Cesarean Section: The Anatomy of a Choice

Women choosing hospital births for themselves have on average a one in five chance of cesarean section (in many areas, the number is 1 in 2). 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 leave a great deal of pain and trauma which lasts far beyond that of any 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 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, the anesthesiologist had to make four separate attempts. I still have the little pinprick scars that show where all the needles went in.) The catheter itself feels like something being screwed into one’s back; it’s a crunching and grinding feeling. This is a reality that must be known: epidurals hurt. (Epidurals are also very dangerous, for many reasons: see The Epidural Express- Real Reasons Not To Jump Onboard, by Nancy Griffin.)

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 very 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. It is crucial to mention that the drugs women receive whilst undergoing cesarean section- such as narcotics to alleviate inevitable stress, pain and anxiety- are in no way proven safe for infants. Drugs used in any kind of birth have been linked to future drug addiction, violent behavior, neurological disorders, and learning disabilities.

Be aware that for many 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. 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. (Epidurals don’t work on me. Fortunately, this difficulty was discovered before the surgery, and was remedied by putting spinal anesthetic into the epidural catheter. My husband’s idea.)

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. 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 with all his/her might 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 lungs have not been massaged and emptied by going through the vagina, the baby needs thorough suctioning. Be warned that such intensive respiratory work can cause respiratory distress syndrome, a major cause of infant death.

Meanwhile, the surgeon reaches into the uterus again to pull 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.) The uterus is 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. 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. 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.

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), more painkilling drugs, as well as a drug to alleviate the violent shaking that women tend to get after exposure to narcotics during childbirth. A mother should be aware that her colostrum may come in in odd colors because of all the drugs used in and after the surgery: my own colostrum took on a peculiar orange color for two days. 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 attached to her leg).

The woman will not be allowed food for three days: this is because her body cannot handle solid food yet. 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 will be very, very painful to try to move one’s bowels, and even trying to push out farts 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 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. So VBAC women are very commonly induced. Be warned that all labor induction 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 the 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 Prostin (prostaglandin), a cervical gel- it is associated with a 6-fold increase in the likelihood of uterine rupture. Women choosing a hospital birth 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 strongly linked with future infertility.

Finally, women choosing hospital birth must know that by far most c-sections are not needed. In fact, in lay midwifery practices only between 1 and 3 women in one hundred will get one. True informed consent means being informed of all the alternatives, and 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.