Caesarean section (aka C-section, C/s) is where surgical incision(s) are made through a mother's abdomen (laparotomy) and uterus (hysterotomy), to deliver newborn(s).

Patient information

The C section. What is it? Is it a cross section ?
Not really. It's where we make a surgical cut into mom's tummy, and womb, to deliver bub.

Has the C section got anything to do with Julius Caesar?
Yes. It was often said that Julius Caesar was born by C section, but we're not sure about this, since his mother lived on, and back in the day, there was very high risk for mom with the C section.

• Preparation options include:
  • Emergency C section (aka Code 1 Caesar, crash caesar, ELSCS) is when it is not planned before labor begins. In emergencies, usually general anesthesia is used, but when time is available, it is preferable to use regional anesthesia. Code 1's are performed when the complications of pregnancy onset suddenly during the process of labor, and swift action is required to prevent the death of the mother and/or child
  • Elective C section (aka planned Caesar, scheduled Caesar) is when it is arranged of time, most commonly arranged for medical reasons, ideally as close to the due date as possible. This allows it to be performed at a time when hospital resources are optimal, such as at daytime. They can also be elected on a non-indicated maternal request, preferably 39 weeks gestation or later. Also, the woman  should be provided with information on the risk of a planned C section if she insists on the procedure
• Abx prophylaxis used before an incision. Incisions include:
  • Lower uterine segment C-section (LSCS), the most commonly used. It involves a TRANSVERSE cut just above the edge of the bladder, and results in less blood loss, and easier repair
  • Classical C-section, involving a midline LONGITUDINAL incision, allowing a large space to deliver the baby, but is rarely performed as it is more prone to complications
• Uterus is incised, and the incision is extended w/ blunt pressure
• Placenta is delivered
• Placenta is then removed
• Single layer uterine closure is used if the mother doesn't want a future pregnancy. A single suture preferred over a double layer sutured, because it reduces blood loss
• Closure of the peritoneum, although there is debate whether this is required
• If subcutaneous tissue is >2cm, surgical suture is used
• The partner is often encouraged to attend the surgery and support the mother. The anesthetist will usually lower the drape teporarily as the child is delievered so the parents can see their newborn
• Discouraged practices include:
  • Manual cervical dilation
  • Any subcutaneous drain
  • Supplemental oxygen therapy w/ intent to prevent infection

• Performed when vaginal delivery would put the baby or mother's life or health at risk
• Medical indications, generally requires use of discretion to decide if C section is necessary, and may require taking into account many factors
• Complications of labor, and risks associated with vaginal delivery, include:
  • Abnormal presentation (breech or transverse positions)
  • Prolonged labor or failure to progress (dystocia)
  • Fetal distress
  • Cord prolapse
  • Uterine rupture or an elevated risk thereof
  • HTN (increased BP) in the mother or baby after amniotic rupture (waters breaking)
  • Tachycardia (incrased HR) in the mother or baby after amniotic rupture (waters breaking)
  • Placental problems (placenta previa, placental abruption, placenta accreta)
  • Failed labor induction
  • Failed instrumental delivery (by forceps or ventouse, which may be trialled, and if unsuccessful, is delivered by C section)
  • Macrosomia (large baby >4kg)
  • Umbilical cord abnormalities (vasa previa, multilobate including bilobate and succenturiate-lobed placentas, velamentous insertions)
• Complications of pregnancy, pre-existing conditions and concomitant disease, including:
  • Pre-eclampsia
  • Previous high risk fetus
  • HIV infection of the mother, with a high viral load
  • STD, e.g. 1st outbreak of genital herpes very recently before the onset of labor, which can cause infection in the baby if the baby is born vaginally
  • Previous classical/longitudinal C section
  • Previous uterine urpture
  • Prior problems with healing of the perineum, from previous childbirth or Crohn's disease
  • Bicornuate uterus
  • Rare cases of posthumous birth after the death of the mother
• Can be performed upon request (and is requested more frequently than necessary) and is a practice health authorities would like to reduce
• It should NOT be performed before 39 weeks [as this is considered full term for child development] without medical indication to perform surgery

• Recovery, depends on pain tolerance and inflammation. It is recommended to:
  • Abstain from strenuous work (e.g. lifting objects >4.5kg, running, walking up stairs, or athletics) for up to 16 weeks
  • Waiting ~18 months before attempting to conceive another child
• Planning, of the next pregnancy, regarding whether delivery after previous C section will be:
  • VBAC (vaginal birth after C section) → although beware that emergency C section may result
  • ERCS (elective repeat C section)

Source: 2014/pdf/GL2014_004.pdf">NSW Health

Risks to the mother:

• Psychological, including postnatal depression, birth-related PTSD
• Less likely to become pregnant or give birth again (compared with women who've only had vaginal delivery)
• Both a VBAC (vaginal birth after C section) and ERCS (elective repeat C section) will be more likely to be complicated
• Placenta accreta (i.e. all/part of the placenta attaches abnormally to the myometrium muscular layer of the uterine wall), in a subsequent pregnancy
• Hysterectomy
• Abdominal surgery risks, including:
  • Postoperative adhesions
  • Incisional hernias (which may require surigcal correction)
  • Wound infections
  • Wound hematoma
• General surgical risks, including:
  • Cardiac arrest
  • Severe blood loss → may require blood transfusion
  • Postdural-puncture spinal headaches 
• Emergency Caesar risks, including:
  • Increased anesthesia risk, as the Pt's stomach may not be empty

Risks to the baby:

• Elective childbirth before full term is associated with:
  • Higher infant mortality
  • Developmental problems
  • Wet lung

• Increases bad outcomes in low risk pregnancies
• The poor outcomes that occur with C sections are different from those that occur with vaginal delivery
• The risk of death is 13 per 100k, as supposed to 3.5 per 100k for vaginal birth, in the developed world, and amongst those at low risk; or more than 3 times the risk
• More likely to have problems wiht later pregnancies, so women who want large families should not seek an elective Caesar

• 23m C sections are done globaly each year
• In some countries, C section procedures are used more frequently than is necessary, and consequently governments and health organizations promote programs to reduce the use of C section in favor of vaginal delivery
• The ideal for C section rate is 10-155. Some evidence supports a higher rate of 19% for better outcomes
• 60% of C sections are planned
• More emergency Caesars (66%) are performed during the day rather than during the night

• Delivery after previous C-section