Tips & Tools: C-Section

How should I move forward after deciding to plan a vaginal birth or a cesarean section?

• a caregiver who shares your goals and has a conservative practice style
• a birth setting with low rates of cesarean section and other labor interventions
• access to continuous labor support from a trained or experienced woman who will be available for you in labor.

WHEN PLANNING A VAGINAL BIRTH, what are some basic tips I can use during pregnancy to increase my likelihood of having a vaginal birth?

• Find a doctor or midwife with low rates of intervention: Some caregivers have much lower rates of intervention than others. Although there are many exceptions, family physicians tend to have lower rates than obstetricians, and midwives generally have the lowest rates of all. Styles of practice can also vary widely within each of these groups even when the women being cared for are at similar risk. (Choosing a Caregiver will give you detailed information.)
• Discuss your birth plan with your caregivers: Find out how they will work with you to meet your goals and preferences. If their response does not satisfy you and you have other options, seek a better match.
• Choose a birth setting with low overall rates of intervention: Some hospitals have far lower rates of intervention than others. In general, rates of intervention are much lower for out-of-hospital birth centers and at home births, compared with hospitals. (Choosing a birth Setting will give you detailed information.)
• Create your own birth statement: Writing down your values, preferences, and goals can help you clarify your own thinking and feelings. Moreover, this type of birth plan will prepare you to discuss these issues with your partner and your caregivers.
• Arrange for continuous labor support from someone with experience: Arrange for someone other than your partner to provide continuous support during labor. You can work with a trained labor support companion (doula) or invite a female friend or family member to be with you. If you decide to invite a friend or relative, try to choose someone experienced and comfortable with birth. Care that "mothers the mother" in this way lowers your risk for cesarean section (and for dissatisfaction with your birth experience). Having such a person with you can also help your partner by sharing the work and seeing that your partner's needs are also met. (You can find detailed information on continuous labor support in Labor Support.)
• Explore your options for pain relief: Avoiding epidural analgesia can increase your chances for vaginal birth without vacuum extraction or forceps. If this is your goal, it would be wise to consider your options and make arrangements for other ways of coping with labor pain well before labor. Many women find that tubs, showers, large inflatable "birth balls" and other drug-free measures are quite helpful for comfort during labor. Doulas can offer many "comfort measures." (You can find detailed information in Labor Pain.)

What are some tips I can use in special situations during pregnancy to increase my likelihood of having a vaginal birth?

• If a cesarean is proposed and you're not in an urgent situation: Ask your caregivers about (1) what is involved in having cesarean surgery (2) the benefits that c-section is expected to offer in your case, (3) potential problems, and (4) pros and cons of vaginal birth and of waiting longer before deciding to have a cesarean. If you aren't in labor when the cesarean is proposed, you will probably have time to do your own research and talk things over with your partner and caregivers before making a decision.
• If you had a cesarean with a previous birth: Become informed about pros and cons of VBAC (vaginal birth after cesarean) versus repeat cesarean. Talk with your caregivers and do your own research to learn about the many issues. (See the full Pregnancy Topic VBAC or Repeat C-Section on this website.) Although the research supports VBAC as a reasonable choice for nearly all women, you may have to search to find a caregiver and hospital that offer this option.
• If your baby is in a buttocks- or feet-first position (breech): First, ask your caregiver about turning the baby to a head-first position (external version) when you reach "term" (about the 37th week of pregnancy). Many babies can be safely turned and born head-first through the vagina. You may need to search to find a caregiver who has skills and experience with this hands-on-belly technique.
  
  If you are not able to get the baby turned to a head-first position, learn about the risks and benefits of planning a vaginal breech birth versus planning a cesarean. There are important advantages to cesarean in this situation in comparison with typical hospital ways of handling vaginal breech births, especially lower likelihood of death or serious problems with your baby. On the other hand, vaginal birth avoids the risks of surgery for mothers and babies in the present pregnancy and has many advantages for mothers and babies in future pregnancies. Be sure to talk your situation over with your caregiver before making your decision. If you make an informed decision to plan a vaginal breech birth, it may be difficult to find a caregiver who has skills and experience and will support you in this choice.
• If you wish to plan a cesarean due to an intense fear of childbirth: Consider a series of psychotherapy sessions with someone who is informed about childbirth and has good counseling skills. About half of the women with deep fears who undertake therapy are able to reduce their fears and plan a vaginal birth. If you are especially anxious or fearful, the continuous presence of a trained labor support companion (doula) during labor may make a big difference for you.

What are some basic tips I can use during labor to increase my likelihood of having a vaginal birth?

• Work with your caregivers to delay going to the hospital: If you are having a hospital birth and have no medical concerns that make hospital admission in early labor preferable, wait until you are in "active labor" with regular, well-established contractions and your cervix open (dilated) 4 to 5 centimeters. If you arrive before this, explore going home and returning later.
• Receive good support throughout labor: Support from a doula (trained labor companion), or a female friend or family member who is comfortable with birth, reduces the risk for cesarean section and for vaginal birth with vacuum extraction or forceps.
• Avoid continuous electronic fetal monitoring when possible: Continuous electronic fetal monitoring (EFM) increases the likelihood of cesarean section and of vaginal birth with use of vacuum extraction or forceps, with no clear benefit for babies. Talk with your caregiver and check hospital policies to find out whether they will check your baby's heart beats with a hand-held device or occasional use of EFM instead of continuous EFM. With some types of intervention that involve increased risk (for example, epidural analgesia), you may be required to use continuous EFM.
• Avoid routine use of medical interventions when possible: In addition to concerns about EFM, you can lower your chances of having a cesarean by avoiding whenever possible labor induction (use of drugs or techniques to try to start labor). Also be sure that your bag of waters is not broken by a caregiver (artificial rupture of membranes) before or in early labor. It is also good to avoid arbitrary time limits for your labor. There is no need to turn to a cesarean if you and your baby are doing well. Talk with your caregivers about these practices and how to avoid them.
• If a cesarean is proposed and you're not in an urgent situation: Ask your caregivers about (1) what is involved in having cesarean surgery (2) the benefits that c-section is expected to offer in your case, (3) potential problems, and (4) pros and cons of vaginal birth and of waiting longer before deciding to have a cesarean. You will want to consider any expected benefits of a cesarean along with results of research comparing risks of cesarean and vaginal birth in Best Evidence: C-Section.

WHEN HAVING A CESAREAN SECTION, what are some tips for having a safer cesarean delivery?

• Schedule a planned cesarean after the 38th week of pregnancy if there is no urgent reason to deliver the baby sooner: Babies born before the 39th week of pregnancy are more likely to have breathing problems.
• Use epidural or spinal anesthesia: Regional anesthesia (you are numbed from your ribs down) is safer for you and your baby than general anesthesia (being "put to sleep").
• Request antibiotics at the time of the cesarean: Antibiotics reduce the chance of infection. You do not need them afterwards unless you develop an infection.
• Ask for your uterus to be closed with two layers of stitching (double-layer uterine suturing): In recent years, many doctors have begun closing the uterus with one layer of stitches instead of two. Some studies suggest that this may lead to the scar giving way more often during a future labor. Research that established that there was a very low likelihood of the scar opening during labor was done when double-layer stitching was the norm. Until this controversy is resolved, it may be wise to request the older technique.
• Request care after surgery to reduce the chance of blood clots: Depending on how likely you are to have this problem, preventive care may include getting you up and walking soon after the operation, having you wear elastic support stockings, or prescribing medication.

What are some tips for having a satisfying cesarean birth experience?

• Participate fully in decisions about the birth: The difficulty or ease of the birth and whether the baby was born vaginally or by cesarean have little to do with how women feel about the birth. Women are most likely to feel satisfied with their births when they feel a sense of accomplishment and personal control and when they have a good relationship with caregivers. A good relationship includes such elements as being treated with kindness and respect, getting good information, and having the opportunity to participate in decisions about care.
• Have an epidural or spinal anesthesia (regional anesthesia): Epidural or spinal anesthesia allows you to be awake and aware to greet your baby and to hold and breastfeed your baby in the recovery area.
• Have the bladder catheter inserted after the epidural or spinal is administered: Then you will be numb for this somewhat uncomfortable procedure.
• Keep your partner and any labor companions with you throughout: You can benefit from the support of your partner and any other labor companions during what may be an anxious and stressful time. This is particularly true during the preparation for surgery and administration of the epidural or spinal anesthesia, which many women find more stressful than the surgery itself. Your partner and support team will also have the opportunity to share in moment of birth and to greet the baby.
• Keep your baby with you after the birth, in skin-to-skin contact: Unless your baby has problems at the birth that require care in the nursery - and few babies do - there is no reason not to keep your baby with you so that you and your partner can enjoy and begin to get to know your baby, and you and your baby can get breastfeeding off to a good start. Skin-to-skin contact can contribute to breastfeeding success and your early relationship.
• Work with your caregivers to carry out your preferences: For example, you may wish to:
  • videotape, or at least videotape after the baby is delivered
  • play the music of your choice
  • not have your arms strapped down
  • have the drape that screens your view of the surgery placed low enough that the baby can be laid on your chest; if your arms are free, you can hold and touch your baby
  • have a doctor or nurse explain what is happening throughout
  • have the drape lowered or have a mirror at the time of the delivery (your belly will be covered so you will basically see your baby lifted out of an opening in the sheet)
  • announce or have your partner announce the sex of the baby or be the first to speak to the baby
  • take the placenta home (some people bury the placenta and plant a tree or bush over the site; if of interest, bring a sealable container to contain the blood and relieve staff concerns about contamination in this time of HIV/AIDS)
• Have a narcotic (opioid) medication injected into the epidural tubing catheter at the end of the operation: This provides sufficient pain relief that you will feel comfortable enough to hold and breastfeed your baby in the first hours after the surgery.
• Have your baby and your labor companions with you in the recovery area: Holding and breastfeeding your baby soon after delivery helps both you and your baby get started on the right foot and may avoid problems with breastfeeding.
• Have your partner able to be with your baby in the nursery: This includes the newborn intensive care nursery. If your baby must be separated from you because of concerns about the baby's health, it will be comforting to know that your partner can provide a reassuring presence and can bring you word of your baby's condition.
• Control your pain medication: A new alternative is patient-controlled analgesia (PCA). With this technique, you can give yourself a small dose of medication through the intravenous (IV) line when you need it by pushing a button. A lockout mechanism keeps you from going beyond a preset dose. Since narcotics can make you feel sleepy and nauseous, you may wish to combine narcotic with non-narcotic pain medications. This can reduce or even eliminate your need for narcotics.
• Begin drinking and eating again when you feel ready: Access to food and drink when you feel ready will help you feel more normal and can avoid hunger and thirst.
• Get help with breastfeeding: Breastfeeding can be more difficult right after surgery and with a healing incision. A knowledgeable person can help you find ways to make yourself more comfortable during breastfeeding sessions. Your partner or others can help with switching sides, burping, and diaper changing.
• Get plenty of help at home: You will be recovering from major surgery with all that entails in terms of how you may feel, as well as restrictions on lifting and driving. At the same time, unlike the usual experience of recovering surgical patients, you will have the demands of caring for a newborn and possibly other children.