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Cesarean Section: The Anatomy of a Choice

This BirthLove Column by LLM appeared in Issue 20.0, April 18, 2000 of the OBCNEWS. For a full listing of columns, go here.

"With a scheduled Caesarean section, you and your doctor have agreed to a time at which you will enter the hospital in a fairly calm and leisurely fashion, and he or she will extract your baby through a small slit at the top of your public hair." -From the popular pregnancy book "The Girlfriend's Guide to Pregnancy" (Lovine, V). Scroll down this web page to view the aforementioned "small slit".

"Even a monkey can be taught to do a Caesarean." -Teresinha Cantarim, OB/GYN, Sao Jose do Rio Preto, Brazil, as quoted in the Wall Street Journal

"... the woman who chooses CS puts her baby in unnecessary danger. That some women are choosing CS strongly suggests women are not told this scientific fact...It is only logical that eventually a point is reached at which CS kills almost as many babies as it saves." -Marsden Wagner MD MSPH, quoted from Choosing Cesarean Section

Introductory Notes

Also note that there are a few very good reasons for c-sections. For example- if a woman has severe pre-eclampsia (consistently very high blood pressure), placenta previa (placenta covering vaginal opening), or cord prolapse (cord coming down first), she may well be best served by cesarean delivery. (To reduce the likelihood of cord prolapse, a woman's bag of waters must never be artificially broken.) If a cesarean is indeed considered to be the best possible birth choice- optimally by more than one care provider- a woman should insist that she is treated with respect, fairness and consideration. For help in planning an optimal cesarean section, read Keeping Power in a Cesarean Delivery and How to Have an Empowered Cesarean.

• "Does this look like safe childbirth?"
• "Is this how my child would want to be born?"

"Your material on C-section is excellent. You have organized and pulled together a lot of information."
-Marsden Wagner MD, MSPH. Pediatrician, neonatologist, perinatologist and former head of Women's and Children's Health for the World Health Organization.

Cesarean Section: The Anatomy of a Choice

"If one went to the extreme of giving the patient the full details of mortality and morbidity related to cesarean section, most of them would get up and go out and have their baby under a tree..."
-Neel, J. Medicolegal pressure, MDs' lack of patience cited in cesarean 'epidemic.' Ob.Gyn. News Vol 22 No 10

Women choosing hospital births for themselves have on average approaching a one in four chance of cesarean section. Hence, the woman choosing to give birth in a hospital must be prepared to accept the fact that a cesarean section may well be the end result of her choice.

The laity (non-medical practitioners; the "great unwashed") of the world have been led to believe that the surgical removal of an infant is a clean operation; with little trauma or danger resulting from the procedure itself. But they are not neat little surgeries where the baby slides smoothly out of a little slit made gently into a woman's belly; they are not salvations from the "pain" of childbirth itself. They are unique pains in and of themselves; they excise into the very core of a woman's body and spirit, and leave a great deal of pain and trauma which lasts far beyond that of a vaginal delivery. The sadness and physical infirmities that result from a c-section- like intestinal difficulties or urinary stress incontinence- may even carry into a woman's grave. (And beyond, with her child- who will have unique, undocumented birth trauma too.)

So before a woman seeks out a hospital birth and then consents to the major abdominal surgery that so often accompanies it, she must know the full anatomy of her choice. What follows is a detailed description of what a cesarean section entails. I am trying to write this in the least inflammatory terms possible: but this is not easy; cesareans really are quite terrible.

First, a woman must be anesthetized. If she is undergoing epidural anesthesia- which is preferable than a general anesthetic- she is placed on her left side. She must roll into a tight ball to enable the anesthesiologist to find the exact place for the epidural catheter to be inserted. This is very difficult with a big belly- especially when contractions come; and finding the correct place for the needle to be inserted can take a few tries. (With my own cesarean section at BC Women's Hospital, one of the top OB hospitals in Canada, the anesthesiologist had to make four separate attempts. I still have the little pinprick scars that show where all the needles went in.) For some women, the catheter itself feels like something being screwed into one's back- a crunching and grinding feeling. This is a reality that must be known: epidurals can hurt. (Epidurals are also very dangerous, for many reasons: see epidural links.)

Alerternatively, women will be asked to hunch over, as is illustrated below.

After the epidural is in place, the woman is wheeled down to the operating room. Her arms are strapped away from her body; equipment monitoring vital signs are attached to her arms.

A woman is shaved and sterilized. A catheter is inserted into her urethra: be warned that this can be painful- a catheter upon both its entrance and exit feels just like what it is- a sharp, long tube going where it's not supposed to. Appropriate drugs will be put into the woman's IV, such as narcotics to alleviate inevitable stress, pain and anxiety. It is crucial to mention that the myriad drugs women receive while undergoing cesarean section are in no way proven safe for infants. Powerful painkilling drugs in birth have been linked to future drug addiction (Jacobson, B. et al 1990; Nyberg, K. et al. 1993), and violent behavior, neurological disorders, and learning disabilities (Brackbill, 1979).

Be aware that for some women, epidural anesthetics don't even work. There are many instances where the anesthetic has worn off during surgery, but the mothers were too drugged to speak or cry out, or their cries weren't taken seriously. If a woman is planning a hospital birth, she must consider having a warning signal that her doctor and/or partner would recognize, in the event that an epidural anesthetic is not effective. Perhaps a hand signal would be a prudent measure to rehearse beforehand. (Go to BirthLove's cesarean stories page to read stories from women who have had cesareans with no successful anesthetic.)

Once it has been established that the mother is adequately anesthetized, the surgery will begin. The surgeon makes a scalpel incision just above the pubic hair line on the lower abdomen and pierces through the skin, fascia, fat and down to the muscle layer. Note that there is a 1.9% chance the surgeon's knife will accidentally cut the baby; and the number jumps to 6.0% when the baby is breech. (Smith J, Hernandez C, Wax J, 1997. "Fetal laceration injury at cesarean delivery," Obstet & Gynecol 90:344-6.)

Instruments are used (retractors) to hold all of the layers of tissue wide open. (The surgeon must be careful to avoid cutting the major arteries, bladder, and bowel.) Once through the muscle, the uterus is exposed and cut through. The baby's bag of waters is punctured, and the surgeon reaches into the incision with either hands, forceps or vacuum extractor and pulls to get the baby's head out.

The rest of the body follows with a lot of tugging and pulling. From beginning to this point takes about 7 minutes.

Baby's cord is cut, and the surgeon hands the baby over to a waiting "baby team" who suction the baby's airways. Because the baby's lungs have not been massaged and emptied of fluids via descent through the vagina, the baby needs thorough suctioning. Be warned that the excess fluids and intensive respiratory work can cause respiratory distress syndrome (RDS), a major cause of infant death. View references here. (Another cause of RDS is babies being taken by cesarean before true labor begins. To reduce the chance of this potentially lethal condition, it is by far the most prudent, except in the most extreme circumstances, to wait until labor naturally begins before surgery is performed.)

Also know that the incidence of persistent pulmonary hypertension, a serious complication that hampers the body's ability to oxygenate blood (learn about it here), is nearly five times higher in newborns delivered by cesarean section than among babies delivered vaginally, according to a database analysis of deliveries at the Illinois Masonic Medical Center, in Chicago. Click here to view the reference. Babies born by cesarean are also 33% more likely to develop asthma later in life. (J Allergy Clin Immunol 2003;111:51-56- click to view the reference.) Another study says that cesarean section makes people up to 75%-80% more likely to be hospitalized for asthma in childhood (see this page).

Meanwhile, the surgeon reaches into the uterus again to scrape off the still-attached placenta. (Hemorrhage may result; women are up to sixteen times more likely to die during or after a caesarean delivery than a vaginal birth, and the major cause of c-section death is hemorrhage. (Sultan AH, Stanton SL. Preserving the pelvic floor and perineum during childbirth- elective caesarean section? Br J Obstet Gynaecol 1996; 103: 731-734 See "Women are Dying Needlessly in Childbirth" for more about this; includes links and references.) The uterus is often then pulled from deep within of the woman's body, where it is held in place by strong ligaments, and is placed outside of her body on her abdomen to be sutured shut. (Other times it is left within the abdominal cavity, which is preferable- a uterus left inside is less likely to prolpase later in life. Ask your OB about how he stitches up the uterus before deciding to accept his services for your birth.

The uterus

Once the uterus is closed with stitches, it is returned to the deep layers. Then the bladder must be reattached to the uterus- it was likely "peeled" off initially, which can lead to urinary stress incontinence. All the layers must be sutured shut, one by one; and after sutures, the abdominal wound will be stapled shut. All the stitching up after surgery takes about 30-45 minutes. (For more about stitching, see Suturing a Cesarean Wound.)

After the surgery, the woman will be wheeled up to her room where more drugs will be given: antibiotics to kill any infections that may have resulted from the surgery (she has a 20% chance of infection- a serious complication of cesarean section, and a leading cause of maternal death), more painkilling drugs, as well as a drug to alleviate the violent shaking that women tend to get after exposure to narcotics during childbirth. The woman's vital signs will be monitored consistently, and nurses will frequently be checking her uterine incision for signs of infection and poor closure. The bag to which the catheter is attached will be monitored as well- to see how much urine the woman is producing (the bag is taped to her leg).

In some centers, the woman will not be allowed food for three days (it really depends where you are). She will be given clear fluids; then full fluids; then bland, mushy, non-gassy foods, which is really beneficial because the gas pains that come post-cesarean are agonizing. It may be very, very painful to try to move one's bowels, and even trying to push out gas to alleviate the sickly distended feeling in one's belly hurts terribly. A woman choosing hospital birth can prepare for this by remembering that lying on her left side, and gently stroking her lower belly in light counter-clockwise motions, can be of enormous relief while suffering from gas pains. Also, trying to push one's bottom in the air helps, too- but this is difficult, because many women feel like their bellies will fall apart after surgery, and this vigorous rolling motion may seem too frightening.

A woman should also know that breastfeeding and normal baby care after a cesarean are severely hampered: both by a mother's own pain, and by her genuine physical infirmity. Being connected to myriad tubes, catheters, wires and cuffs also gets in the ways of bonding, and nurturing one's new baby. Feelings of pain and infirmity can carry well on into the baby's first year of life; a woman must be prepared for this. A woman must also be aware that she may cry a lot and have deep feelings of despondence, helplessness, and even violence for months or even years after a cesarean delivery, or other interventionist hospital birth experiences; women must keep in mind that deep feelings of birth trauma are common, and are often even considered normal, treatable responses to childbirth.

A cesarean section increases the probability of a future labor induction. Mothers attempting vaginal birth after cesarean (VBAC) typically have slow, easy labors and births; far too slow and easy for busy, trying-to-be efficient hospitals, and sometimes even midwives. So VBAC women are very commonly induced. Be warned that all labor induction and "augmentation" drugs are associated with rupture of the uterine scar. Especially be wary of Cytotec (misoprostol): it is associated with a 28-fold increase in the occurrence of uterine rupture in VBAC moms; and one out of five of women with Cytotec-induced uterine rupture will have their babies die as a result. Cytotec is an ulcer drug in which its use has spread like wildfire through the medical- and nurse-midwifery!- communities, and it has yet to be approved for obstetrical use by its manufacturer. Also be wary of Pitocin, and Prostin (prostaglandin), a cervical gel- it is associated with a 6-fold increase in the likelihood of uterine rupture. (See the Induction Dangers page for more about all of this.)

Women choosing hospital births for their first births must know that their choices will carry far into their reproductive lives; and since a cesarean is highly likely in any hospital birth, so is a future labor induction. Women should also know that cesareans are linked with future infertility, and an increased risk of placental problems in future pregnancies, like placenta previa (the placenta covering the vaginual outlet- having attached to where the c-section scar tissue is) - which can lead to severe hemorrhage, and death of baby or mother (see "Techonolgy in Birth", linked from end). Cesareans increase the risk of stillbirth in a woman's next pregnancy (see this page or here).

Finally, women choosing hospital birth must know that most c-sections are not needed. The World Health Organization says that the no more than 10% of healthy women should have cesarean sections. There is no evidence that a rate of CS over 7% saves lives (Enkin et al) . These numbers are even lower in most lay midwifery homebirth practices, where between 1 and 3 women in one hundred will need to trasnport for a cesarean; and the lay midwives better overall maternal and infant outcomes as well (see Links).

True informed consent means being informed of all the alternatives, and homebirth- including unassisted homebirth- is an option that must be kept open for any woman who wants the safest and gentlest birth possible, both for herself and her baby.

End Notes

Drugs in birth are linked with future drug addiction, violent behavior, neurological disorders, and learning disabilities:

If you have had a cesarean and are worried about your uterus rupturing in a future birth, know that VBAC is Safe! (Especially without induction drugs!)

For more about lay midwifery, unassisted childbirth, and c-section dangers go to the BirthLove Birth Stories page, Links page, and the Columns page.

For more about cesarean section see:

ICAN International -the website for the International Cesarean Awareness Network.

Plus-Size-Pregnancy.org -an excellent cesarean and VBAC resource that includes a huge amount of research and personal stories.

Technology in Birth: First Do No Harm by Marsden Wagner, MD- pediatrican, neonatologist, perinatal epidemiologist, and former Director of Women's and Children's Health for the World Health Organization. This could possibly be the most important article you will ever read about birth. Written as if speaking to a first-time mom, it tells how technology such as epidural and cesarean section KILLS women, and why doctors are so deadset against changing their practices. (i.e.- OBs make well over a quarter million dollars a year.)

A Butcher's Dozen by Nancy Wainer. This is the ultimate cesarean awareness and VBAC (vaginal birth after cesarean) reference, and should be read by everyone who cares about the history of VBAC, and the future of hospital vaginal birth.

Choosing Cesarean Section -by Marsden Wagner MD, MSPH. This includes the dangers of c-section to mother and baby, and just why c-sections are so"doctor friendly".

Quoted: "It is no coincidence that in the US, Canada and urban Brazil where obstetricians attend the majority of normal births and there are few midwives attending few births, the highest CS rates in the world are found...Promoting more CS by encouraging women to choose CS is part of a campaign to keep the obstetric profession in control of maternity care, a campaign which also includes marginalizing midwives through witch-hunts."

Elective Cesareans: A Women's Rights Issue or Florida Swampland? Cesareans by choice are argued over on "Good Morning America"; includes excellent commentary by Marsden Wagner MD, Suzanne Arms and Henci Goer.

Our True "Right to Choose" Letters by LLM and Suzanne Arms written in response to a cesarean by "choice" Newsweek article.

BirthLove's Cesarean and Vaginal Birth After Cearean Birth Stories, Articles and Links

Rape of the Twentieth Century explains how most cesarean sections are needless; done for reasons that are either idiotic or can be prevented or avoided altogether. "My baby would have died without my cesarean" is a statement for the most part made out of ignorance of childbirth reality. Women must educate themselves about the true nature of childbirth. This page includes my own cesarean birth story, as well as the birth stories of five of my other children.

Also see Marsden Wagner on the BirthLove Site for an incredible list of articles and links by this renowned physician.

All photos Copyright 2001/Patti Ramos Photography.
Please no reproduction, copying or any use of the images on this page without obtaining prior permission from Patti Ramos.