Caesarean Section (C-section)
Introduction
What is it?
Caesarean section is one of the most common surgeries in many countries, and in the UK, 1 in 4 pregnant women has a caesarean birth. This mode of delivery can be a planned (elective) surgery or may need to be arranged urgently as events in the pregnancy and labour evolve. The decision to carry out a caesarean section will be made in conjunction with the mother, the obstetrician, midwife and anaesthetist, where the benefits of caesarean section outweigh the risks.
Why is it done?
Circumstances in which a caesarean section may be considered and planned:
Reasons relating to the baby
1. Abnormal position of the baby- Sometimes the baby can be in a feet-down position (breech position) and cannot be turned.
2. Large baby- Sometimes it may be safer to deliver a large baby (macrosomia) through caesarean section.
3. Multiple babies- Women pregnant with multiple babies may be given the option of a caesarean section.
Reasons relating to the mother
1. Problem with the placenta- Placenta praevia (a low-lying placenta blocks the cervical opening)
2. Previous caesarean section- A previous caesarean section may increase the chance of requiring a caesarean section in the next pregnancy.
3. Infection in mother- e.g. genital herpes infection or untreated HIV
4. To prevent serious tears to the pelvic floor, or for women who have previously experienced 3rd or 4th degree tears (into the muscles of the bottom) with vaginal birth
Circumstances in which a caesarean section may have to be done urgently
:
Pre-labour
1. Excessive vaginal bleeding during pregnancy
2. Intrauterine growth restriction- If the baby’s growth is restricted during pregnancy caesarean section may be recommended.
3. Placental abruption- Caesarean section may be recommended if there is premature separation of the placenta from the wall of the uterus.
During labour
1. The labour is not progressing as expected.
2. Concerns about the baby’s wellbeing- If there is concern about changes in
the baby’s heart rate during labour, caesarean section may be recommended.
3. Prolapsed umbilical cord- The umbilical cord can pass through the cervix (birth canal) before the baby does, which can cut off the supply of blood and oxygen to the baby in certain circumstances.
4. Uterine rupture- Caesarean section may be recommended if the uterus tears.
Some women may want to have a caesarean section for non-medical reasons. If you have concerns about a vaginal birth, your doctor or midwife can discuss with you the benefits and risks of a caesarean section, so you can decide if caesarean section is the best option for you.
Will I need to do any preparation?
The day before the surgery, you will be asked to attend a preoperative appointment. In this appointment, the anaesthesia team can discuss with you the choices of anaesthesia for the procedure and which may be the best choice for you. A blood test will also be done, to check your red blood cells.
You will also be given some medicines to take before the surgery, which are safe to take during pregnancy and include anti-sickness medicine (as the anaesthesia may make you feel sick) and antacids (to reduce your stomach acidity). You can also ask any questions you may have about the surgery at this appointment.
Technique
Anesthesia
The anaesthesia options for caesarean section include general anaesthesia, spinal anaesthesia and epidural anaesthesia. In 95% of cases, women undergo spinal or epidural anaesthesia, meaning that they are awake during surgery but cannot feel any pain waist downwards. Spinal or epidural anaesthesia is often preferred as it is a safer option in most cases, but your doctor can discuss your options with you.(1) General anaesthesia can also be administered in certain circumstances if needed.
What does it involve?
A cannula (thin plastic tube) will be inserted into the arm, to allow giving medicine and fluids.
Anaesthetic medicines will be given. If you are undergoing spinal or epidural anaesthesia, your birth partner can be with you during the operation, as you will be awake.
A catheter (thin, flexible plastic tube) will be inserted into the bladder, to empty it whilst you are under anaesthesia.
A small area of pubic hair may be shaved. The lower abdomen will also be cleaned with antiseptic solution.
Once on the operating table, sterile drapes will be placed over the abdomen and a screen will be placed across it. This is to keep the surgical field sterile. This will also mean you will not be able to see the surgery taking place.
An incision of around 10 to 15cm is made across the lower abdomen, just above the pubic hair line- this is most commonly a horizontal cut but can sometimes be vertical.(2). The layers of the belly wall are cut through and the uterus is reached.
The covering later of the uterus is cut to expose it. Another cut is made in the lower uterus.
The muscle of the lower part of the uterus is separated to enter into the uterus itself.
Amniotic fluid is then suctioned out and the baby will be delivered, which can take between 5 to 10 minutes You may feel some pressure and hear sucking noises as the baby is delivered.
Once delivered, your baby will be lifted so you can see.
Delayed cord clamping for up to a minute is sometimes possible if there are no complications, however, it is not always possible.
If all is well, the baby will be brought over to you for skin-to-skin contact. Medication is then administered to reduce bleeding, and the placenta is delivered.
Each layer of tissue is closed in turn with dissolvable stitches. Advice on suture removal will be provided if required. The wound in your lower abdomen will heal to form a scar. This can fade over time but will remain noticeable in some.
How long does it take?
The surgery usually lasts around 40 to 50 minutes.
Post-operative course
How long will I stay in hospital?
After a caesarean section, most women stay in hospital for less than 48 hours.
During your hospital stay, you will be given some painkillers. You will also be given some preventative treatment to reduce the risk of blood clots forming, such as compression stocking or blood-thinning medication. It is encouraged for you to get out of bed and walk around as soon as you can.
You can start breastfeeding as soon as your baby is born. You can also eat and drink as soon after surgery if you wish to. The catheter (thin plastic tube inserted in your bladder) will be removed around 12 to 18 hours after the operation.
Will I need someone to stay with? Will I need any special equipment when I go home?
You will need to arrange someone to take you home, as you will not be able to drive for a few weeks.
You will be given some advice on how to take care of your wound by your midwife, which will involve wearing loose clothing and watching out for any signs of infection. The wound should be cleaned daily (but do not wash with soap) and kept dry. The stiches will be taken out by your midwife around a week after the
operation, if needed.
As you may experience some pain for up to few weeks after the surgery, you will be given some painkillers to take at home, such as paracetamol or ibuprofen.
You will also experience some vaginal bleeding for up to 6 weeks, so sanitary pads should be worn. Tampons are not recommended.
What follow up care is needed?
You will have a postnatal check with your GP, around 6 to 8 weeks after your baby’s birth. During this appointment, your doctor will check how you are feeling after the delivery and how you are recovering.
When can I start my normal activities again (e.g. driving, sports or work)?
The time until you can resume your normal activities varies between women.
It is recommended to avoid driving a car until you are able to carry out an emergency stop without pain. This is usually 4-6 weeks after the caesarean section. It is also advised to check your car insurance company, as some will not cover you until the doctor has cleared you to drive.
You should avoid lifting heavy objects and anything heavier than your baby, until around 6 weeks after surgery. Strenuous exercise should also be avoided until 3 months after surgery, to allow the abdominal muscles to fully heal. However, you are encouraged to stay active, such as by taking a gentle walk daily.
People are able to resume sex at different stages after surgery, and there are no special recommendations regarding this. However, it is advised to discuss with your GP about contraception and when it is safe to get pregnant again. It is recommended to wait a year after a caesarean section to become pregnant, due to increased risks in the next pregnancy.(3)
You can always ask your midwife or GP if you are not sure if it is safe to resume your normal activities.
Where can I find more information?
NHS information on caesarean section: https://www.nhs.uk/conditions/caesarean-section/
NHS Your pregnancy and baby guide: https://www.nhs.uk/conditions/pregnancy-and-baby
Comprehension quiz
1. Which one of the following is the most common maternal risk of caesarean section?
a) Infection of the uterus
b) Excessive bleeding
c) Post-operative pain
d) Deep vein thrombosis
2. What is the most common method of anaesthesia for caesarean section?
a) Spinal or epidural anaesthesia
b) Local anaesthesia
c) General anaesthesia
3. How long do you normally stay in hospital after caesarean section (without any serious complications)?
a) 2 days
b) 10 days
c) 4 weeks
d) 1 week
4. Which of the following is not an indication for caesarean section?
a) The labour is not progressing
b) Problems with the placenta
c) Low blood pressure of the mother
d) The baby is in an abnormal position
5. How long should you expect on average until you can return to your normal activities?
a) 2 weeks
b) 6 weeks
c) 1 week
d) 3 months
Answers: 1. C 2. A 3. A 4. C 5. B