Labor is a physiologic process during which the fetus, membranes, umbilical cord, and placenta are expelled from the uterus. Natural childbirth means a labor without any medical pain relief, leading to a vaginal birth, and possibly third stage, without any interventions at all (such as artificial rupture of membranes, induction of labor, epidural, etc.), that lasts more than 24 hours. Cesarean delivery (C-section) is a surgical procedure used to deliver a baby through incisions in the abdomen and uterus.

Indications for Caesarean Section:

There are no guidelines and rules for choosing a caesarean section over normal childbirth because each pregnancy is unique. There are, however, some indications (relative or absolute) that determine whether a normal birth is possible or whether a caesarean section should be performed. Elective cesarean section, performed solely at the wish of the mother, without any medical indication, is considered a separate indication. The indications for caesarean section are as follows:

• If the pregnant woman who either has developed a health problem during pregnancy or suffers from an illness that worsens during pregnancy or due to anatomical abnormalities, cannot give birth vaginally (i.e. previous caesarean section, previous fibroid removal, increased maternal age, failure to progress to childbirth – uterine dysfunction).
• Abnormal conditions found in the fetus may prevent a normal delivery i.e. irregular fetal heart rates, placenta accreta, low birth weight, fetal macrosomia, etc. If the fetus is in an abnormal position or presentation, labor may be more difficult, and delivery through the vagina may not be possible i.e. when it is in a transverse lie position or breech presentation (the buttocks or sometimes the feet present first
• For some babies, this trip through the “birth canal” doesn’t go smoothly and vaginal delivery is impossible. This condition may occur due to the size of the baby, the shape of the bones of the mother’s pelvis, or weak contractions of the uterus. (i.e. cephalopelvic disproportion, failed induction of labor, hypertensive pregnancy, active genital herpes, diabetes mellitus that was not properly treated, etc).

Because complications from a caesarean section can occur for both the mother and the newborn, any possibility of a normal delivery should be considered. In general, however, the rate of cesarean sections has increased (tripled or quadrupled) compared to previous decades. It is often decided that the baby will be born by caesarean section long before the time of delivery approaches. In some cases, a caesarean section is decided only after an extensive effort to achieve vaginal delivery.

Once a Caesarean section, always a Caesarean section?

For years, women who’d had a C-section were encouraged to skip vaginal deliveries altogether and schedule C-sections for all future births. This was due to a fear that the uterus had been weakened by the previous cesarean section. It is now felt that patients who have had a cesarean delivery in which the incision of the uterus (womb) is across (low transverse) the uterus rather than up and down (high or low vertical), are considered candidates to have attempts at vaginal delivery in subsequent pregnancies (vaginal birth after cesarean section – “VBAC”). The physician and the patient should be able to discuss the need for future cesarean deliveries if that is a consideration for the patient). About 60% to 80% of women who attempt vaginal delivery after a cesarean delivery will succeed. Unfortunately, there are no ways to predict which women are more likely to be able to give birth vaginally and which will have complications, leading to a caesarean section. The main benefits of a VBAC include shorter hospital stay, less need for blood transfusions, and lower chance of infection. The most serious risk associated with VBAC is the possibility of uterine rupture at the site of the previous incision. This probability is less than 1%. This is more likely to happen when a woman has given birth more than once by caesarean delivery or may have had an unusually difficult birth during the current pregnancy. In order to minimize the risks to the mother and baby, close monitoring of the mother and fetus is required. Also, proper preparation should have been done by the nursing staff and the hospital as there is a possibility of an emergency caesarean section if complications occur.

Cesarean section technique:

When the caesarean section is designed and scheduled, it is called “selective”. There are, however, those cases in which the caesarean section is chosen due to a complication that endangers the life of the fetus and therefore an emergency caesarean section is decided and the technique of cesarean section remains the same. Depending on the hospital’s policy, you may or may not be allowed to have someone with you in the operating room. If entry is allowed, then this person will be sitting on the edge of the operating table, on the side of your head, away from the area where the operation will be performed. The operation is performed by the surgical team, under sterile conditions. If you receive epidural anesthesia, you will be able to hear the operating team talking and you will feel the pulling of tissues, without feeling any pain. The baby, as soon as it is born, is handed over to the nursing staff. “Closing” the procedure usually takes several minutes after delivery. After the operation, the intravenous line (i.e. the venous catheter) remains in order to provide you all necessary medication. The catheter will also not be removed until you can walk. When the anesthesia wears off, you will feel pain in the abdomen. Your vital signs (blood pressure, temperature, pulse) should monitored regularly and the incision should be checked by your doctor on a daily basis. Do not forget to move while you are lying down and do not lie in the same position for a long time. It is important to walk as soon as possible after surgery to prevent blood clots. It may be difficult at first as the pain at the incision will be intense but with the help from the hospital staff and the encouragement your close ones, you will make it! In case of any symptom (pain, nausea, dizziness, etc.) you should contact your doctor or nursing staff to provide you the appropriate medication.

Diet:

Immediately after surgery you are allowed to drink liquids. Your doctor will inform the nursing staff about the diet that you should follow for the next few days until you leave the hospital. As it takes time for your digestive system to adjust and function properly after surgery and anesthesia, it is perfectly normal to feel discomfort in the abdomen due to gas pain.

Returning home:

The first few days after you go home you may feel some discomfort and find it difficult to breastfeed your baby. Starting breastfeeding after a cesarean section it is proven to be more difficult than usual. Bonding with the newborn as well as recovering from the cesarean delivery at the same time is more challenging than after a vaginal birth. In addition, mood swings may occur just like they occur after vaginal delivery and these emotions should be discussed with your physician to prevent any significant problems.