Even if you planned to have a cesarean delivery for medical reasons (and therefore read that chapter on C-sections more closely), there’s likely something about the procedure that caught you by surprise. We talked to several mamas who wished they’d known more about the surgery itself or the recovery. “I wish someone had walked me through the process,” says Rebecca Clark, adding her doctors did an amazing job preparing her for the fact she’d probably need a C-section due to gestational diabetes and a big baby, but she wished she’d known more specifics about the procedure, such as that all-important bladder catheter. For Amanda Oetzel, it was the recovery that surprised her: “I wish I had known how tough recovery could be.” And for Michelle Ruettinger, it was trying to balance recovery with a preschooler: “The hardest part about the second C-section was really that I wasn’t able to pick up my older child for six weeks post surgery. She and I were both really sad about that.”
Make no mistake: a C-section is major surgery. And with major surgery comes surgical risk. “We know that the risks of a C-section are higher to mom than the risks of a vaginal delivery,” says Dr. Dana R. Gossett, M.D., Professor of Obstetrics and Gynecology at the University of California, San Francisco (UCSF). For that reason, there is an effort within the medical community to decrease the rate of cesarean deliveries. The most recent figures do, in fact, show a continued decline in the cesarean delivery rate, to 32% of all 2015 U.S. births. “The big push in the obstetrics community in the last number of years is to avoid the first C-section,” says Gossett. “Don’t do the first one so that you don’t have to be faced with doing the second and the third and the fourth.”
That said, there are medical reasons why a cesarean delivery may be necessary. And for women who must have a C-section, preparing for that major surgery can make recovering from it a little easier. We spoke more with Dr. Gossett to learn about cesarean deliveries, including what to expect during and after a C-section and how to best prepare for one.
Why a Cesarean Delivery May Be Recommended. “There are some reasons that have to do with baby’s well-being and there are some that have to do with mom’s well-being. When we think about baby, one of the more common reasons that a woman may be recommended to have a cesarean is malpresentation of the baby, typically breech, meaning the baby’s got his bum down instead of his head down. There are alternatives to cesarean. There’s a procedure called Version [external cephalic version (ECV)], which is an attempt to turn the baby by pushing on the baby through mom’s belly. And when a baby is diagnosed as being breech at full-term, that’s actually the first thing that most obstetricians would recommend—to try to turn the baby around so we can get the baby to a head-down position and allow that woman to have a vaginal delivery. If that doesn’t work or if the woman decides she doesn’t want to attempt a Version, then typically in the United States, we do cesarean for breech delivery. …The other most common fetal indication for cesarean in the United States would be that the baby doesn’t tolerate labor or doesn’t come out—so a problem during labor that would not necessarily be anticipated in advance. … In terms of maternal reasons for cesarean, the single most common one in the United States is a prior cesarean. So, once a woman has had one C-section, she is usually given a choice as to whether she’d like to try for a vaginal delivery with her subsequent pregnancy or whether she simply wants to have a repeat cesarean. Vaginal birth after cesarean is, unfortunately, less common than it was about 20 years ago. In the 90’s, there was a real push to try to improve the rate of vaginal birth after cesarean, but currently, a lot of women simply choose a repeat C-section. There might be other, much less common reasons, [such as] certain maternal heart conditions or brain conditions where it really isn’t safe for mom to push and where a cesarean might actually be better for her health.”
The Procedure. For a scheduled cesarean, most institutions will ask a woman to arrive two hours prior to surgery. And for safety reasons, she should not eat or drink for eight hours prior to surgery. “That’s important because she will be lying on her back during surgery, and she will have anesthesia, and the anesthesiologist wants her stomach to be completely empty so that if she gets sick she doesn’t aspirate food into her lung,” says Gossett. “Some hospitals actually do allow clear liquids up to two hours in advance, but it would be important to check with the specific hospital and doctor because that’s not universally true.”
A labor and delivery nurse will then place an IV into one of her arms to administer medication and fluids intravenously. The woman will also see the anesthesiologist and her obstetrician or her obstetrician’s partner, whoever is doing the cesarean. And if she is at a teaching hospital, she will meet an OB/GYN resident doctor who may assist her surgeon with the C-section. “Then, in order to get her ready for surgery, most women have their pubic hair trimmed so that the C-section area doesn’t have hair to interfere with sewing,” says Gossett. “Many institutions will do some sterile wipes even in the preoperative area before she gets to the operating room to reduce the risk of infection, and she’ll have to sign consent forms—she’ll have to sign permission both for the anesthesia and for the surgery itself.”
Once finished in the preoperative area, she’ll go to the operating room. In many places, she’ll walk to the operating room herself with her nurse and doctor. She’ll sit on the operating room table and have spinal anesthesia administered. “Spinal anesthesia is a lot like a labor epidural, but it’s a little bit different,” says Gossett. “A spinal anesthetic is when the anesthesiologist finds the space between two of the vertebrae and inserts a very tiny needle into the fluid around the spinal column and injects a combination of pain medicine and numbing medicine—usually a medicine that is derived from morphine and another medicine that is somewhat similar to Lidocaine.” The needle is then removed and the woman is allowed to lie down. “The spinal anesthetic works very quickly,” explains Gossett. “Usually within one to two minutes she starts feeling that her legs are warm and heavy and numb, and the numbness will gradually move from her feet all the way up to her belly. The numbness lasts about 2 1/2 hours in most cases, which is usually plenty of time to do a cesarean.”
In some cases, the anesthesiologist may choose to do a combined spinal-epidural procedure, which is a spinal injection for immediate numbness in addition to an epidural catheter. The combined spinal-epidural allows the anesthesiologist to give a continuous flow of medicine if the surgery is anticipated to be very long. In uncommon circumstances, a woman may be unable to have spinal anesthesia or an epidural. Instead, she would have general anesthesia and actually go to sleep with a breathing tube, just like for most major surgeries.
“Once the spinal or epidural is done, the woman will be asked to lie down on the operating table … then usually we put compression stockings on her legs,” explains Gossett. “These inflate and keep blood moving in her calves and in her legs and helps reduce the risk of blood clots after surgery. We also put a catheter into her bladder to drain the bladder and keep it out of the way for surgery.” Also, because of the spinal anesthesia, a woman will not know she needs to urinate right away, so the catheter is usually removed within 24 hours. Her stomach will then be cleaned with a special sterilizing solution, and a big surgical drape— basically a paper or plastic sheet that keeps her belly clean and protected from the environment—will be put up. “At that point, if the woman has a support person who is going to be in the operating room with her, the support person is usually allowed to join,” says Gossett. “The support person usually sits right beside the [woman’s] head so he or she can talk to her through the surgery.”
And then the surgery itself. “What a C-section is in my mind is very simple,” says Gossett. “The way I usually describe a C-section is three things: you have to open someone’s belly; you have to take out their baby; and then you have to put things back the way you found it. And if you think about what that means, what that usually means, especially for a first C-section, is that baby is born very early during the procedure. So, it usually takes less than five minutes or maybe five minutes to open the abdomen, open the uterus, and to deliver the baby. Then it usually takes anywhere from 25 to 45 minutes to deliver the placenta and repair all of the layers of the body and put everything back correctly. What I usually tell women before C-sections is that all the excitement is early: the baby will be out pretty early, and at that point, we’ll be able to give the baby to either her support person or, in some cases, we can even do skin-to-skin in the operating room so that she has the pleasure of having the baby with her while we finish up the less interesting work of putting things back together the way they ought to be.”
Once the surgery is done, she’ll go to the recovery area, and she’ll usually stay there for a couple of hours. “That allows the nurse to make sure her vital signs are normal and that she’s not having too much bleeding,” explains Gossett. “Then, she and her baby will go to the postpartum room, where they will stay typically three nights after surgery. One of the differences between a vaginal delivery and cesarean delivery is that there’s usually a third (extra) night that we observe mom and baby just to make sure they’re doing well before they go home.”
Medications Given Before and After a C-section. Medications may vary a little depending on the hospital. That said, one very important medication given prior to a C-section is an antibiotic through the IV. “This dramatically reduces the risk of infection for mom after the C-section,” says Gossett. Other medications given in advance are a sour, salty antacid called Bicitra and a medication to prevent nausea if a woman is particularly prone to nausea. At UCSF, the obstetrician will also give pain medication prior to surgery. “UCSF has a protocol, or a way of caring for people in surgery, which is called Enhanced Recovery After Surgery (ERAS), and this includes giving pain medication before the surgery even starts,” says Gossett. “We give 1000 milligrams of Tylenol and we give a dose of a nerve medication called Gabapentin, and both of these actually help reduce the amount of narcotics women need after surgery. As part of this Enhanced Recovery After Surgery pathway, we also give around-the-clock ibuprofen and Tylenol so a woman is getting something every three to four hours, and then she gets a narcotic, typically oxycodone, for breakthrough pain if she needs it on top of the ibuprofen and Tylenol. What we found with this ERAS pathway is that women need far less narcotic than before we instituted it, where we didn’t give anything before surgery and where we weren’t quite as proactive about making sure ibuprofen and Tylenol were going in regularly. Many, many institutions don’t have that ERAS pathway, so, more typically, those women will get the anesthetic—the spinal or epidural—and then typically, we use a combination medicine for pain afterwards, such as Vicodin or Norco, which are combinations of Tylenol and a narcotic medicine, and then ibuprofen on top of that.”
Gossett explains that, typically, most women will need some form of pain medication for about a week after surgery, but it’s uncommon to need narcotics for more than five to seven days—and that’s important. “We want to manage women’s pain, but we also want to be really thoughtful about how much narcotic we give, particularly to somebody who’s breastfeeding because we know that some of that narcotic will go into the breastmilk and will get to the baby,” says Gossett.
Recovery. “Ideally, on the very day of surgery … we would get her up and moving,” says Gossett. “We would get her eating normal food. We want to try to help people get back to normal activity as quickly as possible—that’s been shown over and over to help speed recovery. … We know that when you don’t move, your risk of blood clots in your legs is much higher, your risk of things like pneumonia is much higher, so getting back to normal activity as quickly as possible is important. So, even in the hospital, we get people up and moving and walking in the halls. The bladder catheter comes out the day of surgery or the next day.”
Women will stay typically three nights after surgery. “The way insurance companies do this math is three midnights after delivery,” explains Gossett. So, if you have your baby at nine in the morning, you would go home three mornings later. If you have your baby at 11:50 at night, you’d still go home three mornings later unless there’s a complication or a problem where mom or baby isn’t ready to go.”
Women will go home from the hospital with a variety of medications, such as narcotics, high-dose ibuprofen, and a stool softener because narcotics are constipating. “It’s important that for as long as anyone takes a narcotic, she also regularly takes a stool softener,” says Gossett. As explained above, usually, by the end of the first week, women will not need narcotics. “There’s some pretty convincing data that, after surgery, if somebody takes more than 14 days of narcotic, it dramatically increases the risk of longterm addiction, even if they’re taking it for completely legitimate and appropriate reasons, and they’re taking it as prescribed,” says Gossett. “If you take it for longer, it just increases the risk of dependence and addiction.”
Once home, women shouldn’t lift anything heavier than their baby so as not to strain the incision or pull the stitches. So, one of the big challenges is carrying the baby in the carseat. “We usually tell people not to carry the baby and the carseat,” says Gossett. “So, they’re going to need some help getting home. And they shouldn’t be doing things like carrying laundry up and down the stairs, really for a good six weeks.” Women can go up and down stairs and go for walks, explains Gossett, but no vigorous aerobic exercise or sex until the six-week checkup: “Women can go up and down stairs. They can walk and go for walks, but no vigorous aerobic exercise until they have had their six-week checkup. And no sex until that six-week checkup because the incision on the uterus is very low—it’s right next to the cervix—so having intercourse could actually disrupt the internal incision.”
Six weeks after surgery, women will see their obstetrician for a full postpartum exam and check of the incision. Some women may see their obstetrician before that six-week checkup if they are particularly high risk for infection or for postpartum depression. “Typically at that six-week visit, if everything looks healthy, then she’s allowed to return to all normal activity,” says Gossett.
Preparing for a C-section. “In terms of preparation, you want to make sure that you have identified a support person who is going to be able to be with you. You want to bring comfortable clothes to come home in because you’re going to be sore, and even though you’re having your baby, your belly is still going to be big—you’re still going to look like you’re six or seven months pregnant when you leave the hospital—so don’t bring your skinny jeans, bring your maternity clothes. And bring whatever else you think will comfort you, either during the procedure or while you’re in the hospital. Many women like to bring their own toiletries. Some people want music in the operating room and, usually, the obstetrician will permit that. If there are particular keepsakes, like your baby book for footprints, you should bring all of that with you to the hospital.
And then just remember that it is big surgery, so make sure that you—as much as you can with whatever resources are available to you—arrange for some help at home. Or, help yourself. Make meals in advance and put them in the freezer. If you can get somebody to come clean your house for a couple of weeks or help with laundry for a couple of weeks, that can be an enormous relief not to have to worry about the day-to-day running of your house while you’re recovering from surgery. And be excited about it because even though it’s surgery, it’s also your baby’s birth.”
For additional information on cesarean deliveries, check out The American Congress of Obstetricians and Gynecologists or the American Pregnancy Association.
For more pre-birth prep, check out our hospital bag checklist, what to discuss before baby comes, our how to help a new mom list, the etiquette around visiting new babies, and what songs these moms used for their birth soundtrack.
Anything you wish you’d known before your C-section? Tell us in the comments below.
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