Cesarean Sections
By Lisa Glickstein, Ph.D, Triplet Mom
Originally printed in February 2004

What is a Cesarean Section (C-Section)?

A C-Section, also called abdominal delivery, is the surgical delivery of a pregnancy
through an incision (cut) in the wall of the abdomen and uterus.  The incision can
be made quite low, sometimes called a "bikini cut" because it is made 
just at the top of the line of pubic hair. This is the easiest type of C-Section
to recover from and the only type that permits a later vaginal delivery, also referred
to as vaginal birth after cesarean (VBAC).  Your surgeon may need to make a different
type of incision if indicated by the circumstances of your pregnancy or delivery
(for example, the placement of a placenta, position or distress of one of the babies,
or need for urgent delivery).  Following a low of just over 11% for primary cesarean
(C-Section in a first pregnancy) as recently as 1996, the primary C-Section rate
is now climbing to nearly 17% in Massachusetts.  The overall rate for C-sections
is about 25%, meaning that one in four pregnancies now delivers by C-Section.  There
are small variations between local hospitals, but these are generally not significant.
The smaller regional hospitals, and midwife-attended hospital deliveries, have a
significantly lower C-Section rate (ranging between 7-17%), but these are selected
to exclude high-risk pregnancies that are more likely to require a C-Section.

Will I have a C-Section with my multiple delivery?  A later pregnancy?

The vast majority of higher order multiples are delivered by C-Section.  This is
because of preterm birth (vaginal delivery is too traumatic for early premies), 
position of one of more of the babies that prevents vaginal delivery, medical conditions
of the mother (heart trouble, high blood pressure, other), medical conditions of
the babies, and emergency delivery due to fetal distress.  If you make it close 
to term, you can discuss vaginal delivery with your doctor.

If you have the "bikini cut" incision, you may have a VBAC for a later
pregnancy.  Other types of incisions have been shown to make the uterus susceptible
to rupture during labor; for this reason you may be told that because of a prior
C-Section you can't have VBAC.  For medical liability reasons, as well as new information
on safety, VBAC rates are currently plummeting in the United States, from a high
of over 25% is 1996, to a current rate of between 10-15%.  This is an issue to discuss
carefully with your doctor, and will depend greatly on his or her experience, philosophy,
and your individual history and needs.

Can I be awake for my C-Section?

The surgery can be performed under epidural, spinal, or general (total) anesthesia.
For both epidural and spinal anesthesia, the mother is awake.  The anesthetic (drug)
is put directly into the spinal fluid for a spinal, rather than around the tough
covering protecting the spinal cord (dura), as in an epidural.  For this reason,
the spinal is faster, and somewhat more dangerous with more potential side effects.
You are more likely to have a spinal or general anesthesia, where you are "knocked
out," if you have an emergency C-Section.  In case of a sudden emergency requiring
delivery under general anesthesia, things may move extremely quickly.  Your husband
or partner may not be allowed into the delivery room at this time or may be shown
out suddenly.  This is done to allow the medical staff to focus exclusively on your
needs and the needs of your babies.

What does it feel like?

The placement of the anesthetic around (epidural) or into (spinal) your spinal column
is somewhat painful and certainly uncomfortable.  Usually a local anesthetic (like
novocaine) is put into the skin to numb it.  This causes a burning sensation in 
the skin, much like getting novocaine at the dentist. Then you bend forward, or 
lying down curl forward, to open some space between your vertebra (backbones) in
your mid-lower back.  The anesthesiologist then inserts a needle and injects the
drug.  This part is not painful, but feels like someone is cracking your back (like
a chiropractor); there is also some pressure.  Then, they stretch you out on the
table and start to prep you for the surgery.  As the drugs work, your legs and abdomen
slowly get numb.  The numbness will go up to your lower chest (possibly into your
midchest if you get a spinal).  This may make you feel as if you can't breathe; 
the anesthesiologist will reassure you that usually this is just due to the numbness
and that your breathing is actually normal.  Once the surgery starts, you should
feel nothing as the doctor makes the incision.  It is rare to have a failed spinal
anesthesia, but epidurals can more often be faulty or partial. If you have any painful
sensations, don't hesitate to let the anesthesiologist know right away (he or she
will be sitting by your head, usually talking to you during the procedure). The 
amount of drug may be increased or the cannula (tube) into your back shifted to 
increase the anesthesia.  It is normal even with perfect anesthesia to have sensations
as your uterus is shifted around and the babies are pulled out; these can vary between
pressure, uncomfortable tugging, or nausea.  These are very rarely painful, and 
this part is over quickly.  Finally, the babies are delivered and the surgeon checks
over your uterus, tubes, and ovaries, and sews the incisions in your uterus and 
abdomen closed.  Again, there is rarely any sensation during the sewing.  Your uterus
should continue to contract, which will stop any bleeding.  If it does not, you 
will be given medication (like pitocin) to cause contractions.

Will my partner be allowed into the delivery room if I have a C-Section?

Generally, the answer is "yes."  There might be individual circumstances
where this is not recommended, but even in an emergency C-Section, the partner is
usually allowed to observe.

What will my partner see?

Normally, a large drape (curtain) is put in front of the mother so she does not 
see the surgery.  If the partner sits near her head, he or she will not have to 
see anything either.  The babies will be lifted over the level of the drape after
they are delivered.  The partner can position him/herself to see more, if desired.
Often this is not recommended, as if he/she passes out he/she could be in the way
at the least, or require medical attention at the worst.  Having said this, many
partners, including my husband, observe the C-Section directly.

How will I recover immediately?  Later?

Right after surgery the babies will be taken to the NICU if they are preterm, or
they may be left with you for a short time if they are near or full term.  The partner
usually accompanies the babies while the mother goes to a recovery room.  Gradually,
the numbness wears off.  Once you wiggle your toes, the catheter may be removed 
so you can urinate.  If you had general anesthesia, you wake up and may feel nauseated;
ask for an anti-emetic medication if this is the case.  You can also get a severe
headache rarely from spinal anesthesia if there is a leak of spinal fluid where 
they injected the drugs. If so, you will have to lie flat until the hole seals itself,
which can take 24-48 hours.  The pain is usually a combination of burning at the
incision site, muscle and internal aches, and severe contractions or cramping.  
You can get pain medication through your intravenous line (IV); usually a pump is
hooked up so you can medicate yourself.  It is important to use the pump at the 
first sign of pain or discomfort; the pump is programmed so that you can't overdose
yourself.  At some point, you will be recovered enough to go to a regular room. 
I was taken into the NICU on the way (bed and all) to see the babies.  Usually within
the first day, you will be able to stand (with some help) and walk around.  This,
while uncomfortable or painful, will help your recovery.

Your incision will be checked once to several times a day.  You will need to use
a pillow over the incision with some pressure to sit up or stand up, and once you
are discharged, when you are being driven by car for a week or so.  Sudden stops
or turns can put too much pulling on the incision or crash you into the lap belt
and be painful at the least.  It is also helpful to use a pillow if you are laughing
a lot - my sister actually made me laugh so hard, I busted a stitch!  Your lung 
function will be checked by having you inhale into a special tube.  If you are getting
up and around, you should have no problems with this.  Your temperature will be 
checked to ensure that you don't have a fever, which could be a sign of infection.
It is normal to have a heavy discharge of somewhat bloody mucus (lochia), which 
is coming from your uterus as it shrinks back to normal size.  Heavy cramping is
also a positive sign of recovery and is caused by the uterus squeezing back down
to normal.  If you are pumping breast milk, or breast feeding, the cramping will
accompany the pumping or feeding sessions.  This is helping your uterus return to
normal, and prevent bleeding.  You should not have true bleeding; that could be 
a sign of a retained piece of placenta.  It is normal to urinate in larger than 
normal volume, both because of the IV fluids, as well as your body getting rid of
the excess blood volume you carried during pregnancy.  Over the few days in the 
hospital, your IV pain medication will be changed to oral Tylenol; your IV fluids
will be discontinued once you are off the IV pain meds and are drinking and eating.
It is normal to have some night sweats, especially if you are breast pumping or 
nursing, as your hormones change.  You will get to eat what you want, and get up
and around at will to visit the NICU, care for yourself, have visitors, and so on.

You should start breast pumping immediately once you can eat and drink in your regular
hospital room.  This is usually within six hours of delivery.  The regular nurses
can help you set up the pump.  At first, nothing will happen, or your nipples will
just appear wet.  However, over the next 24 hours, your breasts will enlarge, and
you will be able to tell they are beginning to engorge (swell) as the milk production
machinery gets going.  This may take a bit longer (up to three days) if you delivery
very prematurely (before 30 weeks).  Keep pumping every 3-4 hours (more often if
you are uncomfortable), and throughout the night.  Your breasts will first produce
small (tablespoon) amounts of colostrum, an extremely nutritious clear or yellow
liquid that contains antibodies from your body that will protect your baby from 
infection.  Don't throw it away!  Save it and bring to the NICU for your babies.
Later, true milk production will start, and gradually increase with pumping.  It
is normal to produce more milk in the morning.  It is helpful to manually express
(squeeze) milk from each of your ducts prior to pumping; this will help to clear
any blockages that could lead to breast infection (mastitis).  Taking most normally
prescribed antibiotics or pain medication does not mean that your milk is not healthy
for your babies.  Check with a lactation consultant at the hospital or through the
La Leche League (not with the NICU nurses or doctors, who may be less well informed),
for specific information.

Active recovery continues at home.  Be alert in the first two weeks for signs of
infection in your incision or otherwise, by monitoring for fever or reporting to
your doctor if you begin to feel worse or more fatigued.  Mastitis is also most 
common during the first six weeks.  You need to be sure to keep drinking lots of
fluids, especially if you are breastfeeding (or pumping).  Breastfeeding or pumping
milk will help you lose weight.  Remember that your body is remodeling (healing 
from surgery, shrinking your uterus, destroying extra red blood cells made for pregnancy,
losing weight, and creating breast tissue), which creates waste products and is 
very hard on your kidneys.  Women are very susceptible to kidney stones during the
early post-partum period (up to eight weeks after delivery).  If you feel sudden
onset of extremely severe abdominal or back pain, accompanied by nausea, place an
emergency call to your doctor as you may be passing kidney stones.  Drinking plenty
of fluids, eating healthful foods, and sleeping enough are all important for recovery.
If you are getting up twice at night to pump, be sure to take a nap during the day.
Gentle exercise as your doctor permits (daily walks at first) will help physically
and emotionally.  If you have been on bedrest, take things even more slowly.  Don't
wear yourself out while your babies are still in the hospital; they are receiving
excellent care and will need you to be at your best when they get home.  It is okay
to spend more time at home or even skip a visit if you are not feeling well, especially
if the hospital is far from home.  Let someone else do the housework, as if your
babies were already home.  Emotionally, it is normal to feel weepy, sad, tired, 
exhausted, on edge, angry, or even vacant at times during this early recovery.  
This is even more so if your babies are in the NICU or having difficulty.  However,
if you have disturbing thoughts or feelings, do talk to someone, for example the
social worker in the NICU, your doctor, a psychologist or psychiatrist, or a trusted
friend or advisor.

You should feel better by six weeks after your C-Section, but you will not feel 
"back to normal" for up to a year after delivery.  Do not be concerned
if you don't feel perfect after six weeks, but do contact your doctor if you are
concerned about lingering physical pain, or emotional or psychological disturbance
at this point.  Some changes are permanent, but that is not always a bad thing!