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What to Expect from a Cesarean Section

Even if you are planning for a vaginal birth, it’s worth brushing up on the basics of C-sections so you’ll be prepared in case you have to have one.

This guide was originally published on May 3, 2019 in NYT Parenting.

The rate of cesarean section births in the United States has been declining over the past few years. Still, a full 31.9 percent of births were by C-section in 2016. Even among women who hadn’t had a previous C-section, the rate was almost 22 percent. Some women are prepared; they’ve had the surgery scheduled because of a medical complication or something else that is known in advance. But many will end up having a C-section only after a decision is made during labor that it’s the safest route for the woman and for the baby.

All that is to say that, even if you want and are planning for a vaginal birth, it’s worth brushing up on the basics of C-sections so you’ll be prepared if it happens to you. You’ll want to know what the surgery entails, how it might change your birth experience and how your postpartum recovery will be affected. For this guide, I spoke with two obstetricians, one obstetrical anesthesiologist and one obstetrical nurse practitioner.

Once a decision has been made to perform a C-section, the prep begins. You’ll get an IV, if you don’t already have one, to deliver fluids and an antibiotic. It’s no longer standard procedure to shave pubic hair, because it could permit unwanted bacteria into the body. (Nor should you shave or wax your own bikini area or abdomen right before a scheduled C-section, also due to the infection risk.) Any hair that might get in the way of the incision is clipped.

You’ll get anesthesia, which is most often regional – so you’ll be awake during the operation, though numb from the mid-chest down. If there’s already an epidural in place, the dose of anesthetic will be increased, said Dr. Aaron Caughey, M.D., an obstetrician and gynecologist specializing in maternal-fetal medicine at Oregon Health & Science University. If you don’t already have an epidural, you’ll most likely get a spinal injection, which places the anesthetic closer to the spine in one shot and acts more rapidly than an epidural. Either way, there’s a narcotic in the mix, which helps combat post-op pain for 18 to 24 hours, said Dr. William Camann, M.D., director emeritus of the obstetrical anesthesia service at Brigham and Women’s Hospital in Boston. (Delivering narcotics this way doesn’t carry the same side effects as when taken orally, he added.)

You’ll get a catheter inserted in your urethra and your abdomen will be washed with an antiseptic solution. During the surgery, you’ll be lying on your back, with your hands on armboards so that your blood pressure can be monitored and your IV adjusted, if necessary. And there will be a drape over your body, separating your upper body from the lower, to keep the surgical site sterile.

It typically takes only 10 or 15 minutes to get the baby out. Most of the time, the surgeon will make a horizontal, or transverse, incision that’s two fingers’ breadth above the pubic bone, cutting through the layers of skin and muscle and then the uterus, said Dr. Nazaneen Homaifar, M.D., an obstetrician and gynecologist at the University of California San Francisco Medical Center. (Less frequently a surgeon will use a low or central vertical incision, for example if the position of the baby is breech or sideways, if you’ve had multiple abdominal surgeries or during some emergency procedures.) You’ll likely feel pressure twice during the procedure: once when the layers of tissue are being stretched to get to the uterus, and once when the baby is delivered. It shouldn’t hurt, said Dr. Homaifar, who has had a C-section (because her twins were in the breech position) in addition to performing them, but you might feel pressure — “like a toddler sitting on your belly” or a pulling sensation. You may also have some nausea and vomiting during the surgery for reasons including cutting through the peritoneum (the membrane lining the abdomen), moving the uterus in and out of the abdomen after delivery or low blood pressure.

Once the baby is out, there will usually be 30 seconds or a minute before the umbilical cord is clamped and cut. The baby is passed to the pediatrician to be checked out, and if all is O.K., can often be brought to the mother for skin-to-skin contact and even breastfeeding. Closing the incision takes longer than making it, 30 minutes (or even less) to more than an hour based on anatomy, the incision and previous scars, said Dr. Caughey.

Some C-sections are scheduled ahead of time for reasons including multiple births, a baby in the breech position or certain medical conditions in the mother. (In a small percentage of cases, women will request a C-section for no medical reason.) In that case, you won’t wait to go into labor but will check into the hospital ahead of your due date, at a specific date and time. You’ll meet with the medical team, the baby will be monitored for 20 minutes or so and then you’ll proceed to surgical prep, said Dr. Homaifar.

If a C-section is unscheduled, and you’ve already been in labor, the surgery may be urgent but not an emergency – often because labor isn’t progressing, for example. In that case, surgery will usually start within 30 minutes or an hour from when the decision is made to operate.

But sometimes, when there is a serious and imminent threat to the mother’s or baby’s health, the C-section is an emergency. In that case, there will be a lot of people involved and things will happen fast, said Cheryl Roth, Ph.D., a nurse practitioner at HonorHealth Scottsdale Shea and Osborn Medical Centers and president of the Association of Women’s Health, Obstetric and Neonatal Nurses. The team’s goal is to get the baby out in minutes. It can seem overwhelming for the woman, but it’s important to remember that to the medical personnel, it’s a “very established process,” said Dr. Roth. (Don’t be afraid to ask questions about what’s going on.) Depending on the circumstances, an emergency C-section may require general anesthesia, which means you’ll be unconscious.

You may still have some choices about the birth in the case of a non-emergency C-section. Dr. Camann led the introduction of the so-called “gentle” or “family-friendly” C-section in the United States. He said he realized that with an opaque drape across her abdomen and the fact that the baby was taken to the other side of the room after birth, the first time a mother saw her baby was often on the screen of her partner’s camera. He started using double-layered drapes with opaque and clear layers, so the opaque layer can dropped during the actual birth. “The patients and their partners loved it,” he said. “And the acceptance has been tremendous.”

Also part of this approach is incorporating in the operating room many of the things that have become customary for vaginal deliveries, such as a woman’s choice of music during delivery and skin-to-skin contact after birth.

[How to advocate for yourself in the delivery room]

After the surgery, you’ll be moved to recovery and then, depending on the hospital, possibly to another room for the rest of your stay, said Roth. The catheter will usually be removed the same day to reduce the risk of urinary tract infection, and the goal is usually to get women up and walking around the same day to prevent blood clots, said Dr. Homaifar. Once the narcotic from surgery wears off, you may get IV or oral nonsteroidal anti-inflammatory medications for pain, such as alternating prescription-strength doses of ibuprofen and acetaminophen. (There’s been a move to limit unnecessary oral narcotic use.) If your pain isn’t being controlled, tell your health care team.

Federal law requires that insurers pay for at least 96 hours in the hospital after a C-section, compared to 48 after a vaginal delivery, so you will likely be in the hospital for a few days. But once it’s safe, the goal is to get the mother and baby home as soon as possible. Unlike other recovering surgical patients, though, a new mother can’t go home and sleep for 10 to 15 hours a day. The combination of major abdominal surgery, sleep deprivation and the hormonal fluctuations after childbirth is “a really bad match,” said Dr. Caughey. He advised leaning on family and friends as much as possible to help out during this initial recovery period. (If it’s in your budget, this may be a great time to hire a night nurse.)

Physical recovery depends on many factors, including how long and difficult the labor was before the C-section was performed. In general, Roth tells her patients not to lift anything heavier than the baby for two weeks. Your physical activity can start with walking and ramp up as you feel up to it, though you should talk with your doctor or other medical provider before resuming vigorous exercise. You should also get the all-clear from your doctor before resuming sexual activity.

Also realize that just because you have one C-section you aren’t necessarily bound to have all future births that way. According to the American College of Obstetricians and Gynecologists, a vaginal birth after cesarean, or VBAC, is an option for some women, depending on the type of incision made in the earlier surgery and the birth facility, among other factors. Studies have reported that about 60 percent to 80 percent of women who attempt a trial of labor after a cesarean (called a TOLAC), have a VBAC, and there are calculators available to help gauge a woman’s odds.

Most women recover fine from a C-section, but like any other abdominal surgery, there are risks, including infection, blood loss and blood clots. Your doctor will give you a complete list of symptoms that should prompt you to seek medical attention, including a fever, signs of infection in the incision, excessive vaginal bleeding and leg pain that could signal a clot. The bottom line: If something doesn’t feel right, speak up.

[What to do when your experience of childbirth doesn’t match your expectations]

Katherine Hobson is a freelance health and science writer and a mom.