How C-Sections Work

A baby is born by C-section in Kabul, Afghanistan, in October 2007. See more pregnancy pictures.
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We have all -- hopefully -- learned by now how babies are made, but do you know how they are delivered? The answer depends on the health of the mother and the baby. Delivery options can change, and sometimes very quickly. Vaginal birth is the traditional method, but Cesarean sections, or C-sections, are becoming more commonplace. In a C-section, doctors cut directly into the mother's uterus to deliver the baby.

C-section references date back to the first century, with mentions in ancient texts from Egypt, Greece, Rome and other parts of Europe. In ancient times, C-sections were used to cut the baby from the womb if the mother died in childbirth -- it wasn't until the 1500s that a mother reportedly survived a C-section. In the mid-1800s, the first successful C-section was performed in the British Empire.


With the rapid development of medical procedures -- including anesthesia -- in the late 1800s, C-sections became a little less risky and were used to avoid craniotomies. When a baby couldn't be born vaginally, doctors would perform a craniotomy, which involved destroying the skull of the fetus and removing the remaining parts of the body through the vagina. C-sections were certainly a better alternative, but they still weren't considered safe, with many women dying of infection and blood loss. But doctors continued to refine the technique, and their use has increased steadily since the 1940s. In 2005, nearly 30 percent of women in the United States gave birth via C-section, up from just 6 percent in 1970 [source: BabyCenter]. In fact, according to the Centers for Disease Control and Prevention, the C-section rate has increased more than 45 percent since 1996 [source: CDC].

In this article, we'll learn more about C-sections and how they're performed. We'll also find out why the rate is climbing. What does this mean for women and their babies? What kinds of pregnancy and labor complications can lead to a C-section, and why do some women plan to have them?


The C-section Procedure

Nearly 30 percent of women in the United States gave birth by C-section in 2005.
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C-sections are now considered routine procedures, with a low chance of mortality for mother and child. Doctors have used several C-section techniques over the years, but there are two that are most widely used today.

The most common type is a low transverse incision, also known as a Monroe-Kerr incision. Doctors usually prefer this method because of its lower incidence of blood loss and other complications like infections. The surgeon makes an incision across the mother's belly, usually about 1 to 2 centimeters above the pre-pregnancy upper border of the bladder, or the top of the bikini line. The doctor will then cut through the tissues that lie above the uterus. After these tissues and the abdominal muscles have been separated, the doctor makes a horizontal incision in the lower section of the uterus. The baby's amniotic fluid is then suctioned off for more room during delivery. After this step, the doctor usually can pull the baby out without complication or use forceps or a vacuum extractor if he needs extra help.


The other type of C-section may sound familiar to an older generation of women. The classic C-section is the procedure that leaves women with a large vertical scar across their belly. The doctor makes a vertical incision and cuts through tissue, fat and muscle to reach the uterus, where he makes another a vertical incision. Doctors used this technique in the past to give more room for delivery. But they later realized that there were less complications (and a better-placed scar) if the delivery space were reduced. Today, this method is reserved for specific cases, such as an extremely premature baby. The classic C-section is the best choice in this scenario because the lower part of the uterus doesn't thin out until later in pregnancy. The upper part of the uterus is thinner, so doctors must access the baby that way. Women who have gone through a classic C-section are usually not able to deliver any future children vaginally due to a high risk of uterine rupture.

Before either procedure, the mother is prepped and given pain medication. This usually comes in the form of an epidural, which numbs the mother from the abdomen down but leaves her awake for the birth of her child. In the operating room, the mother is covered with surgical drapes that block her view of the surgery. She'll probably have a catheter inserted into her bladder. The mother's husband or partner can accompany her in most situations -- after undergoing a quick wardrobe change into surgical attire.

After delivery, doctors remove the placenta and use dissolving stitches to sew up the incision. Some underlying tissue and muscle will be able to reattach on its own within a few days without any scars. Doctors then close the skin with stitches or staples. This entire closing process usually takes about 30 minutes, more with a classic C-section incision.

That's what happens when a C-section goes as planned -- but they don't always go smoothly. We'll discuss the most common complications for both mother and baby in the next section.


The Risks of a C-section

Doctors perform a C-section in Kabul, Afghanistan, in October 2007. One out of nine Afghan women die during pregnancy or soon after.
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C-sections are relatively safe, but they are major surgery. So, by definition, they are riskier than vaginal deliveries. All surgeries involve the risk of infection, complications from anesthesia, internal injuries, postoperative adhesions and hemorrhaging. Today, maternal deaths in the United States range anywhere from 6 to 22 per every 100,000 births, with the higher rates usually involving emergency C-sections [source: WebMD]. However, these numbers can be a bit misleading. Many women have C-sections because of medical conditions, and complications from that condition -- not from the surgery -- are more often the cause of the death. About 25 to 50 percent of C-section deaths are directly attributable to the actual operation [source: WebMD].

After a C-section, the uterine tissues become infected in nearly 40 percent of women. This complication, postpartum endomyometritis, is 20 times more likely after a C-section than after a vaginal delivery. Incision infection occurs in anywhere between 2.5 and 15 percent of women. Urinary tract infections are a common risk, affecting as many as 16 percent of C-section patients. These infections, usually a result of the urinary catheter, can be treated with antibiotics. Decreased or absent bowel function can also occur, which is usually caused by pre- and postsurgery narcotics. Another serious risk is blood clotting. These clots are found in 1 out of every 400 pregnancies, regardless of delivery. However, the risk is as much as five times greater after a C-section [source: Emedicine].


C-sections can also put the mother at risk during subsequent births. Complications include preterm birth, breech presentation and low birth weight, with the major risk being a ruptured uterus. This rupture can involve a small tear (with minimal complications) or a large one that results in the fetus and placenta pouring into the abdominal cavity. This happens when the incision scar expands and tears during pregnancy or labor, and it can cause the mother to need a blood transfusion and possibly a hysterectomy -- and the baby could die from lack of oxygen. It's certainly a serious complication, but the actual risk can be as low as 1 percent when the previous C-section was a low transverse incision. It increases to 4 to 10 percent with a classic C-section [source: Emedicine]. So, doctors often advise women not to opt for vaginal delivery after having had a C-section.

The risks increase with each C-section -- one of the most common is placenta accreta. This happens when the placenta, which provides nourishment to the fetus during pregnancy, is attached too deeply to the uterine wall. The risk gets higher with each C-section because scar tissue can build up in the uterus. Another risk that increases with recurring C-sections is the need for emergency hysterectomies at delivery. The chance of hysterectomy increases five times with the fourth C-section and is nearly 20 times greater in women with six or more C-sections [source: Emedicine]. Placenta previa can also occur with multiple C-sections. This occurs when the placenta develops low in the uterus, blocking the cervix and possibly causing a need for another C-section.

Mom is not the only one who faces risks with C-sections. Babies born by C-section can suffer from neonatal respiratory distress -- breathing problems in the first few days of life that usually call for treatment with oxygen therapy. This occurs in 12 to 35 per 1,000 C-section babies -- compared to 5.3 per 1,000 vaginal births [source: Canadian Medical Association Journal]. When a baby is born vaginally, pressure on the lungs pushes out excess fluid. That doesn't happen in a C-section, so these babies sometimes have trouble breathing.

Doctors use the Apgar scale to quickly assess a baby's health immediately after birth -- they rate the baby's skin color, heart rate, reflexes, muscle tone and respiration on a scale of one to 10. Babies who are delivered by C-section often have low scores, usually because of the breathing problems mentioned above, along with the sedation medication given to the mother (and therefore baby), which can make the child lethargic. These sedatives can also make it hard to breast-feed at first. Finally, a rare but serious risk is injury to the fetus from the surgical incisions.

Even with these risks, sometimes doctors and patients plan C-sections. But many C-sections are unplanned -- performed in emergency situations. We'll find out more about unplanned C-sections next.


Unplanned C-sections

Most unplanned C-sections are emergency surgeries, which means they are performed after labor has begun, when the health of the mother or child is at risk. This can happen for a number of reasons.

  • Fetal distress, which is indicated by a dramatic change in the baby's heart rate. This is one of the most common reasons for an emergency C-section.
  • Placental abruption occurs when the placenta prematurely separates from the uterine wall. This can cause excessive bleeding in the mother and decreased oxygen supply for the baby, both of which can result in death.
  • During a vaginal delivery, there can be umbilical cord problems. The cord can wrap around the baby's neck and cut off oxygen supply. It can also slip out of the birth canal before the baby, which can result in a lack of blood supply.
  • A long and difficult labor could also necessitate an unplanned C-section. Labor could stop progressing for several reasons, including cephalopelvic disproportion -- when the infant's head is too large for the mother's pelvic structure.
  • A maternal health condition could result in a C-section if it could be passed on to the child through vaginal delivery. For example, a mother with genital herpes can deliver vaginally, as long as she's not suffering from an outbreak. But if she is having an outbreak when her water breaks or during delivery, the baby is will be delivered via C-section.

C-sections are unavoidable in some situations, but what would make a doctor or mother choose one if there's no emergency? That's what we'll discuss in the next section.


Planned C-sections

Babies born by C-section, like this quadruplet in China, can be at risk for complications.
China Photos/Getty Images

Planned C-sections are scheduled well before labor begins. There are two subgroups: indication-based and patient-requested.

Indication-based C-sections are usually scheduled at the doctor's request when a patient suffers from, or is at great risk of, a medical problem that could result in labor that would harm her or the baby. When a child is in the breech (feet-down) position, vaginal delivery is dangerous. Large babies (more than 9 pounds) are often delivered by planned C-section. Mothers who suffer from chronic conditions that could be exacerbated by labor, like diabetes or heart disease, often plan C-sections.


Multiple births, which are more common these days because of the increased use of fertility medications, are usually an indication for a C-section. The doctor will opt for a C-section when there are three or more fetuses in the womb, or when twins are conjoined or sharing one amniotic sac. Women who have had previous C-sections will often have a planned C-section.

One of the advantages of a planned C-section is the assurance that you will be at the hospital during peak hours, when a full staff is working. The risks of a planned C-section are also lower than those of an emergency operation.

Patient-requested C-sections (planned, without medical indications) are a growing trend in the United States. The National Institute of Health estimates that, in 2004, 4 to 18 percent of C-sections were performed on maternal request instead of for medical reasons [source: NIH]. While the NIH has admitted that these numbers are difficult to validate, they are sure that this type of C-section is becoming more and more common.

We know that the risks of C-sections are greater than risks of vaginal birth, at least with your first pregnancy. So why are women opting for C-sections, even for their first birth? Some theorize that the combination of improved C-section safety, along with increased maternal age, has lead to women being able to control when and how they are going to give birth. This type of control is attractive to women who are balancing family and career -- they can perfectly plan maternity leave, right down to the date of the last conference call. Another popular theory is that some women, fearing the pain of vaginal delivery and wanting to avoid urinary incontinence, jump at the chance to give birth via C-section.

Whatever the reasoning, doctors are quick to point out that women should not make this decision lightly. One C-section increases the necessity for another with the next child -- and the risk of serious complications increases for subsequent C-sections. The NationaI Institutes of Health has guidelines for patient-requested C-sections. To ensure proper fetal lung maturity, they should not be scheduled before 39 weeks of pregnancy. If a delivery is scheduled before this time the fetus' lung maturity must be verified before delivery.

No matter the reason, millions of women have C-sections every year. So what should a mom expect after she's been wheeled out of the operating room and into her hospital room? That's what we will discuss in our next section.



After the C-section

C-section have a longer recovery period than those who have vaginal births.
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The average hospital stay after a C-section is longer than for a vaginal birth -- four days after a C-section and only two days after a vaginal delivery. Women who give birth vaginally usually have a one- to two-week recovery time, which stretches to six weeks after a C-section. Vaginal delivery might be more painful, but C-section recovery pain is often intense, and the new mother needs a few weeks to gain full mobility.

After a C-section, doctors closely monitor the mother for the first 24 hours and give her pain medication throughout the hospital stay. If surgery went smoothly, after about a day, doctors encourage new moms to walk around to help gas from collecting in the abdomen and blood clots from forming in the legs.


The patient might attempt to breast-feed in the hospital, but babies born via C-section are less likely to be breast-fed than those delivered vaginally. One factor is that the mother will need to sleep and recoup from surgery. So she'll have less time with the baby, especially during the first hour after birth, which is the best time to begin breast-feeding. Also, babies delivered via C-section can be lethargic from the pain medication given to the mother, resulting in a disinterest in learning to breast-feed.

Doctors often remove the new mom's staples or stitches before she leaves the hospital. At discharge, they will give extensive information on how to recognize signs of serious complications, such as infection or hemorrhaging.

So what about the next delivery? We discussed the risks of multiple C-sections, along with the dangers of vaginal delivery after a C-section, so what's a woman to do? Each woman is different, of course, but vaginal delivery can be perfectly safe after a C-section. In fact, according to the American Pregnancy Association, nearly 90 percent of all women who have had C-sections are candidates for vaginal delivery in a subsequent pregnancy. Of those who decide on a vaginal delivery, up to 80 percent will have a normal delivery [source: APA].

However, of the 80 percent of women who could opt for a vaginal delivery, only about one in 10 actually does. Why is this? Well, as we discussed, there are risks. One is the rupture of the uterus, which can be as high as 1.5 percent [source: APA]. Other risks include the reopening of the previous C-section scar, rehospitalization after birth and infertility (which can result from an emergency hysterectomy or from uterine scarring). To avoid these risks, most doctors will do a "trial labor." This simply means that the mother begins labor expecting a vaginal birth. She is monitored closely for any complications, and a C-section is an immediate option if needed. Of those women who attempt a vaginal delivery after a C-section, approximately four out of every 10 end up having a C-section [source: WebMD]. A C-section is the safest option if the vaginal delivery is not going well, but the risk of infection doubles.

But there are also many benefits to a vaginal delivery. First, no more scars. This is especially important for women who want more children -- the more scars on the uterus, the greater the chance of complications in future pregnancies. Other benefits include less pain during recovery, a shorter recovery, higher chance of successful breast-feeding and a lower risk of infection.

To learn more about C-sections, check out the links on the next page.


Lots More Information

Related HowStuffWorks Articles

More Great Links

  • Adams, Lisa J. "Mexican-Indian Woman Performs Caesarean on Herself." Oakland Tribune. June 1, 2004.
  • American Pregnancy Association: Vaginal Birth After Cesarean.
  • BabyCenter. "Giving Birth by Cesarean Section."
  • CDC: Percentage of All Live Births by Cesarean.
  • Emedicine: Cesarean Delivery.
  • Hannah, Mary E. "Planned elective cesarean section: A reasonable choice for women?" Canadian Medical Association Journal, March 2, 2004.
  • International Journal of Gynecology & Obstetrics.­March 2004. Vol. 84, Issue 3.
  • March of Dimes: Pregnancy & Newborn Health Education Center.
  • Mayo Clinic: Vaginal Birth After Cesarean.
  • National Library of Medicine: Cesarean Section - A Brief History.
  • NCHS: Births - Preliminary Data for 2005.
  • NIH: Cesarean Delivery on Maternal Request.
  • Pregnancy Info: Cesarean Section Complications.
  • WebMD: Breast Feeding, Common Concerns.
  • WebMD: Cesarean Sections.
  • WebMD: Vaginal Birth After Cesarean.