What is cesarean section

A cesarean section, or C-section, is an operation to deliver your baby through a cut made in your abdomen and womb (uterus). The cut is usually made across your abdomen, just below your bikini line. A cesarean is a major operation that carries a number of risks, so it’s usually only done if it’s the safest option for you and your baby. After the baby is removed from the womb, the uterus and abdomen are closed with stitches that later dissolve ¹.

In the United States, almost one in three women has their babies this way. Some C-sections are planned, but many are done when unexpected problems happen during delivery. Reasons for a C-section may include:

• Health problems in the mother
• The mother carrying more than one baby
• The size or position of the baby
• The baby’s health is in danger
• Labor is not moving along as it should

The cesarean section surgery is relatively safe for mother and baby. Still, it is major surgery and carries risks. It also takes longer to recover from a C-section than from vaginal birth. It can raise the risk of having difficulties with future pregnancies. Some women may have problems attempting a vaginal birth later. Still, many women are able to have a vaginal birth after cesarean section.

Most cesareans are carried out under spinal or epidural anaesthetic. This mean you’ll be awake, but the lower part of your body is numbed so you won’t feel any pain.

During the cesarean section procedure:

• a screen is placed across your body so you can’t see what’s being done – the doctors and nurses will let you know what’s happening
  a cut about 10-20cm long will usually be made across your lower tummy and womb so your baby can be delivered
• you may feel some tugging and pulling during the procedure
• you and your birth partner will be able to see and hold your baby as soon as they’ve been delivered

The whole operation normally takes about 40-50 minutes.

Occasionally a general anaesthetic, where you’re asleep, may be used, particularly if the baby needs to be delivered more quickly.

Recovering from a cesarean section

Recovering from a cesarean usually takes longer than recovering from a vaginal delivery. You might need to stay in hospital for three or four days, compared with one or two days for a vaginal birth.

You may experience some discomfort in your tummy for the first few days, and you’ll be offered painkillers to help with this.

When you go home, you’ll need to take things easy at first. You may need to avoid some activities such as driving for six weeks or so.

The wound in your tummy will eventually form a scar. This may be red and obvious at first, but it should fade with time and will often be hidden in your pubic hair.

Future pregnancies after a cesarean section

If you have a baby by cesarean section, it doesn’t necessarily mean that any babies you have in the future will also have to be delivered this way.

Most women who have had a cesarean section can safely have a vaginal delivery for their next baby, known as vaginal birth after cesarean section.

However, you may need some extra monitoring during labor just to make sure everything is progressing well.

Some women may be advised to have another cesarean section if they have another baby. This depends on whether a cesarean section is still the safest option for them and their baby.

Figure 1. Cesarean section scar

Reasons for cesarean section

A cesarean may be recommended as a planned (elective) procedure or done in an emergency if it’s thought a vaginal birth is too risky.

Planned cesareans aren’t usually done before the 39th week of pregnancy.

A cesarean may be carried out because:

• Breech presentation: your baby is in the breech position (feet first) and your doctor has been unable to turn them by applying gentle pressure to your tummy, or you would prefer they didn’t try this
• You have a low-lying placenta (placenta previa)
• You have pregnancy-related high blood pressure (pre-eclampsia)
• You have certain infections, such as a first genital herpes infection occurring late in pregnancy or untreated HIV
• Your baby isn’t getting enough oxygen and nutrients – sometimes this may mean the baby needs to be delivered immediately
• Your labor isn’t progressing or there’s excessive vaginal bleeding
• Failure of labor to progress—contractions may not open the cervix enough for the baby to move into the vagina.
• Concern for the baby—For instance, the umbilical cord may become pinched or compressed or fetal monitoring may detect an abnormal heart rate.
• Multiple pregnancy—you’re pregnant with twins, a cesarean birth may be necessary if the babies are being born too early, are not in good positions in the uterus, or if there are other problems. The likelihood of having a cesarean birth increases with the number of babies a woman is carrying.
• A very large baby. Larger infants are at risk for complications during delivery. These include shoulder dystocia, when the infant’s head is delivered through the vagina but the shoulders are stuck ². Women with gestational diabetes, especially if their blood sugar levels are not well controlled, are at increased risk for having large babies.
• Maternal infections, such as human immunodeficiency virus (HIV) or herpes, that could be passed to the baby during vaginal birth. Cesarean delivery could help prevent transmission of the virus to the infant.
• Sometimes the placenta is not formed or working correctly, is in the wrong place in the uterus, or is implanted too deeply or firmly in the uterine wall. These issues can cause problems, such as preventing needed oxygen and nutrients from reaching the fetus or causing vaginal bleeding ³.
• Maternal medical conditions, such as diabetes mellitus or high blood pressure

If there’s time to plan the procedure, your midwife or doctor will discuss the benefits and risks of a cesarean compared with a vaginal birth.

Is a cesarean birth necessary if I have had a previous cesarean birth?

Women who have had a cesarean birth before may be able to give birth vaginally. The decision depends on the type of incision used in the previous cesarean delivery, the number of previous cesarean deliveries, whether you have any conditions that make a vaginal delivery risky, and the type of hospital in which you have your baby, as well as other factors. Talk to your obstetrician–gynecologist (ob-gyn) or other health care professional about your options.

Can I request cesarean birth?

Some women choose to have a cesarean for non-medical reasons. If you ask your midwife or doctor for a cesarean when there aren’t medical reasons, they will explain the overall benefits and risks of a cesarean compared with a vaginal birth.

Regardless of the type of delivery, unless there is a medical necessity, delivery should not occur before 39 weeks of pregnancy (called “full term”).

If you’re anxious about giving birth, you should be offered the chance to discuss your anxiety with a healthcare professional who can offer support during your pregnancy and labor.

If after discussion and support you still feel that a vaginal birth isn’t an acceptable option, you’re entitled to have a planned cesarean.

Cesarean section procedure

Cesarean sections are carried out in hospital. You may be asked to come in for an appointment a few days beforehand, and you might need to stay in hospital for a few days afterwards.

Preoperative appointment

If there’s time to plan your cesarean, you’ll be given an approximate date for it to be carried out.

You’ll also be asked to attend an appointment at the hospital in the week before the procedure is due to be performed.

During this appointment:

• you can ask any questions you have about the procedure
• a blood test will be carried out to check for a lack of red blood cells (anemia)
• you’ll be given some medication to take before the procedure – this may include antibiotics, anti-sickness medication (anti-emetics) and medication to reduce the acidity of your stomach acid (antacids)
• you’ll be asked to sign a consent form

You’ll need to stop eating and drinking a few hours before the procedure – your doctor or midwife will tell you when.

Cesarean section preparation

You’ll be asked to change into a hospital gown when you arrive at the hospital on the day of the procedure.

Before you have a cesarean delivery, a nurse will prepare you for the operation. An intravenous line (IV) will be put in a vein in your arm or hand. This allows you to get fluids and medications during the surgery. Your abdomen will be washed, and your pubic hair may be clipped or trimmed. You will be given medication to prevent infection.

A thin, flexible tube called a catheter will be inserted into your bladder to empty it while you’re under the anaesthetic, and a small area of pubic hair will be trimmed if necessary. Keeping the bladder empty decreases the chance of injuring it during surgery.

You’ll be given the anaesthetic in the operating room. You will be given either general anesthesia, an epidural block, or a spinal block. If general anesthesia is used, you will not be awake during the delivery. An epidural block numbs the lower half of the body. An injection is made into a space in your spine in your lower back. A small tube may be inserted into this space so that more of the drug can be given through the tube later, if needed. A spinal block also numbs the lower half of your body. You receive it the same way as an epidural block, but the drug is injected directly into the spinal fluid. This means you’ll be awake during the delivery and can see and hold your baby straight away.

It also means your birth partner can be with you.

General anaesthetic – where you’re asleep – is used in some cases if you can’t have a spinal or epidural anaesthetic.

What happens during cesarean surgery

During the cesarean section procedure:

• you lie down on an operating table, which may be slightly tilted to begin with
• a screen is placed across your tummy so you can’t see the operation being done
• a 10-20cm cut is made in your tummy and womb – the skin incision may be transverse (horizontal or “bikini”) cut just below your bikini line although sometimes a vertical cut below your bellybutton may be made
• the muscles in your abdomen are separated and may not need to be cut. Another incision will be made in the wall of the uterus. The incision in the wall of the uterus also will be either transverse or vertical.
• your baby is delivered through the opening, the umbilical cord will be cut, and then the placenta will be removed– this usually takes 5-10 minutes and you may feel some tugging at this point
• your baby will be lifted up for you to see as soon as they’ve been delivered, and they’ll be brought over to you
• you’re given an injection of the hormone oxytocin once your baby is born to encourage your womb to contract and reduce blood loss
• your womb is closed with dissolvable stitches, and the cut in your tummy is closed either with dissolvable stitches, or stitches or staples that need to be removed after a few days

The whole procedure usually takes around 40-50 minutes.

Cesarean section recovery

You’ll usually be moved from the operating room to a recovery room straight after the cesarean section procedure. If you are awake for the surgery, you can probably hold your baby right away.

Once you’ve started to recover from the anaesthetic, the medical staff will make sure you’re well and continue to observe you every few hours. Your blood pressure, pulse rate, breathing rate, amount of bleeding, and abdomen will be checked regularly.

If you are planning on breastfeeding, be sure to let your doctor know.

Having a cesarean delivery does not mean you will not be able to breastfeed your baby. You should be able to begin breastfeeding right away.

You’ll be offered:

• painkillers to relieve any discomfort
• treatment to reduce the risk of blood clots – this may include compression stockings or injections of blood-thinning medication, or both
• food and water as soon you as you feel hungry or thirsty
• help with breastfeeding your baby if you want it – read more about the first few days of breastfeeding

The catheter will usually be removed from your bladder around 12-18 hours after the procedure, once you’re able to walk around.

You may be in hospital for a few days after a cesarean section, and may need to take things easy for several weeks.

Recovering in hospital

The average stay in hospital after a cesarean is around three or four days. You may be able to go home sooner than this if both you and your baby are well.

While in hospital:

• you’ll be given painkillers to reduce any discomfort
• you’ll have regular close contact with your baby and can start breastfeeding
• you’ll be encouraged to get out of bed and move around as soon as possible. The first few times you get out of bed, a nurse or other adult should help you.
• you can eat and drink as soon as you feel hungry or thirsty
• a thin, flexible tube called a catheter will remain in your bladder for at least 12 hours
• your wound will be covered with a dressing for at least 24 hours

A hospital stay after a cesarean birth usually is 2–4 days. The length of your stay depends on the reason for the cesarean birth and on how long it takes for your body to recover.

When you’re well enough to go home, you’ll need to arrange for someone to give you a lift as you won’t be able to drive for a few weeks.

When you go home, you may need to take special care of yourself and limit your activities.

Looking after your wound

The abdominal incision will be sore for the first few days. Your midwife should also advise you on how to look after your wound.

Your doctor can prescribe pain medication for you to take after the anesthesia wears off. A heating pad may be helpful. There are many different ways to control pain. Talk with your ob-gyn or other health care professional about your options.

You’ll usually be advised to:

• gently clean and dry the wound every day
• wear loose, comfortable clothes and cotton underwear
• take painkillers if the wound is sore – see controlling pain
• watch out for signs of infection – see when to get medical advice

Non-dissolvable stitches or staples will usually be taken out by your midwife after five to seven days.

Your cesarean section scar

The wound in your tummy will eventually form a scar.

This will usually be a horizontal scar about 10-20cm long, just below your bikini line.

In rare cases, you may have a vertical scar just below your belly button.

The cesarean section scar will probably be red and obvious at first, but it should fade with time and will often be hidden in your pubic hair.

Controlling pain and bleeding

Most women experience some discomfort for the first few days after a cesarean, and for some women the pain can last several weeks.

You should be given regular painkillers to take at home, for as long as you need them.

Paracetamol is usually recommended for mild pain, co-codamol for moderate pain, and a combination of co-codamol and ibuprofen for more severe pain.

You may also have some vaginal bleeding. Use sanitary pads rather than tampons to reduce the risk of spreading infection into the vagina, and get medical advice if the bleeding is heavy.

What should I expect during recovery?

While you recover, the following things may happen:

• Mild cramping, especially if you are breastfeeding
• Bleeding or discharge for about 4–6 weeks
• Bleeding with clots and cramps
• Pain in the incision

To prevent infection, for a few weeks after the cesarean birth you should not place anything in your vagina or have sex. Allow time to heal before doing any strenuous activity. Call your Obstetrician–Gynecologist or other health care professional if you have a fever, heavy bleeding, or the pain gets worse.

If you experience severe mood swings, loss of appetite, overwhelming fatigue and lack of joy in life shortly after childbirth, you might have postpartum depression. Contact your health care provider if you think you might be depressed, especially if your signs and symptoms don’t fade on their own, you have trouble caring for your baby or completing daily tasks, or you have thoughts of harming yourself or your baby.

The American College of Obstetricians and Gynecologists recommends that postpartum care be an ongoing process rather than just a single visit after your delivery. Have contact with your health care provider within the first three weeks after delivery. Within 12 weeks after delivery, see your health care provider for a comprehensive postpartum evaluation. During this appointment your health care provider will check your mood and emotional well-being, discuss contraception and birth spacing, review information about infant care and feeding, talk about your sleep habits and issues related to fatigue and do a physical exam. This might include a check of your abdomen, vagina, cervix and uterus to make sure you’re healing well. In some cases, you might have the checkup earlier so that your health care provider can examine your C-section incision. Use this visit to ask questions about your recovery and caring for your baby.

Returning to your normal activities

Try to stay mobile and do gentle activities, such as going for a daily walk, while you’re recovering to reduce the risk of blood clots. Be careful not to overexert yourself.

You should be able to hold and carry your baby once you get home. But you may not be able to do some activities straight away, such as:

• driving
• exercising
• carrying anything heavier than your baby
• having sex

Only start to do these things again when you feel able to do so and don’t find them uncomfortable. This may not be for six weeks or so.

Ask your midwife for advice if you’re unsure when it’s safe to start returning to your normal activities. You can also ask your doctor at your six-week postnatal check.

When to get medical advice

Contact your midwife or Obstetrician–Gynecologist straight away if you have any of the following symptoms after a cesarean:

• severe pain
• leaking urine
• pain when peeing
• heavy vaginal bleeding
• your wound becomes more red, painful and swollen
• a discharge of pus or foul-smelling fluid from your wound
• a cough or shortness of breath
• swelling or pain in your lower leg

These symptoms may be the sign of an infection or blood clot, which should be treated as soon as possible.

Cesarean section complications

A cesarean section is generally a very safe procedure, but like any type of surgery it carries a certain amount of risk of complications.

It’s important to be aware of the possible complications, particularly if you’re considering having a cesarean for non-medical reasons.

The level of risk will depend on things such as whether cesarean section procedure is planned or carried out as an emergency, and your general health.

If there’s time to plan your cesarean section, your doctor or midwife will talk to you about the potential risks and benefits of the procedure.

Possible complications include:

• infection of the wound or womb lining
• blood clots in the legs, pelvic organs, or lungs
• excessive bleeding
• damage to nearby areas, such as the bowel or the bladder or the tubes that connect the kidneys and bladder (ureter)
• temporary breathing difficulties in your baby
• accidentally cutting your baby when your womb is opened

Risks to you

Some of the main risks to you of having a cesarean section include:

• infection of the wound (common) – causing redness, swelling, increasing pain and discharge from the wound
• infection of the womb lining (common) – symptoms include a fever, tummy pain, abnormal vaginal discharge and heavy vaginal bleeding
• excessive bleeding (uncommon) – this may require a blood transfusion in severe cases or possibly further surgery to stop the bleeding
• deep vein thrombosis (DVT) (rare) – a blood clot in your leg, which can cause pain and swelling and could be very dangerous if it travels to the lungs (pulmonary embolism)
• damage to your bladder or the tubes that connect the kidneys and bladder (rare) – this may require further surgery
• reaction to medications or to the anesthesia that is used

Women are now given antibiotics before having a cesarean, which should mean infections become much less common.

Risks to your baby

A cesarean doesn’t affect the risk of some of the rarest and most serious birth complications, such as an injury to the nerves in the neck and arms, bleeding inside the skull, or death.

But a cesarean section can sometimes cause the following problems in babies:

• a cut in the skin (common) – this may happen accidentally as your womb is opened, but it’s usually minor and heals without any problems
• breathing difficulties (common) – this most often affects babies born before 39 weeks of pregnancy; it will usually improve after a few days and your baby will be closely monitored in hospital

If you think your baby is experiencing breathing difficulties after you’ve left hospital, contact your doctor straight away.

Risks to future pregnancies

Women who have a cesarean will usually have no problems with future pregnancies.

Most women who have had a cesarean section can safely have a vaginal delivery for their next baby – known as vaginal birth after cesarean. But sometimes another cesarean may be necessary.

Although uncommon, having a cesarean can increase the risk of certain problems in future pregnancies, including:

• the scar in your womb opening up
• the placenta being abnormally attached to the wall of the womb, leading to difficulties delivering the placenta
• stillbirth

Speak to your doctor or midwife if you have any concerns.

Vaginal birth after cesarean section

If you’ve delivered a baby by C-section and you’re pregnant again, you might be able to choose between scheduling a repeat C-section or attempting vaginal birth after C-section (vaginal birth after cesarean section).

For many women, vaginal birth after cesarean section is an option. In fact, research on women who attempt a trial of labor after cesarean shows that about 60 to 80 percent have a successful vaginal delivery.

Vaginal birth after cesarean section isn’t right for everyone, though. Certain factors, such as a high-risk uterine scar, can make vaginal birth after cesarean section inappropriate. Some hospitals don’t offer vaginal birth after cesarean section because they don’t have the staff or resources to handle emergency C-sections. If you’re considering vaginal birth after cesarean section, your health care provider can help you understand if you’re a candidate and what’s involved.

Why vaginal birth after cesarean section is done

Women consider vaginal birth after cesarean section for various reasons, including:

• Shorter recovery time. You’ll have a shorter hospital stay after a vaginal birth after cesarean section than you would after a repeat C-section. Avoiding surgery will help your energy and stamina return more quickly, as well as reduce the expense of childbirth.
• More participation in the birth. For some women, it’s important to experience a vaginal delivery. Your labor coach and others also may be able to play a greater role.
• Impact on future pregnancies. If you’re planning a larger family, vaginal birth after cesarean section might help you avoid the risks of multiple cesarean deliveries.

The chances of a successful vaginal birth after cesarean section are higher if:

• You’ve had only one prior low transverse uterine incision — the most common type for a C-section
• You and your baby are healthy and your pregnancy is progressing normally
• The reason you had your prior C-section isn’t a factor this time
• Your labor begins naturally on or before your due date
• You’ve had a previous successful vaginal delivery

The chances of a successful vaginal birth after cesarean section are lower if:

• Your pregnancy continues beyond your due date
• You have an unusually large baby — suspected fetal macrosomia
• You’ve had two or more cesarean sections

You’re not a candidate for vaginal birth after cesarean section if you had a uterine rupture during a previous pregnancy. Similarly, vaginal birth after cesarean section isn’t recommended if you have had a vertical incision in the upper part of your uterus (classical incision) due to the risk of uterine rupture.

Vaginal birth after cesarean section risks

Vaginal birth after cesarean section poses potentially serious risks, including:

• Failed attempt at labor. Labor can results in a repeat C-section.
• Uterine rupture. Rarely, the uterus might tear open along the scar line from a prior C-section. If your uterus ruptures, an emergency C-section is needed to prevent life-threatening complications, including heavy bleeding and infection for the mother and brain damage for the baby. In some cases, the uterus might need to be removed (hysterectomy) to stop the bleeding. If your uterus is removed, you won’t be able to get pregnant again.

How you prepare for vaginal birth after cesarean section

If you choose vaginal birth after cesarean section, boost your odds of a positive experience:

• Learn about vaginal birth after cesarean section. Take a childbirth class on vaginal birth after cesarean section. Include your partner or another loved one, if possible. Also discuss your concerns and expectations with your health care provider. Make sure he or she has your complete medical history, including records of your previous cesarean section and any other uterine procedures.
• Plan to deliver the baby at a well-equipped hospital. Close monitoring can decrease the risk of complications. Look for a facility that’s equipped to handle an emergency cesarean section.
• Allow labor to begin naturally, if you can. Drugs to induce labor can make contractions stronger and more frequent, which might contribute to the risk of uterine rupture — especially if the cervix is tightly closed and not ready for labor.
• Be prepared for a cesarean section. Some complications of pregnancy or delivery might require a cesarean section. For example, you might need a cesarean section if there’s a problem with the placenta or umbilical cord, your baby is in an abnormal position or your labor fails to progress.

What you can expect

If you choose vaginal birth after cesarean section, your prenatal care will be just like the care you’d receive during any other healthy pregnancy.

When you go into labor, you’ll follow the same process as any woman expecting to deliver vaginally — although you and your baby will be more closely monitored during labor. Your health care provider will be prepared to do a repeat cesarean section if needed.

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2. Chatfield, J. (2001). ACOG issues guidelines on fetal macrosomia. American Family Physician, 64(1), 169–170.[↩]
3. American College of Obstetricians and Gynecologists. (2016). FAQ: Bleeding during pregnancy. https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy[↩]