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INTRODUCTION — A cesarean birth (also called a cesarean section or surgical birth) is a surgical procedure used to deliver a baby (figure 1). Regional (or rarely general) anesthesia (spinal or epidural) is given to prevent pain, a vertical or horizontal ("bikini line") incision is made in the skin of the lower abdomen, and then the underlying tissues are dissected to expose the uterus. An incision is made in the uterus to allow removal of the baby and placenta. Other procedures, such as tubal ligation (a permanent birth control procedure), may also be performed during cesarean birth. (See "Patient education: Permanent birth control for women (Beyond the Basics)".)
Some cesarean births are planned and scheduled before the onset of labor because of maternal or fetal conditions that warrant cesarean birth, while others are unplanned and performed during labor because of maternal or fetal problems that arise at that time. More than 30 percent of births in the United States occur by cesarean.
REASONS FOR CESAREAN BIRTH — Some women who intend to give birth vaginally will eventually require cesarean birth. The following list describes some (not all) reasons cesarean might be needed:
●Labor is not progressing as it should. This may occur if the contractions are too weak, the baby is too big, the pelvis is too small, or the baby is in an abnormal position. If a woman's labor does not progress normally, in many cases, she will be given a medication (Pitocin/oxytocin) to be sure that contractions are adequate for several hours. If labor still does not progress after several hours, a cesarean birth may be recommended.
●The baby's heart rate suggests that it is not tolerating labor well.
●Heavy vaginal bleeding. This can occur if the placenta separates from the uterus before the baby is born (called a placental abruption).
●A medical emergency threatens the life of the mother or baby. (See 'Emergency cesarean birth' below.)
PLANNING CESAREAN BIRTH — A planned cesarean birth is one that is recommended because of the increased risk(s) of a vaginal birth to the mother or infant. Cesarean births that are done because the woman wants, but does not require, a cesarean birth are called "maternal request" cesarean births. (See 'Cesarean birth on maternal request' below.)
There are a number of medical and obstetric circumstances where a health care provider might recommend scheduling a cesarean birth in advance. Some (not all) of these circumstances are listed below:
●The baby is in a transverse (sideways) or breech position (buttocks first).
●The placenta is covering the cervix (called placenta previa; cesarean is always recommended for women with placenta previa).
●The mother has had a previous cesarean birth or other surgery in which the uterus was cut open. A vaginal birth is possible after cesarean birth in some, but not all cases. (See 'Future births' below.)
●There is some mechanical obstruction that might prevent or complicate vaginal birth, such as large fibroids or a pelvic fracture.
●The baby is unusually large, especially if the mother has diabetes. (See "Patient education: Care during pregnancy for patients with type 1 or 2 diabetes (Beyond the Basics)".)
●The mother has an active infection, such as herpes or HIV, that could be transmitted to the baby during vaginal birth. (See "Patient education: Genital herpes (Beyond the Basics)" and "Patient education: HIV and pregnancy (Beyond the Basics)".)
●The birth involves multiple gestation (twins, triplets, or more).
●The woman has cervical cancer.
●The baby has an increased risk of bleeding.
There is some controversy about the preferred route of birth in certain situations. These include some congenital anomalies, such as spina bifida and abdominal wall defects, and some maternal medical problems.
One of the most important factors in scheduling a cesarean birth is making certain that the baby is ready to be born. In general, repeat cesarean births in otherwise uncomplicated singleton pregnancies are not scheduled before the 39th week of pregnancy. There are other situations where the cesarean is scheduled before 39 weeks.
Most women will meet with an anesthesiologist before planned surgery to discuss the various types of anesthesia available and the risks and benefits of each. Instructions about how to prepare for surgery will also be given, including the need to avoid all food and drinks for at least two and often for several hours before the surgery.
Advantages of planned cesarean — The advantages of a planned cesarean birth include:
●It allows parents to know exactly when the baby will be born, which makes issues related to work, childcare, and help at home easier to address.
●It minimizes some of the possible complications and risks to the mother and baby from labor.
●It helps ensure that a pregnant woman's obstetrician will be available for the birth.
●It may offer a more controlled and relaxed atmosphere, with fewer unknowns such as how long labor and birth will last.
The benefits of planned cesarean birth must be weighed against the risks. Cesarean birth is a major surgery, and has associated risks.
Maternal risks — Because cesarean birth involves major surgery and anesthesia, there are some disadvantages compared with vaginal birth.
●Cesarean birth is associated with a higher rate of injury to abdominal organs (bladder, bowel, blood vessels), infections (wound, uterus, urinary tract), and thromboembolic (blood clotting) complications than vaginal birth.
●Cesarean surgery can interfere with mother-baby interaction in the birthing room.
●Recovery takes longer than with vaginal birth.
●Cesarean birth is associated with a higher risk that the placenta will attach to the uterus abnormally in subsequent pregnancies, which can lead to serious complications.
●Cutting the uterus to deliver the baby weakens the uterus, increasing the risk of uterine rupture in future pregnancy. This risk is small and depends upon the type of uterine incision.
Infant risks — There are few risks of cesarean birth for the baby.
●One risk is birth trauma, which is rare.
●Temporary respiratory problems are more common after cesarean birth because the baby is not squeezed through the mother's birth canal. This reduces the reabsorption of fluid in the baby's lungs.
●The baby is not exposed to the normal bacteria in the mother's vagina, which may be important because exposure to this bacteria appears to be beneficial in several ways.
Potential complications — The most common complications related to cesarean birth include infection, hemorrhage (excessive bleeding), injury to pelvic organs, and blood clots.
●Infection – The risk of postoperative uterine infection (endometritis) varies according to several factors, such as whether labor had started and whether the fetal membranes have ruptured. Endometritis is treated with antibiotics.
Wound infection, if it occurs, usually develops four to seven days after surgery, but sometimes appears during the first day or two. In addition to antibiotics, wound infections are sometimes treated by opening the wound to allow drainage and removing infected tissue if needed.
●Hemorrhage – One to two percent of all women having cesarean births require a blood transfusion because of hemorrhage (excessive bleeding). Hemorrhage usually responds to medications that cause the uterus to contract or procedures to stop the bleeding. In rare cases, when all other measures fail to stop bleeding, a hysterectomy (surgical removal of the uterus) may be required.
●Injury to pelvic organs – Injuries to the bladder or intestinal tract occur in approximately one percent of cesarean births.
●Blood clots – Women are at increased risk of developing blood clots in the legs (deep vein thrombosis or DVT) or the lungs (pulmonary embolus) during pregnancy and especially the postpartum period. This risk is further increased after cesarean birth. The risk can be reduced by using a device that gently squeezes the legs during and after surgery, called an intermittent compression device. Women at high risk of DVT may be given an anticoagulant (blood thinning) medication to reduce the risk of blood clots.
CESAREAN BIRTH ON MATERNAL REQUEST — The concept of requesting a cesarean birth is relatively recent. In the United States and most Western countries, pregnant women have the right to make choices regarding treatment, including how they will give birth.
A woman who wants to request a cesarean birth should discuss this decision with the health care provider, who can provide information about each route of birth and can help to relieve common fears about pain during childbirth, the expected process of labor, as well as the woman's right to determine the route of birth. (See 'Maternal risks' above.)
Regardless of a woman's decision, it is possible to reconsider the decision at any time based upon a change in circumstances.
EMERGENCY CESAREAN BIRTH — In some cases, cesarean birth is performed as an emergency surgery during labor. Time may be of the essence, depending on the situation. Cesarean births performed due to concerns about the mother's or baby's health are generally started as quickly as possible.
By contrast, if a cesarean is performed because labor has not progressed normally or for other, less serious concerns about the baby's well-being, the surgery is usually begun within 30 to 60 minutes.
If an epidural was placed before the attempted vaginal birth, it usually can be used to administer anesthesia for the cesarean birth (a larger dose is necessary for cesarean versus vaginal birth). Otherwise, spinal anesthesia (or rarely general anesthesia) is given. (See 'Anesthesia' below.)
PROCEDURE — After being admitted to the hospital for a planned cesarean birth, a woman may be given an oral dose of an antacid to reduce the acidity of the stomach contents. Another medication may be given to reduce the secretions in the mouth and nose. An intravenous (IV) line will be placed into the hand or arm, and an electrolyte solution will be infused. An antibiotic will be given through the IV to help prevent a postoperative infection. Monitors will be placed to keep track of blood pressure, fetal heart rate, and maternal blood oxygen levels.
Anesthesia — The woman is usually accompanied to an operating room before anesthesia is administered. A partner can usually stay with her in the operating room.
There are two types of anesthesia used during cesarean birth: regional and less commonly, general. For a planned cesarean birth, regional anesthesia is usually performed. Meeting with the anesthesiologist allows the woman to ask specific questions about anesthesia, and allows the anesthesiologist to identify any medical problems that might affect the type of anesthesia that is recommended.
With epidural and spinal regional anesthesia, the anesthetic is injected near the spine, which numbs the abdomen and legs to allow the surgery to be pain-free while allowing the mother to be awake.
General anesthesia, now infrequently used for cesarean, induces unconsciousness. This means that the mother will not be awake or aware during the procedure. After the anesthesia is given, the woman will fall asleep within 10 to 20 seconds and a tube will be placed in the throat to assist with breathing. General anesthesia carries a greater risk of complications than epidural or regional anesthesia because of the need for an endotracheal (breathing) tube and because drugs given to the mother affect the baby.
Women who have general anesthesia will not be awake during the cesarean birth. Regional anesthesia is generally preferred because it allows the mother to remain awake during the procedure, enjoy support from staff and her partner, experience the birth, and have immediate contact with the baby. It is usually safer than general anesthesia.
After the anesthesia is given, a catheter is placed in the bladder to allow urine to drain out during the surgery and reduce the chance of injury to the bladder. The catheter is usually removed within 24 hours after the procedure.
Skin incision — There are two basic types of incision: horizontal (transverse or "bikini line") and vertical (midline). Most women have a transverse skin incision, which is made 1 to 2 inches above the pubic hair line. The advantages of this type of incision include less postoperative pain, more rapid healing, and a lower chance that the wound will separate during healing.
Less commonly, the woman will have a vertical ("up and down") skin incision in the midline of the abdomen. The advantages of this type of incision include a slightly more rapid access to the uterus (eg, if the baby is in distress or if the woman is bleeding excessively).
Uterine incision — The uterine incision can also be either transverse or vertical. The type of incision depends upon several factors, including the position and size of the baby, the location of the placenta, and the presence and location of any fibroids. The main consideration is that the incision must be large enough to allow birth of the baby without causing trauma.
The most common uterine incision is transverse. However, a vertical incision may be required if the baby is breech or sideways, if the placenta is in the lower front of the uterus, or if there are other abnormalities of the uterus.
After opening the uterus, the baby is usually removed within seconds. After the baby is born, the umbilical cord is clamped and cut and the placenta is removed. The uterus is then closed. The abdominal skin is usually closed with absorbable sutures (ie, absorbed by the body so they do not need to be removed).
After the mother and baby are stable, she and her partner may hold the baby.
POSTOPERATIVE CARE — After surgery is completed, the woman will be monitored in a recovery area. Pain medication is given, initially through the IV line, and later with oral medications.
When the effects of anesthesia have worn off, generally within one to three hours after surgery, the woman is transferred to a postpartum room and encouraged to move around and begin to drink fluids and eat food.
Breastfeeding can usually begin any time after the birth. A pediatrician will examine the baby within the first 24 hours of the delivery. Most women are able to go home within a few days after giving birth. (See "Patient education: Deciding to breastfeed (Beyond the Basics)".)
The abdominal incision will heal over the next few weeks. During this time, there may be mild cramping, light bleeding or vaginal discharge, incisional pain, and numbness in the skin around the incision site. Most women will feel well by six weeks postpartum, but numbness around the incision and occasional aches and pains can last for several months.
After going home, the woman should notify the health care provider if she develops a fever (temperature greater than 100.4°F [38°C]), if pain or bleeding worsens, or if there are other concerns (eg, severe headache, abdominal pain, difficulty breathing).
FUTURE BIRTHS — Previously, obstetricians recommended that all women who had a cesarean birth have the same for all future birth. However, this is no longer the case. Many women in the United States who have had one low transverse cesarean birth choose to have a repeat cesarean birth, although these women could try to have a vaginal birth with the next pregnancy. Between 60 and 80 percent of women who try to give birth vaginally after a C-section are successful in giving birth vaginally. However, women who have a vaginal birth after cesarean (VBAC) have a less than 1 percent chance that the uterus will rupture during labor or birth, which could affect the baby's health [1].
WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: C-section (cesarean birth) (The Basics)
Patient education: Anesthesia for c-section (cesarean birth) (The Basics)
Patient education: When your baby is overdue (The Basics)
Patient education: Care during pregnancy for people with type 1 or type 2 diabetes (The Basics)
Patient education: Labor and delivery (childbirth) (The Basics)
Patient education: Postpartum hemorrhage (The Basics)
Patient education: Placenta previa (The Basics)
Patient education: Shoulder dystocia (The Basics)
Patient education: Vaginal birth after a cesarean (The Basics)
Patient education: Having twins (The Basics)
Patient education: Spina bifida (myelomeningocele) (The Basics)
Patient education: Breech pregnancy (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Permanent birth control for women (Beyond the Basics)
Patient education: Care during pregnancy for patients with type 1 or 2 diabetes (Beyond the Basics)
Patient education: Genital herpes (Beyond the Basics)
Patient education: HIV and pregnancy (Beyond the Basics)
Patient education: Deciding to breastfeed (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Anesthesia for cesarean delivery
Cesarean birth: Overview of issues for patients with obesity
Cesarean birth on maternal request
Cervical ripening and induction of labor after a prior cesarean birth
Repeat cesarean birth
The following organizations also provide reliable health information.
●National Library of Medicine
(https://medlineplus.gov/ency/article/002911.htm, available in Spanish)
●The American College of Obstetricians and Gynecologists
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