused by Pre Eclampsia (mother’s high blood pressure and fluid retention).
• Intrauterine Growth Restriction (IUGR)
• Abnormal placental function
• Cord compression
• Intra uterine infection
• Baby’s position, e.g. breech baby (especially footling breech) or transverse lie where baby is positioned sideways
• Twins
• Active Genital Herpes Simplex

What Are The Most Common Non-Medical/Psychological Reasons For Elective C-Section?

• Social reasons e.g. choice of baby’s birthday, work leave for mother or husband, convenience for mother and/or her caregiver
• Retaining control over the birth experience, especially if the mother previously experienced a traumatic (physically or emotionally) birth experience
• Other emotional reasons
• History of sexual abuse of the mother
• To avoid the ‘pain’ of vaginal birth
• To avoid stretching/damage to the vagina. See our article on your vagina after childbirth.

What Are The Most Common Medical Reasons For Emergency Caesareans?

• Failed induction
• Prolonged labour that’s not progressing
• Foetal distress – this is a common reason for emergency caesareans when an induction has been performed.
• Maternal distress
• Placental problems e.g. bleeding, separations, etc.
• Undiagnosed foetal position i.e., breech, brow presentation, etc.

The Different Types of Incisions Used for C-Sections

Transverse Incision (LUSCS)

The most common type of incision used is made on the lower part of your stomach, just above your bikini-line, and is referred to as a transverse incision or LUSCS as it cuts through the lower fibrous part of your uterus to deliver your baby. This part of your uterus heals very well, and involves less blood loss, so it is the preferred site on which to perform the incision.

Classical Incision

Your obstetrician may rarely need to do a classical incision during a caesarean. This type of incision runs vertically (up and down) your uterus. It’s normally done either because your baby is premature, the uterus has not stretched enough to allow a LUSCS to be performed, or because the baby is lying crossways in the uterus, or because the placenta is in the way.

A classical caesarean is only used in these specific circumstances because this approach is associated with a greater blood loss, and may not heal as strongly as a LUSCS, leading to an increased risk of uterine rupture during future births.

‘T’ or ‘J’ Incision

There are other rarely used incisions, entitled ‘T’ or ‘J’ incisions because of the shape of the incision. These are the result of a LUSCS incision unexpectedly being inadequate to deliver the baby. The obstetrician extends the uterus incision in a ‘T’ or ‘J’ shape to increase its size and allow delivery. Usually the baby is in an unusual position, such as a transverse lie (sideways across your belly).

The increased risk of uterine rupture involved in birthing vaginally after a previous classical, T or J caesarean need to be thoroughly discussed with the professional caregivers involved, and acknowledged by the mother

The type of incision used on your skin ‘usually’ indicates the type used on your uterus, but not always. A classical incision on your uterus may have been done after a ‘sideways’ incision was done on your belly, and vice versa. The only way you can be sure what type of internal incision you have is to check with your doctor.

What are the Common Risks Of C-Sections?

For the Mother and/or Baby

• Anaesthetic risks (explained in more detail below) which are related to the drugs used (type of drug and quantity) and possible side-effects experienced by the mother and/or child.
• Increased blood loss, which may lead to a need for a blood transfusion, or a hysterectomy
• Damage to the bladder or intestines
• Wound and uterine infection
• Blood clots forming in the deep veins of the legs, or pelvis. Rarely these clots can travel to the lungs, causing life-threatening pulmonary embolus

In An Elective C-Section

• Unplanned prematurity of the baby if the dates are wrong, which may increase the risk of the baby having breathing problems.
• Respiratory distress syndrome, where the baby retains fluid in his/her lungs (vaginal birth assists the baby to clear this fluid, which normally fills the lungs when your baby is still inside your uterus, whereas some of it can remain after a caesarean). This can be serious, or even fatal.
• Each caesarean increases risks involved in future pregnancies. The risk of the placenta implanting low in the uterus (placenta praevia) or into the uterine scar (placenta accreta) and the risk of uterine scar separation.
• Future difficulties becoming pregnant and increased chance of ectopic pregnancy due to scarring.
• Small risk of the baby being cut by the scalpel
• Increased risk of maternal death (4 per 10,000 births for all caesareans, 2 per 10,000 for elective caesareans and 1 per 10,000 for all vaginal births)

What Sort of Anaesthetic is Used During a C-Section?

The dose of anaesthetic used during a caesarean is very finely tuned. This is to reduce the amount of drug that may be passed, through the placenta, to the baby. So, although the Mother should feel no pain during the surgery, it is common to feel tugging, or pulling, sensations as your baby is being removed from your uterus.

The most common type of anaesthetic, used to control pain during a caesarean, is a spinal. This involves injecting an anaesthetic drug into the actual spinal fluid, which surrounds the spinal nerves and cord. This method of anaesthesia is faster acting than an epidural, and is given in a single injection, whereas an epidural dose can be adjusted.

The other type of anaesthetic commonly used during a caesarean birth is an epidural. In this case the local anaesthetic drug is injected into the epidural space, which contains the spinal nerves and their blood vessels.

Both a spinal and an epidural enable the Mother to remain awake during the surgery, and therefore be aware of the birth of her child, participating in this important life experience.

The epidural catheter, which is a fine plastic hollow tube through which the anaesthetic is administered, is often left in place for the first day after the c/section. This enables immediate pain relief to be given, directly into the epidural space, when requested by the Mother.

Some anaesthetists will use a spinal/epidural technique, which gives fast action and allows for postoperative pain relief.

Using one of these types of anaesthesia, rather than a general anaesthetic has other benefits than being awake to welcome your child. It also avoids the risk of vomiting under general anaesthesia and breathing this into your lungs.

The drugs used for epidurals/spinals also have the side-effect of relaxing the blood vessels in your lower body, below the spot on your spine that they were injected into, which may cause your blood pressure to drop, but it also contributes to less blood loss during the surgery.

Once the spinal/epidural has taken effect, then a urine catheter is inserted, and your bladder emptied. This reduces it in size and thus helps protect it during the surgery. This may remain in place until the morning after your caesarean, when you will be able to walk to the toilet and take care of this need yourself.

Spinals and epidurals do in themselves carry some risk. Between 1 to 10% of women experience fairly severe headaches after the spinal/epidural. Some women have suffered injury to the spinal cord and other severe effects but these are very rare (between 1 in 3000 and 1 in 2 million). Your anaesthetist can further discuss these risks with you.

General anaesthesia, where you are actually ‘put to sleep’ during the caesarean, is usually only used when an extreme emergency occurs (i.e., cord prolapse, uterine rupture). It’s avoided, where possible, due to the drug’s ability to pass through to the baby and make him/her drowsy.

If it should be necessary, this is what may happen. A drip is inserted in your arm, heart monitor dots are placed on your chest and you are tilted onto your left side to remove the weight of your uterus from your major blood vessels, which supply vital oxygen to your baby. Then a mask, flowing oxygen, is placed over your mouth and nose to boost your oxygen levels before proceeding with the surgery. A rapid-acting anaesthetic is injected via the drip, in your arm. You may get a metallic taste in your mouth depending on the drug used.

As you lose consciousness you may feel the nurse pressing on your neck, just below your Adam’s apple. This blocks your oesophagus, to prevent the risk of your vomiting. Another drug is then given to relax your muscles and a breathing-tube is placed in your throat, through which anaesthetic gases are given to keep you asleep. A longer-acting muscle relaxant is also administered.

After your baby has been born, a narcotic is often given to aid your after-surgery pain relief, and at the end of the operation a drug is given to reverse the muscle relaxation. The anaesthetic gases wear off quickly, and the tube is removed when you start to awaken, and begin to swallow or cough.

You may be given antibiotics, to avoid infections, and a drug that thins your blood, to help prevent the possibility of blood clots forming in your legs.

Even after a general anaesthetic your baby will often be able to stay with you and your partner in recovery with your midwife whilst you wake up fully. This may not always be possible, however, and if your little one does have to go to the nursery, you should be able to meet her/him very soon. Staff will make every effort to make sure of this, and you can remind them if they seem to have overlooked the importance of this monumental meeting!

Women have often told me of their concern, if they received a general anaesthetic, that their baby seems like a stranger. They have felt that they have missed out on witnessing the birth of their child. They search their children’s faces for ‘family features’ as they try to connect with their little ones. It’s sad that the natural bonding process has had such a big upheaval right at the beginning. Suggestions on how to recreate that bonding process are contained under the heading ‘Healing’ further on in this booklet.

Suture Materials Used in Your Skin Wound

Your obstetrician will probably have a preference for the method of stitching the skin wound.

It could be a dozen or so individual stitches or metal clips across the wound (they look like staples), or a single, continuous stitch running just under the skin.

This latter type of stitch may be of absorbable material so that it dissolves over a few weeks, or be non-absorbable and need removal – usually on about the fifth post-operative day. If you have your own preference for the type of skin suture, discuss it with your doctor beforehand, so that it can be negotiated.

The Consequences of Caesarean Birth

Birthing by caesarean, especially when repeat caesareans occur, can have some undesired physical effects. As technology has improved, the problems associated with caesarean birth have been dramatically reduced. But there are still a few common consequences to birthing in this way.

One consequence is the scarring and adhesions that will occur as a result of the surgical trauma. No matter how gently the surgery is performed, internal organs will develop some adhesions that may cause problems later in our lives.

The adhesions may cause pain in future pregnancies, as the increasing size of the uterus pulls, stretches or breaks adhesions formed earlier between the uterus and surrounding organs, or the abdominal wall.

They can also cause pain in a non-pregnant woman, especially around the time of menstruation, when inflammation and contractions of smooth muscle (related to menstruation) may irritate adhesions and scarring.

The risk of placental attachment occurring, on the site of the uterine scar, and causing problems with placental retention during third stage, increases with each caesarean a woman experiences. This problem may necessitate manual removal of the placenta after the birth of your baby, and could cause pieces of the placenta to remain behind – causing uterine bleeding and possible infection.

For each subsequent caesarean birth a woman experiences, the surgery becomes more complicated, as the surgeon must negotiate his/her way more carefully through the scarring and adhesions formed from previous surgeries.

Caesarean birth also holds all the consequences normally associated with major abdominal surgery. That is, anaesthetic and other drug risks to both mother and child, the risk of excessive blood loss, surgical damage to adjacent organs, etc. These need to be acknowledged and taken into account when planning a caesarean birth.

Members’ Personal Stories of Caesarean Sections

Elective Caesarean

My caesarean section was at 36 weeks of pregnancy and done for my baby’s safety – I didn’t actually go into labour. I was in hospital from the Friday night before, and from midnight was not allowed to eat or drink anything.

At 6am on Saturday morning, the midwife came in, shaved a huge chunk of pubic hair (but not the whole lot) and got me to have a Betadine (antiseptic) shower and put on the theatre outfit then get back in bed and wait. They told me Saturdays were usually short staffed for theatre, so I was getting ready early.

The anaesthetist came in and had a chat to me about what he’d do and the drugs he’d be using, and asked a million questions.

Then, at about 9.30am I was taken down to the surgical floor, where I was given a couple of tablets – I think one was a relaxant, and the other was to help prevent excessive gas build up in the gut. My husband was with me right up until now, when he was taken off to get all gowned up.

I was then taken into the theatre at about 10ish. Now I can’t quite remember which order the following things happened it, but the anaesthetist sprayed my back with some local anaesthetic spray, then gave me an injection of local, then got me to curl into a ball (I was sitting on the bed edge) and hug a pillow with the midwife helping hold my shoulders and talking to me to keep me calm (this was the point I remember vividly the heart rate monitor skyrocketing!). He then gave me my spinal – it was all over before I realised he’d even started. The catheter was then put in my wrist and I was hooked up to the drip and heart rate monitor. An oxygen mask was placed on me, whilst the Obstetrician (I think) put the urinary catheter in and and started swabbing my belly to clean the incision site.

My husband appeared sometime around now, but I can’t quite be sure when. They were asking me what I could feel and I was describing a tingling to them. A few minutes later I said I could still feel the tingling in my big toe, but couldn’t feel anything else – they informed me they had made the first incision a few minutes ago and not to worry about my big toe (which did eventually go to sleep!).

It wasn’t very long after that and Emma was born. We got a cuddle, then she was taken to be checked by the paediatrician and midwife. Once they’d done their testing, we got another cuddle, then my husband and Emma were taken up to the nursery whilst they finished stitching me up and I went to recovery. I think I was back in my room about an hour after my baby was born. I remember having a conversation with the Obstetrician and anaesthetist as if nothing was happening!

I had internal dissolvable stitches which proved to be no problem at all. I was kept on the oxygen and morphine over night and the following morning a midwife came in and helped me up and to shower.

I can’t really remember a whole lot of that afternoon, except that I was starving and I got to eat jelly! As soon as I could feel my toes I was told to start wiggling them to get everything working again.

Emergency C-Section

I had an emergency c-section after going into spontaneous labour at 28.6 weeks. Labour started on the Friday night and went into hospital on Saturday morning where they administered 2 tablets to attempt to stop contractions. When this did not work I was transferred to the Royal Womens Hospital. I laboured until I was 8cm dilated, but the baby was not dropping.

I was bleeding during the entire labour, but the baby’s heart rate was fine etc. Saturday night I had one dose of pethidine. On Sunday early in the morning I started to bleed heavily (gush) with each contraction. I had some gas and a code green was called – I was taken out to wait for surgery. I was in a fair amount of pain but was quite out of it due to the gas. At this time they were telling me all of the legal info and that I may have to have a transfusion, I also had to sign something. I couldn’t believe this was happening when I was in such agony.

A few minutes later I was wheeled in to the operating theatre – all I remember is being put on the cold table, being told I had to lay straight out (although I was in agony and contracting). I was also told they were waiting on the anaesthetist followed by some cold liquid being splashed onto my belly. I was shaved and there was a sharp pain when the catheter was being put in. The anaesthetist came (I was never so happy to see someone!) and I was put under an anaesthetic. Apparently they cut me open and the placenta was so low that it shot out (the placenta had abrupted and was just over the cervix, preventing natural birth). They had to somersault Kyla in my belly and then take her out.

It gradually seeped into my consciousness that I had a baby girl, but again I was out of it due to being on morphine. When taken into my room the nurses wheeling the bed kept on knocking into things – it was agony and I was so angry that they could be so careless. I didn’t get to see my baby in the NICU (newborn intensive care unit) until the following day but I was shown a photo.

On the Monday the catheter was taken out and I had to walk to the toilet – again I had never felt so much pain. Due to the c-section the nurses had to help with showering etc., and it felt like the entire world could walk in on me in the shower and toilet.

The caesarean scar was awful looking as it was stapled. These came out on the Thursday. They were constantly asking me whether I had done a poo (which I hadn’t, and didn’t feel the need for). The nurse (from Francis Perry – I moved to a private hospital after the operation) said that I would have to have a suppository if I didn’t go soon. On the second last day they gave me a suppository, it felt like I went into labour again, I went to the toilet and out came the suppository – and only that. The following day they gave me coloxil and this worked.

The scar has now healed well and I have most feeling back. If possible I don’t want another caesarean section, it was painful and awful – although I know the doctor who performed the operation was fantastic, as too were the nurses when I was in labour.

Emergency Caesarean Section

My caesarean section was an emergency one so it started off in the labour ward. When it was organised the nurse came in and shaved the top part of my pubic area in preparation and also removed my nail polish as she said they need to see the moons on your fingers for blood pressure. I already had the epidural in so was helped onto the other bed and wheeled to the delivery suite. When we got there Aaron was taken away to get dressed in the sterile suit, mask and hat. While he was away I was left in a little room just outside the operating room. Someone, a nurse asked if I had been given something can’t remember what though. I said no and she was a bit annoyed. She left then came back with a cup of the something and told me to drink all of it in one go as it was to stop me vomiting during the operation.

After a few minutes I was taken into the theatre. I was put onto this weird bed kind of like a lower case t shape with my arms spread out. I had the drip going, catheter in from before and blood pressure things on my hands and feet (I didn’t realise this at the time though). I was shivering and someone said it was because of the epidural. I asked where Aaron was and they told me he was allowed in after the first incision. I’m not sure what happened then, because next thing I know Aaron was beside me. I didn’t feel anything to start with but after a while there was a tugging feeling, kind of like when you go to the dentist and have an anaesthetic – you can feel something is going on but there is no pain. I’m not sure how long this was gong on for. I think about this time I commented on something that was really odd, I felt something weird on my feet every now and then and asked what it was. They said I had to have my blood pressure checked all through the surgery so they had the things on both my feet and hands.

There was much other than the tugging feeling and then they said that the baby was almost out. When he was fully out the cord was clamped and they cut it off from the placenta. Zander was taken over to another table thingy where Aaron got to cut the leftover bit of his cord. At this stage I am still feeling the tugging and stuff moving round but it was feeling different to before, but still no pain. They brought Zander over for me to see but I wasn’t allowed to hold him. Aaron and Zander then went off somewhere, still to this day have no idea what happened with them in the next hour or so.

While they were stitching me up the anaesthetist (who was sitting right next to me the whole time) and I were chatting about the baby etc. Still more tugging but on the right hand side I started to feel a bit of stinging which really scared me. I told the anaesthetist and he topped up the epidural for me. I found out later that apparently with a caesarean you can tear a little as the baby comes out and for me it was on the right hand side and this part was probably what was stinging as the sensation started to come back. At this stage I think I feel asleep for a bit! Just before they finished up I was feeling quite nauseous and threw up before I had a chance to tell anyone, and I ended up vomiting another time before going to recovery.

I was then taken into recovery and was left there on my own for what turned out to be about an hour (I think I was dozing again). The nurse came back with Aaron and Zander and I was finally allowed to have a cuddle with him! I was then wheeled up to the ward still holding Zander.

Don’t forget to check out our article What to Expect After A Caesarean for more information.