What is a caesarean section and what kinds of caesarean section are there?
Caesarean section is an operation in which a cut is made in your tummy (abdomen) and in the wall of your womb (uterus) so that your baby can be delivered without passing down through your vagina (birth canal).
The name caesarean section probably came from the Latin verb 'caedere' which means 'to cut.' It's considered very unlikely that Julius Caesar was born by caesarean, as his mother is known to have survived his birth and, in Roman times, caesarean sections were done only when a woman died in childbirth, in an attempt to save the baby. The first record of a mother and baby surviving a caesarean section comes from Switzerland in 1500. After several days in labour and help from thirteen midwives, the wife of Jakob Nufer, a sow gelder, performed the operation on his wife. She and the baby lived and she subsequently gave birth normally to five children, including twins. These days a caesarean section is an extremely safe procedure for mother and baby.
A caesarean section may be planned (elective caesarean section), or unplanned (including emergency or crash caesarean sections):
- In a planned (elective) caesarean section, you and your obstetric team decide before labour that you will be having a caesarean section. You don't go into labour, and the section is usually performed at 39 weeks, in order to do it before labour begins spontaneously. This means you will know the date of your baby's birth in advance.
- All other caesarean sections are considered emergency caesarean sections. The degree of urgency will vary greatly, depending on the reason. An emergency caesarean section generally means one that was not originally planned. It is often performed after labour has begun, in the first or second stage of labour, because it is felt to be the safest delivery option for you and your baby. Most emergency caesarean sections are performed 1-2 hours after the decision is taken to do one. A crash section will take place when things are more urgent, and things are done very quickly so that your baby will probably be born within half an hour of the decision.
Most caesarean sections are of a type called a lower segment caesarean section; a few are of a type called a classical caesarean section.
- Most caesarean sections are lower segment caesarean sections. This is often written as LSCS on your hospital notes. There is usually a horizontal cut low down on your tummy, and then a horizontal cut across the lower part of the womb (uterus). This type of section causes the least blood loss and has fewer complications for the mother, as well as allowing her to consider a vaginal birth in the next pregnancy.
- A classical caesarean section involves cutting the womb longways. A low vertical incision caesarean section is similar to a classical section, but the cut is as low as possible in the womb. These types of caesarean section are sometimes performed at very early gestations (when the lower segment of the uterus has not yet formed). It is more prone to complications, and any woman who has had a classical section is usually advised to have an elective section in subsequent pregnancies:
- Classical sections are not commonly performed, as it will often be the case that vaginal delivery will be considered equally safe for a very premature baby, and is a safer procedure for you, which doesn't affect your future ability to have a vaginal delivery.
- A caesarean hysterectomy is an emergency procedure: it is a caesarean section followed by the removal of the womb. It is done if life-threatening bleeding can't be stopped, or if the afterbirth (placenta) can't be removed because it has grown abnormally far into the womb (this is called placenta accreta).
How long does a caesarean section take?
A caesarean section typically takes 40 minutes to an hour from start to finish.
Will I be awake for a caesarean section?
Most caesarean sections are performed when you are awake, using an epidural anaesthetic or a spinal block. These procedures are called regional anaesthetics. They numb your lower half, so that you feel no pain but are completely awake during the procedure, and they don't usually make your baby sleepy either. This means you can see and hold your baby as soon as he or she is born, and your partner can be in the room to share the experience too.
Occasionally a general anaesthetic is needed. This may happen because your caesarean is a very urgent, 'crash' caesarean section (a general anaesthetic is much quicker than a spinal or epidural, unless you already have an epidural in place).
Some women don't want to be awake, and choose general anaesthetic. If this is the case the anaesthetist is likely to want to talk to you about the advantages, for you and your baby, of an 'awake' delivery before you finally decide. If you have a general anaesthetic then:
- Unlike epidurals and spinals, the medications used in a general anaesthetic reach your baby, and may make him or her sleepy for a while after birth.
- You and your partner won't see your baby born.
- You are likely to feel groggy and sleepy for an hour or two afterwards.
- Recovery is likely to be a little slower after a general than after a regional anaesthetic.
- Complications such as chest infections are a little more likely after a general anaesthetic.
- You may experience side-effects such as sore throat, feeling sick, muscle pains and shivering.
- Rare complications include acid getting into your lungs, serious allergic reactions and being awake during the procedure.
What is a caesarean section like?
Planning and preparation
If your caesarean section is planned then you will know the date and time of your surgery in advance, and will turn up to the obstetric unit 'on the day'. Usually you will have been asked not to eat or drink for a period beforehand. You will normally speak with the surgeon and anaesthetist before you go into theatre.
If your caesarean section is an emergency then the same plans will need to be made more quickly. You will be given medications to settle your stomach as, unlike someone planning a caesarean, you may not have an empty stomach. Blood will be taken and cross-matched, in case you need a transfusion.
- If you have an epidural the anaesthetist will top it up so that you can feel no pain. If you don't have an epidural the anaesthetist will discuss with you how you want to have your caesarean section. If there is time, you will be able to choose an epidural or a spinal anaesthetic (these are described in the leaflet on pain relief in labour). If things are too urgent you may need to have a general anaesthetic.
In the operating theatre
Your partner can be with you in theatre for a caesarean section if you are awake, although not usually if you have a general anaesthetic, as their role is to support you, rather than to watch. You will have an intravenous drip put in. Then (if you have chosen to be awake, which is usual) the anaesthetist will insert an epidural or spinal anaesthetic and will check that this is working, so that you feel no sensation in your tummy. You will be tilted slightly to your left to stop your womb lying on top of the major blood vessels behind it, as this can otherwise lower your blood pressure.
There will be several people in the operating theatre, including the surgeon and an assistant, one or two theatre nurses, one or two anaesthetists, an operating department assistant, one or two midwives, and sometimes a doctor to check the baby. This typically means 8-10 people are present, apart from you and your partner.
A catheter will be used to empty your bladder, so that it doesn't get damaged during surgery (this will generally stay in until the next day). A screen will be erected in front of you so that you don't see the surgery (although it may be reflected in the lamps above you). This can be lowered when the baby is delivered.
Your partner should be aware that it's often very warm in obstetric theatre, for the sake of the baby, and people who have not been in theatre before are quite prone to feel faint, particularly if they watch the surgery. Your partner will be encouraged to be with and talk to you, rather than looking over the screen. The obstetrician will make a 10-20 cm cut in your tummy, and, usually 5-10 minutes later, your baby will be lifted up for you to see, and may be lifted on to you as soon as the cord is cut. (If this is something you would really like then be sure to discuss it with your midwife beforehand). You should not feel any pain, although you may feel pulling and pressure. Some women describe it afterwards as a feeling that someone is 'rummaging around' in their tummy.
Babies born by caesarean section often do not cry immediately; it can be a couple of minutes before they do so, as they have not had quite the same stimulus to start breathing that a baby has after vaginal birth. Your baby will be checked by the doctor or midwife to make sure that he or she is breathing well and has a good heart rate. Whilst you are stitched your partner can usually hold the baby. Stitching normally takes around 30-40 minutes.
You will be given medicines to protect against infection, to stop you feeling sick, and to help your womb contract down. You may also be given blood-thinning medication (to reduce the chance of blood clots), or be given special stockings to wear for 24 hours. Afterwards you and your baby will be transferred to the postnatal ward, although depending on the layout of the unit, you may be kept in a postoperative unit for observation for several hours first.
How will I feel after a caesarean section?
Everyone is different, of course. You are likely to feel a mixture of tiredness and excitement. you may feel exhilarated and overwhelmed at the birth of your baby, and you may feel deeply disappointed if a caesarean section is not what you planned. If your baby is in any way unwell you may feel very anxious. On top of this you will be tired, you may at first feel nauseated, and you might feel some pain and/or nausea. Pain and nausea after caesarean section can be treated very easily, so you should tell someone immediately.
You will be tired for some time after a caesarean section. This can partly be the effect of anaesthetic and painkillers, but is also because surgery is an injury to your body, and being tired is your body's signal that it needs rest to recover.
You will have vaginal bleeding after delivery, which will tail off over several weeks. You will also experience the same afterpains as women do after vaginal delivery, as your womb (uterus) contracts down after the birth. Most women stay in hospital for three days or do after a planned caesarean section. The scar from a caesarean section is usually low down, and will often be quite numb in the hours and even days after your operation. You may have dissolvable stitches, which will disappear over a couple of weeks. If you have stitches that need removing - this is normally done at five days.
How common is caesarean section?
In the UK in 2016, just over 1 in 4 deliveries were by caesarean section: in the USA the figure is about 1 in 3. About half of these were planned caesarean sections, and the other half were performed as emergencies. This is generally felt to be a rather high proportion, although it is typical of the developed world, where caesarean section is such a safe procedure that some women choose caesarean section when it is not strictly medically necessary.
The chance of needing a caesarean section is higher in older mothers - in women aged over 40, 6 out of every 10 deliveries are by caesarean section, and three quarters of these were emergency, rather than planned, operations.
When is a planned caesarean section offered and can I choose to have one?
There are some situations where a caesarean section will be advised and planned. This may be because a vaginal labour is felt to be a danger to you or the baby, or because it is felt that you could not deliver vaginally.
Reasons for planned caesarean section include:
- Most cases when your baby is in the breech position.
- When you have a low-lying placenta (placenta praevia) which is likely to bleed dangerously or obstruct the baby's birth.
- Some cases of abnormalities of the womb, such as large fibroids, which might obstruct the baby's exit.
- Some cases of pregnancy-related high blood pressure (pre-eclampsia).
- If you have certain infections, such as a first genital herpes infection occurring late in pregnancy.
- Some cases where you are having twins.
- Most cases if you are having triplets or more.
- Some cases where you have had a previous caesarean section (this partly depends on the reason for the last caesarean section, and on how long ago it was).
- Most cases where you have previously had a classical caesarean section.
- When your doctors believe your pelvis is too narrow to allow your baby to be born vaginally, usually because a previous baby was unable to be born vaginally.
- Your baby is distressed in the womb prior to labour.
- Some cases where your baby is very premature.
Sometimes, a planned caesarean section is offered because it's what you really want, even though there's no medical reason to suggest that vaginal delivery is less safe. You may feel this way because you have had a difficult previous vaginal delivery, or have witnessed one, or you may be very worried about vaginal birth, or you may feel you desperately need to set a particular date. This type of section is usually done at about 39 weeks of pregnancy, to allow the baby as long in the womb (uterus) as possible. If you go into labour before this then your caesarean section will be performed as soon as is possible and safe.
Although the risks of caesarean section to mother and child are very low, they are usually higher than the risks of vaginal delivery. For this reason your medical team will want to explore the reasons for your decision with you fully, and make sure that you understand the increased risks, before deciding with you if it is the right thing to do. The team will want to do the right thing for you and your baby, taking into account your feelings, so it would be most unusual to force you to have a vaginal delivery if you remained certain that you wanted or needed to have a caesarean section.
When might an emergency caesarean section be needed?
Emergency caesarean sections are needed when things change in labour so that they become a safer option for mother and baby than vaginal delivery. Emergency caesarean sections can vary in their degree of urgency from a gradual change of plan with thinking time, to a life-threatening situation, although this is fortunately rare. You may be able to have this under epidural anaesthetic, if you already have one sited. Otherwise it is more likely to be performed under a spinal or general anaesthetic.
Reasons for an emergency caesarean section include:
- Your baby is becoming increasingly distressed.
- Your labour is not progressing, despite interventions.
- You have uncontrolled high blood pressure, or pre-eclampsia.
- Your midwife and obstetrician think that the baby won't come down through your pelvis, usually partly because of the baby's size and position and partly because of your pelvic shape.
- Unexpected difficult position of the baby (for example, unexpected breech baby).
What is a 'crash' caesarean section?
In the case of a 'crash' section the team will be dealing with a true emergency situation, when your baby has to be delivered with extreme urgency and minutes may count. There may be very little time for you to take in what's happening or have your say. If you don't already have an epidural in place and working when the decision is taken you will most probably need a general anaesthetic, as these are much quicker.
A crash section is a rare event, performed if lives are thought to hang in the balance. It might be done if:
- You develop very heavy bleeding.
- You have severe or worsening pre-eclampsia or eclampsia.
- There is bleeding from the baby (this is rare as most bleeding in labour is from the mother).
- You have a cord prolapse (when the umbilical cord comes down ahead of the baby and gets trapped between baby and cervical edge, cutting off the baby's blood supply).
- Your baby develops severe fetal distress.
- A forceps or ventouse delivery has not succeeded.
- Your baby is a second twin who presents in a difficult position (for example, lying transversely across the womb) after the first twin is born.
Experiencing a crash caesarean section can be a very traumatic experience. You may feel frightened and powerless and that your choices have been taken away from you. Your plans for your delivery have been dashed and (if you had a general anaesthetic) you will not have seen your baby's birth. There may not have been time for proper explanations, or it may be that, because you were unwell or because of the anaesthetic, you did not hear them or take them in. As a result you may have no understanding of what decisions were taken, and why. Your partner may have felt excluded, rushed and frightened.
It is very important that you have a chance to talk through what happened with the team that looked after you and who made those decisions for you. It is your body and if you have been operated on without fully understanding the situation, it's important that they explain events to you, and that you are able to understand as much of the sequence of events as you want to. Make sure an appointment to do this is arranged before you leave hospital, if it does not happen whilst you are in hospital. Prepare a list of questions and consider starting by asking the doctor or midwife if they would describe what happened to you in the order in which it happened, explaining their decisions, so that you can form a picture of how your baby was born. Whilst you may find it upsetting to go back over a frightening time, it will usually help you to gain a much better understanding of what happened and why.
What are the risks of a caesarean section?
A caesarean is generally a very safe procedure, but like all surgery there are some risks.
These include an increased risk to you of:
- Infection - of the wound or womb lining.
- Blood clots in the leg or lung.
- Excessive bleeding.
- Damage to the bladder or bowel - this happens to about 1 in 1,000 women.
- Temporary breathing difficulties in your baby, because the fluid in your baby's lungs in the womb (uterus) hasn't cleared quite as well as it does during vaginal labour.
- Needing an emergency hysterectomy (occurs in about 7 per 1,000 caesarean sections).
There is an increased risk to your baby of:
- Grazes or small cuts caused when the surgeon makes the first incision into your womb. These are usually only slight, and may be difficult to avoid if your baby is pushed against the area of the womb where the cut needs to be made. They occur in 1 or 2 out of every 100 caesarean sections.
Is caesarean section safer for very premature babies?
There is no clear evidence that caesarean section is safer than vaginal birth in very preterm babies. Vaginal birth can be very gentle for a tiny baby.
Caesarean section is a more difficult operation when a baby is extremely premature. It may also mean you having a classical caesarean section - a vertical cut in the main part of your womb (uterus). Having this type of section means you may be advised not to try for a future vaginal delivery (see section on vaginal birth after caesarean, above).
- Most obstetricians advise that, if your baby has to be born before 24 weeks of pregnancy then unless you are dangerously unwell and urgent delivery of your baby is essential for your health (for example, very high blood pressure or pre-eclampsia) then a vaginal birth is the best option for both you and your baby. Babies of less than 24 weeks of gestation have a very high risk of not surviving, however they are born, and doctors will be considering whether it is right to put your present health and your chance of a future, healthy vaginal delivery at greater risk.
- After 24-25 weeks of pregnancy a caesarean section may be considered if the baby is lying transversely across your womb (instead of in the head-down position), or is in the breech position with a foot down low, as this makes vaginal delivery more of a risk for your baby than caesarean section. You will be involved in the decision of what to do for the best. Again, if you are dangerously unwell with pre-eclampsia then a caesarean may be the safest option for you.
- After 26 weeks a caesarean section will be offered if the baby is not in a safe position to be born vaginally, or if you are dangerously unwell so that a caesarean is the safest option for you.
Can I have a vaginal delivery in the future if I have had a caesarean section this time?
For women who have had lower segment caesarean sections (LSCSs) - which is most women who have had caesarean sections - then vaginal birth after caesarean (VBAC) is often possible if you want to try. The chance of this being successful is greater if you have had a vaginal delivery in the past. If you have had two LSCSs in the past, your doctors may still be happy for you to try for a vaginal delivery, particularly if you have had a vaginal delivery in the past.
About 3 of every 4 women who plan VBACs manage to have a vaginal delivery. For those who don't manage to, it's usually because they went past 41 weeks (you won't usually be induced if you have had a previous caesarean) or because their labour progressed too slowly (doctors will be cautious about giving you oxytocin to speed your labour if it is a VBAC).
The risk that worries doctors is of thinning, splitting or full-on rupture of the previous scar.
- Thinning and splitting (dehiscence) occurs in around 1 in 200 women having a VBAC.
- Uterine rupture is rare, occurring in about 1 in 1,200 women, and can occur whether or not they are having a VBAC. It is particularly seen in women with a (rare) condition called vascular Ehlers-Danlos syndrome.
An experienced midwife will monitor you for any signs that the scar on your womb is starting to split. This typically includes pain that doesn't go away between contractions, scar pain, relaxing of the womb with slowing or stopping of contractions, your baby moving back up the birth canal, and sudden fetal distress. Uterine dehiscence is usually treated with an urgent caesarean section, and when it is carefully managed both mother and baby are usually fine.
Uterine rupture is much more serious but is very rare. It can be dangerous for mother and baby if it is not recognised quickly and treated promptly, as it can cause severe bleeding - the treatment is immediate caesarean section, often with hysterectomy.
- If you've had three or more LSCSs then you will usually be advised not to try for a vaginal delivery in the future, as the risk of the scar on your womb splitting or tearing or developing a true rupture is increased.
- If you have had a true classical caesarean previously, you are likely to be strongly advised against VBAC, as your risk of uterine rupture is believed to be just over 1 in 10.
How many caesarean sections can I have?
There is no fixed limit to the number of caesarean sections that you can have. However the risks of caesarean section for you do start to increase if you have more of them. The increased risks associated with increasing numbers of caesarean sections include:
- Scar tissue on the uterus and in the tummy can make the operation more tricky and more likely to bleed more and heal more slowly.
- Bladder injuries are more likely because the bladder gets stuck to old scar tissue.
- The risks of heavy bleeding and of needing a hysterectomy increase sharply after more than three caesareans, and is thought to be 1 in 40 women having their fourth caesarean. This is partly because the surgery is more tricky, due to scar tissue, and partly because the placenta grows deeply into the scar and cannot be removed.
Further reading and references
Operative Vaginal Delivery; Royal College of Obstetricians and Gynaecologists (February 2011)
Induction of labour; NICE Clinical Guideline (July 2008 - currently under review)
Preterm labour and birth; NICE Guidelines (November 2015)
Birthplace in England Research Programme; National Perinatal Epidemiology Unit, June 2015
Evidence based Guidelines for Midwifery-Led Care in Labour: Immersion in Water for Labour and Birth; Royal College of Midwives (2012)
Hodnett ED, Gates S, Hofmeyr GJ, et al; Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013 Jul 157:CD003766.
Intrapartum care for healthy women and babies; NICE Guideline (Dec 2014, updated Feb 2017)
Caesarean section; NICE Clinical Guideline (November 2011)
Prevention and management of postpartum haemorrhage; Royal College of Obstetricians and Gynaecologists (May 2009 with revisions April 2011)
Smith CA, Collins CT, Crowther CA; Aromatherapy for pain management in labour. Cochrane Database Syst Rev. 2011 Jul 6(7):CD009215. doi: 10.1002/14651858.CD009215.
Singata M, Tranmer J, Gyte GM; Restricting oral fluid and food intake during labour. Cochrane Database Syst Rev. 2013 Aug 22(8):CD003930. doi: 10.1002/14651858.CD003930.pub3.
Guise JM, Eden K, Emeis C, et al; Vaginal birth after cesarean: new insights. Evid Rep Technol Assess (Full Rep). 2010 Mar(191):1-397.
Schvartzman JA, Krupitzki H, Betran AP, et al; Feasibility and safety study of a new device (Odon device) for assisted vaginal deliveries: study protocol. Reprod Health. 2013 Jul 210:33. doi: 10.1186/1742-4755-10-33.
Smith CA, Collins CT, Cyna AM, et al; Complementary and alternative therapies for pain management in labour. Cochrane Database Syst Rev. 2006 Oct 18(4):CD003521.
Byrne J, Hauck Y, Fisher C, et al; Effectiveness of a Mindfulness-Based Childbirth Education pilot study on maternal self-efficacy and fear of childbirth. J Midwifery Womens Health. 2014 Mar-Apr59(2):192-7. doi: 10.1111/jmwh.12075. Epub 2013 Dec 10.
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