Caesarean Section

Collaboration with Maria Pavli, Midwife, MSc Cand

A Caesarean section or CS is a surgical procedure in which an incision is made in the abdominal and uterine wall in order to extract the fetus and placenta. It is applied in those cases where vaginal delivery is not possible or poses a risk to the mother or the fetus. Although the caesarean section may be elective/planned, in many cases the need for it may not be apparent until labour has commenced.

The most common indications of a caesarean are the following:

• Halted progress in labour. When usually for mechanical reasons the progress of labour stops and the baby cannot be born vaginally.
• Irregular foetal position. If the foetal position is transverse or oblique (sideways) instead of longitudinal which is normal, vaginal delivery is not feasible and is an absolute indication for CS. 
• Breech presentation is a relative indication because vaginal delivery has an increased risk and usually – especially in first pregnancies – external cephalic version (turning the baby from the outside) is recommended and CS if this does not work. However, with trained staff a breech vaginal birth is possible.
• Fetal distress in labour due to reduced oxygen supply to the fetus. If it is not possible to expedite the birth, depending on the stage of labour and the severity of the problem, a caesarean is performed.
• Multiple pregnancy is a relative indication. If both babies are coming “head first” vaginal delivery is usually preferred. In other cases of twins or multiple pregnancies, vaginal delivery can lead to complications mainly for the second or one of the subsequent embryos which usually have an abnormal position.
• Placenta previa, meaning if the placenta has grown in a way it is covering the internal cervical opening. This is an absolute indication, as it closes the exit route of the fetus.
• Anomalies of the umbilical cord. Umbilical cord prolapse, as well as velamentous cord insertion (the cord is attached to the membranes instead of the placenta), are an absolute indication for caesarean.
• Uterine Rupture. This is a rare complication that can occur when there has been previous uterine surgery, but not necessarily, and is an absolute indication of CS.
• Severe haemorrhages before or during labour, such as in central placental abruption or bleeds due to trauma, are almost always treated with a caesarean.
• Certain maternal medical conditions such as serious heart diseases, severe preeclampsia, neurological diseases, severe eye diseases can under certain conditions lead to the selection of a planned CS. 
• Some maternal infections such as active genital herpes, extensive warts of the vulva from HPV and AIDS are indications of CS
• Mechanical reasons such as uterine fibroids may prevent the fetus from being born vaginally
• Previous caesarean section mainly after more than 2 previous caesareans. Although it is perfectly reasonable to attempt vaginal birth after caesarean section (VBAC), the doctor may conditionally recommend that a caesarean section be performed again for safety reasons.
• Some congenital abnormalities of the fetus (eg some congenital heart diseases)
• Maternal Request. Many women wish to give birth by caesarean section having the belief or information that they will avoid the discomfort or complications associated with vaginal childbirth. Although it should initially be discouraged, if with correct and sufficient information this remains the woman’s informed choice, it should be respected.

What type of anaesthesia is used during Caesarean Section?

The preferred option is regional anaesthesia, whether it is epidural or spinal. In emergency situations, when there is not the necessary time to apply regional aneasthesia, general anaesthesia is used.

How is a caesarean section performed?

Initially, anaesthesia is performed, preferably regional. A screen or a curtain is erected so that the patient cannot see the operation. A urinary catheter is placed in the bladder once the anaesthesia is working so she will not feel it.

In recent years, caesarean sections are performed with a transverse incision in the lower part of the abdomen of approximately 8-10cm. This incision offers a better aesthetic result than vertical incisions, because it is usually hidden below the height of the bikini line. It is also much safer for subsequent pregnancies.

Then the layers of the abdominal wall are opened in order to reach the uterus. The uterine wall is also opened with a low transverse incision. Although it is technically more difficult, this method is safer for subsequent pregnancies, since vertical incisions in the uterus have a greater risk of rupture.

This is followed by the birth of the baby, the clamping and cutting of the umbilical cord and the receipt of the newborn by the paediatrician or midwife. The newborn is usually placed in an open incubator which is usually located near the mother. There they are dried and if everything is well they are placed for a while on their mother. If it is planned to take stem cells, it is now performed from the umbilical cord of the placenta. If not, the placenta is removed whole along with its membranes. 

Then the uterine wall is sutured with a synthetic absorbable suture (stitch). The remaining layers are closed sequentially in order to fully restore the anatomy of the area. The skin is sutured with an intradermal (in the skin) plastic stitch which is also absorbable. This achieves an excellent aesthetic result and does not require suture removal at a later time. 

During caesarean, except in cases of general anaesthesia, the patient may feel some pressure from the manipulations of the medical team, while in some cases there may be nausea, dizziness or vomiting.

The whole process usually takes about an hour.

Breastfeeding and cesarean section

None of the types of anaesthesia used for caesarean section affects or is a contraindication for breastfeeding.

The postoperative course after caesarean section

After a caesarean, the hospital stay lasts about three days, as in the case of other surgeries. However, we should not underestimate the consequences of caesarean and the observance of adequate rest. Please note that: Along with postpartum discomfort you may experience blood loss and repositioning of the uterus. 

Even after a caesarean, a perineal rehabilitation program may be needed, as in the case of vaginal birth. The pelvic floor, in fact, may be tired from the pregnancy. Speak to your doctor or midwife.

You can start a light exercise, which does not use your abdominal muscles, as long as the incision rhealing is at an advanced stage. Also, in this case, consult your doctor.

Come to our childbirth preparation classes and opt for our postnatal care service at home or our perineal rehabilitation workshop, provided by skilled midwives from Hera Family Care.