Elective Caesarean Section

There are many reasons to have a planned Caesarean section prior to labour, for example, low lying placenta, breech presentation, previous Caesarean section. In some conditions affecting mother and / or baby that necessitate delivery, Caesarean section may be a safer option than induction of labour. Some women will prefer Caesarean section due to their concerns about labour, having an emergency delivery or damage to the pelvic floor.

Prior to Caesarean

There must be no food eaten for 6 hours prior to an Elective Caesarean section. Water may be drunk until 2 hours prior to the procedure. It is necessary to arrive at the hospital 2 hours prior to the procedure time. Waiting will occur in the same room in the ward which will be used for the postpartum stay. A theatre gown will be provided to change into. Blood will be collected to check Blood Count and Blood Group. Approximately 15 minutes prior to theatre time, transfer to a waiting area outside Theatre will occur. Meeting the Anaesthetist and the Midwife who will be looking after baby will occur here.

In Theatre

During the procedure there will be several personnel in theatre including the scrub nurse, scout nurse, obstetrician, surgical assistant, anaesthetist, technician assisting the anaesthetist, paediatrician, midwife assisting the paediatrician and a wardsperson to help with positioning on the theatre bed and transfer to Recovery afterwards.

After walking into theatre to the theatre bed, the Anaesthetist will insert a cannula in a wrist vein and start intravenous fluids. Most Elective Caesarean Sections are performed under a Spinal Block. This is similar to an Epidural but the local anaesthetic and narcotic mixture is injected into the spinal fluid so that the block works more quickly and wears off more quickly. Most Anaesthetists insert the Spinal Block in the sitting up position with feet over the side of the bed resting on a chair. Some Anaesthetists will perform the Spinal Block in the lying on one side position. While the Spinal Block is being inserted there may be some discomfort for a few minutes as curling around the abdomen and pushing the back out is required.

Once the Spinal Block has been performed and after lying down on the theatre bed, a catheter will be inserted into your bladder to drain urine. The catheter is necessary as the sensation of the bladder filling will be lost and the catheter will keep the bladder empty and out of the way during the procedure. Catheter insertion should not be painful as the block will already cover this area. The block will rise to cover the abdominal area and the level can be checked with ice. If the ice does not feel cold, then the nerves that feel cold and pain are successfully blocked. Although there is no feeling of  pain, there will still be an awareness of touch and movement.

When the spinal block is sufficient, the abdominal area will be painted with an antiseptic solution and drapes put up around the surgical field. The block is tested one last time by pinching the skin of the abdomen to ensure that it is working.

Procedure

The quickest part of the procedure is getting baby out. It is usually less than 5 minutes from the time of draping to baby being delivered. The drapes will be lowered so baby can be seen immediately after birth. The Anaesthetic Technician who is assisting the Anaesthetist can take photos of baby at birth. The cord is cut and baby is taken over to the Paediatrician to be checked. At this point the support person can go over to the baby and trim the cord. Once baby has been checked, baby will be brought back and can be held for the rest of the operation.

It takes about half an hour to repair all the layers. There are seven potential layers and most Obstetricians will repair five. The peritoneal and fat layers will repair by themselves without suturing. Just prior to the closure of the skin, baby and the support person will go to Recovery. A dressing will be placed over the wound and the abdomen and legs are wiped clean, prior to joining them in Recovery.

The time away from the room in the ward will be approximately 2 hours (15-minute wait prior to Theatre, in Theatre for 1 hour, in Recovery for 30 minutes plus transfer time).

Caesarean Complications

Infection

With any operation there is a risk of infection. A dose of antibiotics will be given at the beginning of the procedure and this reduces the chance of infection to less than 5%. If there are any signs of infection such as a fever or a red wound while in hospital, then more antibiotics may be prescribed. Infection more commonly shows up a few weeks after the procedure. If there is high fever, heavy bleeding, abdominal pain, offensive discharge or persistent bleeding, then there may be an infection inside the uterus. The wound could get red or lumpy or painful which could be a wound infection. There could be symptoms of bladder infection or mastitis with an infection in the breasts. After going home, most of these infections are treated with oral antibiotics. Occasionally infection may require re-admission to hospital for intravenous antibiotics.

Bleeding

There is a small risk of bleeding with the Caesarean procedure but the risk of having a blood transfusion is around 2%. Blood collected prior to the surgery can help to estimate the total blood loss and be used to crossmatch blood for transfusion if needed.

If there is excessive bleeding it may be necessary to give extra medication to encourage the uterus to contract. It may be necessary to tie off blood vessels on the side of the uterus or put a large stitch around the uterus to decrease the bleeding. Similar to the catheter in the bladder it may be necessary to leave a Bakri Catheter inside the uterus. This is a balloon that can be filled with water to compress the inside of the uterus and stop bleeding from the placental bed. It is usually left in place for 24 hours then the fluid inside the balloon is sucked out and the tubing is withdrawn out of the uterus and out of the vagina to be removed. If excessive bleeding persists, there is a rare chance of needing a hysterectomy (removal of the uterus). This would only be done as a last resort at the time of Caesarean, as a life-saving measure.

Scarring

There will be a scar on the skin and on the uterus. The skin incision is usually made in the horizontal crease of the pubic area and approximately 12cm in length. Rarely, a vertical skin incision may be required. Skin closure is usually accomplished with sutures placed under the skin. Some sutures are dissolvable but some may need removal at Day 5 after the procedure. A dressing is placed over the wound.

The scar on the uterus may be a consideration for future deliveries.

Further surgery

Other complications are rarer. As the uterus is close to the bowel, bladder and ureters,  there is a risk of damage to these structures. The risk of further surgery is about 1 in 10,000 either at the time of the procedure or shortly after.

Clots in legs and lungs

Caesarean Section is associated with a risk of clotting in the leg and pelvic veins and clots travelling to the lungs.

Compression stockings and injections of the blood thinning medication Clexane reduce the risk.

Postpartum in the ward

On returning to the ward from Recovery there will be intravenous fluid running and an indwelling catheter. There may be a Bakri Catheter within the uterus and a surgical drain within the abdominal cavity.

Once eating and drinking resume with no nausea or vomiting, the fluids can be ceased. Around 18-24 hours after the Caesarean section the catheter will be removed. Bakri Catheters and surgical drains are removed around this time. The bladder should be emptied within 4 hours after the catheter is removed. After voiding, a bladder scanner will be used to check that the bladder has emptied successfully. There is a small chance that if the bladder is not able to be emptied, then the catheter may need to be reinserted.

The IV cannula can be removed after voiding successfully providing there is no fever, no excess bleeding, and there is good oral intake.

Postpartum at Home

After going home from hospital, it should be possible to mobilise normally. It may still be uncomfortable moving in and out of bed or in and out of a car. The scar in the sheath under the abdominal muscles will be weak so it is best to avoid heavy lifting or over exertion in the first six weeks.

Simple analgesia such as paracetamol and ibuprofen will help with any discomfort. Initially, oral narcotic tablets may also be needed. It is usually acceptable to drive two weeks after a Caesarean section provided that the legs can be moved easily without pain and narcotic tablets are no longer being used.