Currently in this country more than 1 in 4 babies are delivered by caesarean section. A majority of these are performed as emergency procedures rather than electively (before labour begins). There are 4 grades or categories of Caesarean Section in this country.
Grade 1 – where conditions are life- threatening to the mother or baby for example in the case of cord prolapse, uterine rupture, separation of the placenta or acute and severe fetal distress. In this case the caesarean will be done within half an hour. This is sometimes called a “Crash Section”, and is unusual and quite dramatic. It may sometimes need a General Anaesthetic.
Grade 2 –where there is a threat to the maternal or fetal condition. But not immediately life-threatening. The caesarean will normally be done within one hour. Examples of reasons for a grade 2 section include; failure to progress in the first or second stage of labour, failed instrumental delivery, non-reassuring fetal heart abnormalities. This is generally done with a Spinal or epidural anaesthetic.
Grade 3– today , not tomorrow, within the next couple of hours – for example with failure to progress when the baby is well, or where a caesarean is planned but the mother has gone into labour, or a previously undiagnosed breech baby.
Grade 4– usually Planned or Elective, generally performed at the convenience of parents ,staff and theatre, and often done as a formal operating list.
The procedure does carry some potential extra risks for the mother and occasionally the baby and the decision to perform one is never taken lightly. It can be a good idea to know as much as possible about the procedure before it happens so that you are prepared for it. A caesarean can be a scary prospect especially for those who have never been under the surgeon’s knife before, so we will try and explain what you should expect.
Elective Caesarean Section
Most elective or planned procedures are carried out because of increased risks to mother and/or baby such as:
- Placenta Praevia
- Contracted Pelvis
- Sphincter problems with bladder or rectum
- Breech position of baby
- Previous caesarean section
Planned caesareans are normally performed around 39 weeks when the babies’ lungs are fully developed.
Some caesareans are performed at the mother’s request for no particular medical reason. This would only occur after the potential risks and benefits have been carefully discussed with an obstetrician.
The procedure is nearly always performed under an epidural or spinal anaesthetic so that the mother is awake and can enjoy the experience (as far as is possible).
If you are having an elective caesarean you will usually be given a time and date for the operation. This will be as close as possible to 39 Weeks. Blood will be taken 2 days before this date to confirm your blood type and to make sure that should you need blood, cross matching will go smoothly. No food and drink should be consumed 6 hours before the time of the operation and tablets are given to neutralise your stomach acid. You may be allowed some clear fluids up till 2 hours before surgery. You will normally meet surgeon and anaesthetist before you go into the operating theatre. Your husband/partner can accompany you if he or she wishes but will have to don surgical scrubs, hat and shoe covers! There will be approximately 8-10 people in room – including an anaesthetist and their assistant, the surgeon who will be an Obstetrician and their assistant, a scrub nurse and their assistant, and in some cases a paediatrician and perhaps a medical student.
The baby’s heart will be monitored briefly with a hand- held CTG device and an intravenous drip will be set up in the back of your hand to keep you hydrated and control your blood pressure. You will have a clip on your finger to measure oxygen saturation in your blood and some sticky pads on your chest to monitor your heart rate. The anaesthetist will insert the epidural or Spinal Block which will start to work usually within 5 minutes. They will make sure that the anaesthetic is working by placing both hot and cold items on your feet and seeing if you can sense them. You will usually be tilted to the left with a cushion below your right buttock, this is to take the weight of your womb off the major blood vessels that take blood back to your heart. If this is not done then your blood pressure may drop which is not good for you or the baby.
It may take up to 30 or 40 minutes for all the conditions to be suitable for surgery. Your pubic hair will be shaved up to a few centimetres above your pubic bone and a catheter inserted to allow you to empty your bladder whilst you have the Epidural in.
The doctors and nurses will go through a check-list before the operation can start. Everyone introduces themselves, stating what the operation is and what the expected complications (if any) are and they will go over any unusual features such as allergies.
A screen will be erected in front of the mother so she does not have to see the surgery, this can be lowered when the baby is delivered. The surgeon will make an incision about 10cm wide across the stomach about 3cm above pubic bone. During the procedure you will not feel any pain at all, but perhaps a sensation that has been compared to someone doing the washing up in your stomach or rummaging in a handbag! Sometimes you will feel some pressure as the Obstetrician or assistant helps to deliver the baby’s head. If you like, you can request to have the screen dropped so that you can see as the baby’s head is delivered.
Here are some warnings for your husband or partner especially if he or she is squeamish, and some tips for you to ensure that the procedure is not too much of a shock.
If there is a metallic/silver light above the operating table, do not look up at it unless you want to see a reflection of the operation behind the screen.
Be prepared for a gurgling noise when the incision is made, and also when the nurse uses the suction pipe to suck up some of the blood and fluid.
The smell of blood can seem strong and seem unpleasant to some people.
Amniotic fluid when mixed with blood looks like lots and lots of blood and can seem scary to someone who has not seen it before!
The baby may not cry as soon as it is born, but usually cries within one or 2 minutes of being born. You cannot hold the baby until the cord has been cut and the baby been dried/cleaned at the side of the operating theatre. Stitching you back up again takes between 30-60 minutes and your husband/partner can hold the baby whilst this happens.
Drugs will be given to you during and after the operation to prevent infection. Blood thinning medications will also be administered to prevent clotting and a variety of other medications are given to provide good pain relief and keep the uterus well contracted.
Sometimes the anaesthetic drugs, the antibiotics, the drama and the surgery itself can make you feel nauseous , frightened and occasionally a little distressed. This is not unusual and usually disappears after the operation and helped by seeing and holding the baby, and some appropriate TLC from your midwife, nurse, anaesthetist and partner!
The first 4-6 hours of care will be in the high dependency area to look out for complications such as bleeding.
Your catheter and intravenous drip will be removed after 12-24 hours. You may have a drain to remove fluid from the abdomen, which will also be removed after 24 hours.
Stitches will usually be removed after 4 or 5 days or if they are disolvable then they will not need removing. A feeling of numbness around the scar is normal, and this will usually wear off over the following days or weeks.
You will usually lose blood from the placental site, through your vagina, in the same way as a woman who has had a vaginal birth. You will probably also experience the same after pains as your uterus contracts after the birth. You may also experience pain from the wound and also from abdominal wind. The hospital will offer you pain relief and you should take this if you are in any discomfort. Our advice is to say “yes” to all the drugs offered for pain relief for the first 24-48 hours, and then take them as required. Pain relief can be given in several different ways, intravenously, through the epidural, by intramuscular injection, by suppository, or simply by mouth. Welcome them all!
The average length of stay in hospital is 3 days and usually by day 5 you will be feeling better.
Emergency Caesarean Section
Emergency caesareans are often carried out because of concerns about the baby’s condition- such as:
- Fetal distress
- Prolonged labour and or failure to progress
- Going into labour with a Breech Presentation (where the baby is not head down).
Most emergency caesareans are performed within 1 to 2 hours of the decision, or under certain circumstances can be done within half an hour or even quicker.
In most cases it is not as dramatic as the “Emergency” part of it sounds, as there is no immediate risk to mother or baby. The procedure will pretty much happen as explained above for an Elective Caesarean Section.
All drugs given during and after the operation are safe for breastfeeding.
Vaginal Birth after Caesarean VBAC
Having one caesarean section doesn’t necessarily mean you have to have all babies by caesarean. Many women go on to have a natural birth with the second or third child. This is called VBAC –Vaginal Birth After Caesarean. With the current c section rate of 25 percent it is inevitable that many women will have the opportunity of a vaginal birth after a previous c section. Approximately 75 percent of women who start off with this plan will be successful. The success rate will depend on whether there have been any previous successful vaginal deliveries and will also vary according to the size and position of baby. The 25 percent who are not successful may end up with a planned c section when they get to 41 weeks or an emergency c section because of a slow and complicated labour.
The key to success is to await spontaneous labour and not interfere. This means that everything else has to be perfectly normal and the baby has to be in a good position and of an average size and not too big. Labour should be carefully monitored with extra observations on the baby and mother and continuous fetal heart monitoring to pick up early problems. Its best to avoid induction of labour as the use of strong drugs to stimulate contractions increases the chance of uterine rupture. Chances of uterine rupture are approx 1 in 200 sometimes with devastating effects for both mother and baby. Very often the rupture is a small one and not significant.
Although some units are encouraging VBAC, it is clear that any woman who is not keen to go down this route should be allowed to have a repeat c section after appropriate discussion with midwife or obstetrician.
Can I Request a Caesarean?
Guidelines relating to caesareans have changed recently meaning that essentially caesarean sections are available to all women. However, this does not equate to free caesareans for all on the NHS. It is about making sure that women give birth in a way that is most appropriate for them and their babies. These new guidelines mean that women who are very anxious about the prospect of giving birth will have their fears taken seriously and may be given support from mental health professionals before the event. They will need to discuss their situation with not only their midwife , but also an Obstetrician, and after careful assessment they will be offered a caesarean if it is thought to be in the best interests of the mother and baby.
The operation is not without some extra risks to the mother and occasionally the baby. The wound may not heal well or become infected or suffer form excessive early bruising. There is also an increased blood loss because of the surgery and an increased chance of blood clots or thrombosis in the legs and chest. Very occasionally there is damage to the bowel and bladder and even the baby may be cut in some rare cases. Although the baby does not experience the full effects of labour and a vaginal delivery there is a slightly increased chance of breathing problems for the first few days of life, even if born at 39 weeks.