Amanda Wilde (Host): Of all babies born in this country, almost a third are delivered by cesarean section. We'll talk about when C-sections are necessary and what to expect with Dr. Cheryl Silverbrook. Dr. Silverbrook is an OB-GYN with Capital Women's Care and Chair of the Department of Obstetrics and Gynecology at Holy Cross Hospital in Silver Spring, Maryland.

Host: This is Your Best Life Podcast, Women's Health from Holy Cross Health. I'm Amanda Wilde. Dr. Silverbrook, thank you for being here today.

Dr Cheryl Silverbrook: Thank you so much for having me.

Host: So, lots of questions about C-sections. First of all, why are they necessary and when are they necessary? I assume those two things are tied together.

Dr Cheryl Silverbrook: Yes. So typically, when we look at why a cesarean section might be indicated, we sort of look at maternal reasons and then fetal indication. So for the maternal side, we're going to be monitoring your progress during labor. If for some reason you're not progressing, meaning your cervix isn't getting to fully dilated, or you're unable to push the baby out, and that can be due to something we call cephalopelvic disproportion, meaning the baby is essentially too large to fit out of the maternal pelvis, that would be an indication for a cesarean section. Also if there was something going on with the health of the mother where we would need to expedite delivery, where things like severe pre-eclampsia, et cetera, where we don't want to delay care, that's another reason we might be doing a cesarean.

When we look at fetal indications, sometimes it's based on the position of the baby. So if the baby is not head down, if they're in the breach position or the transverse position, we may need to move forward with the C-section and then also if baby's not tolerating labor. So if we're monitoring the baby and we're seeing that the baby's in distress, that we need to expedite delivery, we would do a cesarean.

Host: So, you are ready to do cesareans in these kind of urgent situations. Sometimes I understand people plan for their C-section.

Dr Cheryl Silverbrook: Absolutely.

Host: In what situations does that happen?

Dr Cheryl Silverbrook: So, some people just have a preference not to go through the labor process, and we do have the option for elective cesarean sections. Some women just are concerned about pelvic floor dysfunction later, or they might have a history of sexual abuse or trauma where they feel that it will be easier for them to recover sort of in total by moving forward with an elective c-section.

Host: Right. So, there's always health reasons behind C-sections. Who is performing the C-section? Who is in the surgery during the C-section?

Dr Cheryl Silverbrook: So, you'll have your primary surgeon who will be an obstetrician gynecologist. Often in the room, you're going to have a circulating nurse, a scrub tech, and then often we have an assistant. So, that's either going to be a surgical physician assistant or an OB-GYN resident.

Host: And is the parent then giving birth awake for the procedure or no?

Dr Cheryl Silverbrook: Yep. So obviously, you also have an anesthesiologist in the room. You're not necessarily always awake. But typically in a non-emergent situation where we're able to provide appropriate neuraxial anesthesia, so that's going to be an epidural or a spinal, you're able to be awake. You will feel touch, but you're not going to feel pain cause of the kind of anesthesia that you have. And as long as it's not an emergency, we also are fine having a support person in the operating room with you.

Host: Now when I think of a C-section, I think of someone cutting in and it doesn't sound like the most painless option, but I don't know that that's correct with all the developments in laparoscopic surgery and things. So, what are the types of procedures that happen that are C-sections?

Dr Cheryl Silverbrook: So unfortunately, we haven't figured out how to get a baby out laparoscopically yet.

Host: Okay.

Dr Cheryl Silverbrook: We still do have to get an incision. We tend to do on the skin what's called a low transverse or a bikini cut incision. The incision on the skin is really more of a cosmetic issue. Once we get into the uterus, there's a couple different types of incisions that we can make on the uterus. And the type of incision we make will be dependent on if you're able to do a trial of labor after. So, the most traditional incision is going to be a low transverse incision on the uterus, so that's going to mimic that bikini cut incision on the skin, and that's the most common type of incision that we do.

There's also a low vertical, that's when we're going to do an up and down incision, but just in the lower uterine segment. And that might be in the case of someone who has had prior cesarean sections where they have a lot of scar tissue where we need to do that. And then occasionally, we do have to do a classical cesarean. That's when we're going to go up and down almost the entire length of the uterus. And that is usually done in extremely preterm cesarean sections where they may not have a developed lower uterine segment yet. Also, if someone has large fibroids that are obstructive in the lower uterine segment or if the baby is transverse, but back down, we may have to do that.

Host: And is that more invasive, the more traditional one?

Dr Cheryl Silverbrook: So, the classical cesarean section, which is not done that often does have a higher risk for blood loss because you are making that larger incision going up and down. The more traditional that we do sort of every day is the low transverse.

Host: What are some of the complications that might happen? You just touched on that with the classic. Are there other complications that could happen during a C-section?

Dr Cheryl Silverbrook: So, I always tell people a cesarean section is like any other surgery. So with that, you have a risk of bleeding. You have a risk of infection, we give you antibiotics to minimize that risk. Lots of things live in your abdomen where we'll be operating, your bowel, your bladder, there are blood vessels and nerves, and those things can be injured during the process of the surgery. With any surgery, there's a risk of blood clots that can form in your legs and go to your lungs. So, we give you special device called SCDs that are going to be like these little massage boots that help to minimize that risk. Obviously, once you've had one cesarean section, you are at higher risk for needing future cesarean sections. However, usually if we do a low transverse C-section with a two-layer closure, you are a candidate for doing a trial of labor after C-section.

Host: That's interesting because that was another question I was just about to ask. After having a C-section, would your future pregnancies also be C-sections? You say it's more likely, but not necessarily.

Dr Cheryl Silverbrook: Right. So, it depends on a few factors. So for one thing, what was the indication for the cesarean section? And we divide that into recurring indications and non-recurring indications. So, a non-recurring indication would be your baby was breach and your next baby is not breach. Or you did an emergency C-section because the baby's heart rate went down and didn't recover. So, those are reasons where you may not have had the opportunity to labor or to see if you could get to fully dilated and push a baby out. Those pregnancies tend to have a higher success rate when they do a trial of labor. After one C-section, the risk of that incision opening up is less than 1%. So, that would be called a uterine rupture, which would of course be an emergency for the mother and the baby. That's really rare after one prior C-section. Many of us also may feel comfortable even letting you try after two prior C-sections. That risk there is only like 2-3%. You can do a trial of labor after a low vertical C-section. After a classical C-section, that risk for uterine rupture starts to approach 10% or more. And so, we do not recommend a trial of labor after that type of cesarean.

Host: I see. And how long does it take for cesareans to heal? Or do they heal fully based on what you were just saying?

Dr Cheryl Silverbrook: So, recovery time is going to be about six to eight weeks for full recovery. Obviously, you also have a lot of other stuff going on when you bring a baby home, but that would be for full recovery. And then between pregnancies, we would want you to wait at least six months, ideally 12 months prior to starting to try to conceive again.

Host: As I mentioned at the beginning, almost a third of babies born in this country are born by C-section. How would you rate the C-section success?

Dr Cheryl Silverbrook: Usually, once we do the C-section, baby is successfully delivered healthy. So, there's been a large focus in the last 10 years really within obstetrics and gynecology saying, "How can we bring that cesarean section rate down?" And one of the big things that came out a few years ago was really looking at labor curves and giving women more time to labor before we say, "Hey, you're not dilating," or "Hey, the baby's not coming down with pushing." So, we do really give women a lot more time now to see if they have the opportunity to have a vaginal delivery, and we've seen some success rates with that in bringing cesarean section rates down across the country.

Host: And as usual in medicine, as comprehensive as it may be, each person is different. So, you really have to be watching that person, their symptoms, what's going on on an individual level.

Dr Cheryl Silverbrook: Exactly. And it's always a conversation, right? So, that's what I tell patients. Our goal is a healthy mom and a healthy baby, we would love for you to have a vaginal delivery as long as that is what is safe and healthy for you and your baby.

Host: Well, thank you, Dr. Silverbrook, especially for this comprehensive information on cesarean sections and also for your good work.

Dr Cheryl Silverbrook: Thank you. The patients make it easy.

Host: That was OB-GYN, Dr. Cheryl Silverbrook, Chair of the Department of Obstetrics and Gynecology at Holy Cross Hospital in Silver Spring, Maryland. For more information, visit holycrosshealth.org/maternity. Thanks for listening to Your Best Life Podcast Women's Health from Holy Cross Health. Until next time, be well.