Cesarean Delivery

What Is a Cesarean Delivery? What Kind of Surgical Procedure Is It?

A cesarean is the delivery of the baby through a surgical operation rather than through the vaginal route. This operation generally includes the following steps:

1. Anesthesia: In most cases, regional anesthesia (spinal or epidural) is preferred, allowing the expectant mother to remain awake. This way, the mother can witness the moment of her baby’s birth. In emergencies or in rare cases where regional anesthesia is not suitable, general anesthesia may be required.
2. Preparation: The surgical site is cleaned with antiseptic solutions and covered with sterile drapes. A temporary urinary catheter is usually inserted to empty the bladder and prevent it from becoming full during surgery.
3. Incision: The surgeon usually makes a horizontal incision in the lower abdomen, just above the pubic hairline (known as a Pfannenstiel incision, or a “bikini incision”). Rarely, particularly in very urgent situations or due to previous surgeries, a vertical incision may also be made. After the skin is cut, the layers of fatty tissue and muscle beneath it are separated.
4. Uterine Incision: The uterine wall is also typically incised horizontally, in the lower segment of the uterus (a low transverse uterine incision). This incision type is preferred because it minimizes the risk of uterine rupture in future pregnancies.
5. Delivery of the Baby: The amniotic sac is opened and the baby is carefully removed from the uterus. The umbilical cord is clamped and cut. The baby is taken by the pediatrician or nurse for an initial assessment.
6. Removal of the Placenta: After the baby is delivered, the placenta (the baby’s afterbirth) is also removed from the uterus.
7. Closure: The uterine wall and abdominal layers (muscle sheath, fatty tissue, skin) are closed with sutures or, sometimes, with special surgical staples.

Cesarean delivery is a major abdominal surgery that can be performed either as a planned procedure or as an emergency.

In Which Situations Is a Cesarean Delivery Necessary? (Medical Reasons)

The decision for a cesarean is made to protect the health of the mother and/or baby, in situations where vaginal delivery is not safe or not possible. The main medical indications are as follows:

Reasons Related to the Mother:

• Placenta Previa: A condition in which the placenta completely or partially covers the cervix. It can cause severe bleeding during vaginal delivery.
• Active Genital Herpes Infection: To prevent the risk of transmitting the virus to the baby during delivery.
• Certain Uncontrolled Infections: Certain active infections in the mother that carry a high risk of transmission to the baby (e.g., untreated HIV).
• Inadequate Pelvic Structure: The mother’s bony pelvis being too narrow for the baby to pass through (cephalopelvic disproportion is usually diagnosed during labor).
• Previous Uterine Surgeries: Women who have previously had a myomectomy that reached the deep layers of the uterus, or other operations that carry a risk of uterine rupture. This is especially true if a previous cesarean incision was of the classical (vertical) type.
• Serious Maternal Health Conditions: Certain serious maternal conditions, such as some heart diseases, uncontrolled high blood pressure, or a cerebral aneurysm, in which pushing during labor could be risky.

Reasons Related to the Baby:

• Abnormal Presentation: The baby presenting with the buttocks (breech presentation), feet, or sideways (transverse lie) instead of the head. While vaginal delivery is sometimes possible in breech presentations, a cesarean is frequently preferred.
• Fetal Distress: Deterioration in the baby’s heartbeat during labor, along with signs of oxygen deprivation. This condition requires an emergency cesarean.
• Large Baby (Macrosomia): The baby’s estimated weight being very high (usually over 4000-4500 g), which can increase the risk of birth trauma, especially if the mother has gestational diabetes or a narrow pelvis.
• Multiple Pregnancies: A cesarean is generally planned particularly when the first baby is in breech presentation in a twin pregnancy, or in the case of triplets or more.
• Umbilical Cord Prolapse: The umbilical cord slipping out through the cervix and entering the birth canal ahead of the baby. The cord can become compressed, blocking blood flow to the baby, and this requires an emergency cesarean.
• Certain Fetal Anomalies: In some cases (e.g., spina bifida – meningomyelocele), a cesarean may be preferred to avoid birth trauma.

Reasons Arising During Labor:

• Failure to Progress (Dystocia): The cervix failing to dilate, or the baby failing to descend through the birth canal, despite adequate uterine contractions.
• Cephalopelvic Disproportion (CPD): The realization during labor that the baby’s head cannot pass through the mother’s pelvis.
• Failed Labor Induction: The attempt to induce labor artificially failing to succeed.

Repeat Cesarean:

• Having previously had one or more cesarean deliveries. Although Vaginal Birth After Cesarean (VBAC) may be an option for suitable candidates, in many cases, or based on patient preference, a repeat cesarean may be planned.

What Is the Difference Between a Planned (Elective) Cesarean and an Emergency Cesarean?

• Planned (Elective) Cesarean: A cesarean performed on a predetermined day, before labor begins, due to the presence of one of the medical reasons listed above (for example, placenta previa, a planned repeat cesarean, or breech presentation). The preparation process is more controlled for both the mother and the team.
• Emergency Cesarean: A cesarean performed when an unexpected situation threatening the health of the mother or baby arises during pregnancy or after labor has begun (for example, fetal distress, umbilical cord prolapse, sudden cessation of labor, or placental abruption – premature separation of the placenta). The goal is to keep the time between the decision and the baby’s delivery as short as possible.

What Are the Advantages and Disadvantages/Risks of Cesarean Delivery?

While a cesarean provides significant benefits when medically necessary, it is ultimately a surgical operation and therefore carries certain risks.

Advantages (When Medically Necessary):

• It can save the life of the mother and/or baby, or prevent serious health problems.
• It offers a safe delivery method in situations where vaginal delivery would be risky (placenta previa, umbilical cord prolapse, etc.).
• With elective (planned) cesareans, the delivery date can be known in advance.
• It eliminates (at least in the short term) the risk of perineal tears, the need for an episiotomy, or damage to the pelvic floor muscles that can occur during vaginal delivery.

Disadvantages and Risks: A cesarean is an abdominal operation and, like any surgery, carries potential risks. These risks are generally higher than with vaginal delivery:

• Risks for the Mother:
  
  • Infection: There is a higher risk of infection developing in the surgical wound, inside the uterus (endometritis), or in the urinary tract.
  • Bleeding: Blood loss during or after surgery may be greater than with vaginal delivery, and a blood transfusion may rarely be required.
  • Blood Clotting: There is an increased risk of clot formation in the leg veins (deep vein thrombosis – DVT) and of this clot traveling to the lungs (pulmonary embolism).
  • Anesthesia Complications: Depending on the type of anesthesia used (spinal, epidural, general), complications can occur, although rarely.
  • Organ Injury: There is a (rare) risk of injury to neighboring organs, such as the bladder or bowel, during surgery.
  • Length of Hospital Stay: This is generally longer than with vaginal delivery.
  • Recovery Process: Recovery takes longer and can be more painful. Returning to daily activities takes time.
  • Risks in Future Pregnancies: In future pregnancies, there may be a slight increase in the risk of abnormal placental attachment to the uterine wall (placenta accreta spectrum), uterine wall rupture (especially if VBAC is attempted), and ectopic pregnancy.
  • Chronic Pain: Long-term pain may develop at the surgical site or in the pelvic area.
• Risks for the Baby:
  
  • Transient Tachypnea of the Newborn (TTN): This can be more common, particularly with planned cesareans performed before labor begins, due to delayed clearance of fluid from the lungs.
  • Surgical Injury: Injuries such as a small cut to the baby’s skin can very rarely occur during surgery.
  • Effect of Anesthesia: Anesthetic drugs given to the mother can cross to the baby, causing short-term drowsiness after birth (this is usually temporary).
  • Microbiome Differences: Research is ongoing into whether not passing through the vaginal canal may affect the development of the baby’s gut flora (microbiome).

Important Consideration: When making the decision for a cesarean, the situation of both the mother and baby is taken into account, and it is carefully assessed whether the potential benefits of the procedure outweigh these risks.

The Cesarean Delivery Process: Details Before, During, and After Surgery

While the cesarean process shows some variation depending on whether it is planned or an emergency, the general steps are similar:

• Pre-operative Preparation (Planned Cesarean): Hospital admission usually takes place one day before surgery or on the same day. The necessary blood tests (complete blood count, blood type, etc.) are completed. An assessment is made by the anesthesiologist and the anesthesia method is determined. You will be asked to stop eating and drinking (fast) for 6-8 hours before the operation. Detailed information is given about the surgery and anesthesia, and written consent is obtained.
• In the Operating Room: A calm and sterile environment is ensured. Anesthesia (usually spinal or epidural) is administered. The abdominal area is cleaned, covered with sterile drapes, and a urinary catheter is inserted. Depending on hospital policy and the urgency of the situation, the partner may be allowed into the operating room.
• During Surgery: The surgeon makes the incisions and delivers the baby and the placenta. The baby’s first cry is usually a very emotional moment for the mother. If the mother is awake, she may see the baby briefly. The closure is then performed.
• The First Hours After Surgery (Recovery Room): After the operation is complete, the patient is taken to the recovery room. Here, blood pressure, pulse, breathing, the amount of bleeding, uterine contraction, and pain level are closely monitored. Pain-relief medication is started. If the condition of the mother and baby allows, skin-to-skin contact and an attempt at breastfeeding are encouraged as soon as possible.

Recovery After Cesarean Delivery and What to Watch Out For

Recovery after a cesarean generally takes longer than after vaginal delivery and requires more care:

• Hospital Stay: A hospital stay of 2 to 4 days after surgery is typical. During this time, pain control, wound care, mobilization (getting up and moving), nutrition, and breastfeeding support are provided.
• Pain Management: Pain after surgery is normal, and it is important to take the pain relievers recommended by your doctor regularly. This both increases your comfort and allows you to move more easily.
• Early Mobilization: Getting up and taking short walks as soon as possible after surgery (usually within the first day) speeds up blood circulation, reduces the risk of clot formation, and helps regulate bowel movements.
• Wound Care: The surgical incision is usually covered with a special dressing. Depending on your doctor’s recommendations, the dressing may need to be changed, or the wound may be left open. It is important to keep the wound site clean and dry. Sutures may be self-dissolving, or they may need to be removed after 1 to 10 days. You should watch carefully for signs of infection (redness, swelling, increased warmth, discharge, increasing pain).
• Nutrition: After surgery, you usually start with liquids, then gradually move to solid foods as bowel function returns to normal. It is important to drink plenty of fluids.
• Breastfeeding: Breastfeeding after a cesarean is absolutely possible. It can help to find a comfortable position at first (such as lying on your side or using the football hold), and to seek support from a lactation consultant if needed. Most pain relievers are compatible with breastfeeding.
• Recovery at Home: Full recovery usually takes 4 to 6 weeks. Rest is very important during this period. You should avoid lifting anything heavier than your baby. You will need your doctor’s approval before you start driving again (usually after a few weeks). Rest plenty, eat healthily, and take good care of yourself.
• Emotional Recovery: A cesarean delivery, especially if it was unplanned or occurred as an emergency, can cause feelings of disappointment, sadness, or trauma in some mothers. Hormonal changes, fatigue, and pain can also affect your emotional state. It is important to talk about these feelings and seek support from your partner, family, or support groups.

Is Vaginal Birth After Cesarean (VBAC) Possible?

Having had a cesarean in the past does not mean that all future deliveries must also be by cesarean. When the right conditions are met, Vaginal Birth After Cesarean, commonly abbreviated as VBAC, can be an option.

• Who May Be a Candidate? Generally, candidates are women whose previous cesarean was performed with a low transverse (horizontal) incision in the lower segment of the uterus, who have an adequate pelvic structure, who have no other condition in the current pregnancy that would prevent vaginal delivery (such as a large baby, breech presentation, or placenta previa), and whose labor either begins spontaneously or can be safely induced. Having had more than one previous cesarean is generally a contraindication for VBAC.
• Risks and Benefits: The most important risk is rupture at the site of the previous cesarean incision (uterine rupture), which occurs in approximately 0.5-1% of cases. Although this risk is low, it can have serious consequences. The benefits include the faster recovery associated with vaginal delivery, a lower risk of infection, and avoiding the risks of cesarean surgery in future pregnancies.
• Decision-Making Process: The decision for VBAC should be made individually, between the expectant mother and her doctor, after all risks and benefits have been discussed in detail. It is critical that the hospital where the delivery takes place has the capability for emergency cesarean and anesthesia. Prof. Dr. Nuray Bozkurt can assess your suitability for VBAC and discuss your options with you in this regard.

Safe Cesarean Delivery in Ankara: Prof. Dr. Nuray Bozkurt’s Approach

Prof. Dr. Nuray Bozkurt has deep understanding and experience in distinguishing when a cesarean delivery is necessary and when vaginal delivery is a safe option. Her approach in Ankara is based on the following principles:

• Priority on Medical Necessity: The decision for a cesarean is made based on medical necessity, grounded in scientific evidence, for the health of the mother and baby. Patient requests for cesarean delivery are carefully considered, but priority is always given to the safest delivery method.
• Safe Surgical Practice: The cesarean operation is performed in modern, fully equipped hospital settings in Ankara, together with an experienced anesthesia and operating room team, using up-to-date surgical techniques.
• Minimal Trauma and Aesthetics: By selecting the most appropriate surgical incision type (usually a bikini-line incision), the aim is both to speed up recovery and to take cosmetic outcomes into consideration.
• Effective Pain Control and Rapid Recovery: Recovery is supported by effectively managing post-operative pain and helping the patient mobilize as soon as possible.
• Mother-Baby-Friendly Practices: To the extent that the condition of the mother and baby allows, early skin-to-skin contact and the initiation of breastfeeding after surgery are encouraged.
• Comprehensive Follow-up and Support: The post-operative recovery process is closely monitored, all necessary information is provided, and patients’ questions are always welcome.
• VBAC Counseling: For suitable candidates, the option of Vaginal Birth After Cesarean is evaluated and counseling is provided on this topic (where this service is offered directly, or referral to an appropriate center can be made).
• Patient-Centered Care: Throughout the entire process, patient satisfaction, safety, and comfort remain the top priority. Reliable and easily accessible communication is provided (0538 983 18 78)(0312 284 00 12).

To learn more about cesarean delivery, to have your specific situation assessed, to create your birth plan, or to get a second opinion, you can consult Prof. Dr. Nuray Bozkurt at our clinic in Ankara. In situations where vaginal delivery is not possible or is risky, we are here to provide you and your baby with the safest, most suitable, and most attentive cesarean experience. To make an appointment, please contact us at 0538 983 18 78.