Elective Caesarean Birth

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Omeprazole 20mg at 10pm the night before surgery

Omeprazole 20mg at 6am on the day of surgery

The purpose of this leaflet is to provide you with information to enable you to plan your wishes for your caesarean delivery and inform you about your recovery period.

An elective caesarean section birth is a planned operation where your baby is born through a cut in your tummy (abdomen) just above your bikini line. You and your partner will have been involved in the decision-making of your care and treatment where this procedure will have been discussed. This leaflet aims to inform you about what will happen during your operation and will also explain some of the reasons why a caesarean birth may have been advised.

A caesarean birth that is done at short notice if complications develop during your pregnancy or labour is called an emergency caesarean. Approximately one in ten women with a booked caesarean section will go into labour/break their waters prior to the planned date. The obstetric (maternity) team will assess you and explain the options available if this does happen (even if you have a caesarean booked and it is carried out prior to this date).

What are the reasons for an elective or emergency caesarean birth?

There are a number of reasons why your baby may need to be born by caesarean section and some of the reasons are listed below. The reason for your caesarean will be discussed with you by your doctor and midwife.

1. Position of the baby: Most babies will lie with their head down getting ready to be born. Occasionally, babies lie in other positions which means they may need to be born by caesarean section, for example:
   • Breech – some babies present bottom first and if this happens the doctor may feel that it is safer to deliver the baby by a caesarean. However, a discussion will take place between yourself and your obstetrician (doctor) to provide you with sufficient information in order for you to make a decision.
   • Transverse – when your baby is lying across in your womb (uterus). This is more common in women who have had more than one baby as there is more room for the baby to change position.
   • Twins – Most twins can be born vaginally, particularly if the first one is head down. If the obstetrician looking after you is concerned about either of them, or if there is a problem with the second baby once the first is born, you may need a caesarean.
2. Placenta
   • Placenta praevia – where the placenta is low lying in the womb and covers all or part of the entrance of the womb (cervix) a caesarean birth would be advised as a vaginal birth is not possible.
   • Placenta abruption – a caesarean birth may be necessary if the placenta comes away from the wall of the uterus and you experience bleeding.
3. Previous Caesarean: In some situations, you may be advised that a repeat caesarean birth is recommended. You will be referred to a consultant or to the VBAC (vaginal birth after caesarean) clinic to discuss your options.
4. Other Medical Conditions: Women with other medical conditions may be advised to have a caesarean section:
   • HIV (depending upon your viral count)
   • Genital Herpes (if you have your first episode in the last trimester)
   • Heart disease (depending on the severity of your condition)
5. Maternal Request: You may request a caesarean when there is no clinical indication. The risks and benefits will be discussed with you to ensure you have accurate information and you may be referred to another healthcare professional before any final decision is made.
6. Emergency caesarean during Labour
   • Progress – if your labour is not progressing as expected.
   • Maternal wellbeing – If there is concern for your wellbeing during labour.
   • Baby’s condition – If there is concern for your baby’s wellbeing during your labour.

Risks/complications with a caesarean section

Although a caesarean section birth is a common and safe procedure, it is still classed as major abdominal surgery; therefore, there are risks and complications involved. Planned procedures carry fewer risks and complications in comparison with an emergency procedure.

• Infection: The most common types of infection that can develop following surgery are to your caesarean wound, and your uterus (6 in 100 women). To reduce the risk, we give a dose of antibiotics during the procedure and afterwards if necessary.
• Blood clots: All women having a caesarean section are at higher risk of developing a blood clot (4-16 in 10,000 women). To reduce this risk, women are advised to wear compression stockings and may require injections which reduce your risk further.
• Injury to internal organs: Injury to the internal organs during the operation such as the bladder (1 in 1000 women) or bowel carries a small risk. This risk increases if the caesarean is done as an emergency or if you are overweight.
• Bleeding: During an emergency caesarean you may be at risk of losing more blood and you may become anaemic following birth. We will check your iron levels and give you iron tablets if necessary.

Future pregnancy risks:

For reasons we do not yet understand, the chances of experiencing a stillbirth in a future pregnancy are higher if you have had a caesarean section (4 in 1000 women) compared with a vaginal birth (2 in 1000 women). More scar tissue occurs with each caesarean section. This increases the possibility of the placenta growing into the scar, making it more difficult to remove during any future deliveries (placenta accrete or percreta 4-8 in 1000 women). This can result in bleeding and may require a hysterectomy. There is evidence to suggest that women who have a caesarean section can be left with secondary infertility.

Risks for the baby: There is an extremely low risk of accidental injury to the baby during surgery this may involve a small scratch or cut to the baby’s skin (1-2 in 100 women). It may be necessary to deliver the baby during surgery by using forceps; this may cause some temporary bruising.

Babies born by a caesarean section may develop some breathing difficulties following the birth. This is more likely if the baby is premature or carried out before 39 weeks gestation. If delivery is recommended before 39 weeks gestation, steroids may be given to you to help mature your baby’s lungs. A caesarean section may also increase the risk of your baby requiring a neonatal unit admission and a prolonged hospital stay.

Can I make a birth plan?

Although a caesarean section is a surgical operation you and your partner will be fully involved in the decisions and choices. Many women would like a more family centered experience, so things to consider are:

• Bring a camera or smartphone into theatre for taking photos.
• Compile a playlist and bring a bluetooth speaker with you.
• You may want to consider having the drapes lowered to see your baby being born.
• You can ask for your partner to announce the sex of your baby.
• Your partner can feel more involved by doing the second cut of the cord (The surgeon will perform the first cut at delivery as part of the operating procedure).
• We can place your ECG leads on your back to aid you having skin-to-skin in theatre.
• Bringing in your own pillow from home to use on the postnatal ward.

Write your wishes down and talk to your Midwife and Obstetrician about your personalised birth plan.

When is a planned caesarean (elective) done?

A planned caesarean birth is usually done after 39 weeks. On the date your caesarean is booked, the obstetrician will discuss the risks and benefits of the procedure and ask you to sign the consent form. If you do go into labour before the date your caesarean is planned, you will need to phone the labour ward in order to come in and be reviewed.

What is enhanced recovery?

Enhanced recovery is about making sure people receive the best possible care before, during and after surgery to help them get back to full health as quickly as possible. Research has shown that the earlier a person gets out of bed and starts walking, eating and drinking after having an operation, the shorter their recovery time will be.

By taking part, you will usually be able to go home the day after your caesarean delivery. If you feel you are not comfortable with being discharged after 24 hours, please feel free to speak to one of our staff. Some women will not be suitable for this pathway due to clinical reasons. This will be discussed with you and we will also tell you as soon as possible if you are no longer suitable to participate.

Planned caesarean – what will happen?

The week prior to your caesarean birth you will be asked to attend an appointment for a pre-operative assessment in the antenatal clinic. At this appointment your bloods will be taken to check your iron levels and confirm your blood group. You will also be asked for a nasal swab to test for a bacterium called Methicillin-Resistant Staphylococcus Aureus (MRSA) and a further nose and throat swab to test for Covid-19.

You will be given capsules to take before surgery to dry up the acid in your stomach. The night before your operation, you should eat normally until 3am. You may drink clear, non-fizzy fluids (water, apple juice, black tea/coffee and non-fizzy isotonic sports drinks) up until 7am on the day of your caesarean. You should not chew gum. You will be encouraged to eat after your surgery.

Why is it important that I follow all of the above steps?

Many micro-organisms (germs) live in and on our body and are also present in our surroundings. Our skin prevents germs from entering our bodies. A surgical wound infection happens when germs enter the cut that the surgeon makes in your skin during surgery. Using the chlorhexidine cloth system will reduce the amount of bacteria on your skin which could enter the cut. This will reduce the chance of you getting a wound infection.

On arrival in hospital

Arriving at 07:30am on the day of your caesarean will allow time to meet the Midwife, Obstetrician and Anaesthetist. The Midwife will give you a hospital gown to change into, special tight stockings to wear and will remove your pubic hair. You should bring slippers and a dressing gown to wear when you walk to theatre. Your birth partner will be given theatre clothes (scrubs). You may wear glasses if you are staying awake but remove any contact lenses, piercings and jewellery. If you cannot remove your jewellery, it can be taped over. You must remove any nail varnish from fingers and toes and remember no gel nails!

There are generally two but sometimes three women on the elective theatre list. The order of the list is done in clinical risk order with higher risk women generally operated on first. You may have a long wait, depending on where you are on the theatre list.

Your anaesthetic

You will meet your Anaesthetist on the morning of the surgery, and they will discuss the type of anaesthetic that is best for you. This is usually a spinal anaesthetic, allowing you to be awake and your birth partner present during the caesarean. This is a good opportunity to ask any questions or tell the Anaesthetist about any worries you may have.

If a general anaesthetic (GA) is required, your birth partner will not be allowed into theatre with you but they can walk you down to theatre and then wait on the postnatal ward for your return in a couple of hours. Information about anaesthesia for caesarean deliveries can be found here: www.labourpains.com

You will see an Obstetrician before the surgery to go through the procedure again and confirm your consent, please feel free to ask any questions you may have.

On arrival in theatre

You may be surprised how many people are in the operating theatre. There will be a Midwife with you, an Anaesthetist and an ODP (Operating Department Practitioner).There will be two Obstetricians to perform the operation, a Scrub Nurse to assist them and a Theatre Assistant. There may also be a Paediatrician to check the baby after delivery and there may be students (with your permission).

What sort of cut will I have?

Most women will have a small cut which will be in the lower part of your abdomen. This is known as a transverse incision or ‘bikini cut’. On rare occasions, the cut may be a vertical incision.

What will happen to my baby?

The Obstetrician will lift the baby out and the Midwife will dry the baby and hand him/her to you or your partner. You will be able to cuddle your baby and take photos and have some time together. Skin-to-skin contact is recommended for all babies, regardless of feeding method and if desired, will be commenced as soon as possible after birth. After surgery has finished you will be taken into the recovery room for further monitoring accompanied by your baby. The Midwife and your baby will remain with you in the recovery area before transferring you to the ward.

After your operation

You will be able to drink water and feed your baby. After about six hours of receiving your anaesthetic, the effects should have worn off enough for you to move around. Once you can move your legs easily, the catheter can be removed, making it easier to get out of bed. Early mobilisation is a key feature of the enhanced recovery pathway and most patients will be able to walk on the day of surgery. If you feel dizzy or faint when you get out of bed, sit down again and ask for help. When you need to pass urine, please ask for a measuring jug so the volume of urine can be monitored. You will be able to eat when you begin to feel hungry.

Emergency caesarean – what will happen?

If you have an emergency caesarean you will have blood taken to check your iron levels and confirm your blood group in case you need a blood transfusion at any stage. The Obstetrician will discuss with you the procedure and will ask you to sign a consent form. The Midwife will give you an anti-acid capsule to help settle the acidity in your stomach and quickly prepare you for theatre (e.g. take your jewellery off, remove your pubic hair and get you changed into a theatre gown).

You will then be taken into theatre to have your anaesthetic which will either be a spinal anaesthetic, epidural or a general anaesthetic. If you have a spinal/epidural anaesthetic you will be awake and your birthing partner will be in theatre with you, however if you have a general anaesthetic you will be asleep and your birthing partner will not be allowed into the operating theatre. The Anaesthetist and Obstetrician will discuss with you which method of anaesthetic would be advised.

Pain relief

Good pain relief is important to help you recover quickly. You will be given a long-acting painkiller with the spinal anaesthetic and you will usually receive a suppository to relieve pain at the end of the operation.

You will need regular tablets, such as paracetamol and ibuprofen, for about a week after the operation. Stronger painkillers such as Dihydrocodeine and Oramorph are available while in hospital if you need them. These have been found to cause drowsiness, poor feeding and breathing problems in breastfed babies so they should be used at the lowest effective dose for the shortest possible duration. If your baby has any of these side effects, seek medical advice. If you are breastfeeding the baby should have a breastfeeding assessment by the Midwife before your discharge.

Discharge from hospital

You will be discharged home the day after your caesarean, if you and the team looking after you agree that you are fit and well enough to go home. You will be visited by the community Midwife on the day after discharge. Please make sure that you have paracetamol and ibuprofen at home, stored in a safe place away from children. These can be bought beforehand. You can take two paracetamol tablets (1g) four times a day and ibuprofen (400mg) three times a day. You will also be given dihydrocodeine tablets to take home.

When you first go home, you will not be fully mobile and will need someone to assist you with tasks that involve bending and heavy lifting. You will need someone to drive you home from the hospital. Please check with your car insurance company about when you can drive.

How should I look after my wound?

You will be given an antibiotic into your cannula before the surgery starts which helps to prevent wound infections. For the first 48 hours your wound will be covered by a waterproof, absorbent dressing. This will be changed by the staff in hospital or the Midwife at home if there is any leakage from the wound. We have specialist dressings and wound care products which may be used if needed. Your Midwife will advise if a wound care plan is required. After 48 hours the Midwife will remove the dressing and check your wound. It is advised to shower after your dressing has been removed.

The Midwife may choose to apply another dressing to provide protection to the wound. This dressing can remain in place for up to three days as long as there is no leakage, or additional pain and tenderness in the wound. Your wound will normally have dissolvable sutures which do not need to be removed, however you may require a stitch that will need to be removed about five days after the surgery. If the dressing has not already been removed, you should remove the dressing on the fifth day after delivery.

The following are the things you can do to help yourself:

• Always wash your hands before and after touching your wound or dressing.
• Showering is preferable to bathing.
• Do not rub soap, shower gels, or talc directly onto the healing wound.
• Pat the wound dry with a clean towel or a piece of clean kitchen roll kept just for this purpose.
• Wear loose-fitting underwear to prevent rubbing the wound.

What are the signs of infection?

• You have more pain in the wound or your womb than you have been experiencing since delivery.
• Your wound is red, swollen or hot.
• Your wound has green or yellow weeping or discharge which may be smelly.
• Your wound appears to be gaping or open.
• You have an unpleasant vaginal discharge.
• You are feeling feverish or have a high temperature.

Wound infections can be treated successfully with antibiotics. You should report any problems with your wound promptly to your Midwife or GP.

Preventing Venous Thrombosis

After surgery, you are at risk of developing blood clots in your leg veins which can travel to the lungs. Wearing tight stockings and staying mobile helps prevent this. Most women will also need a course of self-administered Dalteparin injections, a drug which prevents clot formation. Your Midwife will explain and demonstrate how to do this.

What else can I do?

• Rest when possible.
• Eat a healthy diet and drink plenty of fluids.
• Support your wound during coughing, laughing or sudden movements.

You may not be able to do some activities straight away, such as:

• Driving – please check with your insurance company.
• Exercising.
• Carrying anything heavier that your baby.
• Having sex.