Pregnancy, Childbirth, and the Newborn: The Complete Guide, 4th Ed.

CHAPTER 14 All about Cesarean Birth

cesarean birth (also called a “cesarean section,” “C-section,” “cesarean delivery,” or simply “cesarean”) is a surgical procedure used to deliver a baby through incisions in the mother’s abdomen and uterus. It’s the most common surgery performed in the United States. In high-risk situations, a cesarean can be a lifesaving procedure, vital for preserving the health of mothers and babies. While a cesarean is a relatively safe and routine procedure, it’s still major surgery and should be used only when its potential benefits outweigh its possible risks.

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In this chapter, you’ll learn about:

• Reasons for, benefits of, and risks of having a cesarean birth

• How to decrease your chances of having a cesarean birth

• Cesarean procedure and recovery

• Vaginal birth after cesarean (VBAC)

• How to have the best possible cesarean birth

Cesarean Birth Trends

In 1970, about 5 percent of birthing women in the United States had a cesarean birth. From 1985 to 2001, the cesarean birth rate ranged from 20 percent to 22 percent. In 2002, rates began increasing dramatically. In 2008, nearly one-third of birthing women in the United States (32.3 percent) had cesareans.

Pregnant women, their caregivers, and cultural beliefs all contribute to the rising cesarean birth rate. For example, when compared to pregnant women of just a generation ago, more of today’s pregnant women are older, obese, or carrying multiples. These factors can lead to situations that may make vaginal birth risky. As cesarean surgery has become safer, medical schools have stopped teaching physicians the skills that can make vaginal birth in certain situations (such as a breech presentation of the baby) possible. In addition, caregivers often overuse medical practices known to increase the chance of cesarean birth (such as labor induction and continuous fetal monitoring) and underutilize practices known to increase the chance of vaginal birth (such as continuous labor support). Finally, Western culture embraces technology and the perceived safety it provides. As a result, women and their caregivers may prefer to deliver by cesarean, believing that the technology lets them better control the birth process. Some caregivers practice “defensive medicine,” which arises from a fear of legal action if they don’t do everything technologically possible to control the birth process.

Many people worry that too many babies are born by cesarean. Two leading health organizations, the U.S. Department of Health and Human Services and the World Health Organization, have recommended a primary cesarean (a woman’s first cesarean) rate of 15 percent, a percentage that’s roughly half that of the current U.S. rate. These organizations observed that rates higher than 15 percent seem to harm mothers’ health without improving their babies’ well-being. In fact, despite the sharp increase in cesarean births over the past decade, the number of babies’ deaths hasn’t fallen and the number of mothers’ deaths may be rising.

Maternity care experts suggest that pregnant women can do several things to reduce the chance of having a cesarean birth without jeopardizing their health or their babies’ well-being.

Risks and Benefits of Cesarean Birth

Cesareans may be planned, unplanned, or emergency surgeries. With a planned cesarean, you may have weeks or months to learn the procedure’s benefits and risks, explore whether vaginal birth is an option, and prepare a cesarean birth plan.

With an unplanned cesarean, you begin labor expecting a vaginal birth, then a problem arises (such as failure to progress in labor) and you must make an unexpected decision. It may seem difficult to ask questions and make choices while coping with the challenges of labor, but there’s usually time to discuss your options. Some women believe it’s worthwhile to prepare a cesarean birth plan in anticipation of an unplanned cesarean.

Reducing Your Chances of Having a Cesarean Birth

Read “Ten Steps to Improve Your Chances of Having a Safe and Satisfying Birth” on page 30. After reviewing those recommendations, follow these guidelines:

1. If your baby is breech at thirty-five weeks, attempt to turn her using positions, sound, acupuncture, or chiropractic techniques. Ask your caregiver about external version. (See page 297.)

2. Avoid induction for non-medical reasons or for debatable medical issues. (See pages 275-276.) Research shows induction increases the risk of cesarean.1

3. If labor progress is slow, try a variety of positions and movement to speed it up. Or try self-help techniques, including nipple stimulation, relaxation techniques, eating or drinking, and emotional support to reduce fear and anxiety. (See Chapter 11.)

4. If your caregiver recommends a cesarean for failure to progress or fetal distress, ask the following questions: How much time do we have to decide? Can I labor for another hour before having a cesarean? What other options can I try? Can I change positions? Start or stop Pitocin? Start or stop pain medication? Have oxygen or IV fluids? Use tests to check my baby’s well-being? Use vacuum extraction or forceps delivery? If you’re uncomfortable with your caregiver’s response, ask for a second opinion. Continue to ask questions until you feel that you understand your caregiver’s answers. Once you do, you can make an informed decision.

Be prepared for the possibility that a cesarean may still be necessary for a safe birth. See page 327 for information on how to have the best possible cesarean birth.

Despite the prevalent use of the term emergency cesarean, this surgery is fairly rare. It occurs when a life-threatening situation arises and a physician must deliver a baby within minutes. Time for questions may be limited, and the mother must emotionally process events later.

When considering a cesarean birth, you should weigh the surgery’s possible risks against its potential benefits and against the risks and benefits of a vaginal birth. In general, if a vaginal birth presents greater risks to you or your baby than a cesarean birth, then the risks of a cesarean are worth taking.

RISKS OF CESAREAN BIRTH2

Why does a high cesarean rate concern maternity care experts? At first glance, cesarean birth seems to be a quick, safe, and easy way to deliver a baby without the pain and uncertainty of labor. A closer look at the procedure, however, reveals major risks, leading experts to recommend limiting cesareans to only those cases in which vaginal birth is unsafe or impossible.

The following effects are more likely to happen with a cesarean birth than a vaginal birth. They’re listed in order of most common side effects to rare complications.

Fact or Fiction?

Because a planned cesarean is more predictable and controllable, it’s safer for mothers and babies. Fiction. While cesarean surgery is a vital tool for coping with high-risk situations, it’s not safer than a vaginal birth and shouldn’t be used without a clear medical reason. Studies show that low-risk mothers who had planned cesareans are nearly three times more likely to suffer from severe complications or die than those who had vaginal births.3 Likewise, babies born by planned cesareans are more likely to be admitted to the neonatal intensive care unit (NICU). In one study, the chance of infant death was 1.77 per 1,000 for babies born by cesarean. By comparison, the chance of death was 0.62 per 1,000 for babies born vaginally.4

Effects on the mother

• Longer hospital stay

• Pain from the incision

• Increased blood loss

• Infection

• Rehospitalization and/or admission to the intensive care unit (ICU)

• Injury to the bowel, bladder, or ureter (a muscular tube which connects the kidney to the bladder)

• Hysterectomy

• Blood clots

• Complications from anesthesia

• Death (very rare)

Effects on the baby

• Less immediate contact with his mother

• More likely to have trouble breastfeeding

• Breathing problems at birth

• Admission to the neonatal intensive care unit (NICU)

• Asthma

• Scalpel injury during the surgery

• Death (rare)

Effects on future pregnancy and birth

• Adhesions (excess scar tissue that binds together tissues in the abdomen)

• Higher probability of cesarean birth

• Higher rates of the potentially life-threatening conditions of placenta previa, placenta accreta, placental abruption, and ectopic pregnancy

• Infertility or reduced fertility

• Increased risk of uterine rupture

• Doubled risk of stillbirth

BENEFITS OF CESAREAN BIRTH

The benefits of a cesarean depend on why your caregiver has recommended the surgery. Below are reasons caregivers recommend a planned, unplanned, or emergency cesarean.

Cesareans planned for clear medical reasons5

• Placenta previa (see page 139) or a uterine tumor that blocks the cervix

• Malformed or injured pelvis

• Severe preeclampsia, in which case induction is ruled out (See page 140.)

• Genital herpes, if the infection occurs in late pregnancy

• Human immunodeficiency virus (HIV), if the viral load is over 1,000 copies per milliliter6

• Transverse lie, in which the baby lies horizontally in the uterus

• Twins if the first baby is breech; triplets or more

• Certain birth defects, problems with the baby, or medical problems with the mother

Cesareans planned for less clear medical reasons

• Prior cesarean (See page 323.)

• Recurrent genital herpes with active lesions at the beginning of labor

• Breech presentation (See page 295.)

• Twins if the first baby is presenting head down

• Large baby (See page 275.)

Under these conditions, some caregivers recommend a cesarean; others don’t.

Cesareans planned without medical reason

• Fear, convenience, and so on (See below.)

Unplanned cesareans for situations that arise in labor

• Failure to progress/cephalo-pelvic disproportion (See page 312.)

• Variations in the baby’s heart rate that indicate possible distress (See also page 313.)

Emergency cesarean

• Placental abruption (See page 140.)

• Prolapsed cord (See page 302.)

• Uterine rupture (See page 323.)

• Urgent health problems with mother or baby

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Cesareans without Medical Reason

Some women request a cesarean birth because they fear vaginal birth, want to avoid labor pain, believe the surgery will preserve their pelvic floor (avoid perineal laceration and sexual function problems, and prevent urinary incontinence), want to schedule the birth for convenience, want to feel more in control of the birth process, or have some other non-medical reason. These planned cesareans are considered “maternal request cesareans” or “elective cesareans.”

In 2003, the American College of Obstetricians and Gynecologists issued a statement that affirms physicians are ethically justified to perform a cesarean at a mother’s request. But a statement from the Society of Obstetricians and Gynaecologists of Canada argues that physicians should perform a cesarean only when medically necessary. Statements from other organizations of maternity care professionals also warn that no evidence suggests cesarean births are as safe as vaginal births for the mother or baby. For example, recent studies show that low-risk healthy women planning to deliver by cesarean have a nearly 3 percent chance of developing severe complications during birth, while those planning a vaginal birth have a less than 1 percent chance.7 A statement from the National Institutes of Health declares that, due to specific complications that can result in the mother or baby, maternal request cesareans aren’t recommended for women who plan to have more babies, and shouldn’t be performed before the thirty-ninth week of pregnancy.8

If you’re considering requesting a cesarean, it’s important to learn about both vaginal and cesarean birth so you can make an informed decision. If your goal is to avoid labor pain, remember that while a planned cesarean may eliminate labor pain, it may result in weeks of painful recovery.

Advice from the Authors

If your caregiver recommends a cesarean during labor, here are a few ways to ask for alternatives. Thinking ahead of time helps prepare you in case you’re not able to think on the spot.

• How much time do I have to make the decision? Is the situation urgent?

• What will happen if we wait another hour? What can I do during that hour to help move labor along? Are there any other procedures or medications that may help my labor progress?

• What are the problems you worry may arise, and what other alternatives do we have for preventing or treating those problems?

If preserving your pelvic floor is your reason for a planned cesarean, know that within a few months after the birth, there’s no difference in occurrences of incontinence or sexual dysfunction between women who birthed vaginally and those who had a cesarean. To limit your chances of developing perineal pain, tears, and incontinence in a vaginal birth, use side-lying or hands-and-knees position during the second stage of labor (pushing phase), don’t hold your breath or strain for prolonged times, and avoid an episiotomy and forceps delivery. To limit your chances of incontinence throughout life, do Kegel exercises, don’t smoke, and maintain a healthy weight.

If fear of pain, fear of vaginal birth, or a need to feel in control is driving your desire for a cesarean, there are steps you can take to make vaginal birth seem more manageable. Take childbirth preparation classes to better understand the reality of labor and learn pain-coping techniques, hire a doula for support, talk with women who have had positive birth experiences, and consider seeking counseling to address your fears.

In rare circumstances, these measures aren’t enough and a cesarean may be appropriate for preserving your psychological well-being.

HOW COMMON IS EACH REASON FOR A CESAREAN?

The following is a rank-order list of the most common reasons caregivers give for recommending a cesarean:

1. Failure to progress in labor (See below.)

2. Concerns about the baby’s heart rate (See page 313.)

3. The mother has had a previous cesarean (See page 323.)

4. Concerns about the mother’s health

5. Concerns about the baby’s health

6. Baby that’s breech or in another unfavorable position

About 40 percent of cesareans are planned, and about 60 percent are unplanned and occur because of problems or concerns that arise during labor, such as those listed above.9 The factors that lead to planned and emergency cesareans are typically beyond your control. For an unplanned cesarean, there was a time when you and your caregiver might have made different choices that could have prevented the need for a cesarean (see “Ten Steps to Improve Your Chances of Having a Vaginal Birth” on page 30), but that time has passed. Consequently, when your caregiver recommends a cesarean, surgery often is the safest option.

Understanding Failure to Progress

Failure to progress is the most common reason caregivers recommend a cesarean for first-time mothers. The term can mean two things:

• Labor is taking longer than expected for the cervix to dilate to ten centimeters.

• The pushing stage is taking longer than expected.

A long labor or delivery isn’t necessarily harmful, and if both mother and baby are doing fine, it’s not automatically a reason for a cesarean. Some people call failure to progress “failure to wait long enough.”

Sometimes caregivers diagnose failure to progress as cephalo-pelvic disproportion (CPD), which means the caregiver believes the baby’s head is too large to fit through the mother’s pelvis. Even if you had ultrasound scans to check the size of your pelvis and your baby, they aren’t always accurate. CPD is impossible to predict, often because the position or angle of the baby’s head—and not the baby’s size—causes a poor fit in the mother’s pelvis. To help avoid this problem, mothers should move and change positions in labor so their babies can get in the best possible position for birth. (See page 220.)

A caregiver can’t reliably diagnose failure to progress during the early phase (before your cervix is 5 centimeters dilated), because this phase can progress very slowly and still be normal. (See pages 242–247.) If you become exhausted during the early phase, medications may help you rest. (See page 191.)

If your caregiver diagnoses failure to progress in active labor (after your cervix is 5 centimeters dilated), ask what alternatives to a cesarean are available to help get labor moving. These may include changing positions or other coping techniques (see pages 228–231), augmenting your labor (see page 281), or taking pain medication to help you relax.

If progress is very slow during the pushing stage, ask your caregiver about using different positions, warm compresses, manual rotation of your baby’s head, vacuum extraction, or forceps delivery to help birth your baby vaginally. (See page 289.)

Although trying these options may help labor progress, if they don’t work—or if there are compounding factors, such as concerns about your baby’s heart rate or your ability to continue pushing—your caregiver may recommend a cesarean.

Understanding Concern about a Baby’s Heart Rate

Concern about the baby’s heart rate is the second most common reason for a cesarean for first-time mothers. The clinical term for this concern is nonreassuring fetal heart rate, sometimes also called fetal intolerance of labor or “fetal distress.”

Monitoring the baby’s heart rate is how caregivers monitor his well-being (see page 252), but interpreting this heart rate is challenging. A change in fetal heart rate patterns may indicate that the baby is having problems. But a decreased heart rate may also mean that there was a short-term decrease in oxygen, and the baby is compensating well by conserving it. Monitoring the baby’s heart rate electronically gives caregivers clues about the baby’s currentwell-being, but it can’t accurately predict the baby’s long-term well-being. The following are reasons why electronic fetal heart rate monitoring isn’t a reliable tool for determining a baby’s long-term well-being.

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• How different caregivers interpret the same heart rate pattern varies widely. When analyzing the same heart rate pattern, one caregiver may determine the baby is fine, while another may diagnose fetal distress.

• Heart rate monitoring has a high rate of false positives, in which the heart rate pattern indicates distress but the baby is fine.

• While nonreassuring fetal heart rate patterns have led to an increased rate of cesareans, the surgery hasn’t reduced the number of birth injuries or infant deaths.10

In addition to electronic fetal heart rate monitoring, fetal scalp stimulation is a simple, quick, and accurate way to learn more about how the baby is handling labor. (See page 254.) During a vaginal exam, a caregiver presses on the baby’s scalp. If the baby’s heart rate rises, she’s likely handling labor just fine; if it doesn’t change, she might not be doing well.

When there are significant concerns about the baby’s heart rate, some caregivers recommend a cesarean quite quickly. Others are willing to wait and see whether the baby’s heart rate pattern improves or at least doesn’t worsen, while trying to hasten labor progress. These caregivers have lower cesarean rates for nonreassuring fetal heart rate patterns, and the babies are born just as healthy as babies born by immediate cesarean.

If your caregiver recommends a cesarean because of concern about your baby’s heart rate, ask questions to learn how worrisome it is and whether waiting for an improved heart rate pattern is possible. Also ask whether another caregiver may recommend against a cesarean because of your baby’s heart rate pattern. With these answers, you can better understand your options.

The Cesarean Procedure

Whether a cesarean is planned, unplanned, or an emergency, knowing the procedure demystifies the surgery and helps you prepare for having a cesarean birth, especially if you weren’t expecting one.

PREPARATION FOR A PLANNED CESAREAN

At your final prenatal visit, you’re instructed not to eat anything for the eight hours before the surgery (in case you need general anesthesia) and to arrive at the hospital two hours before the procedure.

PREPARING FOR THE SURGERY

First, a hospital staff member asks you to sign a consent form stating that you understand the reasons for the cesarean and its risks and benefits. A nurse shaves your abdomen and the upper portion of your pubic hair, and then you’re given a liquid antacid medication. The nurse starts an intravenous (IV) drip for fluids and medications, then inserts a catheter to drain urine from your bladder (to reduce the risk of bladder injury). You can request that the nurse insert the catheter after you’ve received anesthesia.

ANESTHESIA

For a planned cesarean, most women have spinal blocks because of their ease of administration, rapid onset, and degree of anesthesia. Twenty percent of women have epidural anesthesia, and a small percentage have general anesthesia.

For an unplanned cesarean, caregivers prefer giving women regional anesthesia (epidural or spinal). If you already have an epidural catheter in place, the anesthesiologist increases the dosage of medication to numb you completely from chest to toes. If you don’t, the anesthesiologist administers a spinal block. Epidurals and spinal blocks let you stay awake and alert, but prevent you from feeling pain during the surgery. If you have regional anesthesia, your partner may be with you in the operating room.

General anesthesia, which makes a woman unconscious for surgery, is used only for these rare situations:

• Emergency cesareans, when the baby must be delivered within minutes

• Unplanned cesareans in small hospitals with limited anesthesia services

• Instances in which an anesthesiologist can’t successfully place an epidural or spinal, or a woman can’t tolerate a regional anesthetic

If you have general anesthesia, hospital policy might not allow your partner to be in the operating room. For more information on pain medications, see Chapter 10.

THE OPERATING ROOM

In the operating room (OR), the staff includes the primary obstetrician, an assisting physician or midwife, an anesthesiologist, a surgical nurse who handles sterile instruments, a nurse for your baby, and an assisting nurse. There may be others present if there are concerns about your baby’s health. The anesthesiologist is next to your head throughout the surgery. Let him or her know if you feel any pain, nausea, or other discomfort. To remain calm and relaxed, use the visualizations, slow breathing, and relaxation techniques that you learned in childbirth preparation class or on pages 216–220.

During surgery, you’re on your back, usually with a foam wedge under your left hip to reduce supine hypotension. (See page 89.) The nurse washes your abdomen with an antiseptic, drapes a sterile sheet over your body, and places a surgical screen at your chest to prevent you from viewing the surgery or touching the surgical area.

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THE SURGERY

First, the obstetrician cuts through your abdominal wall (skin, fat layer, and a fibrous layer of connective tissue called “fascia”). This cut is typically a transverse incision, or horizontal cut, 4 to 6 inches across and 1 inch above your pubic bone (a bikini cut). In unfavorable conditions (such as placenta previa or a transverse baby), for obese women, or in an emergency, this cut may be a vertical incision between the navel and pubic bone (a classical cut).

The obstetrician then manually separates your abdominal muscles and cuts through a fibrous tissue (the peritoneum) that encases your abdominal cavity. He or she then makes a low transverse incision in your uterus. In some cases, it’s a low vertical incision. In very few cases, it’s a classical incision, a vertical cut in the upper uterus.

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After making a small incision, the obstetrician stretches the opening wide enough for your baby’s head to fit through. To control bleeding, he or she cauterizes the ends of cut blood vessels, and you may smell a burning odor. If needed, he or she breaks your membranes, and you soon hear the suctioning of amniotic fluid.

Then the obstetrician reaches in to extract your baby as the assisting physician presses on the top of your uterus to help push out your baby. You may feel intense pulling and tugging while they work on you, but you shouldn’t feel pain. The obstetrician first lifts out your baby’s head (or, if breech, his buttocks). He or she may cup a hand around your baby or apply a vacuum extractor to his head. Then fluids are suctioned from your baby’s nose and mouth before the obstetrician lifts him completely out, clamps and cuts the umbilical cord, then holds him up for you to see.

Immediate Baby Care

The operating room staff may care for your baby at a warming table or they may take your baby to the nursery. During a vaginal birth, contractions squeeze fluids out the baby’s airway, but a baby born by cesarean doesn’t have that advantage. For this reason, your baby’s mouth and nose may need additional suctioning.

The staff evaluates your baby with Apgar scores and a newborn assessment and may do other procedures, including administering eye ointment, injecting vitamin K, and measuring height and weight. (See pages 370-371.)

If your baby is having trouble breathing (which is more likely after a cesarean than a vaginal birth), she may need assistance, supplemental oxygen, and extra observation in the nursery. If she’s premature, she may be given surfactant medication, which makes breathing easier.

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A cesarean surgery takes about one hour, but your baby is born just ten to fifteen minutes after surgery begins. As soon as possible after the birth, a nurse or your partner should bring your baby close to you. He or she can hold your baby so you can get to know her while the obstetrician repairs the incisions.

During the Repair

At the beginning of the repair, Pitocin is added to your IV to make your uterus contract and prevent excessive bleeding. Then the obstetrician manually removes the placenta through the incision site and inspects it.

The obstetrician may lift out your uterus completely for repair, or he or she may do the repair internally. Some physicians feel they can do a better repair if the uterus is outside the abdomen; however, external repair can cause nausea and vomiting.11 To close the incision in your uterus, the obstetrician uses stitches that will dissolve. Most experts recommend obstetricians use the double-layer suturing method,12which requires suturing both the inner and outer layers of the uterus, thereby creating a stronger scar that’s less likely to reopen in future labors. The obstetrician then repairs your abdominal muscles, closes your skin with staples or stitches, and bandages the area.

During the repair, some women develop pain in their shoulder area, which is caused by air that has entered the surgical area. This “referred pain” soon subsides on its own.

During or after the surgery, you may feel nauseated, anxious, or panicky. You may tremble all over. Medications can help ease these discomforts, but may make you so drowsy that you sleep through your baby’s first hours. Instead, try slow, deep breathing and ask for a cool cloth on your forehead to help ease nausea. Warm IV fluids or blankets over your shoulders can help reduce trembling. If you decide you need medications, ask for those that let you stay awake and alert.

After the surgery, you may return to the room where you labored, or you may go to a surgical recovery room. Then staff will transfer you to a postpartum room a few hours after the surgery.

In Their Own Words

While they were finishing the surgery, I started shaking. I wanted to hold my baby, but I was worried the trembling would disturb her. They gave me medication for the shaking, but then I fell asleep for the next hour. I wish I had just put up with it, and snuggled my baby. Instead, I slept for her first hour—and no one even thought to take a photo of her during that time, so I feel as though that part of her life was lost to me.

—Maria

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A NOTE TO FATHERS, PARTNERS, AND OTHER SUPPORT PARTNERS

When the surgery begins, you may feel pushed to the side as the experts do their work. But you have an important role to play. Your job is to support your partner and be the primary caretaker of your baby while the surgery is completed.

During the surgery, you’ll sit by your partner’s head, behind the sterile area. If you’re interested, you may stand and watch the surgery, but you must stay behind the screen and out of the staff’s way.

Whether you sit or stand, hold your partner’s hand, talk to her, stroke her hair, and rub her shoulders. Help her with relaxation techniques and visualization. The medication may make her feel as though she can’t take a deep breath. She may panic and say, “I can’t breathe.” Rest assured, she can breathe—otherwise, she couldn’t talk! Coach her through slow breathing, reminding her that she’s breathing well, even though she can’t feel it.

After your baby is born, go where your partner directs you. Most likely, she’ll want you to stay with your baby, but she may want you close by her side. If hospital policy allows for two support people in the OR, one of you can stay with your baby and the other can remain with your partner.

If you’re with your baby in the OR, tell your partner everything you notice about your baby and describe all the details of what’s happening to him. As you talk, your familiar voice will soothe your baby. Usually, you can touch and hold your baby shortly after birth. In that case, your main goal is to bring him to your partner as quickly as is safely possible so they can begin to bond.

If you go with your baby to the nursery, or if medication and the stress of the surgery makes your partner fall asleep, pay attention to all the events so you can tell her about them later. Take lots of photos. Think of other ways you can capture these moments for her. For example, you may ask visitors (even grandparents) to refrain from holding your baby until after your partner has had a chance.

Remember that it’s important for your partner and baby to begin breastfeeding as soon as possible after the birth. Babies often become sleepy an hour or two after birth, so it’s best if the first feeding happens before then. Some mothers can begin breastfeeding in the OR while their surgeries are completed, but others begin nursing in the recovery or postpartum room. If your partner is groggy from medication, she may need your help holding your baby as he nurses. If she has trouble latching him onto her breast, ask a nurse, doula, or lactation consultant for help. You may be tempted to help her rest by feeding your baby by bottle, but resist that urge. Introducing a bottle at this time may make breastfeeding challenging. Get the contact information of a local lactation consultant or breastfeeding hot line you can call if you and your partner have breastfeeding questions when you’re back home.

Common Q & A

Q: My wife and I just found out she’ll need a cesarean. I want to support her in the OR, but I’m worried I’ll pass out when I see blood. What can I do?

A: Ask ahead of time if you can bring an extra support person (doula, friend, or family member) into the OR in case you need to leave. Be sure to let the anesthesiologist know about your concerns. He or she will have good ideas for what you should do. Plan to stay close to your wife’s head, where the surgical screen will prevent you from seeing the surgery, and focus on her face, giving encouragement and reassurance.

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Recovery

After you’ve had a cesarean birth, you experience all the normal parts of postpartum physical recovery (see Chapter 15) and learn to care for your newborn. But there’s one additional factor—you’re recovering from major surgery!

Here’s an overview of what to expect when recovering from a cesarean: For the first twenty-four hours, you need help doing everything—holding your baby, rolling over, sitting up, walking, and using the toilet. For the first two weeks, you’re sore, move slowly, and need help with baby care and household tasks. At six weeks, your body should feel back to normal.

The following sections provide more detail on the recovery process.

YOUR HOSPITAL STAY

A cesarean birth requires a hospital stay of two to four days. During that time, your nurses regularly monitor your vital signs, check vaginal bleeding (lochia), ask if you’re urinating and moving your bowels, and check your incision to ensure it’s healing well. Nurses are a wellspring of information, advice, and breastfeeding assistance. Take advantage of this valuable resource!

PAIN MEDICATION

During the surgery, you may be given epidural or spinal narcotics that provide many hours of pain relief. Alternatively, after the surgery you may be given patient-controlled analgesia (PCA). PCA lets you push a button to release a narcotic into your IV when you need more pain relief. (The amount of the narcotic is controlled so overdose isn’t possible.)

Take enough medication to be comfortable. When you’re in pain, it’s hard to move around, bond with your baby, learn parenting skills, and relax for breastfeeding. (Only low concentrations of the medication reach your baby through your breast milk, so the effects on your baby are slight.) Don’t let medications wear off completely. Take your next dose when it’s due, even if you’re not hurting yet.

Although the medication options provide effective pain relief and let you move around, itching and nausea are frequent side effects. Other medications counteract these side effects, but they may cause drowsiness or diminish pain relief. If your medications make you groggy, ask to have the dosage decreased or medication changed.

After about twenty-four hours, you’re given oral pain medications, which you may need for several days to a week. As the pain subsides, reduce the dosage or switch to regular acetaminophen or ibuprofen. If you don’t need pain relief, you may stop using pain medications, even if you haven’t taken all of them.

Supporting Your Belly (Splinting)

When you first get up after a cesarean, it may feel as though your belly is sagging and needs support. It may even feel as though your insides are shifting around. Your belly may hurt whenever you change positions, cough, or laugh. To support the area during these times or whenever you need comfort, try using your hand, a pillow, or a rolled-up towel to press gently against your incision area.

PHYSICAL ACTIVITY

Moving as soon as possible after the surgery boosts blood circulation, which lowers the risk of blood clots, and improves digestion and lung function. But don’t overdo it. For the first two weeks, minimize lifting heavy objects and climbing stairs. These activities strain your abdominal muscles.

Rolling Over, Sitting, Standing, and Walking

Within a few hours after a cesarean birth, you’re encouraged to sit on the side of the bed. If you’re on your back, roll onto your side by “bridging”: Bend your knees, press your feet into the bed, and lift your hips. With your hips elevated, rotate them to one side so one hip is directly above the other. Rest your bottom hip on the bed, then use your arms to push yourself to a sitting position with your legs dangling over the side of the bed. Rest for a moment; this move may make you dizzy, especially the first few times you do it.

With the nurse’s help, stand by pushing down with your hands. Stand as tall as you can—you won’t harm your incision even though it may hurt and feel as though it’s pulling apart.

Within eight hours of the surgery, you should be able to walk to the bathroom with help. Within twelve hours, you should be able to walk short distances independently; within twenty-four hours, you should be able to walk the hospital hallways.

Exercises and Physical Activity

The following exercises are recommended to help your body recover from a cesarean.

First day after surgery

Deep Breathing: Take a few deep breaths, bringing air all the way down to your belly. This movement gently exercises your abdominal muscles.

Coughs: Hold your hands over your incision, inhale deeply and exhale with either a gentle huffing cough or a forceful short puff. This movement dislodges any accumulated mucus from your respiratory system.

Ankle Pumps: Flex and point your feet and rotate your ankles to help circulation and prevent blood clots in your legs.

Days two to four

Knee Bends: While lying on your back in bed, flex your feet, bend one leg while sliding your heel toward your bottom, then straighten the leg. Repeat with your other leg. This motion helps prevent blood clots in your legs.

Tension Relievers: While sitting, roll your shoulders and rotate your ankles.

Abdominal Pull-ins: Pull in your belly as if making yourself look thin, then relax.

For the first two to four weeks

• Rest and take it easy. Don’t lift anything heavier than your baby and don’t drive. Limit climbing stairs, reaching into high cabinets, doing laundry, vacuuming, entertaining visitors, and so on.

• Don’t have sex.

• Check with your caregiver about when to begin the postpartum exercises described in Chapter 15.

DIGESTION, ELIMINATION, AND GAS

Abdominal surgery can slow digestion and lead to problems with gas, gas pains, constipation, and urination. As soon as you can walk to the bathroom, your bladder catheter is removed.

Some hospitals’ policies require that women consume nothing by mouth for twenty-four hours after a cesarean, then only clear liquids until day two or three. Research has shown, however, that women who are allowed to eat when desired (within four to eight hours after surgery) have more satisfactory recoveries. They experience less gas, resume moving their bowels sooner, require less IV fluid, and can expect an earlier discharge from the hospital.13Ask your caregiver about your hospital’s policy and note in your cesarean birth plan that you want to resume eating shortly after the surgery.

During the first few days after the surgery, take the stool softeners that your nurses give you, drink lots of water, and gradually add high-fiber foods to your meals. To minimize gas, avoid consuming iced drinks, carbonated beverages, and very hot or cold foods. To help digestion, walk, change positions often, and rock back and forth in a chair.

INCISION CARE

After the surgery, you’re shown how to clean the incision area and check for swelling and infection. (It’s normal for the area to itch and ooze a watery yellow or pink discharge.) Gently clean and dry the wound daily. Avoid touching the incision without first washing your hands. Twenty-four hours after the surgery, you can shower or bathe as usual. Dry thoroughly, then wear loose, comfortable clothes. If you’re overweight, make sure air can circulate around the incision area so it stays clean and dry.

If tape was used to close your incision, it eventually comes off on its own. If staples or clips were used, your caregiver removes them and applies tape to the incision before you leave the hospital. He or she can tell you further what to expect.

After six weeks, your scar shouldn’t cause you discomfort, although it may still feel stretched or pulled. It may also feel numb for three months or more. When the feeling returns, you may experience some “zinging” or prickly sensations, due to the healing of damaged nerve pathways. After the incision has healed, you may notice a hard ridge along it. This is scar tissue, which tends to shrink and attach to the soft tissue underneath. Massage the scar tissue in different directions (along and across the scar) and roll it between your thumb and index finger. These motions ensure the different layers of skin, tissue, and muscles can move freely underneath. If the massage is painful, do it more gently. Massage your scar a few times every day (five minutes each time).

See page 337 for postpartum warning signs of an infected incision.

BREASTFEEDING

Breastfeeding can be more challenging after a cesarean birth, but successful breastfeeding is possible if you know how to manage potential challenges. Some research suggests that, when compared to women who had vaginal births, fewer women who had cesarean births start breastfeeding, or they quit breastfeeding sooner. With education and support, however, initial breastfeeding rates and breastfeeding duration are similar for both mothers who had cesareans and those who didn’t.14

After your surgery, finding a comfortable position to breastfeed may be problematic. To protect your incision from your baby’s weight and wiggling, lie on your side or use the football (or clutch) hold. If using the cradle hold or cross-cradle hold, first place a pillow on your incision. (See page 406 for information on breastfeeding positions.) Your partner or a nurse can help adjust the number and position of pillows to support your baby and protect your incision. They can also help check your baby’s latch onto your breast.

Your baby may be quite sleepy, depending on what medications you had during the surgery. Have patience as she figures out how to latch onto your breast and feed. Also, if your baby needed extensive suctioning of her nose and throat after birth, she may have trouble latching onto your breast during the first days. Skin-to-skin contact between you and your baby helps calm her and promotes a good latch.

The surgery may delay when your milk comes in. Frequent feedings is the best way to increase your milk supply. The sooner you initiate breastfeeding after the birth and the more often you breastfeed your baby, the more milk she takes, and the more milk you make.

After the surgery, you may have a higher chance of acquiring a bacterial or yeast infection, which can cause sore nipples. (See page 422.)

EMOTIONAL REACTIONS TO HAVING A CESAREAN BIRTH

Women have all sorts of feelings about having a cesarean birth. Reactions often depend on prior hopes and expectations. If you learn you need a planned cesarean, you may feel relieved that you don’t have to go through labor. Or you may feel disappointed that you don’t get to experience childbirth. You may worry about your medical condition or the surgery and its risks. Or knowing exactly what to prepare for may reduce your anxiety.

If the need for an unplanned cesarean arises during labor, you may be disappointed or you may be relieved that labor is about to end. You may feel frustrated that you worked so hard for all those hours only to have your baby delivered surgically. Or you may be frightened about facing something you never expected to happen. If concerns about your baby’s heart rate led to the cesarean, you may worry about your baby’s well-being.

Coming to Terms with Your Feelings about the Cesarean

When the surgery is over and you know your baby is fine, you may feel acceptance (if you felt the surgery was necessary), anger (if you didn’t feel part of the decision-making), disappointment, guilt, resentment, or relief. Sometimes women don’t feel any particular emotions about the cesarean right away, but do eventually.

For some women, a cesarean leads to low self-esteem. They don’t feel confident about their mothering skills because of their failure to birth “normally.” They have trouble connecting emotionally to their babies because the birth wasn’t what they’d wanted. They may feel emptiness or sadness when recalling the birth, instead of feeling fulfillment and joy.

If your cesarean birth depresses you, you may feel guilty and upset. You may feel as though you should “just be happy” to have a healthy baby. Know that it takes time to let go of the birth you envisioned and it’s perfectly normal to grieve for one thing as you celebrate another. If possible, talk honestly and openly about the birth with people who understand your feelings.

Sometimes, understanding the reason for the surgery can help you better accept the birth. Your recollection of the experience might not be complete, especially if labor was exhausting or the cesarean was an emergency. Ask your caregiver to discuss with you the events that led to the cesarean, or review your hospital chart together.

Also consider talking with your childbirth educator, doula, or a counselor about your birth experience. Look into joining a support group, such as the International Cesarean Awareness Network (ICAN), or search online for discussion groups that may help you find others who had similar experiences. Continue using these resources until you come to terms with your birth experience and can move forward with your life as a new mother.

Vaginal Birth after Cesarean (VBAC)

If you’ve had a cesarean and are pregnant again, you need to decide between planning another cesarean birth or planning a trial of labor after cesarean (TOLAC), in which labor is allowed to begin and progress with the hope of having a vaginal birth after cesarean (VBAC).

MAKING THE CHOICE BETWEEN VBAC OR REPEAT CESAREAN

It’s your right and responsibility to decide whether to have a repeat cesarean or try for a VBAC. After reading this section on VBAC, discuss with your caregiver the medical benefits and risks specific to your situation. Because caregivers’ views on VBAC vary widely, you may want to consult with multiple providers. Also consider the emotional and practical issues unique to your situation that may affect your decision. For example, you might have lingering fears of labor that may stall a TOLAC, or there might not be a caregiver or hospital near you that permits VBAC.

MEDICAL BENEFITS AND RISKS OF VBAC VERSUS REPEAT CESAREAN

In March 2010, the National Institutes of Health held a consensus development conference to provide maternity care providers and the general public with a professional assessment of the currently available data on VBAC. At the end of the conference, the panel concluded that the benefits of TOLAC to the mother might be balanced by the increased risks to the baby; however, the benefits of a repeat cesarean to the baby might be balanced by the increased risks to the mother. Consequently, when TOLAC and repeat cesarean are medically equivalent options, women and their caregivers should work together to make a decision, and whenever possible, the woman’s preference should be respected.15

When analyzing the benefits and risks of TOLAC and repeat cesarean, you need to examine the relatively rare but real risk of uterine rupture, the separation or opening of the scar from the uterine incision. If rupture occurs, it often results in a hysterectomy for the mother (14 to 33 percent risk) and can lead to the death of the baby (6 percent risk).18

What Influences My Chance of Uterine Rupture?

Although the thought of uterine rupture is scary, the chance of its occurrence is relatively small (one-third of 1 percent for TOLAC).16 Here are some general guidelines of the risk:

• The chance of rupture is lowest for a woman who has had only one prior cesarean with a low transverse scar and who hasn’t been induced.

• The chance of rupture is higher if the woman has had more than one prior cesarean, had an infection after a prior cesarean, had a cesarean less than eighteen months ago, or has had labor induced.

• The chance of rupture is highest (and VBAC is too risky) for a woman who has had a vertical incision or an inverted T- or J-shaped incision for a prior cesarean, had a rupture from a previous labor that caused problems, or has had an ultrasound scan that found the uterine scar to be less than 2½ millimeters thick.17

However, the vast majority of women considering TOLAC or repeat cesarean won’t experience uterine rupture with either option. With TOLAC, the risk of rupture is 325 in 100,000, or about one-third of 1 percent; with a planned repeat cesarean, the risk of rupture drops to 26 in 100,000.19

After balancing the rare chance of rupture against all other factors, the overall risk of the baby’s death is 130 in 100,000 for TOLAC and 50 in 100,000 for repeat cesarean.20 Although this risk may seem alarming, it’s similar to the risk of the baby’s death for a first-time mother laboring with an unscarred uterus (about 100 in 100,000).

Even with the increased chance of rupture, vaginal birth carries fewer overall risks than surgical birth. For example, when compared to repeat cesarean, TOLAC carries a lower risk of hysterectomy, blood transfusion, and deep vein thrombosis; it also involves a shorter hospital stay. The overall risk of maternal death is less than 4 in 100,000 for TOLAC and more than 13 in 100,000 for repeat cesarean.21

Weighing the benefits and risks of a VBAC against those of a repeat cesarean can be challenging, and it’s best to closely consult with your caregiver to better understand your options. If your risk of uterine rupture is high (see above) or your chances of having other complications in labor are high, a planned cesarean may be best for you. A planned cesarean has fewer risks than an unplanned cesarean that occurs after a failed TOLAC. If your risk of uterine rupture is low and your chances of VBAC success are favorable (see page 325), your best option may be to attempt a VBAC.

Monitoring for and Managing Uterine Rupture

During a VBAC labor, the caregiver closely monitors both mother and baby for uterine rupture, which he or she can diagnose by carefully observing the baby’s heart rate, the shape of the mother’s abdomen, and the mother’s blood pressure. If a caregiver suspects a rupture, the mother has an emergency cesarean to prevent excessive bleeding and distress to the baby. With careful monitoring and quick intervention, the majority of babies are fine at birth after a rupture.

Improving Your Chances of Having a Successful VBAC

1. Choose a caregiver who proves his or her support of VBAC by having a high VBAC attempt rate and a success rate of 70 percent or more. You may have to interview several providers. Discuss your goals and preferences and ask questions about how you can work together toward a successful VBAC experience. If your current caregiver doesn’t support your goals, consider finding a new one.

2. Consider hiring a doula who has had a VBAC herself or has worked with women who have had VBACs.

3. Take a childbirth refresher class or a VBAC class.

4. If your cesarean birth was traumatic or you feel anger, mistrust, or fear about your next birth, talk with a birth counselor, childbirth educator, or doula to help you deal with these feelings. You may also want to contact your local branch of the International Cesarean Awareness Network (ICAN). This organization’s mission is to prevent unnecessary cesareans through education, provide support for cesarean recovery, and promote VBAC. They’re a good source of local information and emotional support. You can also find abundant information on their web site, http://www.ican-online.org, including the paper “Your Right to Refuse: What to do if your hospital has banned VBAC.”22

5. Avoid induction with Pitocin or prostaglandins. One study showed the risk of uterine rupture was less than one-half of 1 percent for spontaneous labor, just over 1 percent if labor was induced with Pitocin, and just under 1½ percent with prostaglandins.23 If induction is necessary, non-drug methods, balloon catheters, and rupture of membranes may be safer for a VBAC. (See pages 278-280.)

6. Try to minimize medications for pain relief and use other interventions only if necessary.

7. Review “Ten Steps to Improve Your Chances of Having a Safe and Satisfying Birth” on page 30 and “Reducing Your Chances of Having a Cesarean Birth” on page 309.

By following these suggestions, you’ll have done all you can to ensure a vaginal birth. But always remember that there’s no guarantee a cesarean won’t become the wise option if serious problems arise during labor. Consider writing a VBAC birth plan as well as a “best possible cesarean” plan to use if a repeat cesarean becomes the safest option. (See page 329.)

Likelihood of VBAC Success

Most women who plan a TOLAC achieve a vaginal birth (60 to 94 percent).24 VBAC is more likely if a woman is younger than forty and has had a prior vaginal birth, and if the reason for her previous cesarean hasn’t recurred and her labor is progressing well. VBAC is less likely in the following situations:

• The mother has had multiple prior cesareans, has complicating medical conditions, or is obese.

• Gestation is over forty weeks and the baby is estimated to weigh over 9 pounds.

• Labor is induced or augmented.

AVAILABILITY OF VBAC

Before 1980, common thought in the United States and Canada was “once a cesarean, always a cesarean.” From the 1980s to 1999, experts recommended a VBAC as a safer option than a repeat cesarean. Since 2000, popular opinion has once again turned against VBAC, and many care providers and hospitals no longer offer it.

Hospital staffing changes account for much of this reversion of thought. In 1999 and again in 2008, the American College of Obstetricians and Gynecologists (ACOG) recommended that hospitals permit VBAC only when a physician, staff, and anesthesia are immediately available to provide an emergency cesarean if needed.25 As a result, by early 2010 one-third of hospitals no longer permitted VBAC and one-half of physicians stopped offering it as an option to their patients.26

Not all maternity care experts agree with the ACOG recommendation. The American Academy of Family Physicians as well as the experts who served on the 2010 National Institutes of Health consensus panel have questioned the rationale behind it.27

If you prefer to try for a VBAC but can’t find a caregiver and birthplace that support your decision, consider relocating for the end of your pregnancy to a friend’s or relative’s home near a hospital that allows VBAC, and finding a caregiver who supports it.

EMOTIONAL REACTIONS WHEN DECIDING BETWEEN A REPEAT CESAREAN AND A VBAC

Some women who have had a prior cesarean may have emotional challenges choosing between a VBAC and a repeat cesarean. Emotional challenges also can arise during labor for women who choose VBAC. Because fear and anxiety can slow or complicate labor, it’s best to address these emotional issues during pregnancy. See Chapters 10 and 11 to learn ways to help labor progress smoothly.

Fear

The thought of laboring again may seem more frightening than the risks of major surgery. You may fear labor pain, a long labor, uterine rupture, complications, another cesarean, failure to deliver “normally,” or simply the unknown. Discuss your fears with your caregiver, childbirth educator, doula, or cesarean support group that supports VBAC. These people can reassure you and support your decision. They can help you identify the most distressing parts of your previous birth and help you plan how to avoid or address them. For example, you may plan not to wait for hours before having a cesarean if you have another long labor that doesn’t progress.

Shame or guilt

You may feel ashamed that you might have done things that led to a prior cesarean birth, or you may feel guilty for having agreed to a cesarean. Talk with others who understand your feelings so you can forgive yourself and approach this birth from a fresh perspective.

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Lack of confidence

You may doubt your ability to give birth vaginally and hesitate to invest time and effort in a VBAC because you don’t want to be disappointed. Remember that each pregnancy and birth is different. Get to know women who have had successful VBACs. You may find they also lacked confidence and hope before giving birth. Ask what helped them become confident enough to birth vaginally. For example, perhaps they visualized the birth experience they’d hoped for.

Feeling pressured

You may feel pressured by caregivers, friends, or family to make one decision or another. Always remember that you have the right to make an informed decision. Others can provide information and opinions, but only you can make the choice that’s best for you and your family.

Stress in labor

In addition to the emotional hurdles that arise in most labors (see graph on page 268), specific events in a VBAC labor may raise your stress level.

• When early labor is underway, you may suddenly second-guess whether a VBAC is such a good idea. Be prepared for this “moment of truth” beforehand by thinking of ways to deal with it.

• Particular events in labor may trigger flashbacks of your previous labor that ended in a cesarean. Don’t suppress them, even if they’re unpleasant. Acknowledge them openly and note how things are different this time.

• A big hurdle may be reaching the point in labor that led to a previous cesarean. Until you pass that point, you may continue to question your ability to birth vaginally. After you’ve passed it, you can breathe a sigh of relief and enjoy a boost of optimism.

Two Views on VBAC

I gave birth to my daughter by unplanned cesarean. I was disappointed for quite a while afterward, because I’d had my heart set on delivering vaginally. When I got pregnant again, I didn’t waste any time learning all I could about VBAC. I know there’s no guarantee I’ll deliver vaginally this time, but I want to do all I can to better my odds.

—Jana

When my first labor failed to progress, I ended up needing a cesarean. I remember thinking at the time, “Thank goodness! I’m sick of this pain!” Now I’m pregnant again, and I’m not keen to repeat that labor experience. Part of me wants to skip it all together, but another part realizes that recovering from a C-section is no piece of cake, either. I think I need to learn how to better handle the labor pain so I can avoid the pain of cesarean recovery.

—Samantha

Having the Best Possible Cesarean Birth

Whether or not a cesarean birth is what you want, you can have a satisfying experience. The following steps will help you make your cesarean birth the best it can be.

Educate yourself.

• Learn about the cesarean procedure from books, classes, and discussions with your caregiver.

• Find out your birthplace’s policies and regulations for cesareans.

If a planned cesarean is necessary, prepare in advance.

• Take care of yourself in pregnancy. Eat well and exercise regularly if possible. The more physically fit you are before the surgery, the quicker you recover afterward.

• Tour the hospital, including the special care nursery. Ask to have any lab work, tests, and paperwork done before the day of surgery. Meet with an anesthesiologist to discuss options and learn what medications he or she will use.

• If hospital policy allows for two support people in the OR, ask a friend or family member to join you with your partner for the surgery. Or consider hiring a doula. Her calm, familiar presence and knowledge of cesareans can reassure you. Plus, after your baby is born, she can remain by your side while your partner stays with your baby.

• Take a breastfeeding class with your partner so you both know ways to help make nursing after a cesarean easier.

Common Q & A

Q: I’ve heard of “natural cesareans” or “slow cesareans.” What are they?

A: Historically, cesareans were emergency procedures that emphasized rapid delivery and immediate access to the baby for resuscitation. As cesareans have become more commonplace and oftentimes less urgent, some obstetricians have begun doing the surgery more slowly and encouraging immediate skin-to-skin contact between the mother and baby after the delivery. This woman-centered, baby-friendly way of doing cesareans is new, and your caregiver might not be aware of it. Learn more about natural cesareans and find a journal article to share with your caregiver by visiting http://tinyurl.com/la83t2.

Wait for labor to begin (or at least until week thirty-nine of pregnancy).

If your caregiver recommends a cesarean before your labor begins, be certain that there are clear medical reasons for the recommendation. There are definite advantages to waiting until labor begins on its own. Ask that your caregiver schedule the surgery as close to your due date as possible, and also ask about amniocentesis to verify your baby’s lung maturity before surgery.

• Labor benefits babies. Babies born by scheduled cesarean without experiencing labor are four times more likely to develop persistent pulmonary hypertension, a potentially life-threatening situation.

• Severe complications, including breathing difficulties, infection, and other problems that require admission to the neonatal intensive care unit (NICU), are twice as likely for babies born at thirty-seven weeks than are babies born at thirty-nine weeks.28

• Not waiting for labor to begin for a planned cesarean can lead to accidental prematurity if the estimated gestational age is wrong. Knowing the exact date of conception, having an ultrasound scan early in pregnancy that documents a gestational age, or having the baby’s lung maturity verified are ways to better estimate an accurate gestational age.

Prepare a cesarean birth plan.

Even if you’re planning a vaginal birth, consider writing a cesarean birth plan. (See Chapter 8 for more information on birth plans.) Here are questions to consider asking at a prenatal appointment to learn about your options:

• Can I have two support people in the OR with me?

• What will be the atmosphere in the OR? Can I choose music to play? Will the staff narrate what’s happening? Will they chat with me to keep me relaxed during the procedure? Will they stop chatting if I request it?

• Will staff lower the screen or use a mirror so I can see my baby’s birth? Are there restrictions on photographing and video-recording the birth?

• Can my partner announce our baby’s sex? Will you do minimal suctioning of my baby’s nose and mouth? Can I have skin-to-skin contact with my baby after birth? Will newborn exams be done where my partner and I can see our baby? If possible, can my baby stay in the OR during my repair? Will breastfeeding be initiated as soon after the birth as possible?

• Will you do internal repair and double-layer suturing? (See page 317.)

• If I experience anxiety, trembling, or nausea, will I be offered non-drug options for coping or medications that will keep me alert?

• Can I start eating whenever I wish after the surgery?

If the options and answers don’t satisfy you, consider switching to a different caregiver or birthplace.

Understand the reasons for a cesarean.

If you’re having a planned or unplanned (but nonurgent) cesarean, ask your caregiver as many questions as you need to fully understand the benefits, risks, and alternatives before consenting to surgery. If you have an emergency cesarean, talk with your caregiver after the birth about why it was needed. This information may help you feel that the decisions made during the birth were necessary at the time, which can help you accept the events of birth.

Insist on early, frequent contact with your baby.

Cesarean delivery, narcotic pain medications, and high levels of stress at birth may delay breastfeeding and affect breast milk production. The more time you spend nestling with your baby and the more frequently you nurse, the sooner your milk supply increases. Skin-to-skin contact also enhances the emotional bond between you and your baby.

Develop a postpartum plan.

The postpartum period is more challenging when you’re recovering from major surgery, so plan ahead for the extra support you’ll need. See page 158 for more information.

Key Points to Remember

• More than 30 percent of women giving birth in the United States have cesareans. Although a cesarean is a relatively safe surgery, vaginal birth has fewer overall risks. For this reason, birthing women and their caregivers should consider a cesarean only when the potential medical benefits clearly outweigh the possible risks.

• There are steps you can take to increase your chances of a vaginal birth, and important questions you can ask if your caregiver recommends a cesarean.

• VBAC is a viable option for many women with prior cesareans; however, policies at your local hospital may limit access to a VBAC.

• Preparing a cesarean birth plan helps ensure that if you need a cesarean, you’ll have a positive birth experience that lets you feel nurtured and cared for.