Caesarean birth

By , 3 February 2014

Caesarean birth

 

Giving birth by caesarean section

Many expectant mums plan on delivering their baby by a natural birth.  Other women choose to have an "elective" caesarean section after weighing up the risks and benefits in their particular situation.  For others, a caesarean section becomes necessary due to complications in pregnancy or during labour.  Whatever the method of birth, or the reason, the aim is always to deliver your baby safely into your arms.
 

What is a caesarean section?

A caesarean section is a surgical procedure where the baby is delivered through an incision in the mother's abdominal wall and uterus/womb.  It is a very common surgical operation and is generally very safe; however, it remains a major operation with known risks, and the decision to proceed with a caesarean section needs to be an informed and measured one, after consideration of the safety of both mother and her baby, and the mother's wishes.
 

Why would I need a planned caesarean section?

Sometimes, a caesarean section is clearly needed to preserve the health of the mother or the baby, such as:

  • Placenta praevia - a condition where the placenta covers the opening of the womb, preventing a safe vaginal birth.
  • If you are carrying more than two babies (e.g. triplets).
  • Medical conditions that prevent a mother from "pushing" (e.g. some heart or neurological conditions).
  • Conditions affecting baby that make vaginal birth too risky (e.g. some malformations, fetal bleeding disorders).

In other cases, a caesarean section may be chosen over attempting a higher-risk vaginal birth, where risk factors exist, such as:

  • Previous surgery to the uterus (e.g. previous caesarean sections, previous fibroid surgery).
  • Previous significant tearing during childbirth.
  • Where the baby is thought to be very large, especially in the setting of diabetes in the mother.
  • Where the baby is presenting bottom-first, or "breech".
  • Twin pregnancy, when conditions are not favourable for vaginal birth.
  • Medical conditions pre-existing in the mother, where high physical stress needs to be avoided (e.g. heart or lung conditions).
  • Medical conditions that develop during pregnancy, where delivery of baby needs to be expedited before induction of a vaginal birth can be safely performed.

 

Why would I need a caesarean section after labour has begun?

There are essentially three reasons why a caesarean section may become the safest mode of delivery after labour has started:

  1. Baby: when there is concern for the baby's well-being, and vaginal birth is not imminent (e.g. "fetal distress").
  2. Mum: when there is concern for the mother's well-being, and vaginal birth is not imminent (e.g. heavy bleeding, blood pressure problems).
  3. Labour: when, despite a healthy mother and baby, the progress is labour has stalled and cannot be safely enhanced (e.g. with oxytocin or by instrumental birth), and obstructed labour is diagnosed.

Sometimes, more than one of these reasons may be present.  Part of "the Art of Obstetrics" is managing risks so that every chance can be given for safe natural birth, without over-reliance on caesarean section - while, at the same time, making confident and timely recourse to caesarean section when it is necessary.
 

What happens during a caesarean section?

Caesarean sections take place in the Operating Theatre of a Maternity Hospital.  These theatres are necessarily well-lit, and several personel are needed to ensure things run as safely as possible: the obstetrician, the anaesthetist, the paediatrician, the midwife, the surgical assistant, the surgical nurse, the anaesthetic technician, and additional nursing and theatre support persons (!).   This can, understandably, be a little daunting, and every attempt is made to keep you informed of what is going on, keep you calm and relaxed, and to preserve your dignity during the procedure.  Your husband/partner or support person is able to be with you for the entire process.

The Anaesthetist administers anaesthesia to ensure you are comfortable during the procedure.  This "block" is checked repeatedly for effectiveness before any incision is made.  A tube ("catheter") is placed into your bladder to deflate the bladder, keeping it safe during the operation.  Your tummy is painted with a surgical cleaning solution, and a sterile drape is placed on your tummy which is raised above your chest.  The obstetrician makes an incision in your skin, then gradually down through the layers of the abdominal wall until the uterus (womb) is reached.  Your abdominal muscles are not cut.  An incision is made in your uterus, and baby is delivered carefully by the obstetrician, with the assistant helping by pushing downwards on the top of your tummy.  The sterile drape is temporarily lowered, and your baby is welcomed into the world - and there is plenty of time for photos!

The cord is clamped and cut long, and baby is passed to the midwife and paediatrician for a quick assessment of how well they have adjusted to being born.  Baby's Dad or your support person is able to come and watch this process, and usually cuts the cord a second time, to trim down its length.  In many cases, baby can be wrapped and passed to your chest while the operation is completed.  The obstetrician and assistant close the layers with dissolvable stitches, and a sterile dressing is applied to the skin.
 

What are the risks of a caesarean section?

The risks of this procedure would be thoroughly discussed prior to obtaining your consent to proceed.  In brief, some possible complications include:

  • Bleeding, rarely requiring blood transfusion.
  • Wound infection, usually treated with antibiotics.
  • Difficult moving bowels after the operation.
  • Clotting in veins ("deep vein thrombosis").
  • Damage to bladder or bowel (intestines), which may require further surgery.
  • Minor skin cuts to baby, usually treated with a band-aid.
  • Next pregnancy: scarring or adhesions may make future caesarean sections more complex, and it is possible, in future pregnancies, for the placenta to grow over the scar on the uterus, which can cause further problems.

 

What happens after my caesarean?


Post-delivery

In most cases, women choosing to breastfeed are able to do so immediately after their caesarean, in the Recovery Bay.  The catheter in your bladder will remain until the following morning, after which time your are encouraged to mobilise as much as is comfortable.  Pain is usually manageable with tablets, and you will be seen by a Physiotherapist who will teach you techniques to safely mobilise, and to help your abdominal muscles regain their strength after pregnancy.  Your pain and mobility gradually improve, and by the time of leaving the hospital (often Day 5), most women are managing on simple pain medications like paracetamol and/or ibuprofen.


Recovery

Recovery after a caesarean section is often quoted as taking "six weeks".  While this is a useful guide, the reality is that every woman is different, and the definitions of "recovery" vary.  Most women find Day 2 the most painful - when they start to become more active.  Discomfort gradually fades over the next two weeks, and women are able to resume most normal activities.  Tenderness around the site of the incision, however, may remain for much longer.  Often, the sensation in the skin around the incision is altered, and it may be several months before this goes back to feeling completely "normal".  Driving is usually safe after a two or three weeks, but this should always be discussed with your obstetrician on an individual basis, and it is also a good idea to check with your car insurance company to ensure there are no clauses that may related to recent caesarean section.


Next pregnancy

After a caesarean section, an obstetric specialist should review the circumstances, indication, and outcome of your caesarean, to help you determine the optimum mode of delivery in your next pregnancy.  Some women may choose to have a pre-labour caesarean section in their next pregnancy, while others opt to attempt a vaginal birth after caesarean (VBAC).  Although there are some associated risks, in the right circumstances and with support and expert management, an attempted VBAC can be a successful and fulfilling experience.

 

David is a strong advocate of women's informed choice in their health care, and supports safely attempted VBAC.

 

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Caesarean birth
 

About Dr David Moore

Caesarean birth

David is a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and undertook his specialist training in Queensland.  He is highly skilled in the management of complex and high-risk pregnancies, and has special training in minimally-invasive surgery, endometriosis, pelvic floor and incontinence surgery.  David has completed a Master of Reproductive Medicine and is skilled in the assessment and management of fertility problems, and can offer the full range of assisted reproductive treatments.  He is a Senior Lecturer with The University of Queensland Medical School, and has published both medical journal and textbook contributions.

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