Caesarean birth

Caesarean birth is the birth of a baby by means of an incision in the uterus. It's done when your health care provider decides it's safer — either for you or for your baby — than a vaginal birth. Most first-time Caesareans occur unexpectedly. For that reason, it's a good idea to educate yourself about Caesarean birth as you come to the end of your pregnancy. That way, you'll be more prepared for the possibility, should it arise.

Why a Caesarean birth might be necessary

Many different factors can lead to the decision to perform a Caesarean birth. Your labor is failing to progress normally

The failure of labor to progress normally is one of the most common reasons that doctors deliver babies by Caesarean. In fact, about a third of all Caesareans are done because labor is progressing too slowly or stops altogether. The causes of slow or stalled labor are varied. Your uterus may not be contracting vigorously enough to dilate your cervix completely. Or your baby's head may simply be too big to fit through your pelvis. This is what's known as cephalopelvic disproportion (CPD). It, too, can stop your cervix from dilating completely.

Your baby has an abnormal heart rate pattern during labor

Certain patterns of fetal heart rate are very reassuring in labor. Other patterns may indicate a problem with the baby's oxygen supply. When these heart rate patterns cause concern, your health care provider may recommend a Caesarean birth. This scenario accounts for 10 percent to 15 percent of all Caesarean births. These abnormal fetal heart rate patterns can arise when the baby isn't getting enough oxygen, because the umbilical cord is compressed or because the placenta isn't functioning optimally. For more information on problems with your placenta or umbilical cord, see the sections "There's a problem with your placenta" and "There's a problem with the umbilical cord" on page 190.

Unfortunately, abnormal fetal heart rate patterns may occur without indicating any real risk to your baby. At other times, these findings may indicate a serious problem. One of the most difficult decisions in obstetrics is determining when the risk is genuine. To help make that decision, your health care provider may attempt to test the baby's blood by obtaining a sample through the scalp. Or your health care provider may try certain maneuvers, such as massaging the baby's head, to give rise to reassuring heart rate changes.

Deciding when a Caesarean is necessary depends on a lot of variables, such as how long labor is likely to continue before delivery and what other problems, such as an overdue baby, make the abnormal heart rate patterns more likely to be significant. Although there are times a baby is clearly in trouble, many other times it's a difficult assessment.

Your baby is in an abnormal position

Babies whose feet or buttocks enter the birth canal before the head are in what's known as the breech position. Most of these babies are born by Caesarean section, primarily because of the severity of the possible complications of vaginal birth. For example, in vaginal breech births, it's more common to have the umbilical cord slip through the cervix before the baby (prolapsed umbilical cord). This can cut off the baby's oxygen supply. Plus, the baby's head could become trapped in the birth canal, even if the rest of the body emerges easily.

If your baby is lying horizontally across your uterus, the position is called a transverse lie. This position, too, calls for Caesarean birth.

If your baby is in the breech position, your health care provider may be able to move the baby into a more favorable position by pushing on the baby through your abdomen, before labor starts. This procedure is called an external version. If this doesn't work, Caesarean birth will probably be considered.

You have a serious health problem

If you have diabetes, heart disease, lung disease or high blood pressure, you may need a Caesarean birth. Often, these conditions lead to the decision to deliver a baby earlier in pregnancy by starting (inducing) labor. Early inductions of labor often lead to failure of the cervix to dilate or abnormal fetal heart rate patterns, which increase the chances of Caesarean birth.

In many of these cases, vaginal delivery would be preferable for mother's care. For example, good evidence suggests that women with coronary artery disease should deliver vaginally, especially if they also have pulmonary vascular disease. For these women, Caesarean birth seems to worsen their outcome. Women with severe complications of pregnancy-induced high blood pressure (preeclampsia) may also do better if a vaginal delivery can be accomplished. If you have a serious health problem, discuss your options with your health care provider well before the end of your pregnancy.

Another unusual cause for a Caesarean birth is to protect a baby from acquiring herpes simplex infections. If a mother has primary (first episode) herpes in the genital tract, it can be passed to a birthing baby, giving rise to serious disease. A Caesarean birth is often used to prevent that complication.

Your baby's head is in the wrong position

When your baby enters your pelvis, he or she should be head-down and facedown. His or her chin should be tucked down to the chest so that the back of the head, which has the smallest diameter, is leading the way. If your baby's chin is up or head is turned so that the smallest dimensions aren't leading the way, a larger diameter of the head has to fit through your pelvis. The fit can be quite tight. In these cases, the top of your baby's head, forehead or face may be the body part farthest down in the pelvis, ready to be born first. Even though your cervix might be fully dilated, your baby simply may be unable to fit through your pelvis, and Caesarean birth may be necessary.

Some babies also move into the birth canal head-down but faceup, in what's known as an occiput posterior position. Most babies will turn during labor and be born facedown. Your health care provider might have you get on your hands and knees with your buttocks in the air, a position that causes the uterus to drop forward and seems to help babies turn. Sometimes the health care provider may try to turn the baby's head during a contraction by way of a vaginal exam. Occasionally, turning the baby with forceps and helping the baby be born that way is the safest route to delivery. If that doesn't work, a Caesarean birth may be the safest option.

Many women, especially those of African ancestry, have perfectly normal labors with their baby in the faceup position. It may not be a problem for you and your baby.

You're carrying twins, triplets or other multiples

About half of all women who have twins have Caesarean births. Twins can often be born vaginally, depending on their position, estimated weight and gestational age. Triplets and other multiples are a different story. Studies show that more than 90 percent of triplet births are by Caesarean birth.

When more than one baby is present inside your uterus, it's not unusual for one to be in an abnormal position. In this case, Caesarean birth is often safer than vaginal birth, especially for the twin born second. In fact, some research suggests that second twins born vaginally are at greater risk of death due to complications during labor and childbirth than are the twins delivered first.

Each multiple pregnancy is unique. If you're carrying twins, triplets or other multiples, discuss your birth options with your health care provider and decide together what's best for you. Remember to stay flexible. Even if both babies are head down during your examinations, that may not be the case after the first baby is born.

There's a problem with your placenta

Two problems with the placenta may warrant Caesarean birth: placental abruption and placenta previa.

Placental abruption occurs when your placenta detaches from the inner wall of your uterus before labor begins. It can cause life-threatening problems for you and your baby. If your health care provider suspects that you have a placental abruption, he or she can recommend steps to manage it based on your condition and the condition of your baby.

If electronic fetal monitoring shows that your baby is not in immediate trouble, you may be hospitalized and monitored closely. If your baby is in jeopardy, immediate delivery will likely be required. Caesarean birth may be necessary, although in some situations vaginal birth may be possible.

The decision-making process is quite different with placenta previa. With this condition, your placenta lies low in your uterus and partially or completely covers the opening of your cervix.

Women with a placenta previa in late pregnancy will likely need a Caesarean birth. The placenta can't be born first, as the baby would no longer have access to oxygen. In addition, it's very unlikely that the mother would be able to tolerate the blood loss that resulted. So for both mother and baby, Caesarean birth is safest.

There's a problem with the umbilical cord

Once your water has broken, it's possible that a loop of umbilical cord will slip out through your cervix, before your baby is born. This is called umbilical cord prolapse, and it poses grave danger to your baby. As your baby presses against your cervix, the pressure on the protruding cord can block your baby's oxygen supply.

If the cord slips out after your cervix is completely dilated, and if birth is imminent, you might still be able to deliver vaginally. Otherwise, Caesarean birth is the only option. Fortunately, this problem is very rare when babies are head down.

Similarly, if the cord is wrapped around your baby's neck or is positioned between your baby's head and your pelvic bones, or if you have decreased amniotic fluid, each uterine contraction will squeeze the cord, slowing blood flow and the delivery of oxygen to your baby. In these cases, Caesarean birth may be the best option, especially if cord compression is prolonged or severe. This is a common cause of abnormal heart rate patterns, but it usually isn't possible to know for sure where the umbilical cord is until after birth.

Your baby is very large

Some babies are just too large to deliver safely vaginally. Your baby's size may be of particular concern if you have an abnormally small pelvis, which may prevent the baby's head from passing through. This is rare unless you have had a pelvic fracture or another deformation of the pelvis.

If you've developed gestational diabetes during your pregnancy, your baby may have gained too much weight before birth — a condition called macrosomia. If your baby is overly big — generally defined as 9 pounds, 14 ounces or more — Caesarean birth is more likely.

For the most part, electing to do a Caesarean birth because of the anticipated size of the baby isn't warranted. Ultrasound and clinical examination (just feeling the baby through the abdomen) are about equally accurate at guessing a baby's weight once the baby exceeds about 8/2 pounds. There's enough error in this estimation that if Caesarean births were recommended for all babies estimated to be over nine pounds, a good number of babies who actually weighed only 8 pounds would never have the chance to be born vaginally.

Your baby has a health problem

If your baby has been diagnosed in the womb with a developmental problem, your health care provider may recommend that you have a Caesarean birth. Examples include spina bifida (a spine defect resulting in failure of the vertebrae to fuse) or hydrocephalus (increased size of the fluid-filled cavities of the brain). For babies with the most common severe form of spina bifida called myelomeningocele, some evidence shows that Caesarean births lead to a better neurological outcomes than vaginal births do.

Unfortunately, few definitive studies are available to help health care providers and parents-to-be decide between Caesarean and vaginal birth for babies with birth defects and other health problems.

Work with your health care provider to gather the facts that apply to your situation. Discuss your birth options with your health care provider, and decide together what's best for you and your baby. In these situations, a Caesarean birth might not be necessary to prevent damage to a baby, but being born in a controlled situation with a team of surgeons on hand may benefit the baby greatly. Often, the only way to orchestrate this kind of timing is through Caesarean birth.

You've had a previous Caesarean birth

If you've had a Caesarean birth before, you may need to have one again. But this isn't always the case. See "Considering vaginal birth after Caesarean birth" on page 345.

The Complete Compendium Of Everything Related To Health And Wellness

The Complete Compendium Of Everything Related To Health And Wellness

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