In the United States, approximately 30 percent of all babies are delivered by cesarean. Most women prefer a vaginal delivery because it feels natural to them, the recovery is easier, and there are no surgical risks. However, we can’t forget that "natural," in the days before modern medicine, meant that childbirth was one of the riskiest and potentially deadliest times in a woman’s life. Even today, women in third-world countries routinely lose a baby or their own lives during delivery. In developing countries, the mortality rate (deaths associated with childbirth) can be as high as 1,400 per 100,000 births; in the United States, the maternal mortality rate is 24 per 100,000 births. 6 Doctors, midwives, and medical technology can intervene when, for whatever reason, nature isn’t coming through.
When our patients ask us why we perform a cesarean, we always answer that we do so for medical indications only. The majority of cesareans are decided about five minutes before they happen. Sometimes we can speculate on the need for a cesarean based on the size of the baby and the size of the mom, but we never know for sure until we see how the labor progresses. Near their due date, moms often ask us whether we think they will end up with a cesarean. On rare occasions, we may have a feeling one way or the other, but we always counsel our patients that we won’t really know until they try giving birth vaginally.
You may need a cesarean delivery for many reasons. In this section, we describe the most common ones.
History of previous cesarean: After being counseled by your obstetrician about the risks and benefits of a trial VBAC (vaginal birth after cesarean) versus an elective repeat cesarean, you may decide that you want an elective repeat cesarean. (We describe VBAC later in this chapter.)
Failed VBAC: In this situation, you tried to deliver vaginally after a previous cesarean, but the baby shows signs of distress, you haven’t dilated enough, or your baby hasn’t descended through the vagina.
Arrest of dilation: In this circumstance, your cervix fails to dilate to the full ten centimeters, which is often a sign that your baby and your pelvis are not a good fit or that the baby is not coming down straight. A few millimeters makes a huge difference when you are fitting a larger infant through a small opening.
Arrest of descent: In this situation, you’ve dilated to ten centimeters but your little one just won’t descend through the birth canal despite your best pushing efforts. Again, this is a sign that your baby and your pelvis are not a good fit.
Fetal distress: When your baby is intermittently or continuously monitored, we can detect whether the baby is getting enough oxygen. Fetal distress can occur for a variety of reasons. Perhaps the umbilical cord is wrapped around the neck of the baby a little too tightly or the baby is grabbing on to the cord. Maybe the cord is positioned such that it is getting squeezed during contractions. Or the placenta might not be providing adequate oxygen to the baby during labor.
Multiples: If you have twins or other multiples, your doctor may suggest that a cesarean is the safest route of delivery.
Breech, oblique, or transverse baby: If your baby is positioned breech, oblique, or transverse and the ECV (in which we try to turn the baby to a head-down position) fails or you have decided not to attempt an ECV, you might need a cesarean.
Chorioamnionitis: When an infection develops in the uterus–called chorioamnionitis–the mother and baby can be affected. If you are close to delivery, you may still be able to have a vaginal birth. However, if the delivery is many hours away, the risk of the infection spreading to the baby is higher, and your doctor may recommend a cesarean delivery. Remember that a newborn does not have the immune system that we adults have. An intrauterine infection is a risk factor for cerebral palsy.
Placenta previa: For information on this high-risk condition, see Chapter 9.
Active outbreak or prodromal symptoms of genital herpes: If you have an outbreak of genital herpes when you go into labor, you must have a cesarean to prevent transmission of the virus to the newborn. Neonatal herpes is a serious disease that can cause permanent neurologic damage or death.
Placental abruption: In this condition, the placenta detaches from the uterus prematurely and the baby does not receive enough oxygen. Placental abruption is characterized by excessive vaginal bleeding and fetal distress.
Maternal medical problems: If the mother has a medical condition, such as certain heart, lung, or musculoskeletal conditions, the act of pushing could be dangerous to the mother.
We always try to correct the problem before we resort to cesarean delivery. For example, we can alter the mother’s position to untangle an umbilical cord, give her extra oxygen to deliver more oxygen to the baby, increase the intensity and frequency of contractions if they are not strong enough to dilate the cervix, and help her relax with pain medication if she’s overly tense. Nonetheless, in some cases, nothing helps and a cesarean is the only option.
Some women are terrified of labor in general and simply don’t want to feel pain or have no desire to go through the process. Others are afraid of the consequences of vaginal injuries, such as urinary or fecal incontinence or changes in sexual function. Still others may have had a bad vaginal delivery experience. In our opinion, no matter what the reason, choosing to have a cesarean is the right of every mother. Before we will proceed with one, however, we have a thorough discussion about her reasons for wanting the elective cesarean and we describe the risks and benefits of cesarean versus a vaginal birth. After we are confident that our patient is well informed, we feel it’s our job to support whatever choice she makes.
So what are the risks associated with cesarean births? As with any surgical procedure, a cesarean has a risk of infection, either in the uterus or skin. You may need a blood transfusion if the bleeding during the procedure is excessive. You risk forming a deep venous thrombosis (blood clot) in your legs or damage to the organs surrounding the uterus, including the bowel and bladder. All of these except the last are complications that can occur with vaginal births as well but are more common after cesarean births.
The ultimate goal of any delivery, whether vaginal or by a cesarean, is a healthy mom and a healthy baby. If your doctor recommends a cesarean, make sure you thoroughly understand the reasons why. Ask lots of questions, and make sure that all your alternatives have been exhausted. In the end, we hope that you trust our recommendations from years of training and experience.
LAST RESORT, HAPPY ENDING
Energetic, active, and outdoorsy, Julia and Al were having their first baby, a son they hoped to take hiking in Yosemite one day. All throughout her pregnancy, Julia took excellent care of herself, following our directions about diet and exercise to the letter. Because of her high level of fitness, and also taking into account her tall build, we all felt confident that she would be a strong pusher, successfully capable of pushing out a large baby.
What we did not anticipate was Julia going two weeks past her due date, with no sign that her cervix was ripening. Starting around her due date, Julia did everything under the sun to get her cervix ready for the work ahead, including walking, hiking, taking evening primrose oil, and undergoing acupuncture. She had intercourse with her husband often; so frequently, in fact, that Al said, "I’m not sure I can keep this up." The couple even went to a pizza place in Studio City to eat "the" salad, at Alane’s suggestion. (Local rumor says something in the salad dressing can trigger labor.)
Alane started seeing Julia twice weekly after her due date passed to check that her amniotic fluid was still plentiful, and to check the baby’s heartbeat with a fetal heart monitor using a nonstress test (NST). This test reassured us that the baby was happy in mom’s uterus and getting plenty of oxygen. Alane considered membrane stripping, but because Julia’s cervix remained tightly closed, the procedure could not be performed.
We finally set a date for induction. Julia was aware that she was going in with an unripe cervix and that she would need Cervidil to help ripen it. Alane suggested that we use Cervidil for an extra twelve hours–a total of twenty-four hours–to maximize Julia’s chances of successful cervical ripening. Unfortunately, Julia’s nurse called after twenty-four hours to tell Dr. Park that the patient’s cervix was still the same, disappointing news for both Julia and Alane.
Alane delivered Julia the next day by cesarean, birthing a beautiful baby boy weighing nine pounds. Tears of joy and smiles were all around the OR, as Al looked lovingly at the son who’d finally arrived. "You’re late," he said, clutching his new baby in his arms, "and you’re grounded."
While a cesarean may not be your first choice of delivery routes, the miracle of birth is still just that: a miracle. You finally get to meet your baby for the first time and welcome him into the world.
When a woman agrees to have a cesarean, she signs the consent forms and is then taken to the operating room. The first thing she’ll notice is that the room is quite cold to prevent the spread of infection. She receives her anesthesia, either a spinal or an increase in medication through an already-placed epidural. After she is completely numb from the chest down, a Foley catheter is placed into the bladder to drain the urine. The nurse will clean her belly with a sterile solution and cover her in a blue operating drape. At this point, we ask her husband, partner, family member, or doula to come into the OR to be with their loved one.
The skin incision needs to be roughly the size of the baby’s head, usually about twelve centimeters (about five inches). Normally this is a bikini cut, a low horizontal incision made at the top of the pubic hairline. Next, we open the many layers between the skin and the uterus. However, we do not cut the abdominal muscles because the midline has a natural separation that we simply stretch apart.
After we are inside the abdominal cavity, we make an opening in the uterus. One doctor guides the head and body, as seen in Figure 6-11, while a second doctor applies pressure on top of the uterus to push the baby through the incision. You may feel pressure, like someone is sitting on your chest. The umbilical cord is cut, and your baby has officially entered the world! At this point, you may hear the voice of your baby for the first time. The baby is then handed to a pediatric team awaiting the delivery in the OR.
Next, we remove the placenta and repair the uterine opening with stitches. Often we pull the uterus outside the abdomen to do this. When finished, we place the uterus back inside, and then sew closed each layer from inside out. The surgery usually lasts approximately thirty minutes, but may take longer if you have scar tissue from a previous surgery.
The hardest part of recovery from a cesarean is the pain at the incision site, but you can take medication to ease the pain. We also recommend not lifting anything heavier than your baby and no strenuous exercise for four to six weeks.
CESAREAN DELIVERY VERSUS VAGINAL DELIVERY
I had a normal vaginal delivery with my son and a cesarean delivery with my daughter. I needed the cesarean because I had placenta previa. If I had gone into labor with the placenta covering the cervix, I would have hemorrhaged. Would I rather have had a vaginal delivery with my daughter? Ideally, yes, but that wasn’t in the cards for me. After my cesarean delivery, the first few days were painful, but the pain went away quickly. I went back to work when my daughter was four weeks old.
I quickly got over my disappointment over not having a vaginal delivery. In the end, it didn’t matter which way she was delivered. What I really cared about was that she was happy, healthy, and all smiles.–Yvonne
From Unicef’s maternal mortality statistics. http://www.unicef.org/index.php (accessed February 10, 2011).
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