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C-Sections: What You Need To Know

I can still remember how the sun lit up our bedroom the morning I finally went into labor. Nearly two weeks overdue, I was ecstatic. Later my husband, Gary, called the doctor, who wanted me to come in so he could to see how far I'd dilated. Around noon, Gary and I arrived at the doctor's office, located in the Brooklyn hospital where I was due to deliver. A quick exam showed that my cervix hadn't even begun to dilate. When I mentioned that the baby hadn't been very active that morning, my doctor wanted to put me on the fetal monitor for a few minutes.

Hunched in front of the machine, the nurse frowned at the monitor's paper readout in her hand. She hurried out and came back with the doctor. "This is what we don't want to see," he said, showing us how the peaks of the tracing flattened out after each contraction. "Late decels," he called them. The baby's heartbeat wasn't recovering its strength and rate as it should after each squeeze of my uterus. "Often these things clear up on their own," he said. "Let's move you to the delivery floor and keep monitoring you."

Gary and I -- and a half-dozen medical students -- ended up in a draped-off corner of the maternity ward. Our dreams of a natural childbirth slipping away by the minute, the two of us watched in silence as the doctors-in-training clustered around the fetal monitor.

After three long hours spent watching and waiting, my doctor ordered, "Let's go. Now!" Suddenly, I was on a high-speed gurney ride toward the swinging doors of an operating room. We later learned that the placenta had partially separated from the uterine wall, and my baby had already begun to suffer from oxygen deprivation.

Cesarean delivery. It ushers in more than 1.3 million babies a year -- 31 percent of all births -- in the United States. An emergency c-section is usually performed after labor has begun -- because labor hasn't progressed or the baby's in distress, or for rare but dire situations, when every second counts in saving the life of mother, child, or both. The emotional and physical effects of a c-section can be wrenching, and it's something many parents-to-be don't even want to consider. Yet it can be tremendously helpful to hear how others not only coped with the experience but came away deeply bonded with their baby, and deeply grateful for the technology and expertise that made this new life possible.

When the Baby's in Trouble

Fetal distress is usually recognized by a markedly slowed or accelerated heart rate because the baby, like her mother, can become exhausted by prolonged labor. A fetus can also contract an infection in the womb, suffer the effects of maternal illness, or become oxygen-deprived as a result of problems with the placenta or umbilical cord. My daughter Eva was surgically delivered -- limp, blue, and awash in meconium, a greenish stool that an overstressed fetus can pass into the amniotic fluid. Watching from the side of my surgical drape, Gary saw it all and heard me cry out, "Is my baby okay?" once, twice, three times.

Though their silence was terrifying at the time, doctors tend to ignore such questions as they rivet their attention on the lifesaving tasks at hand. Sixty seconds after her birth, Eva's Apgar score was a dreadful one, on a scale of zero to ten. A cluster of neonatologists rushed her to intensive care, as Gary ran behind.

On day two, Eva rebounded. A nurse pushed a rocking chair into a storage closet outside the intensive-care unit, and there I held my daughter to my breast for the first time.

When Labor Doesn't Progress

Joy Alex, of Pittsburgh, had been laboring nearly 26 hours when she felt herself giving up: "Here I was, pushing with all my might, and this baby wasn't moving!" In medicalese, Alex was experiencing "failure to progress."

Progress through labor and delivery requires three things: strong contractions that effectively dilate the cervix to ten centimeters; a fetus that is able to descend successfully through the birth canal (called second-stage labor); and a pelvis roomy enough to permit that passage. When any of these are absent, progress can slow or stop.

At what point does such a delay mean a c-section? Although obstetricians have guidelines, various factors, including the mother's wishes, influence the final call. In general, though, doctors will perform the procedure when little dilation has occurred after 24 hours of labor, though some will wait longer if both mother and baby are doing well. Similarly, most doctors suggest it if second-stage labor lasts more than two hours.

Alex was well past these benchmarks before she was willing to even think about a cesarean. She'd tried all sorts of positions -- "on my knees, on my side, with my belly on a ball" -- but the baby still needed to make a quarter-turn to slip through the birth canal. The doctor on call believed he could deliver the baby with forceps following an episiotomy (a cut in the muscle between the vagina and the anus). If that didn't work, he would deliver the baby surgically.

Alex agreed to this plan; half an hour later, she was headed for the operating room, where her daughter, Elena Noelani Alex-Finley, was born. After the doctors closed her incisions, a nurse placed Elena on the gurney, by her mother's head, and wheeled mom and daughter out to greet the relatives who were waiting anxiously outside.

When  the Baby's in an Awkward  Position

Rebecca Sullivan, of Alpharetta, GA, was already prepared for a long labor: "After examining me vaginally, my midwife could tell that the baby wasn't in a great position."

Ideally, a fetus readies itself for birth by lying with its head down, then rotating to face his mother's spine as labor begins. At the other extreme is the breech (bottom-first) baby, who almost always warrants a planned cesarean.

Between "ideal" and breech positions are the transverse (crosswise) and posterior (face up) positions, which can make vaginal delivery difficult, though not impossible. Most babies weather the arduous journey without harm -- but some falter under the strain.

Sullivan's baby was face up. But after 27 hours of labor, his exhausted mother still wasn't fully dilated. Shortly thereafter, it was clear that the baby too was weary of the long labor; fetal monitoring showed that his heart rate was beginning to slow after each contraction. "That decided it," Sullivan remembers. "I was down the hall in the operating room."

In 15 minutes, her son, Brian, was out. "The sound of his cry was just so wonderful!" Sullivan recalls. While Sullivan's incisions were closed, her husband, Michael, took the baby to the nursery to be weighed. They were already in the recovery room when Sullivan arrived there. "I got to nurse him right then," she says.

 When  the Mom Is in Danger

Lori Dammeyer, of Silverdale, WA, sailed through her first and second trimester without complaint. "But just after my 26-week checkup, everything fell apart," she recalls. "I swelled like a balloon. I began getting migraines." At her 29-week checkup, Dammeyer got the dire news: She'd developed toxemia, or preeclampsia, a little-understood type of hypertension that develops in five to seven percent of all pregnancies. Most cases remain mild. Not hers: "My doctor said my blood pressure was sky-high, and the protein in my urine was off the scale."

Her O.B. insisted on checking her into the hospital immediately to control her blood pressure with an intravenous infusion of magnesium sulfate. Though a sonogram showed the fetus to be fine, Dammeyer's blood pressure remained at 220/140; anything over 160/110 could trigger seizures, coma, organ damage, and death for her and the baby. So her doctor recommended an emergency c-section. At 29 weeks the baby's chances of survival outside the womb were excellent, but the risk of losing both would be far greater if the mother went into convulsions, as Dammeyer could have at any moment.

Still concerned about seizures, the surgeons ordered general anesthesia. After her daughter Kelsey Renee's birth, Dammeyer woke up dazed, a day later, in intensive care. The first thing she asked her husband, Robert: "'Does she have ten fingers and ten toes?' He told me she was doing fine." So serious was Dammeyer's condition that she continued to lapse in and out of consciousness for several more days.

Five days after her c-section, she was able to shuffle to the NICU. "I remember staying a few minutes by Kelsey's incubator," Dammeyer says. "After I walked out, everything that had happened hit me for the first time. I broke down right there in the hallway."

Two days later, Dammeyer was discharged, armed with a breast pump. Kelsey came home eight weeks after she was born, three weeks before her due date. "We were lucky," says Dammeyer. "She was small but healthy."

Just like these parents, Gary and I will always feel a tumult of emotions when we think back on the traumatic yet wonderful day when Eva entered our world. To say it was worth it seems like a gross understatement. That much was already clear on day two, when all the pain was washed away by the bliss of three people bonding.

JESSICA SNYDER SACHS is a freelance writer.