Dr. Sarp Aksel returns to Healthful Woman to talk about scheduled cesarean deliveries, which he calls “a whole different beast” compared to unplanned C-sections. He and Dr. Fox review reasons for planned C-sections, potential alternatives, why patient responses are mixed, and more.
“Scheduled Cesarean Delivery” – with Dr. Sarp Aksel
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Sarp, welcome back to the podcast, how are you doing?
Dr. Aksel: Great. Thanks for having me.
Dr. Fox: Fantastic. So, we’re going to be talking today about scheduled cesarean sections or scheduled cesarean deliveries, which are to be differentiated from cesareans that are done for people in labor.
Dr. Aksel: Right. It’s kind of a different beast, you know, the scheduled sections. There’s a whole host of reasons why you might schedule a cesarean, as opposed to sort of see if you can labor and then end up in a cesarean. And I think it’s important to sort of differentiate those.
Dr. Fox: Yeah. And I think part of this is, number one, a lot of people are sort of curious why would someone “need” a cesarean, sort of from the beginning, they wouldn’t try to labor? But also, for people who are either in that circumstance or might find themselves in that circumstance, there’s a lot of questions people have, like, what does that mean? What’s going to happen? And I think that this would be a good opportunity just to…we’re going to go through a sort of step-by-step, you know, why might we recommend it, you know, what’s going happen, what to expect, what to do, and sort of tips from us.
Whereas people who are in labor and end up with a cesarean, it’s a much different experience because, again, their expectation is they’re going to deliver vaginally. Obviously, they understand that they might end up with a cesarean, but they think a lot more about what’s the vaginal birth going to be like? What’s labor going to be like? Do I get an epidural or not? Like all these things, and then the cesarean sort of happens. Whereas here, you’re walking into it knowing you’re going to have a cesarean, so the preparation and expectation is a little bit different, for better and worse, sort of depending on exactly how you look at it.
Dr. Aksel: Right. There are a host of reasons, either the baby’s not cooperating, maybe there’s medical history or surgical history that might preclude an attempt at a vaginal delivery. If a mom doesn’t want to have, you know, a trial of labor after a cesarean, so they have a history of a C-section in the past and they don’t want to take on, you know, the risks that might be associated with the trial of labor. If the baby’s not cooperating and, you know, it was breech. Regardless of whether it’s one baby that’s breech or two babies, and baby is like, you know, “I’m not ready for this. I’m going to go feet-first.” That’s a scenario where we would schedule a cesarean.
Dr. Fox: Right. And have you found amongst your patients, for people who are scheduled for cesarean, there’s definitely a range of emotions with that, from being very happy about that, to being very upset about that, and everything in between. What has been your experience in terms of patient’s response to the need for a cesarean delivery upfront?
Dr. Aksel: I’ve seen it mixed, right? On one hand, they’re upset at the fact that they can’t even try for a vaginal delivery. You know, whether it’s the placenta is blocking the exit route and so, you know, a vaginal attempt is contraindicated, you know. In those scenarios, they’re kind of like, “Darn it, I wish I had the option of a vaginal delivery.” But there are also a lot of patients who are like, “This is great. I get to schedule this.” This is going to be, you know, I’m going to schedule my life and my childcare. So, I think the predictability of a scheduled cesarean seems to be what patients are sort of that’s their silver lining around it, but I have a whole host of them.
Dr. Fox: Yeah. And there are definitely circumstances, you know, we’ll go through the specific reasons, but in terms of categorizing the reasons, there’s definitely reasons where it’s just not an option to have a vaginal. It’s not on the table. Like you said, a placenta previa because, like, literally, it would be, you know, a risk to the mother’s life were she to try to deliver vaginally. So, it’s just not an option and people may be upset about it, but they wrap their heads around it like, “Okay, like, you know, I don’t want to die in labor, so, okay, I’ll have a cesarean delivery.” That’s, you know, one possibility. There’s another possibility where there’s an option either way, sort of, hey, we have an option for this, option for this. You know, there’s pluses or minuses, you know, minus is the classic example is one prior cesarean delivery. Do I want to try VBAC? Do I not want to try VBAC? And, you know, we’re sort of okay with both options and then it’s the patient’s choice. I mean, she’s saying, “I will choose to do this versus this.”
And then, I would say, there are circumstances where patients ask us for a cesarean. They just want it. In our practice, that’s really the exception. It happens periodically. And we’ll discuss that, you know, that concept of saying, “Hey, I don’t want to labor. I’d rather have a cesarean.” But that would be the other end of the spectrum where it’s totally, you know, her choice versus us saying, “Hey, this is something we think you should do.”
In terms of the specific reasons, you know, I put together a list. I think the most common reason is just a repeat cesarean. Someone had one before and either we told them it wasn’t wise or it wasn’t safe to try again or they chose not to try again. That’s probably the most common of all the scheduled cesareans we do. So, it’s typically not their first, and for many women, they’ve either had a scheduled cesarean before, so they know what to expect, or, if they had a cesarean the first time in labor, they understand the idea of recovering from a C-section. But here, it’s sort of novel that they say, “Hey, I mean, I just get to wake up and go in for a cesarean,” versus laboring for 36 hours and pushing for 2 hours and then having a cesarean, and they’re like, “That sounds a little bit easier to me, the walking in.”
Dr. Aksel: I definitely find that, with repeat cesareans, patients are very calm about the prospect. The ones where there’s a little bit more anxiety and a little concern is, like you said, someone who’s never experienced it. So, like a breech, you know, where this is their first pregnancy, right? Or the first pregnancy they continue to term and the baby just isn’t cooperating.
Dr. Fox: Right. So, you have breech presentation, where the baby is feet-first, that’s another reason. And then placenta previa is one we mentioned where it’s just not safe. There’s something called vasa previa, which is, we’re gonna have a whole separate podcast on that, but it’s another condition which is actually not dangerous to the mother, but dangerous to the baby if she goes into labor. And then there’s, you know, some women who’ve had a history of operations on their uterus, like, where fibroids are removed. And in some circumstances, they can labor, in other circumstances, they can’t, but that would be a reason. And so, there, they‘ve never had a C-section before, but they have clearly had surgery before. So maybe they sort of understand what to expect there in that circumstance.
Dr. Aksel: And one point to make about patients with prior fibroid surgery, I think it’s really important, as you mentioned, you know, for some, we might consider allowing them to labor, for others, we wouldn’t. And so, if I have a patient like that, I impress upon them how important it is for us to get the operative report from that surgery if we didn’t do it, just so we can get the nuances and be able to counsel patients on what’s best for them.
Dr. Fox: Right. And then there are circumstances where rarely we think the baby is measuring very large. Again, that’s a very controversial topic in terms of how large you have to think the baby is when you would recommend a cesarean as opposed to try and deliver vaginally, but it happens, right? There are reasons, you know, that that is a reason why people would have a cesarean. Rarely, there are certain infections that women can have, you know, certain women with HIV, for example, if their viral loads aren’t extremely low, it’s recommended to have a cesarean, and that’s to protect the baby from getting infection. Again, it’s not that common, but it happens.
Dr. Aksel: Genital herpes would be the other one that comes to mind.
Dr. Fox: Yeah, exactly. Genital herpes, if it’s active, that’d be another reason. And then, occasionally, women have fibroids that are not removed and are physically in the way, not allowing for a vaginal delivery. And that’s the exception. I would say, of all the women with fibroids, probably, you know, more than 9 out of 10, they’re not in the way and it’s fine, but occasionally, you’ll have a circumstance where it’s not an option. And those are the reasons, again, based on how significant they are, how strong our recommendation is, and also when we’re going to do it. And then there is that, as we said, subgroup of women who say, “I just want a cesarean.” Do you have those conversations frequently, infrequently?
Dr. Aksel: I do. I mean, there’s always that question of like, should I just go for a cesarean? Right? And I approach it as balanced as I can, right? Obviously, I want, for me, first and foremost, making sure that, you know, my patient has the birth experience that they want is really important. And then, for some patients, when they come to me, they already have an idea. Either because of, you know, stories from their mother, right? Or stories from their sister, or their friends, you know, who had particularly challenging labors and may have even had complications from a vaginal delivery. Those are the ones where I find they’ve come to it. They’ve thought about it. And my job in those scenarios is really just to lay out the risks of a cesarean without even an attempt at a vaginal. And as much as I want an easy labor process, patients come with their own idea of how they want to bring their child or their children into the world. And it’s tough for me to get in there and be like, you know, you absolutely should have a vaginal delivery. I think vaginal delivery has tons of benefits over a cesarean, you know, avoidance of major abdominal surgery, you know, the recovery is simpler, but, as someone who never will have to face that question, I do empathize with women who…and I don’t like to call them elective cesareans, you know, cesarean for maternal request, I think, is completely appropriate. You know, weighing there’s a timing concern, right? Making sure that we don’t deliver before the baby is ready. But other than that, making sure that they’re well-informed about both short-term and long-term risks of cesarean, I think is a conversation I have pretty frequently.
Dr. Fox: When I was training, this came to the forefront because, prior to then, it really wasn’t a thing. It didn’t happen that much in the U.S. And then, around the time I was training, women, again, we’re not talking about majority, we’re talking, you know, a few percent of women would ask for it and say, “I want to have a cesarean.” And when I was training at the time, there was actually a debate in the obstetrical community let’s say, an ethical debate about whether it was appropriate to do a cesarean if there’s no medical indication for the mother. Meaning, a woman says, “I want to have a cesarean,” and you talk to her about it and says, “I choose a cesarean.” There was a debate about whether you should agree with that request.
And ultimately, what happened was, and it didn’t take very long to sort of sort this out. People thought about this in terms of the medical side, the ethical side, and said, “What are we going to do? Force women to go into labor?” Like, it just didn’t make sense. And ultimately, I think, you know, the way I thought about it was, yeah, there are risks to a cesarean, but there’s also risks to a vaginal delivery. And it’s not really my place to put value on those risks as much as just quantify them for women. And, you know, here’s what they are, and if you really have a strong preference. I mean, people have plastic surgery that has greater risks than a cesarean delivery, and we don’t say like, “It’s illegal,” right? “You can’t have it.”
If this is what someone chooses to do, and they go to someone who’s reputable, who’s licensed and tells them what the options are and they choose to do it, okay. It’s not everyone’s cup of tea, but if it is, God bless. And so, that’s sort of where it fell out with cesareans. As long as the doctor is being appropriately balanced in terms of like, okay, here’s the risks of a cesarean, here’s the risk of vaginal delivery. Here’s what we know. Here’s what we don’t know. Here’s what this is like, here’s what this is like. If that’s someone’s decision, then we should respect it and do it. And that’s sort of how it is now in most places, if not all, but it’s not that common.
Dr. Aksel: Yeah. It’s not that common.
Dr. Fox: I mean, we’re talking in our practice, it‘s certainly under 5%. I don’t know. It’s probably under 1% is my guess. Yeah.
Dr. Aksel: I would say so. I mean, over the last year, I think I’ve maybe two cesareans for maternal request and, you know, one of them was because the patient herself had been involved in a shoulder dystocia at her own birth.
Dr. Fox: Oh, okay.
Dr. Aksel: And so, you know, there was so much storytelling from her mother about the experience that she was just like, “I’m not doing this.” You know, and those are the scenarios where I’m like, “Okay, let’s talk about this.” You know, this is what a vaginal delivery typically is. And this is what a cesarean typically is. And she was like, “Yep, nope, I’m going with a C-section.” And she was very happy. You know, her recovery, I followed her up, two weeks, six weeks. I’ve seen her three months after the surgery. And she’s very happy with the choice that she made. She’s very happy with the birth that she had.
Dr. Fox: Right. Other than a longer recovery, on average, again, you could have a short recovery from a C-section and a long recovery from a vaginal birth, you know, those are bell-shaped curves that overlap somewhat. But on average, your recovery is longer for a cesarean. Other than that, the likelihood it’s going to have a major impact on your life and health, which way you go, is very low, unless you plan on having, you know, more than four kids or something, and you do this on your first, because then you’re signing up for five cesareans versus one. But if you’re having one, two, or three kids, the likelihood it’s going to have a huge impact on your life either way, medically, is pretty low.
Dr. Aksel: I’d agree with that.
Dr. Fox: And so, this is not the highest stakes decision people are going to make medically, although people, there’s a lot of weight in it, sort of emotionally, culturally, sort of psychologically, people put a lot of weight in the birth experience, which is fine, but from a medical side, it doesn’t tend to be a huge difference, for most people. There are exceptions. And in terms of, so someone is having a scheduled cesarean, for whatever reason, how do we decide when to do it? So, how do we categorize that? Because we don’t do them always at the same time in the pregnancy.
Dr. Aksel: No. No, we don’t. What I like to tell patients is, given what we know about babies and development and gestations, once the baby gets to the 39 weeks, what I tell patients is, the only reason why we keep you pregnant longer is to end up, you know, giving you as much a chance as possible to go into spontaneous labor.
Dr. Fox: Right. And by 39 weeks you mean one week prior to the due date?
Dr. Aksel: Correct. That’s right.
Dr. Fox: Due date’s 40 weeks. Okay.
Dr. Aksel: Due date’s 40 weeks. We usually, you know, by 39 weeks, one week prior to the due date, we say, you know, the benefit that the baby is getting by staying inside mom has, you know, kind of peaked. Typically, at 39 week, you know, this would be for a breech, right? Where there’s no other medical concern.
Dr. Fox: That’s the default. Right.
Dr. Aksel: The default is 39 weeks.
Dr. Fox: Right. And by 39 weeks, so if someone’s due date let’s say, you know, we’re recording this on April 6th, so someone’s due date is April 13th. Today, they’re 39 weeks. So, we would do it either today or it wasn’t available or they didn’t want it today, tomorrow. Some time in that week, it doesn’t have to be 39 weeks even. And again, this is sort of, again, assuming there’s no other reason to deliver early, right? If someone has a reason like their blood pressure’s up or the baby’s small, fine. But in terms of just for the cesarean itself, 39-plus weeks. And that’s pretty typical and that’s the majority. The next group has the people who the reason we’re doing the cesarean is because we don’t want mom to go into labor because that’s dangerous.
Dr. Aksel: Exactly.
Dr. Fox: In those people, we do it earlier because even though, like you said, there is some advantage to keeping the baby to 39 weeks, once you get to like 36, 37 weeks, the advantage for the baby to staying inside is low, right? It’s there, but it’s not that high to outweigh the risk to the mother. So, the classic one is like a placenta previa. Because if she goes into labor, number one, she could start hemorrhaging, or number two, either she just has light bleeding, now you’re having a C-section at 3 in the morning, it’s very stressful. You know, maybe the doctor who’s supposed to do it is also delivering someone else who’s in labor, you know, then you try to go to the hospital to check your blood, and it becomes a whole event that’s very scary for people. And we try to not have those sort of delivery. We like things to be calm, and easy, and pleasant, and memorable in a good way.
And so, something like that is typically done around 36, 37 weeks or it depends on the circumstances for cesareans. Similar to that is, for example, let’s say someone had like that myomectomy where the fibroid is removed, or they had a prior cesarean in a certain way they were worried the uterus can’t tolerate labor, like it would open up in labor. Again, we do it 36, 37 weeks, somewhere in that range. I mean, we don’t typically wait until 39 weeks, and rarely we do it earlier. That case of vasa Previa is one of the few examples where we might do it even earlier than 36 weeks. And that’s sort of how we decide.
There are some situations where there’s disagreements. I mean, you can, the American College of OB-GYN has a list saying, if you have this, do it at this time. If you have this, do it at this time. But those are more just consensus. A bunch of people said this seems to be the best way, but there’s a lot of disagreement. One of the big ones we frequently encounter in our practice, it’s not that common elsewhere, is someone having their fourth, fifth, sixth, seventh, eighth cesarean, when do you do it? And I find asking people around the country, it’s all over the place.
Dr. Aksel: I think a lot of that has to do with sort of regional differences in practices, especially if this is the…
Dr. Fox: Yeah. Not even regional, I could tell you, even around New York City, people do it differently. It’s really interesting.
Dr. Aksel: Really?
Dr. Fox: Yeah. Because people, you know, sort of, they would say, “Well, it’s not on the list, so the default’s 39 weeks.” And then we’re like, “Well, yeah, but if she goes into labor at 38 weeks and she has eight prior cesareans, we have all the same problems. You know, scar tissue maybe, or bladder is going to injure, and then, you know, we’re doing it at 2 in the morning and this is a really hard operation. And so, we tend to do it around 37 weeks. People disagree with us, people agree with us. But that’s an area I would see a controversy where no one knows for sure the right thing to do, but that might be one reason why someone will get differing opinions on when to do a cesarean if there’s like just this gestalt that the operation is going to be hard enough to do for the surgeons. I mean, technically challenging enough that you want to sort of lump them in with the people who it’s not a good idea for them to go into labor and others disagree with that.
And I would say, as of now, that question remains open, but that’s the way we do it around 37 weeks for those people. Again, the myomectomies, the fibroid removal, there’s disagreement because no one could say for sure, you know, that operation warrants a cesarean later and that operation doesn’t. We sort of, again, use our best judgment with these things. Because every operation’s unique, it’s hard to know exactly, you know, which ones do and which ones don’t. How do you feel about giving steroids before a scheduled cesarean delivery? And then these are steroids given to the mother to help the baby’s lungs to mature, to lower the chance of respiratory complications of the newborn.
Dr. Aksel: Right. And the general gist with the steroids is, it can help accelerate the baby’s lung maturity. And so, usually, I would say, you know, 36 to 37 weeks scheduled cesareans. Assuming that there is no contraindication to steroids, I’d probably go for that. And then there might be some benefit between 37 and 38, but it’s a lot less clear.
Dr. Fox: Yeah. And it’s one of these things where also what does benefit mean? Is it short-term benefit, long-term benefit? And there is debate. With cesareans, you know, babies born at let’s say 37-plus weeks from a cesarean have a higher chance of ending up in the NICU with respiratory issues. Again, we’re not talking about crazy dangerous ones, but whatever. Ending up in the NICU…
Dr. Aksel: Just like the short-term. Yeah.
Dr. Fox: Yeah. It’s a higher chance than if the baby were born vaginally. There’s something about just sort of like yanking the baby out of a pool of water, you know, that they have a harder time getting it out of their lungs versus letting the baby get squeezed slowly, you know…
Dr. Aksel: Through. Yeah.
Dr. Fox: Yeah. Sort of like it’s sort of a sponge.
Dr. Aksel: A tunnel.
Dr. Fox: It sort of like gets all the water out, which is just true. And so, we tend to give it, certainly if it’s under 37 weeks and we do usually, for our scheduled cesarean, it’s 37 to 38 weeks. And again, that’s another area where not everyone does that. In our hospital, most people do, but that is an area of controversy, as we say.
Dr. Aksel: Healthy debate.
Dr. Fox: Yeah. Sometimes healthy, vigorous debate, you know, like our political climate.
Dr. Aksel: There you go.
Dr. Fox: Healthy, vigorous debate. It’s the American way. Someone’s scheduled for a cesarean, and we know when it’s going to happen, we know the reason, let’s go through sort of what someone should expect, what someone should anticipate is going to happen. And I broke it down to, before the day of, the day of, and then after, right? So, before the day of the cesarean, what are the things that people might be asked to do or like tasks or things to keep in mind or things to prepare for the cesarean?
Dr. Aksel: So, since it is a scheduled surgery, there are certain protocols, right? You know, in the time of COVID, it involves getting COVID tested before the surgery. Your doctor may ask you to get blood tests done just to make sure that, you know, your blood counts are good, any other necessary blood work that the hospital may request. And that usually gets scheduled a few days before the scheduled surgery.
Dr. Fox: And a lot of this is just logistical, because these are things they need for your operation, and if it’s done in advance, it makes the day of move smoother. I mean, you’re not waiting for the blood bank to run your sample the day of, they have two days to do it. So, when you show up, it’s ready to roll.
Dr. Aksel: Right. Right. And especially if you’ve never delivered before and this is your first experience, you definitely want blood bank to sort of be on board, have all their I’s dotted and T’s crossed. And so, getting them the specimen that they need helps the day of surgery go a lot smoother.
Dr. Fox: Right. What about in terms of, you know, people eating and drinking before surgery? This is something that is, again, we’ve talked about area of healthy debate, this is…
Dr. Aksel: Absolutely.
Dr. Fox: Yeah. And this is all over the place. And one of the ideas is, for people having surgery, one of the risks when you get put to sleep for surgery, which again, does not usually happen for cesareans, but just, in general, is that, while you’re falling asleep for anesthesia, the contents from your stomach are going to come up into your throat and then back down into your lungs. It’s called aspiration, which can be very, very dangerous. And so, anesthesiologists, before someone’s having a scheduled operation, really want people to show up with an empty stomach. And now, there’s a few issues with that. Number one, people argue on what does that mean to have an empty stomach? How long do you have to wait in order to consider your stomach empty? And it’s different for solid foods versus clear liquids. You know, and you’ll see rules all over the place. And number two, pregnant women, it’s even more complicated because, even if they haven’t eaten in 12 hours, they still have this pregnancy pushing up and the acid from the stomach can still come up and go down their lungs, even if they haven’t eaten. And so, ultimately, the most important thing is, know what the rules are where you’re going, because they may be different from hospital to hospital. And the way you’ll know what the rules are is, typically, the person who schedules your surgery will give you a piece of paper that says, “Here are the rules.”
Dr. Aksel: These are the rules.
Dr. Fox: Yeah, the rules. Like, don’t eat solid foods after X hours before your surgery. And don’t drink any water until, you know, through X hours or Y hours before your surgery. And look at those closely and follow them.
Dr. Aksel: If there’s one thing that frustrates, you know, patients, it’s timeliness and delays, right? So, making sure that you follow all the rules is the best way to make sure that the day of your delivery, the day of your cesarean, things are going to go as smoothly as possible. If you follow the rules, you know, there can always be unexpected delays, but at least you’re not the cause of those delays.
Dr. Fox: Right. I mean, anesthesiologists will cancel the case.
Dr. Aksel: Absolutely.
Dr. Fox: If you have an 8:00 cesarean and their instructions were, don’t solid foods for eight hours, let’s say, and you said, “Oh, I woke up at 4 in the morning and had a cookie.” They’ll say, “We’re not doing it.” You know, because there’s no emergency right now, you’re not dying, your baby is not dying, we’re not doing it. We’re either gonna wait till noon, eight hours after you ate, or we’re going to reschedule it till tomorrow. And people get very frustrated by that. And, you know, clearly, people don’t intend to, you know, go against the rules, it’s usually they just didn’t bother to read them and will be like, “Well, what’s the harm of a cookie?” And the anesthesiologist is like, “I’ll tell you the harm of cookie, or I won’t, I’m just canceling your case because I’m the boss. Like, I’m not giving you anesthesia.” And that’s even though most people having a cesarean are not going to be put to sleep. They’re gonna have a spinal epidural. It’s just, since they might need to be put to sleep, they see no reason to take additional risk for you, the patient, and for them, sort of as doctors. And so, there’ll be as cautious as possible. So, different hospitals have different rules with these things based on whether you’re pregnant or not, what operation you’re having, and sort of how, you know, the wind blows in that hospital with their recommendation.
So, definitely, definitely be aware of that, that that is an issue. Now, if you’re in labor and you have an epidural, they will do it. And obviously, if you need a cesarean, they will do it regardless of whether you’re eating or drinking or not, or this or that, because they can’t, sort of, you know, cancel labor. But if you had a scheduled case, they will delay or cancel it potentially if those are not followed to the T.
Dr. Aksel: On that topic, I know, you know, some patients have medications that they’re supposed to take in the morning. They’re supposed to take at night. It’s really important to check with your doctor and your surgeon beforehand to see if the medications that you’re taking ought to be taken regardless.
Dr. Fox: And with what.
Dr. Aksel: And with what. Exactly. I’ll tell you this, no pill should ever be taken with milk. Milk is just… Of all the liquids that you could consume, milk is probably the worst because that’s going to stick around. So, getting those instructions, those individualized instructions are going to be really important if you’re someone who has to take medication every day.
Dr. Fox: Right. And also, on the same topic of medications, even if it’s not related to, will they be in my stomach or not, things that are injected, for example, like if people take blood thinners or injector, or they take insulin, for example, that’s something to make sure that you review with your doctor beforehand. Okay, am I doing this the night before? Am I doing it the morning of? You know, what’s my dose? Just to have a plan in place for all medications, you know, should I take them? When should I take them? How should I take them? All those things.
And another thing that a lot of people find very valuable, I would say more so in our practice than others because we have this “high-risk” practice is, for people with maybe complicated deliveries before, or maybe significant medical problems, or sometimes people have had spine surgery before, have a meeting with the anesthesiologist in advance. Like, if you know you’re having a cesarean and you know they know you know that there’s going to be some sort of anesthetic placed, even if it’s just a spinal, and there’s some concern that you might be, you know, more than run-of-the-mill, right? There may be something, you know, unique about your history or about your anatomy, these can be scheduled. And not only do you, the patient, find it typically very valuable, anesthesiologists love having those meetings because it helps them get prepared in advance so there are no snags the day of. Because again, you don’t want to show up in the day of and go like, “Wait a second, we need to check this blood test, or we need to get this MRI before I do this.” It doesn’t happen a lot. But even if the thought comes up that they might need it, the stress level goes sky high and you definitely don’t want that. And so, I found that those meetings are invaluable for people in advance. Not everyone needs it, most people don’t, but certain people definitely benefit from those.
I think the other thing is really just logistics. A lot of people want to know, “Who’s going to be doing my surgery.” You know, so if someone says you need an operation. If it’s something you care about, ask. Say, “What are my options? Do I have an option? Who does my surgery?” You know, in our practice, we give people an option, in other practices, that might not be possible based on how they cover the labor floor on this. But if it matters to you who does your surgery, see if it’s an option. If it matters to you what day of the week it is, for example, if you want to say, “I want to make sure I’m home by the weekend.” Don’t schedule your C-section for Thursday or Friday. And if you say, “I want to be in the hospital over the weekend, but not during the week.” Try to schedule your section for a Thursday or Friday. And if there’s leeway in terms of the timing of delivery, then that is more likely to be doable compared to if there’s not leeway. For example, either in your own condition or in the scheduling.
Dr. Aksel: This goes back to sort of the silver lining I was talking about. Like, with the cesarean, you kind of get to be in control, right? As the patient. You get to decide what day within limits, you decide what doctor within limits. And so, I definitely encourage patients to sort of ask those questions as a way of taking back some of the power that a scheduled cesarean might have taken away from them. And I do find that patients feel a lot more comfortable with that when they feel like they have the ability to pick the date, the time, the doctor.
Dr. Fox: And a lot of that is just straight-up scheduling like with the hospital. And I tell people, you know, we’re in the hospital every day. A lot of it is just what the hospital schedule’s like for cesareans. And so, the earlier someone could either make that decision, or, you know, if we know from the get-go that the cesarean is going to be recommended, we try to book them as far in advance as possible, even two months in advance, as early as the hospital will let us. Or if it’s a circumstance where someone might need a cesarean, we’ll sometimes schedule it and then say, hey, listen, if circumstances change, the baby is breech. We can schedule a cesarean, and if the baby turns or we turn the baby, fine, we’ll cancel it. Much easier to cancel a cesarean than it is to schedule one.
And so, the earlier these things could be scheduled, the more likely you are to get whatever it is you might want. So, if someone says, “Hey, I’m having a cesarean and I really want Dr. X to do my cesarean. He’s got great hands. He’s the best. He tells great jokes. He sings in the operating room. He’s just wonderful.” And two months in advance, you know, in our practice, the one who does our scheduling, Linda, who’s a saint from heaven. She gets, okay, if I know this, I can rework a schedule so he’s on the labor floor Monday, as opposed to Tuesday, for example. Whereas, if we only know three days in advance, it’s hard to make those changes. Another thing that people sometimes ask is, how many people are going to do my cesarean? And it’s always a two-person operation, right?
Dr. Aksel: A minimum.
Dr. Fox: There are two surgeons, right?
Dr. Aksel: A minimum of two surgeons. Right.
Dr. Fox: And I would say the default is that, at least in sort of academic, you know, university hospitals, typically, one surgeon is going to be your doctor, “the attending surgeon,” and the second person will be usually a resident in training. But by in-training, like they do cesareans all day every day. They’re really good at it. And ultimately, the person who is your doctor, the attending, is the one in charge and could do 100% of the operation as long as the resident can hold a retractor and sort of show you where you need to go. But it’s a two-person, you need two people there. Occasionally, we’ll have two of us there, either just for scheduling purposes or we think it’s going to take a really long time. We want two people there either to actually be able to do the cesarean. Or even more so, if we think it’s going to be a longer cesarean, we want a second person there in case someone else is in labor. That way the second person can run out. You don’t want your doctor running out during the cesarean. So, if we have two people there, there’s always that opportunity.
But that’s something that most people will know in advance of their cesarean, who is doing it. Is it, you know, one attending plus one of the residents, or is it two? Ultimately, none of us would put patients in a circumstance where their surgeons are not qualified to do what they need to do. And so, we sort of gauge based on sort of what the complicated nature of the cesarean is for who’s going to be doing it. For example, we have residents, you know, the more straightforward cases are more junior residents, the more complicated are more senior residents. And so, we do that assessment all the time when we do cesareans, and we’re quite confident that it’s totally fine.
Dr. Aksel: Yeah, absolutely. I’ve had some patients, the happiest cesareans they’ve had were the ones that the residents were involved in because they felt like I might be running around and managing a number of different things in preparation for the surgery. But what they really appreciated was the resident sort of walking them through every single step and being there for them. So, I’ve had a lot of patients who were very happy with the residents that were involved in their care.
Dr. Fox: Yeah. And similar to what I tell people with epidurals, you know, the residents, they do this all day every day. They’re really good at it.
Dr. Aksel: They are.
Dr. Fox: Yeah. You’re not getting shortchanged by having your doctor and a resident do the cesarean. That’s what’s typically done. And it works out really, really well.
Dr. Aksel: That’s how we trained.
Dr. Fox: Yeah.
Dr. Aksel: That’s how we trained. And we were residents once.
Dr. Fox: Yeah. That’s how my babies were born.
Dr. Aksel: There you go.
Dr. Fox: Excellent. Okay. So, that’s in advance. And then, on the day of, based on the time the cesarean is scheduled, usually they’ll ask you to arrive some amount of time in advance, maybe it’s one hour, maybe it’s two hours. In our hospital, it’s usually two hours in advance. So, if you have a 10:00 a.m. C-section, we’ll have you come at 8:00. And a lot of that’s, again, just logistics, time to get things done before the cesarean. So, take me through, what is it like for someone who’s the day of surgery? Let’s call it a 10:00 a.m. cesarean is scheduled with you, right? It’s going to be with Sarp Aksel, MD. You’re doing my C-section at 10:00 a.m. So, someone’s going to show up in the hospital at 8 in the morning, what happens when they get there?
Dr. Aksel: Right. So, one of the first things that I always tell patients is, make sure your partner knows where the parking lot is, because they’re probably going to drop you off.
Dr. Fox: Unless you’re taking a cab or Uber.
Dr. Aksel: Unless you’re taking a cab or Uber, you’re gonna more than likely get dropped off where we tell you your cesarean’s going to take place and then your partner has to figure out where to park the car. So, making sure that they know where to go, A, to park the car, B, to come find you is going to be really important.
Dr. Fox: Right. Because the cesarean is not in the parking lot.
Dr. Aksel: No, the cesarean is not in the parking lot and I’m not taking it there. So, making sure that they can find the parking lot and then they can find you is really important. Ask your doctor for a map. Dr. Silverstein has multiple maps that are very informative, very clear to make sure you have that down cold. Once you arrive, you’ll get registered. So, make sure you bring all your identification, know who your surgeon is. So, just say that you have a scheduled surgery at 10:00 with Aksel, and then you’ll get taken in. You’ll probably get taken in to the preoperative area where a nurse will give you a gown to change into, they’ll put you on the monitor, make sure that the baby is doing okay, and have you fill out all the paperwork that is necessary beforehand.
Dr. Fox: Unless they had you do in advance. Some places have you do it the day before or two days before, again, different places do it differently.
Dr. Aksel: Exactly. And we usually do, say, two hours, I think that’s a perfect amount of time to get you in, get you situated, registered, monitor the baby, and get all the upcoming case arranged. Now, your partner will be able to join you in the pre-op area. And you guys will probably sit there for half-hour, 45 minutes, maybe an hour, depending on what is going on that day on the labor floor. So, one of the things that I always talk to patients about and give them a heads up, because I think that setting expectations is the number one way to have a good experience. I tell patients, there’s always going to be a chance, because you have a scheduled cesarean, that you might get bumped. What do I mean by that? I mean that, someone else is in a far more emergent state, whether that be because they were in labor and now the baby is distressed, or they’re in labor and that they’re not progressing. There are cases on the labor floor that will take precedent ahead of your scheduled case. And I always give patients this heads up, because I want them to have a good experience, but I also want them to understand that, if someone else needs the operating room, we are happy to give it to them.
Dr. Fox: Right. There is a room that’s dedicated to the scheduled cases and they usually schedule them every two hours, and it will run on time, however, there’s only a certain number of operating rooms and if they’re filled and someone else needs a case, they’re certainly going to bump a scheduled cesarean rather than do a cesarean in the hallway, right? So, that’s really just the options and that happens. And I say the same thing, I always tell people like, expect to be delayed, hopefully not much. Hopefully just a few minutes, not a few hours.
Dr. Aksel: Right. And, you know, you would always want the same kind of treatment. If you were in an emergency situation, you would want the less urgent cases to sort of get delayed a little bit to make sure that everyone’s safe and sound. And so, once that’s done, you’ll also probably end up meeting the residents that are going to be involved in your case. There’s usually one, there might also be a physician assistant who might be around as well. And then on top of that, you’ll meet with the anesthesiology team that’ll come, they’ll do their evaluation of you and sort of give you a step-by-step of what their game plan will be to make sure that you are as comfortable as possible through the surgery.
Dr. Fox: Yeah. One of the big goals of that whole preoperative phase is to do a lot of the things that need to be done before you have to walk into an operating room. Because once people walk into the operating room, they’re like, “This just got real.” And, you know, people are understandably more anxious when they walk into an operating room. It’s cold, it’s weird, it’s very like sterile, and it’s surgical. And it’s not like…there aren’t like, you know, bunnies on the wall.
Dr. Aksel: There are no bunnies.
Dr. Fox: It’s a scary room to be in that sense. And so, we like for people to have all of the tests that need to be done in advance, meet the anesthesiologist in the preoperative area, see the surgeons in the preoperative area, ask all your questions there. Any conversations that you want to have, or talk about things, or what are we doing? What’s the plan? All these things are done in a much more calm environment. Usually, for this type, for C-sections, they’ll usually also put in your intravenous line in that room rather than the operating room. All those antibiotics they’ll give you for… I mean, everything is pretty much done in the preoperative or holding area where it’s not crazy. It’s sort of a more light atmosphere. People are smiling and you’re with your partner. It’s sort of a nicer environment to be in. And then, when that’s all done, then it’s time to go into the operating room. And it’s also a little bit scarier for people because we separate people. Meaning, we don’t let someone’s partner come in with them for the anesthesia part for the spinal/epidural, and that’s purely because we’re worried that that person might plop. People do pass out when watching these things. And as I say, we lose more partners than patients during the epidural placement.
Dr. Aksel: Absolutely.
Dr. Fox: Because the person who’s getting it, doesn’t see it. They’re looking forward, the person’s working on their back. They have no idea what’s happening other than they feel it. But if someone’s watching that, it’s creepy to see that. So, we say, “You’re not coming in yet. We’re going to get this all teed up for you.”
Dr. Aksel: Not yet. We make it nice and clean for the partners. But I also tell them, I was like, “I only have one patient today. I don’t want to have an unscheduled patient.”
Dr. Fox: Yeah. And it happens sometimes…
Dr. Aksel: It does.
Dr. Fox: …during deliveries or during cesareans where, you know, someone has to deal with the other person who’s lying on the floor getting fanned and apple juice fed to them. But we try to minimize that chance. So, everything is done preoperative. All the questions are answered. Everything is done, all the papers are formed, IV is in. And so, usually, she’s going to walk into the operating room, and you walk in on your own two feet, right? Nothing has happened to you yet.
Dr. Aksel: You walked in. Yep.
Dr. Fox: You walk in the little socks we gave you and the gown.
Dr. Aksel: Yeah. They give the socks with the grippies, make sure you don’t slip.
Dr. Fox: Yeah. You got the gown. You come into the operating room. In the operating room, typically, there’s a couple of monitors on your heart, you know, EKG leads, little thing on your finger, a blood pressure cuff.
Dr. Aksel: The first blood pressure reading is going to be really tight. It will get better.
Dr. Fox: Yeah. It hurts, the first one.
Dr. Aksel: It does, but then they adjust it.
Dr. Fox: And then they do, again, for the 99 out of 100 people whose anesthesia is going to be a spinal epidural, the anesthesiologist sits you up, takes you through it, does that. And then when it’s finished, they lie you down on the table, you’ll frequently get lightheaded, dizzy, and nauseous. They treat that. That’s a known complication from… not complication, but side effect from the epidural or the spinal.
Dr. Aksel: Side effect, yep. Legs get heavy.
Dr. Fox: Right. And then once, we check the baby, and then once we’re very confident you’re numb, we do like four, five, six checks.
Dr. Aksel: Absolutely.
Dr. Fox: We clean off your belly with, you know, the alcohol solution we use. We go wash our hands, you know, all scrub up as we say, and then put on our gowns and the drapes and get everything set. And then, before we start, it’s like the grand entrance of the partner. He or she comes in, we wait, they get ushered into the room. They sit down next to you and that’s all before we actually start the operation.
Dr. Aksel: Correct. And the other thing that I always like to give folks a heads up about is that, laying down, and I’ve actually done this, I’ve gone and I’ve laid down on an operating table. It is very narrow and you end up staring at the ceiling, and at some point someone is going to put a blue drape over your face. And it’s probably going to be really, really close to your face. And that’s something that I talk about and I’ve read about and talked to patients about, there’s a name for it. They call it the blue sky and it freaks them out. And so, I like to give folks a heads up that they are going to be staring for the majority of the case. If they look straight up, they’re going to see a blue drape. And that’s a good thing, because you don’t want to be seeing what I’m seeing.
Dr. Fox: Yeah. Sometimes people see like reflections in the lighting of what’s going on. And I mean, it’s fine. It’s not dangerous, but it’s gory. I mean, that’s for sure. And one of the reasons we put up the drape is so that she and also her partner aren’t looking at the operation. But in that time when they’re looking up, they can turn their head to the left or right and, you know, see their partner. Again, if you had a spinal epidural, you’re awake. You can see, you can hear, you can talk, you can smell, you can breathe. If someone does need general anesthesia, again, you’re the 1 out of 100 people who need to be completely asleep with like a tube in your throat. Usually, your partner will not be allowed in the room because that’s a very freaky thing to see, to see a loved one lying there anesthetized with a tube in the throat is not a pleasant picture. Again, it’s safe, but it’s very unsettling for people to see. So, in that situation, they don’t let the partner in. But for everyone else, yes.
Again, we’re checking out like the 12th time to make sure that nothing’s going to hurt, that the anesthesia is working. And then we announce that we’re starting, and we start. And usually, people are having the C-section, they’ll feel that we‘re touching them, but nothing will hurt. And if anyone had the experience of having, let’s say stitches like sutures placed, you know that sensation where like, I can feel that someone’s sewing my skin together, but it doesn’t hurt. It’s really weird.
And that’s what a C-section’s like. You will feel touching, you’ll feel pulling, you’ll feel pressure, you’ll feel tugging, but there’ll be no sharp pains. There should not be any sharp pains, essentially. And from when we start till the baby’s out, I don’t know, 5 to 15 minutes based on the situation. If it’s emergency, it shouldn’t be, but if it were, it could be in a minute. But typically, even if we’re just going at a regular pace, 5 minutes for a first C-section, maybe 10 minutes for a second, not that long. And then when the baby comes out, there is an option. If you want to see the baby coming out of your belly, they can sort of drop the drape or sort of is like a flap to make it a clear drape. Some do, some don’t. When they see it…
Dr. Aksel: Baby sometimes wave, mums pretend to be pushing.
Dr. Fox: Yeah, we hold the baby over the drape sometimes and let the baby like drool all over mom’s forehead and whatnot. But then the baby sort of gets put in a warmer that’s on your side of the drape, so you can be looking at the baby pretty much the whole time after birth while the pediatricians, the nurses, whoever sort of attend to the baby, and then they wrap up the baby, and either the partner can hold the baby, or someone is like put the baby sort of on your chest and, you know, help you, your arms aren’t quite as mobile as you would need them to be to do these things. But sometimes they are.
And then, from when the baby is out till we finish, I don’t know, about another half hour, give or take, you know, sometimes it’s quicker, sometimes slower. And that’s it. That’s the cesarean. From when we’re done till you get back to the recovery area, could be 5, 10, 15 minutes. We have to, you know, clean you off. You know, there’s things that have to be done, you know, to make sure that all the instruments we use are accounted for, all the lap pads we used are accounted for. That’s one of the safety measures that we don’t leave things inside of people.
Dr. Aksel: As Dr. Bender likes to say, we want to make sure that you’re not taking anything from the operating room. That always gets a good chuckle.
Dr. Fox: But they do multiple checks of that, beyond normalcy.
Dr. Aksel: Way more than is necessary.
Dr. Fox: Yeah. It is really, really crazy. And then everyone goes to the recovery room together. Typically, you know, the partner went in advance, because, again, when we’re going to sort of clean off the mom, it’s lying there and you take off the gown. So, usually, we have to escort them out, clean off the mom, and then she usually goes into the recovery room on a stretcher holding her baby. And then you’re in the recovery room a couple of hours, and that’s the day of, typically.
Dr. Aksel: The one thing that I would like to add is, depending on how you feel and your relationship with music and the calming effect that music might have, I have had some patients request to have their own playlists. And that is definitely something that, if we know ahead of time, I’m always happy to bring a portable speaker, or a Bluetooth speaker and hook up with, you know, Spotify so that you at least have, you know, John Mellencamp and his soothing ballads, you know, drowning out the beeping of the anesthesiologist machine. So, I definitely have had some patients who wanted to curate an audible experience and…
Dr. Fox: They wanted to DJ their birth.
Dr. Aksel: They did. They did. They wanted to and…
Dr. Fox: That’s cool.
Dr. Aksel: Yeah, we’re cool with that.
Dr. Fox: Yeah. And sometimes people will just bring their own speaker and then say, “Hey, do you mind if we set this up?”
Dr. Aksel: Or that.
Dr. Fox: I mean, sometimes the surgeon won’t want it or sometimes anesthesiologist, but most of the times, particularly for cesareans, people are usually pretty cool with that.
Dr. Aksel: Especially a scheduled. Yeah.
Dr. Fox: Yeah. So, usually, it’s fine, but it’s, you know, something to ask either in advance or the day of, and usually, it’s okay. One of the other things and one of the nice things about scheduled cesareans, the chance of complications is really, really low in terms of major complications. There’s always a risk of like a blood transfusion. We’re talking in the range of 1%. The chance of an injury to another organ is always present, but again, it’s a really low percentage. The bulk of the issue with a cesarean for almost everybody is just the recovery is harder, right? Instead of staying in the hospital one to two days, you stay in the hospital two, three, or four days. Based on how you’re doing, how you’re feeling, COVID issues, you know, what you got going on at home, do you have help? Do you not have help? And I think that part of a scheduled cesarean, one of the nice things about planning it is planning your recovery, because you know it’s going to be cesarean, right? So, when you go into let’s say labor, again, the expectation is you’re going deliver vaginally and you’ll have a certain type of recovery. But if you know you’re having a cesarean, you should try to figure out, “Okay, what am I going to do when I get home for the first couple of weeks? Do I have someone who can help me just for my own sake? You know, I may need help getting in and out of bed. I may need help, you know, getting in and out of the shower, or I’m not going to be able to leave the house and get groceries. Can I get them delivered, can someone pick them up for me?” Things like that.
And then also, of course, you have a newborn, right? And so, am I gonna be able to do this with the pain? Am I not going to be able to do this with the pain? Do I need help, all the time, some of the time, none of the time? If so, who’s that going to be? And again, there’s no one answer for anybody, but these are things to consider beforehand so you have a plan in place because it’s difficult to make these plans when you’re recovering from surgery and you have a newborn that’s under your care. So, try to make as many plans as you can in advance. For example, pain medicine. Right? So, you know you’re gonna need pain medicine of some form when you go home, so when you’re seeing the doctor in the hospital, have them send in the prescription to the pharmacy before you go home, so someone can pick it up, it could be waiting for you when you get home, for example. That’d be, you know, one good way to plan for these things.
Dr. Aksel: And to help us out, make sure you have your pharmacy’s information. If you recently moved, make sure you keep an eye on, you know, just scope out what pharmacies are available to you so you know how we can help you.
Dr. Fox: Right. Right. Things like, for example, who is your pediatrician going to be? Or if you’re Jewish and having a boy and planning a brit, who’s the mohel going to be. Because again, not that you can’t do this after a cesarean, but it’s a little bit harder. And so, if you know your recovery is going to be difficult, the more things you can sort of have lined up and teed up before you deliver, the less sort of mental and physical work you’re going to have to do after the birth. What are you gonna do about visitors? Right? Do you want visitors in the hospital? Can you have visitors in the hospital with COVID? If you can, who are they going to be? You know, do I want people parading through my room all day if I’m going to be recovering from surgery? Maybe yes, maybe no. But these are things just to think about because you know you’re going to be having a potentially more difficult recovery from somebody else.
What kind of like tips or advice do you give people before a scheduled cesarean? You’re in the office, they’re 38 weeks, they’re scheduled in a week or so. And just, you know, this is, oh, you know, from my experience, you know, keep a lookout for this or make sure to do this.
Dr. Aksel: I mean, making sure that you have everything that you’ll need for that short two to three-day stay, I think is important, right? Whatever amenities you want, I think packing those, making sure you have your bag set up. I think that’s really important, specifically for C-sections. In my experience, what I have found is the best recoveries are those from patients who get up, start moving early, and are working on that mobility, because studies show, the sooner they’re out of bed, the more often they’re out of bed after surgery, the sooner the recovery, the more tolerable taking care of themselves, taking care of the baby will be. You know, making sure that you have all the meds that you need at home where you don’t have to keep going out or sending your partner or your helper out is going to be really important.
Dr. Fox: Yeah. I agree with all that. Also, one thing I would add is, one of the advantages of the scheduled cesarean is, since you know when it’s going to be, right? If it’s going to be on a Tuesday morning, have a good dinner Monday night. Go out to eat, enjoy yourself. Or if you’re at home, eat something you like, eat a big meal, you know, really, enjoy it. And get a good night’s sleep if you can. Really, it’s so nice to go into surgery rested, as opposed to going in after, you know, 36 hours of labor. So, the best you can to get a good night sleep and to enjoy, if it’s your first kid, you know, the night before surgery will be the most peaceful night you’ll have for the rest of your life. So, enjoy it. You know, go to a movie, do something that you want potentially, and I guess, again, that’s one of the advantages to a scheduled. Sarp, this was great. Very thorough. We covered the scheduled cesareans.
Dr. Aksel: Always a pleasure.
Dr. Fox: Awesome.
Dr. Aksel: Thanks for having me.
Dr. Fox: All right. Have a good one. We’ll see you in the operating room.
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