Caesarean section basics

What is a caesarean section?

A caesarean section is an operation in which an obstetrician makes a cut through your belly and uterus (womb) so that your baby can be born. It's the most common major surgery that women have (Anorlu et al 2008). In Canada, about one in five pregnant women gives birth by caesarean every year, although this number varies widely between provinces (CIHI 2004) .

What's the difference between a planned and an emergency caesarean?

A planned or elective caesarean is scheduled to take place before your labour begins. While the Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends against elective C-section, it is still widely offered for a number of reasons (SOGC et al 2008).

An emergency caesarean is not planned before labour begins. It can happen if:

• You were planning a caesarean, but went into labour before the operation. Your caesarean can go ahead within a few hours of your labour starting, as long as you and your baby are well.
  
• You or your baby developed a complication during pregnancy or labour. This is more urgent and a caesarean should be done within about an hour.
  
• You or your baby had a life-threatening complication during pregnancy which meant that you needed an immediate caesarean. Your baby should be born as soon as possible, ideally within 30 minutes (Thomas et al 2001, NCCWCH 2004).
  
• Your labour has stalled, or is very slow.

Although most caesareans in Canada are unplanned, only about six per cent of these are real emergencies (Thomas et al 2001). Most unplanned caesareans give you, your partner and the maternity staff time to be prepared for the operation (Thomas et al 2001:54).

We've drawn up a birth plan to help you decide what to do if you have a caesarean section - whether you are expecting to give birth that way or not. Download and print our caesarean-birth checklist.

What will happen before my caesarean?

Your doctor or midwife should talk you through the procedure. They will:

• tell you what will happen during the caesarean section
  
• explain why they think you need the operation
  
• explain any possible risks to you and your baby (RCOG 2006)
  
• ask for your consent (RCOG 2006, NCCWCH 2004), which you have the right to refuse

Before surgery, you will need to change into a hospital gown. You'll have to take off jewellery, apart from a wedding ring, which can be taped over. If you have a retainer or false teeth, you'll need to remove these, too.

If you wear glasses, give them to your partner or a nurse, so that you can put them on to see your baby (Chippington Derrick et al 2004).

In most cases, your partner will be with you during your caesarean. He or she will have to change into hospital scrubs. These will include a mask for his nose and mouth, a hat and special footwear.

During your caesarean you'll lie on an operating table, which is tilted or wedged to the left. It's tilted so the weight of your uterus doesn't reduce the blood supply to your lungs and make your blood pressure drop.

Quite a lot of things will happen to prepare you for your caesarean:

• You'll have a blood sample taken. This is to check that your iron levels and platelets are high enough and you haven't got anemia. It's important information for your medical team, because women who have anemia can’t tolerate blood loss as well as those who haven’t.
  
• A drip will be inserted into a vein in your arm. This will give you fluids and make it easy to give you drugs later if you need them.
  
• You'll be given an anesthetic. This will usually be regional, which means it numbs your bottom half, via a spinal or epidural. It's safer for you and your baby than a general anesthetic, which puts you to sleep.
  
• A thin tube, or catheter, will be inserted into your bladder via your urethra. This will make sure your bladder is empty. It can be put in after the painkiller is working so that you don't feel it.
  
• The area where the cut will be made will be shaved and cleaned with antiseptic (Hadiati et al 2008), although some hospitals have stopped doing this.
  
• You'll have a cuff put on your arm to monitor your blood pressure.
  
• Electrodes will be put on your chest to monitor your heart rate. You may have a finger-pulse monitor attached, too.
  
• A sticky plastic plate will be attached to your leg. This is the ground for the electrical equipment used by your obstetrician to stop bleeding during the surgery. Don't worry, the plate won't affect you (Chippington Derrick et al 2004, NCCWCH 2004).

You'll be offered:

• an injection of antibiotics to ward off infection
  
• anti-sickness medicine to stop you from vomiting
  
• strong pain relief during and just after the caesarean
  
• pain relief for lasting soreness (NCCWCH 2004)
• oxygen through a mask, if your baby is in distress

You may be surprised how many people are needed to do a caesarean section.

What happens during my caesarean?

A screen is put up over your chest so that you can't see the operation. But you can ask for this to be lowered as your baby is born. Your anesthesiologist will check that your painkiller is working properly.

Once you're numb, your doctor will make a straight cut, called a bikini cut, into the skin of your belly. It is usually two fingers’ width above your pubic bone, at the top of your pubic hair.

This sort of cut is less painful after the operation and looks better as it heals than a cut down the middle of your belly (NCCWCH 2004). Layers of tissue and muscle are opened to reach your uterus. Your stomach muscles are parted, rather than cut. Your bladder will be moved down to expose the lower part of your uterus.

The cut to your uterus is usually small. Your doctor will make it bigger using scissors or fingers, so that it is torn. This causes less bleeding than a sharp cut (NCCWCH 2004). The opening to your uterus is usually in the lower part. This is why the operation is sometimes called a lower segment caesarean section (LSCS).

If you have a lot of fluid, you may hear and sense it whoosh out through the opening. Your obstetrician will lift out your baby. You may be aware of the assistant pressing on your belly to help your baby be born. This may be uncomfortable. If your baby is breech, he will be born bottom first.

This all happens quickly. It's possible that only five or 10 minutes after arriving in the operating room you will be able to meet your baby.

If you're having twins the lower twin is born first, just as if you'd given birth vaginally. Sometimes, forceps or vacuum are used to bring out your baby's head carefully (NCCWCH 2004). They are usually only needed when your baby is in a breech position or is premature (RCOG 2006, NCCWCH 2004).

Surgeons may make a larger, vertical cut in your uterus if:

• your baby is very premature, or is lying across your uterus (Alderdice et al 2003)
• you have a condition such as a low-lying placenta or growths, known as fibroids

What will happen after my baby is born?

Your baby may be placed on your chest for you to cuddle, or he may need to be checked by a midwife or pediatrician. Your partner can usually hold your baby if you are unable to. If you're having twins, you may be cuddling one baby each sooner than you expected! Babies born by caesarean tend to be a little colder than babies born vaginally, so they need wrapping up well (NCCWCH 2004). Also, babies born by C-section do not clear their lungs as well as babies born vaginally and may sometimes need extra oxygen.

Your baby will be given an Apgar score one minute and five minutes after he's born. The score measures your baby’s wellbeing.

If there has been concern about your baby's health, a pediatrician will do the checks. Some babies need oxygen (NCCWCH 2004:74) or to go to newborn intensive care unit for a while.

You'll be given the synthetic hormone pitocin (replacing natural oxytocin) via a drip. This will help your uterus contract and reduce blood loss (NCCWCH 2004). Your doctor will gently tug the umbilical cord to pull out the placenta. This will be checked to make sure it is complete before you're stitched up.

You'll be in the operating room for up to an hour. This is because it takes much longer to close you up than to open you up (Chippington Derrick et al 2004). The process may take longer if you have had one or more caesareans. It depends on how many bands of scar tissue (adhesions) you have from previous operations (Chippington Derrick et al 2004).

Your doctor will probably use a double layer of stitches to repair your uterus. The cut in your belly will be closed in layers. Finally, your skin wound will be closed with stitches or staples (NCCWCH 2004:67). When you're ready, you'll be moved into the recovery room where you, your partner and, if all is well, your baby or babies can be together.

You may start shivering, because your body temperature drops during the operation (RCOA 2006). The anesthetic affects your body's ability to regulate your temperature, and operating rooms are often kept cool. The shivering can be unnerving, but is usually harmless and only lasts about half an hour. The nurse looking after you will warm you up with blankets and fluids.

If you want to breastfeed, it's a good idea to try while you're still in the recovery room. Your midwife or nurse will help you get comfortable for breastfeeding and to take care of you straight after the operation (NCCWCH 2004).