C-Sections: Understand How C-Sections Work So You're Prepared In The Labor Room

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Our Experts In This Episode

Dr. Mark Landon is a specialist in maternal-fetal medicine at Ohio State University Medical Center who authored a landmark study and vaginal births after cesarean sections that received national and international attention.


Patricia Chavez is a neonatal nurse who specializes in high-risk obstetrics at Texas Children’s Hospital, America’s largest children’s hospital.




Welcome to your Pea in the Podcast, I'm Bonnie Petrie with everything you need to know about your body, your baby and the big changes ahead in your life in your journey to becoming a mommy.


This week, we're talking about cesarean sections, from why you might end up delivering you baby surgically…


"Most cesarean sections are performed for failure to progress in labor."


To what will happen in the operating room…


"Primary cesarean sections almost always takes under one hour."


We'll talk to the nurse who takes care of babies born by c-section, about what it is like for your little one, and we'll touch on the emotions you may feel if your birth doesn't go as you so carefully planned…


"I just want the moms to know not to feel bad about themselves."


That's all coming up in this Pea in the Podcast.


You've been planning your labor and delivery for months. You’ve attended classes, you've read books, you've learned how to relax through pain, but suddenly you're on your way to an operating room to have your baby surgically.  What in the world happened?


"In the United States, most cesarean sections are performed for labor abnormalities, mainly failure to progress in labor or for what has been termed ‘cephalopelvic disproportion.’"


That's when your baby's head or body is too big to fit through your pelvis. That's rare because during labor your baby's head molds and the pelvis joints spread to accommodate your baby as it makes its trip through the birth canal, but that does happen. Dr. Mark Landon is the Vice Chair of Obstetrics and Gynecology at the Ohio State University Medical Center, and he says also if you agree to have your labor induced -- that is you don't go into labor on your own, so your doctor gives you medication that will bring labor on --  well, you might have to come to terms with the idea that you might have a surgical birth.


"There is no doubt that induction of labor increases cesarean section rates, and there have been numerous studies now to demonstrate this, particularly in these women having their first pregnancy whose cervix may not be favorable for induction, there is no doubt that if induction is undertaken, it will increase the risk of cesareans."


Some doctors or midwives will calculate what's known as a Bishop score to see how likely it is for your induction to be successful and lead to a vaginal birth. They’ll consider whether your cervix, for example, is dilating and softening and shortening, and whether your baby is moving into position for delivery (dropping). If these things are occurring, you have a better chance of having a successful induction and avoiding a cesarean. If they’re not, it’s possible that your induced labor will fail to progress -- or stall -- and you'll need a cesarean. This is something I know a little bit about as it happened to me; more on my experience later.


Really, there are many, many reasons your labor may end up as a cesarean. Your doctor will talk them through with you as you approach your due date, and if any problems begin to arise that might make that option more likely. When the decision is made, though, finally to have surgery, things can move rather quickly. For some of you it all might be a little bit hazy because a labor that fails to progress can be very, very hard on a mom-to-be.


For me, the labor and delivery team prepared me for surgery twice. Once in a rush of an emergency in the middle of the night, but when the emergency was managed and the danger passed, they did allow me to labor longer, and the next day when it became clear that my baby was not going to come out the old-fashioned way and it was becoming very dangerous to keep her in, they started the preparations again.


It begins with the good old-fashioned shaving and then they insert a catheter, and I had this done twice. That's a small tube that drains your urine from your bladder and I'm not going to lie to you, it's not fun. It's not horrible either; it's just a weird sensation. You may have an IV and heart monitors and those kinds of things placed now, but if you're like me, you've had this stuff for hours. You'll get an antacid to deal with stomach acids, and they will do some other things like that, and then you will deal with pain relief. 


Some of you may have joined the epidural club a long time ago; I wanted a natural childbirth, so this is when they put mine in place. Your anesthesiologist will clean and numb a spot in your back and will insert a needle and then they will thread a tiny tube through that needle into the epidural space in your spine. When that tube is threaded, they can start putting some pain medicine in there, and the tube stays in so that if you need more, they can give you more.


Some of you might get a spinal block, that's a one-time shot and no tube stays there, so you can't get any more medicine in that way. And some of you may get knocked out, but that doesn't happen very often anymore. General anesthesia means you won't be awake for your baby's birth, and it usually is only used for very serious emergency surgeries.


Okay, what then? At some point they are giving your partner scrubs, they are getting ready to go with you, and you'll be taken to the operating room.


Two things struck me about the OR: it was cold and it was confusing. Also, it seemed like they didn't let my husband join me for a very long time, so it was lonely, cold and confusing. The confusion was caused I think, in part, by the number of people in the room and there was a lot of activity. There is the anesthesiologist, and then my OB was there and there was another OB there, several nurses were there.   They are all very busy, and one of those nurses is there just for the baby.


That is the kind of nurse Patricia Chavez is. She works in Houston, and while you're getting prepared for surgery, a nurse like her is getting ready to meet your baby.


"I have to review the maternal history, look for any high-risk complications that could occur or that might signal that there might be a high-risk complication besides the fact that we are a c-section. I also assemble all of my equipment and make sure I have everything ready that I would possibly need such as oxygen, suction, a pulse oximeter and then we greet the mom and take her into surgery and then prepare her from there."


And while Chavez is getting ready, she is preparing for the complications with which c-section babies often struggle that are unique to them, including trouble breathing, which is caused by fluid in the lungs that would normally be squeezed out during a vaginal birth.


"The contractions themselves help to squeeze some of that fluid out. Also the baby won't have the benefit of being birthed a little bit more slowly like in a vaginal delivery and they don't get that big squeeze effect by coming down the birth canal to get that fluid out. So once they are delivered, there is no way that we can mechanically take that out of their lungs, they have to work at it, and they work pretty hard the first few minutes of life by reabsorbing that fluid, and that is why a lot of times you'll see the nurses will encourage them to cry to kind of aid them in that. Otherwise they end up on oxygen, they have to have an IV and they go to the NICU in the hospital.  We try to avoid that so the mom can keep the baby with them."


And then it's time for your surgery. Dr. Landon describes what happens, now get ready, this is pretty technical.


"In general, if the procedure is performed for failure to progress in labor or a scheduled procedure, most obstetricians today would make a transverse skin incision, known as a Pfannenstiel’s skin incision, also called a bikini incision, and then the incision is carried down through the subcutaneous tissue until the deep, firm, fascial layer of the abdominal wall is encountered, and then that is incised and then the peritoneum is identified and then entered and then the lower uterine segment is then identified and the incision is generally made in the lower uterine segment and the baby is delivered and then the uterus is repaired along with the abdominal wall."


When this is all going on, even though you have a spinal block or an epidural, you will feel pushing and pulling, and that can be kind of distressing for some moms. It doesn't hurt, although some moms do say that their pain medications haven't worked well or have stopped working and they have felt some or all of their surgery. I felt no pain but I was surprised by all of the strange sensations I did experience.


So how long does this all take?


"For a primary cesarean section almost always takes under a hour and in some cases it could take as little as 30 minutes or so. Repeat operations tend to take a little bit longer because of the scar tissue, and obviously the bigger the mother is in terms of body weight, the longer the operation takes and it becomes a little bit more difficult."


While your surgery is happening, your baby's nurse is standing by.


"I like to watch, too, because sometimes if you have problems there with the delivery, you can actually foresee it in the fact such as if it is a repeat c-section, a mom has a lot of adhesions that might be difficult for them to deliver the baby. And sometimes with those babies, they have been really stressed, it has taken awhile to get them out and you might have to end up resuscitating them."


And you are lying flat on your back, feeling all that pushing and pulling and you're waiting because there is a curtain between you and your baby. You can't see what is going on and you can't see them emerge and you're waiting for the sound of their first cry.


That is magic.


Then Nurse Patricia Chavez gets to work.


"The baby is placed on the warmer. We dry the baby off as quickly as we possibly can, because if you have a baby that is cold, nothing that you do for the baby is going to help the baby. You have to really get them dried quickly, get them off the wet blankets and we check the ABCs. We check Airway, Breathing, Circulation, make sure that the baby is breathing okay, does have a patent airway and that we do have a good heart rate. We usually give a little supplemental O2 to the baby just to kind of help the baby out, to help pink it up a little bit quicker than if you do let the baby get it on it's own on room air. And we basically will monitor the baby from there, monitor vital signs, and make sure that the baby is getting warmed up and is transitioning to extrauterine life okay. And once the baby does all of that, we'll weigh the baby and then let the mom hold their baby. We usually let her hold the baby across her chest until she gets tired or if the dad wants to hold the baby."


They will also check your baby's APGAR score, which assesses its muscle tone, its pulse, its reflex irritability, its skin color, its respiration.


 "A cesarean baby that has an APGAR score of 8 or 9 has done very well. For 1 minute and then 5 minutes of age. And very, very, very seldom does a newborn baby actually get a 10. So a mom that has a baby that has an APGAR of 8 to 9 needs to be proud."


Some moms may worry that their plans to nurse their babies immediately after they're born will not happen when they have a c-section. That is not necessarily true. Some moms may, in fact, be too drowsy to nurse or they may have some nausea or vomiting from the medications they have been given or there may be some other things that stand in their way after surgery, but many, many, many moms can get started right away.


"And there are some babies that will nurse while the mom is lying flat. There are other babies that won't, but the majority of them will do okay and that helps to stimulate colostrum, and it also helps with the mom to feel that bonding process begin and deepen a little bit better."


Make sure you tell your OB and your nurses this is important to you, if it is, so that they will help make it happen.


Then it’s on to recovery.


"We'll take the dad with us with the baby to the nursery, identify bracelets and offer the dad, he can stay there with the baby or else he can come back and be with mom. And then, sometimes, you know, we will let the baby go with the mom to recovery and let her nurse. Other times we'll take the baby up to the nursery and they will do their initial assessment and if the baby is okay, then we can bring the baby back down to mom and let her nurse."


My baby's father and I talked about this beforehand. If we had a cesarean, I wanted him to go with the baby and stay with her at all times, and I would do the recovery thing alone. This is what we did. He says that time alone with our baby in the nursery is the most precious time of his life. I was taken to recovery where a nurse sat nearby.


One thing I didn't expect was to be freezing and shivering. Shivering is very common after you have received an epidural, as is itching, so don't be surprised if that happens to you. When your caregivers are sufficiently convinced that you have tolerated your surgery well, you will be reunited with your baby. Those of you who didn't get a chance to nurse right away may try now.


"A baby about an hour of age goes into a sleepy stage where they will sleep for an hour or two, but then they should wake up and they should want to nurse. But some c-section babies, if they still have a stomach full of mucus, they might be a little less apt to want to nurse. But the majority, they do want to nurse."


Obstetrician Mark Landon says recovery from a c-section is more difficult than from a vaginal birth.


"Most women who are in reasonably good physical condition can expect that their recovery from a cesarean may be a few weeks delayed compared to a vaginal delivery."


And the time you'll need to spend in the hospital may vary. For most women, the length of stay for a cesarean section in the United States averages about 3 days or so. Some women may stay 4 days and some women may recover quick enough to go home in 2 days, and a lot of this, or course, depends upon the physical state of the mother and whether she has been through labor and so forth.


Then it is on to recovery at home. Remember, you have had major abdominal surgery and you do need to take it easy -- hard with a newborn, right? I know.  Call on your family and your friends, and if you live far away from those as I did, consider hiring a postpartum doula to help you out. And take good care of your incision, because Dr. Mark Landon says one of the greatest risks of having a cesarean section is that your incision won't heal well.


"I think that wound problems are always going to be an inherent risk of any abdominal surgery, including cesarean section, and they are going to be more common in women who are obese, more common in women who have had infection during labor itself -- something called chorioamnionitis --  more common in diabetics, and despite the best surgical approaches, including the use of  prophylactic antibiotics, wound infections can occur and they can be minor nuisances, just a mild separation of the incision that needs to be cleaned until closes on its own, or they can be very substantial problems, including life-threatening infections in rare cases."


So what do you need to consider when taking care of it?


"Keeping it dry, keeping it clean, not letting opposing skin, especially in obese women, touch and trying to keep it air dry as much as possible without moisture, and sweat in particular, collecting in that area. That is very important."


More and more American women are ending up with surgical births, and this is controversial. The World Health Organization says no region should have a c-section rate higher than 10-15%. In the U.S., 31.1% of women gave birth by a cesarean in 2006. Dr. Mark Landon has some thoughts on that.


"Well, c-section rates are rising for many reasons. One is clearly that the population is increasing in age and there is delayed childbearing, and for older women, there clearly is a lower threshold for obstetricians and birth attendants performing cesarean deliveries. There are increased medical/legal concerns that have no doubt driven the cesarean section rate up."


In other words, some doctors and their insurance companies are afraid of getting sued in the event that something goes wrong in a vaginal delivery, so they opt to do the cesarean.


Other reasons for the rise?


Well as we already discussed, inductions do increase the chance that you'll have a cesarean.

Also a few women are having elective c-sections, surgeries they schedule so they fall on a convenient date and so they don't have to go into labor at all. This is also controversial.


"Women who elect this have to be fully informed regarding the risks of cesarean sections versus the risks of vaginal delivery."


Oh, there's one more reason that c-section rates are rising. Many doctors and hospitals are refusing to let women to try vaginal births after c-sections, so if you want to have a vaginal birth after a c-section, that may be something that you will have to fight for, you might have to look around for a doctor or a hospital that will allow it. And if you end up having a c-section and you want to try for a vaginal birth next time, we have much more information in a future Pea in the Podcast that focuses on that topic, vaginal birth after c-section.


If you do end up having a surgical birth, some of you may feel very sad. You may mourn that you didn't have the birth experience that women have shared over the centuries.  You may feel like a failure. I felt this way a little bit. It was an experience I wanted to have because I felt, in my case, it would give me a connection to my late mother. She delivered 4 babies the old-fashioned way, and since she had passed away, I kind of wanted to share that experience with her. And I didn't get to. But labor nurse Patricia Chavez wants you to remember something after you bring your baby into this world by a cesarean.


"I just want the moms to know not to feel bad about themselves, and not to feel like they are any less of a mom than a mom that delivers birth vaginally. The fact is, I mean, that is an extra sacrifice that you're doing by having major surgery and a lot of times it is for the benefit of your baby. So I think they need to feel really proud about themselves and give themselves extra credit."


Extra credit for a job beautifully done.


We hope you've enjoyed this Pea in the Podcast: Cesarean Sections. Please visit our website, peainthepodcast.com for more information about our experts, to find links and transcripts and to register to receive tailored week-by-week shows for each week and stage of your pregnancy. It's everything you need to know about your body, your baby and the big changes ahead in your life in your journey to becoming a mommy. For Pea in the Podcast, I'm Bonnie Petrie. Thanks for listening.