Caesarean section is an operation to deliver a baby through an incision in the mother’s abdomen. A caesarean section is needed when delivery through the birth canal (vagina) is not possible or when vaginal delivery would pose a danger to the mother or baby. A caesarean section may be planned in advance as “elective” surgery. Alternatively, it may be performed as an emergency if a serious complication that may be harm the mother or baby develops during labour. Many are performed during labour if it becomes likely that vaginal birth will not occur without a high risk of harm to mother or baby. Such cases are neither elective nor emergency. About one birth in every four in Australia is by caesarean section, and that rate appears to be increasing. The proportion of births by caesarean vary significantly from region to region, and the most appropriate rate is a matter of some debate. A casesarean section if often referred to as a “c section”.
Reasons for Caesarean Section
The most common reason for considering a caesarean section are as follows:
- The baby appears to be too big to pass through the birth canal
- Part of the placenta (afterbirth) is covering the opening of the uterus (placenta praevia)
- The mother had a previous caesarean section, and it is likely that attempting a vaginal birth will result in the same out-come that led to the previous caesarean. A vaginal birth may be too risky for the mother or baby or both
- The baby is in a breech position, that is, the baby’s buttocks or feet are presenting to the birth canal.
- There is concern about the baby’s (or babies) condition, and adequate monitoring during labour is not possible
- Labour is not progressing as it should, and the advantage of caesarean for the mother and baby are greater than the risks of persisting with a vaginal delivery.
- The mother has active vaginal herpes that could infect the baby as it passes through the birth canal.
- The mother has a medical condition such as pre-eclampsia ( a condition of pregnancy where the mother’s blood pressure is too high)
- There is concern that the baby may be too stressed by labour
- There is concern about the health of the baby and its supply of oxygen and nutrients.
- A few women choose to have a caesarean because their concerns about vaginal birth.
Your complete medical history
Your obstetrician and anaesthetist need to know you medical history. Tell your obstetrician about any health problems you have had because some problems you have had because some problems interfere with the surgery, anaesthesia or recovery. This information is confidential. Tell your obstetrician if you have a history of:
- An allergy or bad reaction to antibiotics, anaesthetic drugs, or any other medicines
- Prolonged bleeding or excessive bruising when injured
- Recent or long-term illness, or previous surgery
Give your obstetrician and anaesthetist a list of:
- All medicines or herbal remedies you may be taking or have recently taken, including medicines prescribed by a doctor and those bought “over the counter” without prescription
- Long-term treatments such as blood thinners, aspirin, arthritis medication or insulin
You obstetrician may ask you to stop taking some medications for a periods of time before your operation, or you may be given an alternative dose.
Before Surgery
If you are having an elective caesarean, not eat or drink (not even water) for six hours before the operation is scheduled. On admission to hospital, the following procedures may be undertaken. In the case of an emergency caesarean, the procedures will be more urgent.
- Blood pressure, pulse rate and temperature will be assessed.
- The anaesthetist will discuss the most suitable and safe form of anaesthesia.
- A plastic cannula will be inserted into the vein in your hand or arm so that fluids and medications can be given.
- Any hair on the abdomen around he incision site may be removed
- The abdomen will be cleansed with an antiseptic wash.
- A urinary catheter will be inserted before or after the anaesthesia to keep you bladder empty during surgery and until you can use the toilet after surgery.
- Some women may receive “antibiotic prophylaxis” to reduce the risk of wound infection.
The presence of other people
Your partner or support person may be encouraged to be with you once the operation is about to begin. In some cases, this may not be possible.
Your preferences can be discussed with your obstetrician during your antenatal visits, if possible. Doctors and other healthcare professionals will be present during the operation. They may include:
- Your obstetrician
- The obstetrician’s surgical assistant
- The anaesthetist
- The anaesthetist’s assistant
- A “scrub nurse” who takes care of the sterile instruments and passes them to and from the obstetrician
- A paediatrician to care for your baby at birth
- The paediatrician’s assistant (often a midwife)
- A “scout nurse” who assists the others
- A theatre technician who helps move you on and off the operation table, positions the lights and so on.
In some hospitals, medical and nursing students may be present.
Anaesthesia
A caesarean section may be performed under either general or regional anaesthesia (spinal anaesthesia or epidural anaesthesia). General anaesthesia is usual for emergency situations or when regional anaesthesia is contraindicated. Spinal anaesthesia or epidural anaesthesia is usually preferred, especially when the operation is not an emergency. Your obstetrician and anaesthetist can explain more about which anaesthesia is best for you. Modern anaesthesia is safe with few risks. However, a few people may have serious reactions to anaesthetic drugs. If you have ever had a reaction to an anaesthetic drug, tell you obstetrician. If general anaesthesia is recommended, you will be asleep during surgery. With regional anaesthesia, you may feel some tugging, pulling or similar sensation, but this is not painful. If you feel pain, then you should inform the anaesthetist. Sometimes regional anaesthesia does not work completely and conversion to general anaesthesia may be necessary.
Caesarean Surgery
The obstetrician will make a 10-20 cm low transverse (side-to-side) incision in the skin and then separate the muscles of the abdominal wall. In some cases, the incision may be vertical (up and down).
The bladder is pushed away from the lowest part of the uterus, and an incision is made into the uterus. This incision can be either transverse or vertical. In most patients, the incision is transverse in the lowest part of the uterus. A vertical incision may be used in certain rare situations.
If you have regional anaesthesia, you will have some sensation but should not feel pain. You may hear some unfamiliar sounds such as amniotic fluid being suctioned out of the uterus or clicks as the surgical instruments are used. The baby is lifted through the opened uterus, head or buttocks first. You may feel a considerable degree of pressure as the baby is delivered. You will usually see your baby very shortly after delivery, but it is often placed quickly into a warm blanket so it does not get cold. After the placenta is delivered, the uterus is repaired with stitches. The layers of the abdominal wall are stitched, and finally the skin is closed with either stitches or clips. From time of the initial incision, the obstetrician usually takes between one to five minutes to deliver the baby. The rest of the surgery (including closure f the uterus, muscle and skin) usually takes a further 15 to 40 minutes.
Recovery from a Caesarean section
After surgery – You will be taken to the recovery room for observation while the anaesthetic wears off. Your baby may be taken to a nursery during this time: this is something you can discuss with your doctors and hospital staff. You may have cramps in the uterus and feel shaky or nauseated. Your legs may be numb for a few hours after a regional anaesthesia.
A nurse will monitor your blood pressure, heart rate, temperature and other signs. The firmness of the uterus, vaginal bleeding, and the incision will be checked. The skin around the incision will be checked. The skin around the incision will often be bruised. Pain reief will be available if you need it.
Mobility: You will usually be encouraged to walk with the assistance of a nurse within for to eight hours of the birth. Walking is important to prevent pneumonia and blood clots. The first time you get up and move after surgery is the most difficult. Strand as straight as possible and avoid slumping forward. You may also be instructed to do some deep breathing to help your lungs expand fully.
Bladder and bowels: The catheter placed in your bladder will be removed 12-24hrs after the birth. You may have wind pains around the second or third day after delivery; this often occurs after abdominal surgery. Physical activity can help the bowel to function and to reduce wind. Try to move around as much as possible, even if you find this difficult and uncomfortable.
Vaginal Flow: The colour and amount of blood flowing from the vagina will change gradually. For the first three to four days, the flow will be bright red. With time, the blood will become darker and the flow less heavy. The passage of some clots of different sizes is common.
Removal of stitches: Absorbable stitches are used for all layers beneath the skin and may also be used for the outer abdominal incision. Absorbable stitches do not need to be removed. If non-absorbable stitches or clips are used to close the abdominal incision, they will need to be removed, usually five to seven days after surgery. You will usually remain in hospital for 3-6 days after a caesarean. If you require pain relief, your obstetrician can give you a prescription when you go home.
Full Recovery: Full recovery usually takes from four to six weeks, and sometimes more. Accept help from your family and friends, and get as much rest as possible. Avoid lifting heavy objects (including other children) and climbing stairs, but most other activities are possible soon as you feel comfortable doing them. To help bladder function, drink plenty of water each day. Eat a high fibre diet to avoid constipation. Some obstetricians recommend the use of a mild laxative (bulk forming and faecal softening), especially as some pain killers can cause constipation.
General risks of surgery
Caesarean section is considered to be a safe operation for the mother and baby. However, as with all surgical procedures, it does have risks, despite the highest standards of surgical practice. While your obstetrician makes every attempt to minimise risks, complications may occur that may have permanent effects. A doctor does not usually dwell at length on every possible side effect or rare complication of a surgical procedure. However, it is important that you have enough information to fully weight up the benefits and risks of surgery. Most patients will not have complications, but you can discuss your concerns about possible side effects with your obstetrician. Women who smoke, are overweight or have other significant medical problems are at greater risk of having complications. The following possible complications are listed to inform and not to alarm. There may be others that are not listed.
Wound Infection: All surgery has risks of infection. It may occur some days after the operation. Wound of abdominal infection can usually be effectively treated with anti-biotic. Not all wounds that discharge a little fluid or blood-stained material are infected.
Blood Clots: A blood clot may form in a deep vein, most often in a leg or thigh (deep vein thrombosis DVT) after surgery. This can be life threatening if it breaks off and travels to the heart and a lung. A DVT can be treated. Your doctor may suggest a medication that reduces the risk of blood clots.
Scarring: A hypertrophic or keloid scar may form from the incision. This scar tissue is raised and irregularly shaped, and may be itchy and inflamed. Most incisions heal well, and few people will develop a keloid or hypertrophic scar. This scar can be annoying but is not a threat to health.
Specific Risks of a Caesarean
Damage to organs: Rarely, tissues and organs close to the uterus, especially the bladder and ureters (tubes that drain urine from the kidneys to the bladder), may be damaged. The risk of damage to the bowel or veins and arteries at the dies of the uterus is small. Further surgery may be needed to repair damage.
Decreased bowel function: The bowel sometimes slowed down for several days after surgery, resulting in discomfort and bloating.
Bleeding: About twice as much blood is usually lost during a caesarean than with a vaginal birth. The risk of bleeding is increased in the case of placenta praevia or a medical condition that makes it difficult for the blood to clot. Blood transfusions can be life-saving but are not commonly need during or after a caesarean. As the chance of requiring a transfusion is small, it is not usually necessary or desirable to put aside your own blood or to arrange for a blood donor.
Uterine Atony: This is uncommon condition in which the uterus does not contract enough after delivery. It can lead to substantial blood loss.
Emotional and psychological effects: Some women experience a sense of failure and disappointment after a caesarean, especially if they had expected a vaginal birth. This feeling of disappointment is more common in women who have had an emergency caesarean. If you think you are experiencing depression related to the caesarean, talk to someone about it: family, friends, family doctor or other women who have had a caesarean. It can also help to talk to a counsellor who is experienced in dealing with women who have had depression following child birth.
Numbness: Areas of numbness or altered sensation may persist near the caesarean scar. These usually resolve after a period of months but may persist in the long term.
Report to your Obstetrician
Be sure to tell your obstetrician if any of the following occur:
- Fever greater than 38C or chills
- The incision becomes red, swollen, hard , opens up or has blood of fluid coming from it
- Blood from the vagina smells bad or large clots are expelled
- Increased abdominal pain or feeling generally unwell
- You feel as if you have to empty your bladder more often than normal, or if it burns when you urinate.
- You have any concerns about yourself or baby.
Any surgical or invasive procedure carries risks.
Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.