Caesarean section (c/s) involves the removal of the baby from the intact uterus by abdominal operation.
In recent years, the indications for the operation have increased considerably. In most teaching hospital trusts in the UK, the rate of c/s ranges from around 30 – 40% of the number of term births, which is a massive increase to the WHO recommendation of a 15% incidence. The main reason for having a c/s are dystocia, fetal distress, breech presentation and previous c/s. It is difficult to determine how valid these indications are, as paradoxically the c/s rate amongst private patients is always much higher!
We believe that the objective of a c/s is to reduce perinatal mortality and morbidity – unfortunately this is not always clearly defined. The introduction of antibiotics and better techniques of anaesthesia has made the operation much safer – however it is not always the solution to all obstetric difficulties and as midwives, we need to continue to campaign for c/s rate to be kept within reasonable limits – a caesarean is a major operation that carries several risks, so it only needs to be done if it really is the safest option for you and your baby – remember – the decisions made about your pregnancy and your childbirth journey, will go on to shape your health/life for many years.
There is so much information around currently, so many options and opinions – which aren’t always women-centred. It is crucial that you take time to consider your situation carefully and utilise the BRAINS acronym.
Today the majority of c/s are performed as lower uterine segment sections via a bikini line incision of around 15 – 20 cms. A c/s will be performed as a planned/elective or an emergency procedure – planned caesareans are usually done from the 39th week of pregnancy.
A c/s will either be performed under regional or general anaesthetic. The vast majority are done via a spinal/epidural – regional block. A general anaesthesia is usually used because it is quicker, in an emergency if there is insufficient time for a regional anaesthetic to work, where there is an immediate threat to life of mother or baby. Other reasons for its use include situations when a regional anaesthetic isn’t possible, such as a blood clotting condition, an infection or a back issue or because a woman refuses a regional technique, has an inadequate regional block, or because there are regional contraindications. A baby can be born within a few minutes following a general anaesthetic if necessary.
Statistics from the Royal College of anaesthetists indicate that currently around 15% of emergency c/s and 5% of elective c/s surgery, is performed under a general anaesthetic.
A c/s is performed in an operating theatre. Partners can attend for a regional procedure but not for a general anaesthetic. Strict aseptic technique is adhered to, with everyone wearing surgical gowns and masks. The theatre team consists of at least 2 obstetric doctors to perform your surgery, a scrub nurse, your midwife, an anaesthetist, and assistant and possibly a neonatal doctor. The environment is very bright, clean, and clinical but does feel extremely cold. This is because of the ventilation systems which must be in operation to keep the air fresh. Theatres have piped gases and the air needs to be constantly changing to deduce the risk of infection.
For this little piece, I want to focus upon an emergency c/s – being done under general anaesthetic – as there appears to be little information around. It is something that you will not be planning for as such – especially not if you are planning upon using hypnobirthing techniques – whereby only concentrating on positive birth stories and a controlled water birth scenario, but will poatentially be good to read at some stage to store somewhere in you sub conscious mind – just in case – because it is good to be informed! To start with you need to remember – partners are not allowed in theatre with you – you will be alone. But your midwife will remain with you and will be there when you wake up. Obstetric maternity units have maternity theatres within their labour wards so you will not need to travel too far once the decision for theatre has been made. You will need to have an intravenous cannula to administer intravenous fluids, this is usually done via a vein in your forearm. You will have had your bloods taken – to check for such things as your blood group, for cross matching and to check your rhesus factor and your haemoglobin levels and you will also need to have a urinary catheter fitted. This is because your bladder needs to be kept emptied during surgery – your bladder lies in front of your uterus – so this is especially important. You will have a hospital gown on, a theatre hat and will have ted stockings on your legs.
The whole atmosphere will feel electric and you will be extremely anxious, but be reassured the theatre team are a group of amazing professionals who have had much experience – as previously discussed with our contemporary rising c/s rates – ha ha!
Your midwife will leave your partner to pack up your belongings and choose a nappy and baby outfit for your baby to wear once born. You will be taken on a trolley to the theatre after saying goodbye… remember this is such a difficult time for partners too. They will feel so vulnerable, anxious and alone. In some instances, an anaesthetist may allow your partner to accompany you into the theatre, however his is not the norm – in all the years of my midwifery practice I have never seen this happen. Therefore, I was so happy when I heard about Laura and Peters birth story.
A general anaesthetic provides a state of controlled unconsciousness. Medicines are administered by an anaesthetist to send you to sleep so that you will be unaware of surgery and cannot move or feel any pain. It is not clear exactly how it works, but it is known that all anaesthetics interrupt the passage of signals along the nerves. This means that any stimulation to the body does not get processed or recognised by the brain.
You will generally have met your anaesthetist and obstetrician before you go into theatre to discuss the procedure and which anaesthetic is most suitable for you and you will have signed a consent form – with is so important. It is important that you and your partner understand what is going to happen and agree to what is being planned – although the situation is generally rushed/tense and you will feel completely unable to listen/understand anything. You will be having lots of things done to you and your baby all at the same time – baby monitoring/blood pressure checks/observations recorded/bloods taken/anti embolic stockings being pulled up your legs/ you may also be given a premedication – an antacid medicine. The anaesthetist will also inform you of the complications – which include failed intubation, aspiration of gastric contents, increased blood loss, and awareness.
You may have time to discuss vaginal seeding – which refers to the practice of inoculating a cotton gauze with your vaginal fluid before your surgery. This is most generally done in cases where labour has not started so that some of your normal vaginal flora can be transferred to your baby after birth. Research is being done to support this practice as it has been found effective in reducing the incidence of newborn allergic conditions such as childhood asthma – as it allows for the proper colonization of the fetal gut. If you are having an urgent procedure for fetal distress – this will possibly be omitted, but if time allows – vaginal seeding is good to consider.
You may also have time to be informed about delayed cord clamping – there have been several studies regarding this and the effect of delayed clamping in c/s. Research seems to suggest that 60 seconds is optimum or clamping as soon as pulsation stops. This practice is now widely used as a routine but something that most parents like to be aware of.
Your anaesthetist will look at your medical history and will ask whether anyone in your family has had problems with anaesthesia. They will also ask about your general health and lifestyle, including whether you:
- have any allergies
- smoke or drink alcohol
- are taking any other medicine
Your anaesthetist can answer any questions you have. Let them know if you are unsure about any part of the procedure or if you have any concerns. Ideally you would not be allowed to eat anything 6 hours before surgery – although in an emergency this is obviously not possible.
Just before you have surgery, your anaesthetist will inject a liquid into your veins through a cannula (a thin, plastic tube that feeds into a vein, usually on the back of your hand and place an oxygen mask over your face. You will be encouraged to take some deep breaths through the mask.
The anaesthetic should take effect very quickly. You will start feeling lightheaded, before becoming unconscious within a minute or so.
Your anaesthetist will stay with you throughout the procedure. They will make sure you continue to receive the anaesthetic and that you stay in a controlled state of unconsciousness. They will also give you painkilling medicine into your veins, so that you are as comfortable as possible when you wake up.
After your operation, the anaesthetist will stop the anaesthetic and you will gradually wake up. You will usually wake up in the operating theatre and see your baby immediately – before being transferred to a ward. Your midwife will hold your baby next to you and try to enable skin to skin contact asap. This is sometimes not possible, depending on your situation.
Skin to skin is so important as we know. We cannot imagine the shock of coming into this world but we do know that the only things a new-born baby recognises are its mothers skin, the rhythm of its mothers breathing, heartbeat, and its mothers and fathers voices and their smells. A newborn baby does not need to be wiped – following surgery a c/s will generally be clean as it will be passed by the surgeon from the abdomen to the midwife to be dried and checked, but it does need to be kept warm. Heat loss for a new-born can be very rapid and damaging. As previously alluded too, the temperature in an obstetric theatre is cold and therefore skin to skin can be challenging. It some instances your partner will be the first person to provide this, depending upon your post-operative condition. Babies can maintain their core temperature perfectly against a warm chest. This will allow for its normal responses and feeding cues initiate spontaneously. The first hour is an especially important time for a new baby.
Depending on your circumstances, you will usually need to stay in hospital for around 2 -4 days after your c/s. you will be encouraged to wear your ted compression stocking for 6 weeks and will need to take blood thinning injections. General anaesthetics can affect your memory, concentration, and reflexes for a day or two, so it’s important for a responsible adult to stay with you for at least 24 hours after your operation, if you’re allowed to go home. You’ll also be advised to avoid driving, drinking alcohol and signing any legal documents for 24 to 48 hours.
General anaesthetics have some common side effects. Your anaesthetist should discuss these with you before your surgery. Most side effects occur immediately after your operation and do not last long. Possible side effects include:
- feeling sick and vomiting – this usually occurs immediately, although some people may continue to feel sick for up to a day
- shivering and feeling cold – this may last a few minutes or hours
- confusion and memory loss – this is more common in elderly people or those with existing memory problems; it’s usually temporary, but occasionally can be longer lasting
- bladder problems – you may have difficulty passing urine
- dizziness – you will be given fluids to treat this
- bruising and soreness – this may develop in the area where you were injected or had a drip fitted; it usually heals without treatment
- sore throat – during your operation, a tube may be inserted either into your mouth or down your throat to help you breathe; afterwards, this can cause a sore throat
- damage to the mouth or teeth – a small proportion of people may have small cuts to their lips or tongue from the tube, and some may have damage to their teeth; you should tell your anaesthetist about any dental work you have had done.
- A number of more serious complications are associated with general anaesthetics, but these are rare.
Following your Caesarean Section
Adequate pain relief is very important following a c/s. You may be prescribed morphine following surgery for the first 24 hrs but generally will manage with Paracetamol and Ibuprofen – providing you take it regularly. You may be given a pain killer in the form of a suppository. It is better to take analgesia and mobilise than restrict your movement due to discomfort.
A wound infection is common, probably affecting up to 1 in 20 mothers, despite them being given a preventive dose of antibiotics at the time of delivery. For most women this is an inconvenience, but some will have more prolonged infections which delay healing. See more information below · A chest infection is also possible but more so in smokers and after general anaesthetic.
The more serious complications include: · Surgical complications such as damage to bladder VT (blood clots in the veins of the legs) 1 in 300, as compared to 1 in every 1000 pregnant women overall. Treatment for this condition involves the use of blood thinning medication for several months after the clot is detected. ·
Pulmonary embolus (when a clot in a leg vein breaks off and then lodges in the patient’s lungs) affects 1 in every 100 patients who have had a DVT and this can be fatal. To prevent this complication women who are at a higher risk of developing blood clots are given injections of a blood thinning drug every day into the abdomen or thigh and this may continue for either 10 days or 6 weeks so will need to be continued at home.
Massive haemorrhage (bleeding) leading to blood transfusion and or hysterectomy. This happens more with mothers who have had previous abdominal surgery or those with a low lying placenta.
Most babies born by Caesarean birth are well after birth. However, a small number of babies may develop problems. In most cases, the baby will be seen by a neonatologist (baby doctor) and may need to go to the Neonatal Intensive Care Unit.
A hat is especially important as we know babies lose heat from their heads. Your baby’s temperature will be checked by your midwife. Babies have stores of energy to use in the hours after birth. Sometimes, this energy may be used up during delivery or if the baby is cold, they may not use it properly. If the midwife is worried, she/he will test your baby’s blood sugar level by taking a drop of blood from the baby’s heel. Feeding your baby usually resolves a low sugar level. If the level is exceptionally low or your baby appears unwell in any way, he/she will be seen by a member of the neonatal team.
Your midwife will offer you help and assistance with baby care, feeding and helping you to move around. It is good for you to move your ankles and calves whilst you are in bed to prevent blood clots forming in the backs of your legs (a DVT – deep vein thrombosis). It is important to be getting out of bed and moving around gently as soon as you feel able, to reduce the risk of both DVT and chest infections delaying your recovery. Women who are at a particularly higher risk of these complications are prescribed treatment to reduce the risk of such problems. Your urinary catheter will be removed approximately 12 hours following the operation and the “drip” in your arm will be removed after you have started to eat and drink. Your midwife will ask you to measure how much urine you are able to pass when you use the bathroom: please tell us if only small volumes are being passed – you may need to have your catheter re inserted.
You will feel exhausted and extremely emotional following a c/s birth. It is possibly much like you are on a continuous night flight with much discomfort, an abdominal wound, backache, and vaginal bleeding. But you will have a baby your little baby to care for.
Have a read of Laura and Peter’s amazing birth story to hear just how wonderful their recent birth experience was. They had an emergency c/s under a general anaesthetic for a pulmonary embolism, at term. She looks amazing 2 weeks following and is an inspiration to us all. Having planned extensively for a natural, drug free birth, both Laura and husband, Peter, re-routed their pathway in order to have their beautiful little son – as a matter of urgency. She relays feeling ‘in control’ and ‘confident’, despite the surrounding heightening anxiety levels, amongst the health professionals and that her birth experience was brilliant.
My birth story could not be further from the birth I had hoped for but I came to terms with it in the days before and made we asked questions and had the confidence to make requests that were sure we wouldn’t have done without the hypnobirthing.
Due to the risk of the GA affecting him we agreed I’d remain awake in theatre for the entire prep and I’d go under right at the last moment. Pete was scrubbed and with me for all of this part and we breathed together through the cannula, catheter and prep.
The days before I felt quite bereft that I wouldn’t have any experience of our baby’s birth, not even a normal section. So I asked if photos could be taken so we could reflect afterwards. I particularly wanted a photo of him being raised out of me and it was important that I was still the first to have skin contact with him on my chest even if it was momentarily and that I wanted to have the photo to treasure…
….well our amazing team delivered and one of the wonderful midwives went full David Bailey!
We have the entire birth filmed and photographed from the incision, the waters going as he’s lifted out and the theatre wishing him happy birthday, his cord cutting and first cry, meeting daddy outside and then back to me.
And when they put him on my chest, the clever little chap actually latched on and our other amazing midwife held him there and helped him feed for 20 mins whilst they put me back together. The photos are beautiful and I keep looking at them with such pride and awe of what my body went through and is healing from so quickly.
We came home late on Christmas Eve and we’re just finding our feet and winging it with the little chap, who is a content and lovely little time vampire. 5 day check yesterday and he’s now gained a lb over his birth weight which I’m so pleased about! I’m putting that entirely down to the skin to skin and feeding, as his latch has been perfect from day one.
Thank you again for everything – joining yoga and then hypno became a really important part of our pregnancy. I’m now looking forward to being able to come to baby yoga!!
Laura literally experienced the complete opposite birth than they had both planned for. They had an emergency procedure incorporating so much technology and intervention but because they felt involved and safe were able to enjoy and embrace their experience of childbirth.
Thank you to Laura and Peter for sharing your story, its both beautiful and empowering.