Caesarean Section

Every pregnant woman has individual concerns and choices within pregnancy. After reading this article, please discuss any questions you may have with the MUMS team.

A Caesarean section is where a baby is delivered though a cut on the lower part of a woman’s abdomen. This now accounts for 25% of all births within the UK. There is great debate, myths and controversy over the use of C-Sections within the UK. This leaflet is designed to try and answer these issues and help you make your correct choice for the birth of the baby.

A Caesarean section is performed only after Mike has carefully consulted you over the matter. The indication for Caesarean section may be evident at any time during the pregnancy but sometimes the need for a Caesarean section is evident only after the onset of labour, either in the early stage or after a woman has been in labour for a while. The presence of several conditions during pregnancy or labour may necessitate a Caesarean section.

Please also read the NICE guidelines for C Section

Some of the most common conditions for which a Caesarean section may be advised for include:

• Prolonged or Ineffective Labour. When labour is prolonged for various reasons, including insufficient contractions of the uterus, a Caesarean section may be necessary to speed the birth process.

• Placenta Praevia. This condition exists when the placenta (or afterbirth) becomes positioned abnormally low within the uterus and there is a possibility that it could completely block the cervix. This condition could prevent the baby from advancing through the birth canal and it also could cause hemorrhaging (severe bleeding).

• Placenta Abruptia. Occasionally, the placenta can suddenly separate from the wall of the uterus prior to the delivery of the baby, possibly causing the mother to hemorrhage, and the baby to have an abnormal heart rate.

• Disproportion. This condition occurs when the baby’s head is too large or the mother’s birth canal is too small to allow for a safe vaginal delivery.

• Abnormal Presentation. In some instances, the baby’s position in the uterus may make vaginal delivery dangerous. This problem may occur when the baby is in a breech (buttocks or feet first) or transverse (side or shoulder first) position.

• Prolapsed Cord. This condition exists when the umbilical cord precedes the baby through the vagina during labour. A prolapsed cord could strangle the baby as it is being born, or block the baby’s progress through the vagina during avaginal delivery.

• Fetal Distress. If the baby has a slow or very rapid heart rate, deceleration of heart rate, or a heartbeat that does not fluctuate, it may be advisable to speed the delivery by performing a Caesarean section.

• Medical Problems. The mother may have medical problems, such as diabetes, genital herpes, hypertension, cardiac disease, toxaemia, or ovarian or uterine cysts or tumours that could make labour hazardous to both the mother and the baby.

• Multiple Births. Multiple births, such as twins and triplets, are be delivered more safely by Caesarean section (particularly if one or more of the babies’ position in the uterus will result in an abnormal presentation).

• Previous Caesarean Delivery. Previously, women who had one Caesarean birth would deliver subsequent births by the same method.

• Birth Defects. Some babies with birth defects diagnosed by ultrasound have a better outcome when delivered by Caesarean section. The risks and benefits should be discussed with a qualified obstetrician. Although any of these conditions may make a Caesarean section advisable, they do not necessarily rule out the possibility of a normal vaginal delivery.

• Maternal concerns. The extreme fear of childbirth is termed tocophobia and we are increasingly recognising this as a problem for women who find themselves pregnant and concerned about the delivery. We can offer carefully counselling around this and will support you in whatever your choice of delivery.

• Maternal choice this is something being increasingly recognised in toady’s society with concerns over pelvic floor and vaginal trauma. If this is a concern for you we can discuss this in great detail with you.

Maternal Choice for C-Section is now well and truly embedded in modern obstetric care. NICE recognises this in its most review and supports this choice when appropriate discussions and information has been provided to the woman.

The Operation Itself

A C-section is a fairly straightforward operation in most cases. Mike has been performing the operation for over 20 years and still perform on average 5 per week each.

We do not recommend having a C section before 38 weeks (unless there is a medical need) as the risk for baby needing admission to a baby care unit is 1 in 25 whereas after 38 weeks the rate halves. If you were to go into labour prior to your date for the operation the risk for admission of baby to the unit reduces to less than 1% as the hormones produced by labour accelerate the lung function of the baby.

Preparation for the operation on the day

If you are having an elective C-Section you will be asked to wash everyday for a week prior to the date with antiseptic soap wash from your breasts to your thighs. This soap is available at all major supermarket chains. You will be asked to shave or wax the all of your pubic hair at least a week before the operation. We will give you a medication called ranitidine. Ranitidine or Zantac will help to reduce the acid in the stomach on the day of the operation. It is best to take one  tablet the evening before surgery at about 10 pm and then take one at 7 am the next morning. These tablets are used in nearly every C Section in the UK and are considered safe for the baby. Ranitidine is a drug used in the UK for treating heartburn and ulcers.

Will I be awake or asleep?

While the type of anesthesia used for a Caesarean section is determined by the condition of the mother and baby. In 95% of cases either a spinal or epidural anesthetic is administered to numb the mother’s legs and abdomen. Either anaesthetic will allow the mother to remain awake without feeling pain. Sometimes, however, a general anesthetic that allows the mother to be asleep during the operation may be preferable. This will be discussed in more detail with you be the anaesthetist. A good website link for this is provided by the Obstetric Anesthetists Association which is available on our patient links area. After you are made numb or put asleep we insert a catheter to drain your bladder and this usually stays in until you are mobile or for 24 hours. We do this as the bladder lies over the area of the womb that we need to cut through.

What sort of cut is used?

We only use the horizontal incision or cut made just below the bikini line. If you have had a previous operation we try to go through the same scar. The vertical scar is rarely used these days.

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After gently cutting and stretching through the tissues we make a horizontal incision into the womb. We then break the membranes containing the fluid and baby. Then we gently remove the baby and afterwards the placenta from the uterus. The incision in the mother’s uterus is then tightly sutured, and the abdomen is closed in the same manner that is used for any other operation. All the stitches used dissolve on their own and no suture can be seen on the skin after the operation. Steristrips are then applied to the wound to allow the natural scab to collect at the wound site. These can be removed over the following week after the operation. Do not worry if these start coming off almost immediately after your first shower but don’t try and take them off before 5 days after the operation.

What happens after the operation?

You are taken to the recovery room for approximately an hour where your baby is weighed and checked over by the midwife. You are encouraged to breast feed the baby if this is your intention within 30 minutes of birth.

How long do I stay in hospital?

The average hospital stay after a Caesarean section is two days. Most patients are encouraged to get out of bed within 24 hours after the operation. The urinary catheter is removed within 24 hours of the operation. Any drips – fluid bags into your veins – are also taken down within 24 hours. We have performed a few C Sections where the patient has gone home the same day.

How long is the recovery?

Most patients are able to care fully for their baby in the first week after the operation. You are able to return to driving a car two weeks after the operation with full activities in approximately four to six weeks. The recovery time though is dependent upon many factors including your own fitness as well as any complications following the surgery.

Wound care after the operation

The steri-strips can be removed 7 days after the operation. The whole wound is covered with a large plaster that can be removed 48 hours after the operation. The easiest way to remove the large sticking plaster is to soak in the shower so as it becomes moist and then remove it. It is common to have oozing for the first few days after the operation. Do not get the wound wet in the first 48 hours as this increases the risk for infection to the skin.

What happens after I go home?

Your NHS midwife and health visitor will visit you at home to check that all is going well for you and baby. If you have any concerns you can contact the practice or Mike directly and we will sort things out for you. We then make a routine appointment to see you some 2-3 weeks after the operation.

When can I start exercising and swimming?

We advocate walking from as soon as you feel up to it and then leading to light gym activities at week 6 and swimming just after. However, some people return slightly earlier whilst others return at a later date. You will have to see how you feel. As long as you can perform an emergency stop in your car you can start driving after 2 weeks from the operation but check with your insurance company that this is OK.

What are the complications of the operation?

The following list is not exhaustive but deals with the commonest examples of problems following surgery

• Infection of the wound, womb or urine – approximately 10% (national figures) – usually easily treated with antibiotics. In a recent audit of all our private patients we found a need for antibiotics post operatively in only 2% of women undergoing C Section

• Bleeding at time of operation – approximately 1% of women require a blood transfusion at the time of the operation and usually there are factors present which can identify this. To date none of our private patients have required a blood transfusion.

• Thrombosis – 1 in 500 cases. We give a blood thinning drug called clexane for 7 days after a C Section and you are asked to wear support hosiery called Scholl Ultima Hold ups for 2 weeks after the operation to prevent thrombosis in the veins of your legs. Thrombosis is classically diagnosed when one or both of your legs become swollen and or red.

• Future childbirth – there is an increase in the need for further C-Sections – approximately 50% of women undergo further C-Sections. If a vaginal birth is contemplated after a C-Section the success rate ranges from 50 to 85% depending on the indication for the original C Section

• We usually say that 5 C Sections are the maximum that are considered safe in any one individual as each time a C Section is performed the risk for damage to internal organs increases. However, this again depends upon the individual concerned.

More likely after a Caesarean section than a vaginal birth

Pain in the abdomen (tummy) – This is due to surgery and the cut on the skin and womb. We reduce this by giving you two forms of pain relief to go home with – ibuprofen (taken regularly, 400mgs up to 5 times a day). Most women are not using anything stronger than paracetamol 7 days after the operation.Bladder injury, Injury to the tube that connects the kidney and bladder (ureter) Needing further surgery, Hysterectomy (removal of the womb) and admission to intensive care – The above 5 issues are dramatically reduced as you have experienced operators and indeed on a first C-Section these are virtually never encountered. The chance of these happening either singularly or together are less than 1 in 500.

Developing a blood clot and longer hospital stay

We reduce the risk for developing blood clots by using blood thinning agents, support stockings and early mobilisation after the operations as well as ensuring you keep well hydrated in the post operative period and minimising operating time. By minimising operating time and good post operative pain relief and the organisation of home help we find that the average hospital stay for a C-section can be reduced from 4 to less than 2 days.

Re-admitted to hospital after going home for complications

This again is usually found if infection occurs or if the wound breaks down. This happens in about 2% of patients but to date we have not had this problem in our private practice. We have had wound infections requiring antibiotics which take up to 7 weeks to fully heal in two cases out of our practice in the past 10 years.

Death of the mother

This is a very rare occurrence and often preventable by appropriate levels of care and preventative measures. The risk of this happening is somewhere in the region of 1 in 5000 Vs 1 in 15000 from national figures but smoking and obesity play a major factor in this calculation.

Having no more children

This is extremely rare after a Caesarean section and we have not encountered this in our practice In a future pregnancy, the placenta covers the entrance to the womb (placenta praevia) This occurs after a vaginal birth in 1 in 200 women and after 1 C-Section in 1 in 75 women.

Tearing of the womb in a future pregnancy
This occurs in 1 in 250 women attempting a vaginal birth after a C-Section. 1 in every 10 women who tear or rupture the uterus during subsequent childbirth will have a baby who has severe brain damage or resultant death. This equates overall to 1 in 2500 risk for women undertaking vaginal birth after C-Section.

In a future pregnancy, death of the baby before labour starts
This is extremely small risk and still a matter of some controversy. The risk of losing a baby before birth without a previous C-Section is only 1 in 1000 for normally fit and healthy women with no pregnancy complications. After a C-Section this risk is at worse increased to 1 in 800. Again smoking and other factors come into play.

The following points are all reduced by having a C Section

• Pain in the area between the vagina and anus (the perineum)
• Bladder incontinence 3 months after the birth
• Sagging of the womb (prolapse) through the vaginal wall. This is not an uncommon complaint in women who have large babies delivered vaginally and can be a major problem later on in life.

There is no difference in the following between C Section or vaginal birth:

• Breast feeding
• Infection of the womb
• Post natal depression
• Pain with sexual intercourse
• Back Pain
• Bowel incontinence

 

July 2014

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