Caesarean section birth
There is concern about the rise in the number of babies being born by caesarean section, with studies indicating that women are now around five times more likely to give birth by caesarean than they were forty years ago. Caesarean section (also referred to as an ‘operative birth’) is the commonest major operation performed on women worldwide and can also be a life-saving procedure. It is usually performed where it is felt that a vaginal birth (also called ‘normal delivery’) could put the health and wellbeing of the mother and/or her baby at risk. Caesarean section is performed by senior doctors in a Delivery Suite Operating Theatre.
Having a caesarean section involves making an incision (cut) into the mother’s abdominal wall (tummy) through which the baby and placenta (afterbirth) are delivered. This cut is usually made in the lower abdomen along the bikini-line, where there is a natural crease in the skin just above the pubic bone – this is called a ‘Pfannenstiel incision’. However, if a caesarean is required much earlier in pregnancy, the incision may need to be made vertically down the centre of the abdomen, because the baby is premature and still small, and the lower segment of the uterus hasn’t yet formed – this is called a ‘classical’ incision. However, the incision to the skin is the same as with a full term caesarean; it is only the uterus that is cut vertically.
There are two types of caesarean section:
- ‘Elective’ (planned) caesarean section – where the decision to deliver the baby by caesarean is made during pregnancy because there is a clinical indication (reason)
- ‘Emergency’ (unplanned) caesarean – where there are maternal and/or fetal (baby) concerns that necessitate delivery by caesarean section.
Why might I need a caesarean section?
Because a caesarean section is major abdominal surgery, it is only undertaken where there is a clinical indication to do so. Elective caesareans are usually performed for the following reasons:
- Placenta praevia – where the placenta (afterbirth) is low-lying in the uterus and lies close to/or covers the cervical os (opening to the womb)
- The baby is lying in an awkward position in the uterus – lying horizontally (transverse lie) or diagonally (oblique lie)
- The baby is in the breech position (bottom first). See also our article, ‘I’ve been told that my baby is ‘breech’!’
- The woman has had one or more previous caesarean births
- Twins, triplets or more – a caesarean birth is recommended where (i) one of the babies is lying in an awkward position eg breech or lying feet first (called a ‘footling’ breech); (ii) two or more of the babies share a placenta, in which case, a caesarean section is undertaken to prevent either baby becoming starved of oxygen; (iii) labour starts prematurely and it is safer to deliver the babies by caesarean
- The mother has a medical condition which could put her or her baby’s health and wellbeing at risk, should she labour or attempt to deliver her baby vaginally eg a cardiac (heart) condition
- Genital herpes infection – where there is a first episode of active genital herpes infection, there is a risk that the baby will become infected by the virus during a vaginal birth
- The baby’s health and wellbeing is a concern eg the baby is small and not growing as well as they should be – called ‘fetal growth restriction’
- Severe pre-eclampsia – this is pregnancy-related hypertension (high blood pressure). It is a serious condition that requires emergency treatment
- ‘Failed instrumental’ birth, where it has not been possible to deliver the baby vaginally using the ventouse or forceps.
Sometimes, circumstances can alter very suddenly during labour. Where there are significant concerns about you and/or your baby’s health and wellbeing, the decision to deliver the baby by caesarean may need to be taken quickly. Where this is the case, it may not always be possible for the doctor looking after you to fully explain the benefits and disadvantages of having a caesarean birth. However, your informed consent will always be sought and the midwife and doctor will explain the reasons why your baby needed to be delivered urgently, as soon as possible after the birth.
Emergency caesareans tend to be performed for the following reasons:
- The baby is being deprived of oxygen and there are abnormal changes to its heart rate – called ‘fetal distress’
- The woman starts bleeding – called ‘antepartum haemorrhage’ (APH)
- Labour is not progressing as it should be and the cervix is dilating too slowly, or the baby is too big to be born vaginally (called ‘dystocia’)
- Failed induction of labour (IOL) – where labour is being induced but the cervix is not dilating as it should be, or the contractions aren’t strong enough for the baby to be born vaginally. See also our article, ‘What happens when your baby is overdue?’
- An obstetric emergency called ‘umbilical cord prolapse’. Where the baby is lying in an awkward position and/or their head/bottom isn’t ‘engaged’ (in the pelvis). If the membranes rupture (waters break), the umbilical cord can prolapse down and the baby can become deprived of oxygen.
What are the advantages and risks of having a caesarean birth?
Caesarean sections are much safer than they were 70 years ago. However, because a caesarean is classified as major surgery, it is associated with an increased risk of complications. The two main advantages of having a caesarean are; knowing the date when your baby is going to be born and the avoidance of perineal trauma – see also our article on ‘Severe perineal trauma: Third and Fourth degree tears’. Risks to the mother include haemorrhage (excessive bleeding) and anaemia, and, in the most critical cases where bleeding cannot be stopped – the risk of needing a hysterectomy (removal of the uterus) – this is extremely rare however! See also our article, ‘Anaemia after childbirth’. Other risks include; haematoma (bruising), thrombosis (blood clots in the legs or lungs), uterine (endometritis) and wound infections, and damage to the bladder. Studies have also found that having a caesarean section is associated with a delay in getting pregnant again; ectopic pregnancy (where the ovum – egg, is fertilised in the fallopian tube) and placenta praevia in a subsequent pregnancy. Women who have had a caesarean section are also more likely to be readmitted to hospital from home post birth.
For the baby, the main risk is breathing difficulties, although this tends to be more of an issue for babies who are born prematurely. However, term babies who are born by caesarean can start breathing faster than they should do in the early postnatal period. This condition is called transient tachypnoea of the newborn and most babies recover completely within a couple of days; however, some will require antibiotics and care on a neonatal unit.
Sometimes, the baby’s skin can get cut when the opening in the uterus is made. These cuts tend to be very superficial and quite rare; occurring in around two out of every 100 caesarean births.
It is understandable that hearing about all these risks can be very worrying. However, it is important that you understand the risks and benefits associated with caesarean birth, so that if you are considering a caesarean birth, you can make an informed decision.
There has been a lot of discussion in the media about women requesting to have caesarean births and being considered ‘too posh to push’. However, to clarify this position, although midwives and doctors are keen to support choice in childbirth, women are not automatically entitled to have a caesarean birth if they do not have a physical or mental need for it. If you are considering asking your doctor for a caesarean section, they will want to know why you want your baby to be delivered this way and will ask you the reasons behind your request. The doctor will also explain the advantages and risks associated with having a caesarean section. Of course, there will be other circumstances where women have a history of being sexually abused or assaulted/raped and caesarean section will, understandably, be their preferred option.
The National Institute for Health and Clinical Excellence (NICE) has published guidance which aims to reduce unnecessary caesarean sections. These include the recommendation that women who request a caesarean because they are frightened to give birth vaginally, should always be referred to a health professional who has expertise in counselling and mental health support. If after discussion, the woman still feels anxious about giving birth vaginally, then it is recommended that she is offered an elective caesarean section.
NICE guidance also recommends that women are given a dose of intravenous antibiotics before rather than after having a caesarean to prevent uterine or wound infection developing. They also recommend that some women who are HIV positive and women, who have had a previous caesarean, should be offered the option of having a vaginal birth.
Who can I have with me?
You can usually have one birth partner with you during the caesarean section. This can be your partner, a close friend or relative, or a doula. See also our article, ‘Who can support me during labour?’ Because the operating theatre needs to be kept as clean as possible, they will be asked to wear a gown over their clothing and put on a theatre hat (like the maternity staff) and plastic overshoes (shoe covers).
Where there is a need to deliver your baby very urgently and/or you need to have a general anaesthetic (GA) – (ie go to sleep), then your birth partner will usually be asked to sit in the Recovery area while the caesarean is performed. They will however, be regularly informed by the maternity staff how you and the baby are doing.
What happens at a caesarean birth?
A caesarean section is normally undertaken under epidural or spinal anaesthesia (also called regional anaesthesia), which may be performed in a small room next to the operating theatre or in the theatre itself. You will need to have an intravenous infusion (drip) before having an epidural or spinal; for further information see our article, ‘Pain relief options for labour and birth’.
Having a caesarean section under regional anaesthetic means that you are awake during the procedure, but the lower part of your body is completely numb so that you cannot feel any pain. You may still however, be able to feel slight pulling sensations as the doctors help your baby to be born, but this won’t be painful. The anaesthetist will make sure that the epidural or spinal is working effectively before the doctors’ start the surgery.
Once you are numb and cannot feel any sensation, the midwife will insert a fine catheter (tube) into your bladder. This keeps your bladder empty and drains urine away into a catheter drainage bag. It helps to protect your bladder during the caesarean and also means you don’t have to worry about getting in and out of bed immediately after the operation. The catheter is left in place after the caesarean for at least 12 hours and prevents difficulties with passing urine because of a lack of sensation. See our related article, ‘Caring for your bladder after childbirth’.
The theatre staff will also attach a special pad to your thigh; this is for a piece of equipment called the ‘diathermy’. This is a machine that uses electricity to produce heat that ‘cauterises’ small capillary blood vessels to stop bleeding. The diathermy makes a small buzzing noise each time it is used, but you are unlikely to notice it much because you’ll have your new baby to focus on and the midwives and doctors usually have a radio playing in the operating theatre for background music.
The lower abdomen from your umbilicus (tummy button) downwards, will be cleaned with a pink (Chlorhexidine) or brown (Iodine) -coloured disinfecting solution. This makes sure that the skin is as clean as it can be before the doctors’ start the operation. You will also be covered in paper drapes that help to keep the area clean and also provide a temporary screen between your line of vision and the doctors operating. This means you cannot see what the doctors are doing; however, you can ask to have the screen lowered so that you can see your baby being lifted out.
When the doctors are ready, the operating table is tilted to the side to an angle of at least 15 degrees. This is done to stop the weight of your uterus/baby pressing on your major blood vessels which can make you feel nauseous (sick) and faint. The anaesthetist can give you specific drugs that can treat this and then once your baby has been born the operating table will be levelled again. After the baby has been delivered, the anaesthetist will give you a drug called oxytocin which makes your uterus contract, so that the placenta separates away from the uterine wall and can be delivered. Oxytocin also helps to reduce the amount of blood lost at the birth.
An elective caesarean section normally takes around 40-50 minutes from start to finish; however, in an emergency situation, it can be performed much quicker.
What happens if the epidural/spinal doesn’t work?
Where concerns for you and/or your baby mean that the baby needs to be delivered urgently and you don’t already have an epidural in place, the anaesthetist may advise that you have a GA. This is because it is much quicker to give a GA than waiting for an epidural/spinal to take effect. Very occasionally, the epidural is not effective and women can still feel some sensation; where this happens it is called a ‘failed epidural’ and the anaesthetist will need to give a GA in order to deliver the baby.
The abdominal wound is sutured (stitched) in layers starting with the uterus and then the abdominal muscles, up to the skin. The skin is the very last layer to be closed and sutures are normally put in just under the surface of the skin – these are called subcutaneous sutures. Because they are under the surface of the skin, they are invisible and dissolve away without needing to be removed. An adhesive wound dressing is applied and this usually stays in place for the first 24-48 hours following the caesarean. Sometimes the sutures that are used will need to be removed at a later date – these are called interrupted sutures and are usually removed five days after the birth. Other types of skin closure include, staples that are also removed at around five days post birth. More rarely, the skin edges may be glued together using special skin glue – in some hospitals this tends to be the preferred closure for women with raised BMIs (body mass index). Wherever possible, the doctors will explain which type of skin closure they will be using beforehand.
While the doctors are suturing your wound, the midwife will weigh and measure your baby; check them over, apply the umbilical cord clamp and put two identity bracelets on the baby – one on their wrist and the other on their ankle. Where your baby needs to be transferred to the neonatal unit (NNU) immediately after they have been delivered, this will all be done on the NNU.
After your caesarean section, you will be transferred on a trolley from the Operating Theatre into a Recovery area. This is where you and your baby will be monitored closely for a couple of hours, and, you will be offered a wash and helped to change into your nightwear ready for transfer to the postnatal ward. The epidural will be removed and if you are tolerating oral fluids, your intravenous infusion will also be discontinued; however, the venflon (fine plastic needle) in the back of your hand will be left in place.
The midwife will check your pulse, blood pressure, respiratory (breathing) rate, temperature and monitor any pain or drowsiness at very regular intervals. They will also check your wound dressing and lochia (postnatal vaginal bleeding) – see also, ‘Blood loss after your baby’s birth’ and monitor the amount of urine that is draining into the catheter bag.
Unless there is a concern with your baby’s health and wellbeing, you should always be offered skin-to-skin contact within an hour of your baby’s birth, or as soon as is practicably possible. This can sometimes take place in the Operating Theatre, but more usually happens in the Recovery area where skin-to-skin can be facilitated in an unhurried manner and you can be supported with pillows. If you are breastfeeding your baby, the maternity staff will help you with this too. See also our article, ‘Breastfeeding’.
On the postnatal ward
The maternity staff on the postnatal ward will monitor your temperature, pulse, blood pressure, respiratory rate and oxygen saturations every four hours for the first 24 hours post birth and then twice daily thereafter until you are discharged home. If there are any concerns about your health and wellbeing, these observations will be undertaken more regularly. They will also want to check that your wound is healing as it should be and that your lochia is reducing.
Having a caesarean section can often be the first time that a woman has had any surgery; coping with post-operative wound pain and caring and feeding a newborn baby can be very challenging. The maternity staff will ensure that you remain as comfortable as possible and the doctors will prescribe regular analgesia (pain relief) for you. This is normally a combination of Paracetamol and a non-steroidal anti-inflammatory, such as Ibuprofen with a stronger drug such as Morphine or Tramadol. For more detailed information see also our article, ‘Recovering from your Caesarean birth’.
The urinary catheter will usually be removed around 12 hours following the caesarean or first thing in the morning if your baby is delivered late evening/during the night; unless the doctor advises otherwise. The maternity staff will encourage you to try and pass urine within six hours of its removal and your voids will be measured and recorded each time you go to the toilet for the first 24 hours, to ensure you are emptying your bladder properly. See also our article, ‘Caring for your bladder after childbirth’. Twenty-four to 48 hours post birth the maternity staff will ask to take a small sample of blood from you to check your haemoglobin level (iron count). If you are found to be anaemic, the doctor will prescribe iron therapy – Ferrous Sulphate tablets, which you continue to take when discharged home. Where the anaemia is found to be more severe, the doctor may suggest that you have a blood transfusion. See also our article, ‘Anaemia after childbirth’.
Because a caesarean section is major abdominal surgery, it will take longer to recover from the birth than if you had a vaginal delivery. For more detailed information see also our article, ‘Recovering from your Caesarean birth’.
When considering future pregnancies, just because you have had a caesarean section with your last pregnancy, doesn’t mean that you will have to have a caesarean again. There are a number of factors that will be taken into account when your midwife and doctor discuss your future pregnancy options with you. These will include; (i) the reason(s) for your previous caesarean (ii) your personal preferences (iii) the advantages and risks of having a caesarean section (iv) the risk of uterine rupture (where the scar line from the previous caesarean section tears open, and (v) you and your baby’s health and wellbeing. However, if the previous caesarean was undertaken because you have a health condition such as cardiac disease, or because of the shape of your pelvis, then it is likely that you will need to have a caesarean birth each time. See also our article, ‘Vaginal birth after caesarean (VBAC)’.
Your midwife and doctor should always support your wishes, but will also want to make sure that you make an informed decision and understand the advantages and risks associated with caesarean birth. For some women ending up with a caesarean section can be a massive disappointment; especially, if they had set their heart on having a natural birth. The priority however, is always the health and wellbeing of mother and baby, and the maternity staff will be able to help you to talk through these feelings, and ensure you receive any support that you need. Most UK maternity services offer a birth afterthoughts service and are happy to answer any queries you may have about your labour and/or baby’s birth.