Caesarean Section (C-section)

What is a caesarean section?

A caesarean section is the name given to an operation performed on a woman to deliver her baby. An incision is made into the front wall of the woman's abdomen and womb. This is normally done when a vaginal delivery could put the mother or baby at risk.

During regular checkups throughout pregnancy it may become apparent that a vaginal delivery is not going to be possible for medical reasons. An elective (planned) caesarean will be arranged. Approximately 40% of UK caesarean sections are planned.

Sometimes during labour, complications may occur, meaning a vaginal delivery would be dangerous for mother and/or baby and the baby needs to be delivered quickly. In this instance an emergency caesarean will take place.

Approximately one in four babies is delivered by caesarean section in the UK. If a woman has their first baby by caesarean section it is likely that she will have subsequent babies by caesarean too. In the UK repeat caesareans account for one quarter of the UK's overall caesarean rate.

Why would I need to have a caesarean section?

Elective Caesarean Section

An elective caesarean section may be necessary:

• If you have placenta praevia - this is where the placenta is low lying in the womb and covering part of the womb entrance.
  
• If you have a viral infection such as HIV, hepatitis C or genital herpes as there is a risk that the virus could be transferred to the baby through a vaginal delivery.
  
• If your baby is breech (feet first) it may mean that the baby is unlikely to fit through the birth canal.
  
• If you have severe pre-eclampsia (pregnancy related high blood pressure).  
• If you are expecting twins or other multiple births. It is safer to deliver multiples by caesarean section because they may be premature. Also one or more babies may be in an abnormal breech position (feet or bottom first) and two or more babies may share a placenta which means that the babies could be deprived of oxygen.
• If you have a small birth canal. During routine scans it may become apparent that your baby will be too large to fit through your birth canal.
  
• If you have a medical condition such as diabetes or heart disease which means a vaginal delivery puts you at risk.
  
• If you have a small or premature baby. If a baby is not growing well in the womb or are born prematurely they can become quite ill at birth. There is no evidence to prove that a caesarean delivery makes any difference but it is likely that you will be offered one.

Emergency Caesarean Section

An emergency caesarean section may be necessary:

• If your labour is not progressing naturally causing distress to you and your baby.
  
• If your labour starts prematurely.
  
• If your baby is not receiving sufficient oxygen and a vaginal delivery would take too long, putting your baby at risk.
• If your labour has been induced for medical reasons but the methods are not producing effective contractions.
• If you have vaginal bleeding during labour.
• If your baby needs to be delivered quickly (e.g. within half an hour) to protect you and your baby.

Older Women

Women over the age of 35 are more likely to need a caesarean section because they are at greater risk of certain complications during delivery.

• Having a large baby.
  
• Slow dilating cervix.
  
• High blood pressure.
  
• Gestational diabetes.
• Baby in a breech position.
  
• Placenta praevia.

What happens before my caesarean?

Before the operation your doctor or midwife will talk you through the operation and will explain what will happen and why. They will tell you why you need to have a caesarean instead of a vaginal delivery and explain any possible risks. The doctor/midwife will also ask you to sign a consent form to say that you are happy to have the operation, which you have the right to refuse.

Before the operation takes place you will be asked to change into a hospital gown and to remove all jewellery, although you may wear your wedding band which can be taped over. If you have a brace or false teeth, you will be asked to remove them.

As this is an operation, you will be asked to remove all make-up and nail varnish so that your skin tone may be monitored. If you wear glasses you need to give them to your birthing partner so that you will be able to see your baby once they are born. Contact lenses cannot be worn.

In the majority of caesarean sections your birth partner may be with you though they will need to change into thin cotton theatre clothes including a face mask, hat and special footwear.

A blood sample will be taken to ensure that you have sufficient iron levels and do not have anaemia. Women with anaemia do not cope as well with blood loss so this is important information for your medical team.

Next a canular (drip) is fitted into a vein in your arm to give you fluids and administer drugs later if you need them.

You may be given white stockings, extra fluid or blood-thinning injections to reduce the risk of a blood clot forming in one of your legs (deep vein thrombosis).

A cuff will be placed on your arm to monitor your blood pressure.

Electrodes will be put onto your chest to monitor your heart rate and you may need to have a finger-pulse monitor attached too.

Finally, a sticky plastic plate may be attached to your leg. This is called an earth plate and is for the electrical equipment used by the doctor to stop bleeding during surgery. The earth plate is nothing to worry about and will not affect you.

How is a C-section performed?

Anaesthetic

A caesarean section is usually performed under regional anaesthetic which numbs the lower part of your body; you will be awake for the operation. The regional anaesthetic is administered into your spine (an epidural). You might also be offered pain relief at the same time which will come into effect after the operation.

You will have a catheter fitted into your bladder to empty it as you will have no control of your bladder due to the effects of the anaesthetic. This is done after the anaesthetic so you won't feel it.

Procedure

The operation usually takes approximately 30-45 minutes to perform though in an emergency it can be performed in 30 minutes.

A screen will be placed across your abdomen during the operation so that you cannot see the operation taking place. If you wish to see your baby being born you can ask for the screen to be lowered at the appropriate time.

The operating table will be tilted 15degrees to the left so that the weight of your uterus does not reduce the blood supply to your lungs resulting in low blood pressure.

The area to be cut will be shaved and cleaned with antiseptic. Then an incision is made horizontally across the lower abdomen approximately two fingers' width above the top of the pubic bone, often described as your bikini line. The layers of tissue and muscle are opened in order to reach your uterus. The tummy muscles are parted, not cut, and the bladder is moved down to allow access to the lower part of the uterus. A further incision is then made to the wall of the uterus to deliver the baby. Having the incision here will cause less pain afterwards and will look cosmetically better than a vertical scar.

As the incision is made you may hear and sense a whoosh as the fluid rushes through the opening. Then your baby will be lifted out. You might feel pressure on your abdomen from the assistant to help your baby to be born. If your baby is in breech position, they may be born bottom first. Approximately 2 in every 100 babies can receive a cut to their skin when the incision is made. If you are having twins, the lower baby will be born first, sometimes with the help of forceps to ease the baby's head through the opening. This is generally only the case when baby is breech or premature.

The doctor may need to make a larger incision if the baby is very premature, if they are lying across your uterus or if you have placenta praevia or growths known as fibroids.

What happens after my baby is born?

Your baby may be placed straight onto your chest if you so wish or he may need to be checked first by a midwife or paediatrician. If you are unable to hold your baby initially, your partner may hold the baby for you. A baby born by caesarean is usually colder than a baby born vaginally so they need wrapping up well after birth.

At one minute and five minutes after birth, your baby will be given an Apgar score which measures your baby's wellbeing. If there have been any concerns about your baby, they may need to be checked over by a paediatrician or go to special care for a while.

Shortly after the baby has been delivered you will be given an injection of the hormone oxytocin to encourage your uterus to contract and reduce blood loss. The placenta will separate and the doctor will gently pull on the umbilical cord to remove it. The placenta is then checked to ensure is it complete before the wall of the uterus and abdomen are closed with stitches which will safely dissolve after a few days. You should expect to be in theatre for up to one hour as it takes longer to stitch you back up than it does to cut you open. If you have had one or more caesareans previously stitching can take longer, depending on how many bands of scar tissue you have from pervious operations. You will also be given antibiotics to reduce the risk of infection.

It is likely that you will feel cold and shivery after the operation because your body temperature drops during surgery. This can be unnerving but it doesn't last long and is usually harmless. Your midwife will ensure you have sufficient fluids and blankets to help you feel better again.

If you would like to breastfeed it is advisable to attempt this before leaving the operating theatre. Your midwife will be able to help you find a position which is comfortable.

Recovery

Having a caesarean is a major operation and so the recovery time is considerably longer than having a vaginal birth.

Approximately 24 hours post delivery the wound dressing will be removed and you will be encouraged to get out of bed. Generally women are advised to stay in hospital 3 to 4 days after a caesarean section, however if you and your baby are well enough and you wish to go home earlier you may be able to leave after 24 hours and receive your postnatal care at home.

It is very important that you try to get as much rest as possible in the weeks following baby's birth to allow your body time to heal properly. Try to avoid walking up and down stairs too often as this can put strain on your abdomen. Have gentle walks daily to reduce the risk of blood clotting. Take regular painkillers for as long as you need them. Your midwife will advise you on the best way to care for your wound to avoid infection by cleaning it daily and keeping it dry. Wear loose clothing and cotton underwear.

As a general rule, it can take up to six weeks to heal fully, though during this time you should be able to undertake basic duties such as caring for yourself and your baby. Some activities will not be possible such as driving a car, exercising, carrying heavy things or having sex. Do things only when you feel able, do not rush and ask your midwife if you are unsure.

If you drive, check with your insurance whether you are covered for driving after a caesarean. You may need a certificate from your GP to say that you are fit to drive. Many women wait until after their six-week postnatal check.

Future pregnancies

It is possible to have a Vaginal Birth After Caesarean (VBAC) but this is something you will need to discuss with your GP/midwife. If you had to have a caesarean because of a health factor which is still present at your next pregnancy then it is likely that you will have to have a caesarean again.

If you want to have a VBAC then you need to make your midwife aware of this so that they are able to support your decision. You need to be aware of the risks involved, such as your scar tearing.

In subsequent labours you should be offered foetal heart rate monitoring and be in a maternity unit that has the facilities to do a blood transfusion if necessary and an emergency caesarean section should the need arise.

Risks

Risks to you

Caesarean sections are a common procedure but as with any operation there are always going to be risks involved. These can be:

• Infection of the wound.
• Infection of the uterus lining (known as endometriosis) which can lead to fever, uterus pain and abnormal vaginal discharge.
  
• Thrombosis (blood clot) in your legs. This is very dangerous if the clot breaks up and lodges in your lungs.
  
• Excess bleeding.
• Damage to your bladder or urethra which may require further surgery.

Aspiration

If you have an emergency caesarean section there is a risk of vomiting during the operation. Food and fluid particles can pass from your stomach into your lungs, this is known as aspiration.

Aspiration pneumonitis is a potentially serious swelling to the lungs.

Eating during labour can increase the amount of food and fluid in your stomach, increasing the risks of aspiration if you need to have an emergency caesarean. However if you drink isotonic drinks during labour the risk is lower. Isotonic drinks have the same concentration of salt and sugar as human body fluid and so can give you the energy you need in labour without giving you a full stomach.

Risks to baby

The most common risk to babies born by caesarean section is breathing difficulties. Approximately 35 out of 1,000 babies born by caesarean have breathing difficulties compared with 5 out of 1,000 born vaginally.

Immediately after birth and for the first few days they may breathe abnormally fast, this is known as transient tachypnea. Most newborns with this condition recover fully within two to three days.

A baby born by caesarean section does not have any increased or decreased risks than babies born vaginally of serious complications such as injury to the nerves in the neck or arms, bleeding inside the skull, cerebral palsy or even death. Complications such as these are very rare and affect less than 20 in 10,000 babies.