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Cesarean Section

Osher Ben Or, Certified Midwife
15 June 2024

During a cesarean section, the newborn emerges into the world through an incision in the abdomen and uterus. A cesarean section can be preplanned, decided in advance (elective), or an emergency procedure in cases in which a regular delivery has commenced.

The reasons for a cesarean section are diverse and linked to risk factors for both the mother and the fetus. Usually, a planned cesarean section follows a predetermined scenario, such as a breech presentation, a woman in her second pregnancy opting for a cesarean section, and more. This procedure is usually performed after at least 38 gestational weeks and at the discretion of the medical team. The preparation stages of a cesarean section include a preoperative procedure, during which the medical team assesses the situation, provides information, refers to a maternity ER and records vital signs (blood pressure, pulse, and temperature), checks for protein in the urine, and monitors fetal activity.

Afterwards, you will undergo a medical examination, receive an explanation of the surgery, and sign the consent forms.

Usually, a cesarean section is performed under regional, epidural, or spinal (regional) anesthesia. General anesthesia is performed only on rare occasions. As preparation for the surgery, you will be asked to fast for 8 hours. During the course of surgery, a low, transverse incision is made in the lower abdomen, and the abdomen walls are opened in layers until reaching the peritoneum, the membrane that lines the internal abdominal cavity.

An incision other than transverse may be necessary, depending on the gestational week, fetal presentation, and medical judgment. A cesarean section lasts around 45 minutes (including preparation and anesthesia). After the surgery, the newborn will undergo initial care, including weight estimation, temperature measurement, and examination of vital signs.

Cesarean section: reasons, preparation, and course of surgery

A cesarean section is a medical procedure by which the newborn emerges into the world through an incision in the abdomen and uterus. This procedure necessitates prior preparations, both by the medical center and the birthing mother. A cesarean section can be preplanned, decided in advance (elective), or an emergency procedure in cases where a regular delivery has commenced.

While a cesarean section is now considered highly common, with approximately 20% of all deliveries concluding with this procedure, it remains a surgical process with inherent risks. It is entirely natural to have numerous concerns. To help you alleviate some of the stress, you should familiarize yourself with all the details about the surgery and the anesthesia, the reasons for performing the surgery, the preparation, and the various stages of the procedure.

The reasons for performing a cesarean section

The indications for a cesarean section are diverse and divided between maternal and fetal reasons. In some cases, it is possible to consider whether to perform the surgery or to allow a vaginal delivery.

Reasons related to the mother

  • Lack of progress in childbirth.
  • Obstetric history: after previous cesarean sections.
  • Multiple births: and according to fetal presentations and the mother’s preference.
  • Mechanical obstruction of the birth canal.
  • An active maternal infection in the vagina or the birth canal: a situation that may infect the newborn and cause a severe morbidity, including nerve damage, and various developmental issues.
  • Placenta previa: a condition in which the placenta partially or entirely obstructs the cervix. In such cases, a cesarean section becomes the only viable option.
  • Structural defects in the uterus: examined according to the defect, the presentation of the fetus and medical discretion.
  • Placenta accreta: a placenta accreta occurs when the placenta (afterbirth) grows into the uterine wall, potentially penetrating through to adjacent organs such as the bladder or intestines.
  • Various maternal illnesses that do not enable a vaginal delivery (including maternal heart defects or malformations in the nervous system, depending on the nature of the defect and its severity).

Reasons related to the fetus

  • Suspected fetal distress: according to the fetal monitor or ultrasound assessment.
  • Pathological presentation (a presentation that is not head down): a condition in which the lower preliminary part is not the fetus head, for example, breech or transverse presentation.
  • Suspected fetal macrosomia: a condition in which the fetal weight exceeds 4,500 grams (in cases of gestational diabetes, a cesarean section is typically recommended when the estimated weight is around 4,200 grams, subject to the discretion of the medical team). A newborn vaginal delivery with a large weight estimation poses a risk factor for shoulder dystocia, in which it is difficult to extract the upper shoulder during labor. This is an emergency situation that may lead to substantial damage both to the mother and the newborn.
  • Multiple birth, subject to the discretion of the medical team.
  • Low fetal platelet level.
  • Extreme preterm.
  • Certain fetal defects.
  • Umbilical cord prolapses: a condition in which the umbilical cord precedes the head of the newborn and the blood flow in the umbilical cord is damaged. This is an emergency situation, necessitating an immediate cesarean section.

How is the urgency level of a cesarean section determined

The urgency level of a cesarean section depends on specific circumstances:

Scheduled (elective)

A scheduled cesarean section performed according to a predetermined scenario, and not under urgent circumstances. The reasons can be diverse, including the condition after previous cesarean sections, a fetus not in a head down presentation, a twin pregnancy in which the first twin is not in a head down presentation, and more.

Urgent

A cesarean section performed during delivery. In this situation, the birthing mother has initiated a regular delivery process, and due to an urgent medical reason related to either the mother or the fetus, there is a need to promptly terminate the delivery. While surgery is necessary in such cases, preparation is still feasible.

Emergent

A cesarean section performed immediately in a condition in which a medical emergency is suspected.

Scheduling of a predetermined cesarean section

A predetermined cesarean section is usually performed after at least 38 gestational weeks. Some maternal or fetal medical conditions affect the surgery scheduling, subject to the discretion of the medical team.

Preparatory steps for an elective cesarean section

  • 1
    Referral letter

    When a planned cesarean section has been determined, your gynecologist will provide you with a detailed referral letter, and you will be instructed to get in touch with the medical center where you intend to undergo the surgery. It is recommended to contact the delivery room administrative office or check the medical center's website to learn how to schedule a cesarean section and submit the referral letter.

  • 2
    Preoperative stage

    Shortly before the surgery, you will be called for a preoperative procedure. On this day, the medical team will assess both your and your fetus's health, requiring all the tests conducted during your pregnancy, your pregnancy follow-up card, and any other relevant information. During this visit to the preoperative clinic, you will receive details about the arrival schedule and the necessary preparations. Additionally, you will receive some detailed information about the procedure on the operation day and on the hospitalization after it. If you take regular medication, it is important to ask what is allowed and what should be stopped prior to the operation (for example, antithrombotic).

  • 3
    Referral to the maternity ER

    After opening a medical record, you will be referred to the maternity ER or the preoperative clinic (the process varies between the various medical centers). At the clinic, the team will ask you questions regarding your pregnancy and your general health, inquiring about medication/substances or food intolerance. They will record your pregnancy follow-up, measure your vital signs (blood pressure, pulse, and temperature), check your urine protein level, and conduct a fetal monitor.

  • 4
    Medical examination

    A gynecologist will perform an assessment before the cesarean section and gather information about your general health, obstetric history, and current pregnancy follow-up. Following this, you will undergo a physical examination and an ultrasound to assess the fetal condition. Subsequently, you will receive a detailed explanation about the operation and be required to sign consent forms for the cesarean section (including consent for blood transfusion, if necessary). Additionally, any required blood tests will be conducted.

  • 5
    Checking the mother’s preferences

    If you prefer to have zero separation from your baby and this option is available in the medical center where you will give birth, inform the midwife so that they can make the necessary arrangements. Please note that usually, an escort is required in the recovery room and in the ward during zero separation, until you feel well enough to be mobile and can independently take care of your baby.

You should know

  • In the case of a planned cesarean section, most medical centers permit one escort to be present in the operating room, provided that the escort receives advance guidance on conduct during the surgery (usually the guidance is the responsibility of a midwife). Additionally, the escort has to sign a designated form in advance
  • In some medical centers, a friendly cesarean section can be selected. Some have a transparent screen where parents can watch their newborn emerge into the world. In some cases, when both the mother and the newborn feel well and do not require special supervision or care, the medical team may allow placing the newborn on the mother’s chest or skin-to-skin contact with the other parent until the conclusion of the operation. Afterwards, there can be a transition to ongoing skin-to-skin contact with the mother in the recovery room. Moreover, in certain medical centers, a "zero separation" procedure is implemented during a planned cesarean section, wherein the newborn remains with the mother (or the other parent) continuously, without any separation, until the transfer to the maternity ward. Choosing a friendly cesarean section with zero separation allows the mother and newborn a good initial bonding experience.

Pre-operation anesthesia process

As part of the preoperative process, a doctor from the anesthetization staff will explain the anesthesia process, considering the emergency extent of the operation and any limitations the patient may have in receiving a specific type of anesthesia. Additionally, you will be asked to sign the consent form for anesthesia. Usually, a cesarean section is conducted using regional anesthesia, such as epidural or spinal, with general anesthesia being rarely employed.

A tube is placed into the epidural space, positioned between the lumbar vertebrae, through which an anesthetic is then administered. Usually, this type of anesthesia is administered when the patient is already in labor. It is decided, with her consent, to conclude the delivery with an operation due to reasons such as suspected fetal distress, lack of progress, and more. Epidural anesthesia enables the patient to be fully conscious and feel a complete or substantial relief of pain. Epidural anesthesia has little impact on the fetus because the anesthetic substance does not pass into the fetal bloodstream. Additionally, the tube enables adding medications, so the impact of pain relief is prolonged as long as necessary.

Side effects: headaches, inability to spontaneously produce urine (a catheter is inserted during the operation), decrease in blood pressure, shivering, or itchy skin. Complications are rare and may involve local inflammation at the injection site, temporary nerve damage, or dural membrane puncture leading to a leak of the cerebrospinal fluid into the epidural space, which spontaneously resolves within several days. Potential impact on the newborn: A sharp decrease in maternal blood pressure can lead to a drop in the fetal pulse. The anesthesia team promptly responds by providing fluids and medications that can raise the blood pressure in a few seconds.

In most cases, a cesarean section is performed under spinal anesthesia, during which anesthetics are injected into the lower back, anesthetizing the lower body, so that you are conscious during the operation but do not experience any pain. The anesthetic substance is injected once into the spinal space in the spine (no tube is left to add substance). Its impact is quick and starts to subside after around two hours (as mentioned above, no substance can be added). Spinal anesthesia has various benefits: the patient experiences rapid anesthesia of the lower body from the moment of substance injection while remaining fully conscious. Moreover, the impact of the anesthetic substance on the fetus is minimal, as it does not pass into the fetal bloodstream.

Side effects: decreased blood pressure, dizziness and nausea, an itchy body, and shivering. Complications are rare and can involve local infection, bleeding, or temporary nerve damage. A sharp decrease in maternal blood pressure may lead to a drop in the fetal pulse. However, as previously mentioned in relation to epidural anesthesia, the anesthesia team promptly responds by administering fluids and medications.
Dizziness, nausea, or anesthesia failure may, in some cases, necessitate the medical staff switching to general anesthesia. Less common phenomena are nerve damage, bleeding around the injection site in the spine, or infection.

This type of anesthesia involves the administration of anesthetic substances into the vein while providing full respiratory support. General anesthesia is usually employed in cases of emergency operations where there is an immediate threat to the birthing mother or suspected fetal distress requiring prompt delivery. Additionally, general anesthesia is performed when spinal anesthesia is not feasible (because of counter-indications). The advantage of general anesthesia is its prompt application, which facilitates a rapid extraction of the fetus. However, it has several disadvantages: Under general anesthesia, the mother is unconscious and may feel as though she missed the experience of giving birth. Recovery from the operation is longer; therefore, the initial bonding of the mother with her baby may happen later. The anesthetic substances pass through the placenta to the fetus and may result in temporary respiratory suppression. Consequently, the newborn may require respiratory support at the beginning of life. For proper supervision during any general anesthesia, the presence of an obstetrician is necessary. However, usually, it is a short general anesthesia with minimal impact on the newborn. Additionally, the anesthetic substance has an impact on the mother as well, due to the risk of aspiration of gastric contents.

Side effects: low blood pressure, a general sense of discomfort, throat ache, and discomfort swallowing due to the presence of a tube in the trachea (windpipe), along with nausea, vomiting, shivering, chills, and a risk of aspiration of gastric content. In general, recovery is longer in a cesarean section with general anesthesia.

Preparation for a cesarean section

  • 1
    Fasting

    An 8-hour fasting is required before the operation.

  • 2
    Hair removal

    In some medical centers, you will be asked to remove the hair from the operation site in accordance with the center’s policy.

  • 3
    The day of your operation

    When you arrive at the maternity ER, a midwife will greet you and inquire about your pre-operation preparations at home, including fasting, hair removal, jewelry, contact lenses, etc. The medical team will measure your vital signs, listen to, or monitor the heartbeat of your fetus, ask you about your contractions and water breaking, and eventually prepare the required equipment for caring for the newborn in the operating room.

  • 4
    Taking antacids

    In some medical centers, about half an hour before the operation, the team will ask you to take liquid antacid medicine. This precautionary measure is taken to prevent the aspiration of gastric contents into the lungs in the event of vomiting during the operation as a reaction to the anesthetic substances.

  • 5
    Elastic bandages

    In accordance with the medical center's policy, in some delivery rooms, the medical team bandages the patient's legs with elastic bandages before the operation to help prevent the formation of blood clots due to lack of movement. Occasionally, a special pneumatic device is used to improve the blood flow in the veins of the legs during and after the operation.

  • 6
    Entering the operation room

    You will enter the operation room with a gown without underwear. You will be provided with disposable coverings for your feet and a disposable cap to cover your head.

  • 7
    Setting up an intravenous fluid line

    Before the operation, the medical team will establish intravenous (IV) fluids for the administration of fluids and medications.

  • 8
    Anesthesia

    The aesthetician team will administer your anesthesia.

  • 9
    Insertion of a catheter into the bladder

    After administering the anesthesia, the surgeon will insert a catheter into your bladder to empty it and to prevent the risk of damaging it during the operation. Moreover, after the operation, the catheter will be used to monitor the mother’s stability (measuring urinal production as an index of blood loss). The catheter is usually removed approximately 6 to 8 hours after the operation.

  • 10
    One-time antibiotic coverage

    You will be administered a preventive antibiotic to reduce and prevent the incidence of surgical site infection.

  • 11
    Preparing the patient

    This process involves washing the surgical site with a special substance, covering the patient with sterile drapes, erecting a screen to shield the operated site, and ensuring that the patient does not feel the surgical site.

  • 12
    The support person will join

    If possible, your support person will be allowed in the operating room.

Surgical team members

During the surgery two surgeons specializing in gynecology will be present in the operation room, along with an operating room nurse who assists with the surgery, brings equipment, and supports the surgical staff; anesthesiologist, whose role is to make sure the patient is free of pain and maintain her hemodynamic condition (as well as monitor her blood pressure and pulse and provide medications and fluids); an anesthesiologist’s assistant; and a midwife.

In pre-planned cesarean sections, the attendance of an obstetrician is determined by the medical center's policy. It is important to note that, in any situation, they are in close proximity to the operating room.

Course of the surgery

  1. Performing surgery: a low transverse incision is made in the lower abdomen, and the abdominal walls are opened in layers until reaching the peritoneum. When the uterus is exposed, another incision is made on the uterus, usually a low, transverse incision. A non-transverse incision may be required, depending on the gestational age of the fetus, the fetus's position, and at the discretion of the medical staff.
  2. The duration of surgery: an average cesarean section takes approximately 45 minutes, inclusive of preparation and anesthesia. Additional time may be required in the case of complications during surgery or the presence of adhesions in the abdominal cavity.
  3. Extracting the newborn: this process is performed according to the fetus’s position in the uterus. The newborn is, then, taken to the initial care station, accompanied by the support person. In the newborn assessment, the staff will conduct an assessment, including weight, temperature, and vital signs. Occasionally, the newborn may require some assistance in the transitioning from fetal life to the life outside the uterus, such as suctioning of secretions, administration of oxygen, etc.
  4. Linking the newborn to the mother: linking between the mother and the newborn is performed through ID wristbands, with the mother’s details confirmed by the birthing mother, and the newborn is brought to the parents shortly afterwards. Later, the baby is taken (with the other parent) to the newborn nursery, or according to the zero separation rules in the medical center.
  5. Separating the placenta and incision closing: while the nurse attends to the newborn, the surgeons proceed to separate the placenta from the uterus, remove it, and then gradually close the layers. Typically, incision closure is achieved with staples; however, there are additional techniques available, and you may inquire with the surgeons about them.
  6. Tubal ligation: you have the option to ask for this procedure to be performed during your cesarean section. Tube ligation is an irreversible procedure and is performed on patients who have no plans for further pregnancies. If the patient regrets her decision later on, the only option for conception would be through IVF treatments. Tubal ligation is recommended for women who have undergone multiple deliveries, especially those who have had several cesarean sections.

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