C-section

- [Voiceover] A c-section, or a cesarian section, is a type of surgery that's used to deliver a baby. Basically, the surgery begins with the mom receiving anesthesia, whether that's local anesthesia so she remains awake, or general anesthesia that puts her to sleep. Then the surgeon makes an incision on the abdomen. So usually the incision is horizontal or transverse, so it goes across the abdomen about one to two inches above the pubic hair. And the reason why we tend to prefer that horizontal incision is because it tends to cause less post-operative pain. And the wound from it tends to heal better and it tends to be stronger. And also because it results in a better cosmetic appearance, since the scar from the horizontal incision kinda blends in with the crease at the bottom of the abdomen, so it's not as noticeable. Sometimes though, if the surgeon needs to get in more quickly, either because the mom is bleeding a lot or because the baby's in danger, the incision that's made will be vertical, so up and down the abdomen, kinda like this. Since that's a quicker way of getting in and generally vertical incisions cause less bleeding. Now, after the incision is made, the surgeon then makes his way through all of the layers of the abdomen to access the uterus. He then makes an incision in the uterus to remove the baby. Then the umbilical cord is clamped and cut, the placenta is removed, and then finally, when everything's done, the uterus and the abdomen are stitched and stapled closed. And generally speaking, most women, provided that everything goes well, are able to go home in about three days. So, how common is this and why would a woman need to have a c-section, rather than a vaginal delivery? Well, one in every three babies born in the U.S is born through a c-section. And that's not even the highest rate in the world. The highest rate in the world is actually seen in China at 46% of all births. So that's quite a bit. Now in terms of who gets a c-section, I guess you can split things off into two groups. So, there are the women, the group of women, who have planned c-sections. So, they know from before they're gonna get a c-section. So there's planned c-section. Versus the group of women who have unplanned or emergency c-section. So there's planned c-section versus unplanned or emergency c-section. So sometimes c-sections are planned in advanced, several weeks before the mom goes into labor. And the most common reasons for planning a c-section include, for example, if the mom has had a c-section in the past, that's a pretty common reason to have a c-section, if she has a history of a c-section in the past. If the baby is very large. So that's called fetal macrosomia. Fetal marcosomia. Macro for large and soma for body, so the baby has a really large body, which tends to make vaginal delivery pretty difficult. So in that case, we opt for a c-section. Another indication is if the mom has an infection such as herpes or HIV. So infections that can spread to the baby as the baby's passing through the vaginal canal. So we attempt to avoid that transmission of infection by delivering the baby through a c-section. If the woman is carrying more than two babies, two babies or more, or if the mom has a condition called placenta previa. So a condition called placenta, placenta previa, in which case the placenta blocks the way to the vagina. So the baby can't exit through the vagina, its path is blocked. And speaking of that, any type of mechanical obstruction to delivery such as a uterine fibroid or a displaced pelvic fracture. Anything that would block the way of the baby through the vagina would be an indication for a c-section. In other cases, the mom plans on having a vaginal delivery and she goes through with the vaginal delivery, but plans change during labor and she needs to have an emergency c-section. So some of the reasons for an unplanned and an emergency c-section include contractions that are not strong enough to get the baby out. So the labor ins't progressing as quickly and as effectively as it should, which if labor lasts too long, that can be detrimental to the baby, it could lead to the baby not getting enough oxygen. So we decide to go in through an emergency c-section to get the baby out as quickly as we possibly can. Another indication is if the mom's pelvis is too small and that's discovered during labor, again because the labor isn't progressing as it should. If the baby is in an odd position such as sideways or chin first or feet first, whatever it might be. If the baby's in an odd position, that's a good reason to do an emergency c-section. And also, if the baby's life is in danger. So for example, if its heart is beating too slow. Or if the mom's life is in danger. So for example, if she's bleeding too much. Those are both very good reasons to have an emergency c-section. And these are just the most common reasons for having a c-section, by no means are they the only situations in which a c-section is necessary. Okay, so c-sections, just like all surgical procedures, are not without complications. So for example, with each c-section one of the biggest complications that you'll hear about, the risk of placental attachment disorders increases. So the risk of placental, placental attachment disorders increases. So there's some disorder, something's going wrong with the way that the placenta attaches and this is in subsequent pregnancies. So pregnancies following that c-section. So a lot of that has to do with the fact that each c-section causes scar tissue to form in the uterus and that scar tissue can cause the placenta to attach to the uterus incorrectly. So the placenta can attach in the wrong location such as with placenta previa. Or the placenta can adhere to or stick to the uterus too strongly, too firmly, which is called placenta accreta. So the risk of placenta previa and placenta accreta, which are two types of placental attachment disorders, increases with future pregnancy following a c-section. And there's some other complications including complications relating to anesthesia, which of course occurs with any major surgery. There can also be damage to the bladder, the blood vessels, or the intestines during surgery. And generally, c-sections do involve longer healing time than vaginal deliveries do. And of course there's also the risk of infection as a result of all that instrumentation inside the body that's occurring throughout the c-section. So pretty standard surgery-related complications. But let's talk about a couple of issues unique to c-sections. So firstly, there's a lot of thought and some pretty decent evidence to suggest that c-sections are associated with an increased risk of respiratory problems in the baby. And perhaps with an increased risk of death of the baby as well. And also, keep in mind that with a c-section, we're making an incision into the uterus, a pretty large incision, and then we're sewing that incision up after delivering the baby. And sure, these incisions tend to heal pretty well, but imagine that with future pregnancies the uterus stretches and during delivery it contracts with great pressure. And because a scarred area of the uterus isn't as strong as the rest of the uterus, that portion, that scarred portion, is really prone to rupture. So uterine rupture is a grave, potentially fatal complication of c-section. And it's this fear of uterine rupture that's led to a greater than 100-year-long debate over how to deliver a woman who's had a c-section in the past. This is a really controversial issue in medicine. So if you think about it, there are three possibilities for a pregnant, laboring woman who's had a c-section in the past. She can choose from the very get-go to have a planned, elective c-section. That's kind of the first possibility, right? She can plan from the very beginning to have an elective c-section. So that's a first possibility. She could also attempt to labor. Right? Which is called a TOLAC. T-O-L-A-C, which stands for trial of labor after cesarean. So she could try to labor and that TOLAC could be successful, so it could end with a vaginal delivery. Everything could go well after she labors and the baby could be delivered vaginally. Or, the TOLAC could fail and would have to be followed by an emergency c-section. So those are kinda the three possibilities. Either she could choose from the very get-go to have a planned, elective c-section. Or she could try to labor, which could end with a vaginal delivery. It could all go great and be successful and end with a vaginal delivery. Or the TOLAC could fail and it would have to be followed by an emergency c-section. And I'll tell you, up until about 30-ish years ago, every woman who'd ever had a c-section in the past was told that every delivery of hers in the future would have to be a c-section. But considering all the complications that we just talked about associated with c-section, in the 80s we really sat down and really thought about whether that's necessary. And we realized that in some women who've had a c-section in the past, it's worth it to attempt a TOLAC to avoid the complications of a c-section, because a TOLAC could proceed successfully, right? And we would, in that case, avoid the complications of a c-section. Whereas in other women, mainly those women who have a really high risk of uterine rupture with a TOLAC, it's necessary to stick to c-sections for every delivery after the woman's first c-section. And deciding which of those categories a woman falls into is really no easy feat. So there's no real standardized way of deciding which women are good candidates for TOLAC and which aren't. We really, currently, we really do things on a case by case basis, which hopefully will change in the future as we gather more data on the topic. But currently, as it stands, it's a very controversial issue and we tend to manage things on a very case by case basis. So, in a nutshell, those are some details about c-section.