Caesarean birth

A caesarean birth, often called a C-section, is the birth of a baby through a cut in the belly and the uterus. In many countries about one in four or five babies is born this way, some by plan and some after labour has begun. It is major surgery, and it is also a birth. Knowing what happens, step by step, makes it far less frightening.

Planned, unplanned and emergency caesareans

Your team may use numbered categories of urgency, but the ideas are simple. Planned. The date is booked ahead, usually at or after 39 weeks, because a reason is known before labour. You come in calm, having fasted, and the pace is unhurried.

Unplanned, not urgent. During labour it becomes clear that a vaginal birth is unlikely or unwise, but you and your baby are both well. There is time to talk and get ready.

Urgent. There is a concern, such as a baby's heart rate showing strain, that is not immediately life-threatening. The team aims to have your baby born within about 30 minutes to an hour.

Emergency. There is an immediate threat, such as heavy bleeding, the cord slipping down ahead of the baby, or a heart rate that drops and stays down. The aim is birth within minutes, and a general anesthetic is more likely because it works fastest.

Most unplanned caesareans are not emergencies. Even when the room fills and everyone moves fast, that speed is the team doing exactly what they have practised.

Why a caesarean may be recommended

Some reasons are known before labour: a baby who is breech or lying sideways (see "Special situations"), a placenta lying over the cervix (placenta previa), twins with the first baby not head down, two or more previous caesareans, some health conditions in you or your baby, or an active genital herpes outbreak at the time of labour. Some people choose a caesarean after talking it through, sometimes because of a previous traumatic birth or a deep fear of vaginal birth. That is a valid choice, and it deserves a serious conversation.

Other reasons arise during labour: labour that stops progressing despite help, a baby's heart rate that shows distress and does not settle, an assisted birth that has not worked or is not safe (see "When labour needs help: induction, speeding things up and assisted birth"), or bleeding or a sudden change in your health.

It is always reasonable to ask: "Why is this recommended, what happens if we wait, and how much time do we have?" When there is no time, ask for the full explanation afterwards.

What you can ask for

Even a surgical birth leaves room for choices, often called a family-centred or gentle caesarean. Things many people ask for:

Your partner or support person with you, which is usual when you are awake.

A clear drape, or the drape lowered at the moment of birth, so you can see your baby lifted out.

Skin-to-skin contact in the operating room as soon as your baby is born. Delayed cord clamping, usually for at least a minute, if your baby is well. Your own music, and the team talking you through what is happening. Monitor stickers placed away from your chest and one arm left free, to make room for holding your baby.

A first feed in the recovery room.

Not every hospital offers all of these, and some depend on urgency. Talk them through before the day and add them to your birth plan (see "Getting ready for birth").

Preparing for a planned caesarean

In the days before, you will usually have blood tests and sometimes a meeting with the anesthesia team. Ask which of your usual medicines to take.

You will be told when to stop eating and drinking. A common instruction is no food for about six hours before surgery and clear fluids until about two hours before, but follow your hospital's timing exactly. Shower beforehand. Do not shave your pubic hair in the days before: tiny razor nicks raise the risk of infection. If hair needs removing, staff will use clippers. Pack soft, high-waisted underwear that sits above the scar.

Step by step in the operating room

Getting ready

A nurse puts an intravenous line (a drip) in your hand or arm. The operating room is often bright, cool and busier than you expect. Your partner changes into scrubs and usually waits outside while the anesthetic goes in, then joins you.

A typical team includes the obstetrician and an assistant, an anesthesiologist, operating room nurses, a midwife or nurse, and often a pediatric doctor or neonatal nurse for your baby.

The spinal anesthetic

Most caesareans use a spinal anesthetic, or an epidural from labour topped up with stronger medicine. You sit curled forward over a pillow while the anesthesiologist numbs a patch of skin on your lower back and passes a very fine needle between the bones of your spine. Most people feel a sting, then pressure.

Within minutes your legs feel warm, heavy and impossible to move, and the numbness rises to about chest level. The team tests it with something cold before starting. Shivering, nausea and a brief drop in blood pressure are common; tell the anesthesiologist, who can treat them quickly.

The catheter and the screen

Once you are numb, a thin tube (a catheter) is passed into your bladder to keep it empty. You will not feel it. Your belly is cleaned, antibiotics go into your drip, and a screen goes up across your chest. Your partner sits by your head, where you can see each other.

The incision and the birth

Most caesareans use a low, horizontal cut just above the pubic bone, about 10 to 15 cm (4 to 6 in) long. The surgeon opens the layers beneath, separates the stomach muscles rather than cutting them, and makes a second cut low in the uterus.

You should feel no pain, but you will feel things: pulling, tugging, rocking and strong pressure, sometimes like someone rummaging in a bag inside your belly. Just before the birth, someone may press firmly on the top of your belly. If you feel anything sharp or painful, say so at once: more medicine can be given.

Your baby is usually born within about 5 to 10 minutes of the first cut. You may hear suction, then a cry. The cord is clamped, after a short delay where possible, and your baby is placed on your chest or checked a few steps away first and then brought to you.

The rest of the operation

The placenta is delivered and medicine is given to help your uterus contract. Closing each layer takes most of the time: usually about 30 to 45 minutes after the birth. The skin may be closed with dissolving stitches, ordinary stitches, staples or glue.

When a general anesthetic is needed

A general anesthetic is used in a true emergency when there is no time for a spinal, when a spinal is not working well enough, or when it is not possible for medical reasons. You breathe oxygen through a mask, medicine goes into your drip, and you are asleep within seconds.

Your partner usually cannot be in the room, but ask whether they can hold the baby skin to skin while you wake. Waking can be confusing, with grogginess and a sore throat. Many people grieve not being awake for the birth. Ask your partner and the staff to take photographs and tell you everything when you are ready. "When birth doesn't go as hoped" talks about these feelings.

The recovery room

You will spend an hour or two in a recovery area, ideally with your baby and partner. A nurse checks your blood pressure, pulse, uterus, bleeding and dressing, often every 15 minutes at first. Expect vaginal bleeding: you still have lochia after a caesarean. Feeling returns to your legs over a few hours, starting with tingling. Itching is a common side effect of the spinal medicine and can be treated. You can usually drink, and often eat something light, soon after. This is a good time for skin-to-skin and a first feed (see "The first hours after birth").

The first days after a caesarean

Most people stay in hospital for one to three days. Recovery is real: you are healing from major surgery while caring for a newborn.

Pain relief

Take pain relief regularly for the first days, on a schedule rather than waiting until the pain is bad. Most options offered are compatible with breastfeeding. Stronger medicines may be offered for a short time; use them if you need them. Holding a pillow firmly against your wound helps when you cough, laugh or stand.

Getting up early

You will be helped to sit, stand and walk a little within about 6 to 12 hours. The first time is slow and hard, and it gets easier quickly. Moving early helps your bowels, clears your lungs and lowers the risk of blood clots. To get out of bed, roll onto your side, drop your legs over the edge and push up with your arms. The catheter usually comes out within about a day. Trapped wind can cause surprising pain, even in the shoulder; walking and warm drinks help.

Blood clot prevention

The risk of a blood clot is higher after a caesarean. You may be given compression stockings and injections of a blood thinner, sometimes for days or weeks after going home. Drink well, move your feet and ankles often, and walk a little every few hours.

Wound care

The dressing usually comes off after a day or two. Let shower water run over the wound, pat it dry, and wear loose clothes. No baths or swimming until it has healed. Numbness around the scar is normal and can last months. Staples or non-dissolving stitches come out after about 5 to 10 days.

Lifting and driving

Lift nothing heavier than your baby for about six weeks, and ask for help with car seats, laundry and older children. Short walks are good from the start. Most people can drive again when they can turn to look over their shoulder, brake hard and wear a seatbelt comfortably, often around four to six weeks.

Signs to watch for

Call your midwife or doctor if your wound becomes redder, more swollen, hot or more painful, leaks fluid or pus, or starts to open; if you have a fever of 38 °C (100.4 °F) or higher; if peeing burns; or if your bleeding smells bad.

Get help right away if you soak a pad in an hour or pass large clots, have chest pain or sudden shortness of breath, cough up blood, have a painful, red or swollen calf, a severe headache or vision changes, or feel very unwell and shivery.

Feeding after a caesarean

You can breastfeed after a caesarean, usually within the first hour. Milk may come in a little later, especially after a long labour or a general anesthetic, so frequent feeds, skin-to-skin and hand expressing colostrum all help. Choose positions that keep weight off your wound: lying on your side, the rugby or football hold with your baby tucked along your side, or laid back with a pillow over your belly. Ask for help positioning your baby at first. If you are formula feeding, your partner can do many early feeds while you rest.

How you might feel

Some people feel only relief and joy. Some feel a sense of loss, especially after an unplanned caesarean, or feel they "missed" the birth or that their body "failed". It did not. A caesarean is a way of giving birth, and the courage involved is real. If feelings stay heavy, read "When birth doesn't go as hoped" and talk to your care provider.

Birth after a caesarean

Next time, you will likely choose between a vaginal birth after caesarean (VBAC) and a planned repeat caesarean. For most people with one previous low, horizontal cut, both are reasonable. "Special situations" explains VBAC in more detail. Ask for a copy of your surgical notes, or at least the type of uterine cut, so you have it for the future.

In short

Caesareans range from calmly planned to emergency, and most unplanned ones are not emergencies.

With a spinal anesthetic you are awake: expect pulling and pressure, not pain, and your baby is usually born within about 10 minutes.

Ask ahead about gentle options such as skin-to-skin in the operating room and delayed cord clamping.

Take pain relief regularly, get up early with help, and lift nothing heavier than your baby for about six weeks.

Watch for signs of wound infection, heavy bleeding or a blood clot, and call promptly.

A caesarean is a birth, and whatever you feel about yours deserves care and time.