03 Aug 2010

Coming out through the sunroof – Caesarean childbirth

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For those women planning on having a caesarean, the prospect of delivering your baby in the unfamiliar setting of an operating theatre can seem quite daunting.

Therefore it’s important to have some understanding of what goes on before, during and after a caesarean.  This also applies to women counting on a vaginal delivery, because although I aim to satisfy your wishes with regard to birth options, sometimes certain unforeseeable circumstances (such as fetal distress during labour) mean that the safest option is to head to the operating theatre for an unexpected caesarean.

Before the caesarean – and what the hell is an anaesthetist?

For an elective caesarean – i.e. planned in advance, as opposed to an emergency caesarean – you will be ‘nil by mouth’ for at least six hours before the procedure: that means no food or drink (not even water).  This is to prevent you from being sick during the operation.

With a couple of brief exceptions your partner will be with you all throughout the caesarean process. He or she can and should bring a camera to record the whole event.

Before you go to the operating theatres, you’ll put on a rather unflattering hospital gown and you’ll both meet your anaesthetic specialist. Your anaesthetist has a number of important roles and is a critical member of the team looking after you. His or her primary role is – obviously – making sure that you feel no pain during your caesarean operation. The anaesthetist also carefully monitors your physiological parameters (pulse, blood pressure and oxygen delivery to your tissues) and gives the very small number of medications that you require during your caesarean. In addition the anaesthetist organises and monitors your pain relief after your operation. Finally the anaesthetist assists me in managing any complications of your caesarean.

With remarkably few exceptions your anaesthetic will be a regional block (an epidural or a combined spinal / epidural (CSE)) so you will be awake throughout the birth of your baby. Your level of consciousness will not be altered so you will be completely aware of everything going on during the birth of your baby. Regional blocks are much safer for the mother than general anaesthesia plus they help significantly with pain relief and recovery after the operation.

Regional blocks have a couple of downsides however. Firstly they block your ability to pass urine so you will have a catheter inserted into your bladder before your operation (mercifully this is inserted after your anaesthetic is working). The second downside of regional blocks is that they affect your ability to move your legs during and after your operation. It takes a good four to six hours for this effect to wear off after the birth. It is worth noting too that regional blocks do not mean that you will feel NOTHING during the birth. It is usual to feel movement and stretching and pulling during the birth. Remember though that the great benefit of is that this type of anaesthetic is that it allows you to be awake during the whole procedure and be the first to meet your new arrival.

So once you get to the operating theatres the steps are as follows:

• A drip is inserted into a vein in your arm
• A blood pressure cuff is put on your upper arm and some cardiovascular monitoring leads are placed on your chest and one of your fingers
• Your anaesthetic is inserted with you either lying on your side or sitting up and leaning forward
• Your baby’s heartbeat is checked
• Your urinary catheter is inserted and
• If necessary the top 2 to 3 cm of your pubic hair is shaved (although if possible I recommend a “caesarean wax” prior to your caesarean if you know you are having one).

During the caesarean

Once the anaesthetic has started to work, you’ll be transferred onto the operating table. You might be surprised by the number of people in the theatre:

• Of course I will be there and I will have another doctor assisting me
• The anaesthetist will have an anaesthetic nurse assisting him or her
• There will be a scrub nurse and a circulating nurse
• A midwife will be present to handle, check and wrap your baby
• Usually a specialist paediatrician will be there although with completely straightforward caesareans at term we often just ask the paediatrician to check on your baby after the birth.

In straightforward situations I like to have some music playing throughout your caesarean although not all of my patients (or colleagues for that matter) appreciate my taste in music!

Once we are ready to start my assistant or I will give your abdomen a good clean with disinfectant, and we’ll lay sterile drapes over you.  We’ll also put a sheet up between your head and your tummy so that you and your partner don’t see any of the action.  Before we make any incisions, we always double-check that the anaesthetic is effective by pinching your abdomen and making sure it doesn’t hurt.  Once that’s shown to be the case, we proceed to make a horizontal incision of about 12-14cm in the skin of your lower abdomen (just below the ‘bikini line’). Very very rarely we need to perform an “up and down” incision in your abdomen but if this is necessary we will have discussed it before your operation. The procedure involves working our way through the layers of the abdomen until we get to the uterus. Contrary to popular belief we do NOT cut through the muscles of your abdomen (your “six pack”). We push the bladder down off the lower uterus and then make a cut in the lower part of the uterus. The cut in your uterus mimics that in your skin in that it is a low transverse (side to side) incision. Very rarely we need to do an up and down incision in your uterus (this makes your operation a “classical” caesarean) although we will discuss this possibility and its implications before doing so. Within about five minutes of the initial incision, your baby is welcomed to the outside world.  I ask you to give a push to help your baby out and the assistant will push on your upper abdomen to assist the birth. Sometimes I need to deliver your baby’s head with the gentle use of the obstetric forceps. This is usually because the baby’s head is relatively high in your abdomen. This is not the same as using forceps to deliver babies vaginally. The anaesthetist will immediately give you a shot of oxytocin to help the placenta detach and make the uterus contract to prevent bleeding. After delivering the placenta we get on and suture all the layers we cut through to get your baby out. This process takes about thirty minutes. I usually close the skin with a continuous suture that is easily (and painlessly) removed on the day you go home from hospital. Once the surgical dressing is over the wound I just check the vagina for bleeding and insert some pain relief suppositories (voltaren and paracetamol) into your bottom.

In the meantime your baby is very quickly checked and brought to you. I encourage skin to skin contact so you and your partner get to spend quality time with your baby while I’m closing the incision. In very rare instances your baby (or babies) may need to go to the baby unit for care but even under these circumstances there is usually time for a cuddle before your baby leaves the theatre.

Although giving birth in the operating theatre is quite different to doing so in the delivery suite, it really is a friendly environment in which you’ll be able to cuddle and bond with your baby.

Immediately after the caesarean

Once the operation is over, you will be taken to the theatre recovery area for about half an hour or so. Unfortunately – and I am very unhappy about this – most hospitals do not allow your baby to come to recovery with you. So usually your baby goes up to the ward with your partner and you join them a short time afterwards. While you are in recovery the following parameters are carefully checked:

• The usuals – temperature, pulse, blood pressure, urine output and oxygen delivery
• Your skin incision, epidural site and vaginal bleeding
• Your pain levels and need for pain relief, and
• Your regional block.

Once all of these parameters are normal you will join the rest of your family on the ward. It takes about four to six hours for your regional block to wear off so that you can feel and move your legs normally. It takes a little longer for bladder sensation to return so we usually re move your urinary catheter the morning after your caesarean. Similarly we remove your drip the next morning so you are unencumbered the morning after your caesarean. There is quite a lot of variation as to when your epidural is removed after your caesarean, reflecting different anaesthetic opinions and practices. Some anaesthetists remove your epidural in theatre immediately after your caesarean while others leave it in for between one and three days. The reason epidurals are left in is that they are a good way of delivering effective pain relief without systemic side effects or impairment of mobility. If we put pethidine down your epidural it just works on your nerves giving good pain relief without the side effects of systematic narcotics (drowsiness, nausea, vomiting, poor gut function, constipation, impaired respiration and poor mobility).

As good as epidurals are you will need other forms of pain relief to make sure that you are comfortable after your operation. In almost all cases you will only need tablets (as opposed to injections). The tablets we use for pain relief after caesarean includes:

• Paracetamol
• Voltaren (a non steroidal anti inflammatory agent)
• Di Gesic (a mixture of paracetamol and a mild narcotic)
• Narcotics such as tramadol and oxycodone.

So by 8 (best case) to 24 (worst case) hours after your caesarean you will be:

• Up and around and moving independently
• Eating and drinking normally
• Going to the toilet normally
• Not attached to anything other than (in some cases) an epidural
• Wearing your normal clothes or pyjamas
• Taking tablets for pain relief

Vaginal bleeding is normal after caesarean just as it is with vaginal birth – in fact the bleeding relates to your placental blood vessels slowly diminishing in size and is not influenced by how you gave birth.

Typically you’ll remain in hospital for five to six days after the caesarean and I’ll visit you at least once every day to make sure your recovery is going smoothly.  Like all mothers (especially first timers) your hospital stay is dominated by getting to know your baby and getting used to breastfeeding rather than how you gave birth.

Going Home

Going home having had a caesarean can be quite daunting, not least because your still very much in the early stages of you and your baby getting used to each other and establishing feeding. From a physical point of view though most women return to normal activities quite rapidly. I place some restrictions on what you can do for the two weeks after you have given birth by caesarean  (remembering of course that the first five or six days of this interval are spent in hospital). I advise against strenuous exercise and driving, as well as any heavy lifting – though lifting your baby in his or her capsule is okay – as these things can interfere with wound healing. After two weeks (in the absence of problems) you can return to aerobic exercise, swimming and driving although you need to take it easy and listen to your body. If you go for a swim just insert a tampon immediately before entering the water and remove it on getting out. After six weeks you will be able to resume all activities including heavy lifting.

You will need to take your pain relief tablets for a week or so after you go home and I will make sure you have a prescription for these medications when you leave hospital.

As with all births you will bleed for up to six weeks after the birth. The blood loss is initially like a period and then it becomes progressively less heavy and it changes colour to a dark or pink colour. Changing pads (don’t use tampons except when you go for a swim) approximately four times a day is about normal.

The thing that got you into this mess in the first place – sex

It is comparatively unusual to resume sexual activity until around six weeks after the birth. This interval usually has nothing to do with how you gave birth but is predominantly a result of being completely exhausted by your new baby. From my perspective you can resume this activity once your bleeding has settled.

Some women who have had caesareans are dismayed to find sex uncomfortable after having a caesarean. This discomfort has nothing to do with how you gave birth – it reflects the low blood oestrogen levels associated with breastfeeding. I can prescribe you some local oestrogen cream to help with this problem if it occurs.

Complications of caesareans

While caesareans are usually very straightforward and without complication it is important to remember the operation is major surgery and it is not without risk. Then again you must realise that planning to give birth naturally is not without potential risk and that the risks of an elective planned caesarean are almost certainly lower than those if an emergency caesarean. The risks of a caesarean are:

• Bleeding. On average women lose more blood at caesarean section (500 – 600 ml) when compared to natural birth (200 – 300 ml). However the incidence (or likelihood) of significant bleeding causing clinical concern and / or a blood transfusion is similar with both modes of birth – around 2%. Significant bleeding is more likely at emergency caesareans and at those performed for placenta praevia (where the placenta located in the lower part of the womb. I usually organise for a sample of your blood to sit in the blood bank ready for cross matching just in case you might need a transfusion. Taking iron tablets or your pregnancy multivitamin after your caesarean will help you to recover from the birth.

• Infection. Approximately 2% of women who undergo a caesarean will suffer an infection in either the womb or the caesarean incision afterwards. Again this complication is more common after emergency caesareans as opposed to elective caesareans. We give you intravenous antibiotics during your operation to prevent postoperative infection although this approach is not always effective.

• Damage to other organs. With a caesarean it is possible to damage your bowel, ovaries, uterus, bladder or the tubes that connect your kidneys to your bladder (your ureters). With straightforward first caesareans these complications are extremely rare. They are more common when women have had previous operations (including caesareans) or at emergency caesareans, particularly those conducted late in labour. The most important issue with injuries occurring at caesarean is that they are recognised and repaired effectively.

• Numbness above the scar. Sometimes when we make the caesarean cut we also cut the superficial nerves that run through your skin. This can cause numbness around – but usually above – your incision. While this numbness improves with time some women have a small amount of numbness permanently.

• Breathing problems for the Baby. While I hold the view that caesarean is ultimately safer for the baby than natural childbirth (albeit by an extremely small margin) there are definitely more breathing problems for babies after elective caesarean than after natural childbirth or even an emergency caesarean (where the baby has been exposed to contractions of the uterus). This is because:

Contractions help to squeeze fluid out of the baby’s lungs in order to prepare it for breathing air (as opposed to fluid), and If the baby can initiate the birthing process it usually does so once its lungs are mature.

While never fatal babies suffering these lung problems can be very unwell and require admission to the Neonatal Intensive Care Unit and – rarely – breathing assistance with a ventilator.  More commonly a baby can require simple observation in the baby unit just while it clears the fluid out of its lungs. The risk of significant breathing problems at 37, 38 and 39 weeks gestation is 5%, 2% and 1% respectively. This is why we try to perform elective caesareans at around 39 weeks rather than 37 or 38 weeks. If I have to perform an elective caesarean before 38 weeks gestation (for example if I’m concerned about the condition of you or your baby) I discuss giving you steroid (not Ben Johnson steroids) injections to help mature the baby’s lungs.

• Damage to the Baby. Very rarely the baby can be cut (usually on the cheek or – if the baby is breech – the bottom). I go to great trouble to avoid this complication but it has still occurred very rarely. Very occasionally a baby can receive forceps marks to its head when I use these instruments at caesarean. These usually resolve rapidly.

• Blood Clots. If you have a caesarean you are more likely to develop a blood clot in your leg (a Deep Vein Thrombosis or DVT) than if you give birth normally. The problem with DVTs is that they can travel to your lungs and become a Pulmonary Embolus or PE. Very rarely (1 to 2 women in every 100,000 having a caesarean or fewer) a PE can be fatal. We do a great many things to prevent DVTs and PEs, including:

• Giving you a lot of intravenous fluid during your operation in order to keep your blood relatively thin. This is why your ankles swell after your caesarean – it takes a little while for you to turn that fluid into urine and pee it out.

• Having a regional block greatly reduces your risk of a DVT compared to a general anaesthetic. This is because even though you cannot feel or move your legs the muscles are still active and help blood to circulate.

• We organise for you to wear anti embolism stockings during your caesarean. These aid the movement of blood during your operation.

• While you are having your caesarean we place calf compressors on your legs (you do not feel them) to assist blood flow and help to prevent clots.

• Your pain relief “cocktail” includes voltaren. Voltaren thins the blood slightly and helps to prevent blood from clotting.

• We get you out of bed early the morning after your caesarean. This early mobilisation prevents blood clots from forming in your legs (it also assists with preventing breathing problems after your caesarean).

• In women other than those at very low risk of clots I give you a medicine called Clexane after your caesarean to prevent clots. Clexane is a variation of heparin – a blood thinning agent. Clexane is given by daily injections under your skin while you are in hospital after your caesarean.

Long Term Consequences of Caesareans

While I don’t want to belittle the immediate recovery from and risks of caesareans, it is probably more important to consider the longer term complications of caesareans. These are:

• Vaginal Birth after Caesarean or VBAC. This is the topic of another information sheet but in essence these days most (definitely not all) women who have a caesarean have their subsequent children by caesareans. The reasons for this are complex but in essence there is a small (about 1 in 600) risk of a baby suffering a significant brain injury during a VBAC, usually because of the scar on the uterus rupturing in labour. Now VBAC is definitely an option for women and I am happy to look after VBAC labours although most women who give birth by caesarean do so by caesarean again. If you do wish to have a VBAC it would be a good idea to delay your next pregnancy so that there is more than two years between the births because this interval (or longer) is associated with a lower risk of your uterus rupturing in labour than an interval of less than two years.

• Reduced fertility in future pregnancies. Some studies have suggested there is reduced fertility after caesareans. The reasons for this are not clear but alterations in blood flow within the pelvis after caesarean have been one possible suggestion. A major reason is couples simply choosing not to have another child after caesarean, or voluntary infertility. This usually occurs when a couple goes through a long, difficult, painful labour that ends in a caesarean. They can be so traumatised by the experience that they simply decide not to go through a similar experience again.

• Stillbirths. Studies conflict as to whether there is an increased risk of stillbirth in pregnancies after caesareans. If this association exists at all it is likely due to the fact that women who undergo caesareans ultimately are medically and obstetrically more complex – and hence are at higher risk of stillbirth – than those who give birth normally.

• Placenta Praevia. This is where the placenta implants in the lower part of the uterus causing increased bleeding at caesarean childbirth. For some reason placentas have a slight preference for attaching to the scar on the uterus (which of course is very low in the uterus, hence placenta praevia). The risk of placenta praevia occurring in a woman’s first pregnancy is around 3 per 1,000 pregnancies. With one previous caesarean the risk is around 5 per 1,000 pregnancies. However if the placenta implants into the scar there is a risk it may burrow abnormally far into the scar and the wall of the uterus causing a condition called placenta accreta. If this condition occurs the placenta is difficult to remove at caesarean and significant bleeding can occur, necessitating an emergency hysterectomy (removal of the womb) to stop the bleeding. Placenta accreta is identified before the birth and appropriate precautions are taken to ensure maternal safety.

• Hysterectomy (removal of the womb). The chances of a hysterectomy being necessary at the time of a first birth – either normally or by caesarean – are extremely remote. However the chances do increase with the number of subsequent caesareans. If a woman has had one previous caesarean her risk of having a hysterectomy is considerably less than 1 in 1,000. However with two previous caesareans that risk rises to somewhere between 1 in 300 and 1 in 400. These hysterectomies are usually – but not always – performed because of placenta praevia and accreta where the placenta has implanted into the scar on the uterus.

• Accordingly caesareans are generally best avoided – if possible – in women planning families of 3 or more children. This includes young women because it is very hard to predict your own child bearing future (remembering that some of us have two families in our reproductive lifetime). On the other hand a woman planning to have one or two children can reasonably expect not to run into significant complications should she choose to have her children by caesarean. Pragmatically this group includes women who have their first baby at 40 or more years of age.

Advantages of Caesareans

In the interests of balance it is worth pointing out that not everything about caesarean childbirth – particularly elective caesareans – is negative. There are some advantages to giving birth by caesarean although I would not argue that a caesarean is better than a completely natural birth.

Advantages for the baby. Unfortunately with even the best care in the world labour and childbirth is associated with a small risk of the baby suffering a hypoxic (“lack of oxygen”) brain injury or physical trauma (usually some form of brain bleeding or nerve damage). Because we tend to monitor labour closely and have a comparatively low threshold for intervention in labour these types of injuries are much less frequent than they used to be, although somewhere around three babies out of every thousand will suffer such an injury. Approximately one of these three will die before birth (i.e. during labour), one will die after birth and one will survive but suffer ongoing problems. To all intents and purposes elective caesarean childbirth eliminates this – admittedly small – risk.

Advantages for the mother – with respect to vaginal birth. Approximately two percent of women giving birth vaginally suffer a tear of their anal sphincter during the process. If this is recognised and sutured correctly there should be no complications although such injuries carry a small risk of ongoing anal problems. Caesarean childbirth eliminates the risk of anal injuries during childbirth. While caesareans do not eliminate the risk of vaginal prolapse or urinary incontinence (because pregnancy per se causes these problems) elective caesarean reduces the likelihood of these ongoing problems by approximately one third.

Advantages for the mother – avoiding emergency intervention. Approximately 15 – 20 percent of women having their first baby will require an emergency caesarean in labour and a further 10ish percent will require a forceps or ventouse birth. While the vast majority of these emergency procedures are straightforward and without complication we would have to accept that these events have risks and the maternal risks of an emergency caesarean (especially if it is performed late in labour) are greater than those of one performed as an elective procedure

Caesarean Myths Busted!

There are a number of caesarean myths out there and of course everyone is an expert. However I can bust a few caesarean myths for you.

• The recovery is awful. I have described the recovery from caesarean section in detail above. It certainly is not the same as a straightforward natural birth but it is not necessarily worse than for women who have a complicated vaginal birth (such as a forceps birth) and recovery from elective (i.e. planned) caesareans is almost certainly less complicated than for emergency caesareans. Most of my patients are surprised by how comfortable they feel after a caesarean and how rapidly they return to normal activities.

• A caesarean will prevent incontinence. Sorry. It won’t. Approximately 10% of women who never have a baby will suffer from urinary incontinence in their lifetimes. About 20% of those who give birth exclusively by caesarean (i.e. have no natural births) will suffer incontinence and around 30% of those who give birth naturally will suffer incontinence. Accordingly there is something about being a woman and being pregnant that causes incontinence regardless of how you give birth. That said caesarean childbirth exerts a modest protective effect against urinary incontinence. Approximately 2 to 4 percent of women who give birth vaginally suffer a tear to their anal sphincter and a small proportion of these women will have ongoing problems. Caesareans prevent such injuries.

• Caesareans are better for your sex life. Not so. Sexual satisfaction after childbirth is not influenced by how you gave birth.

• Caesareans are associated with a higher likelihood of you developing Post Natal Depression (PND). Again this is not true. Good quality scientific evidence demonstrates that the manner in which a woman gives birth has no bearing on her risk of developing PND.

• Having a caesarean reduces your chance of successfully breastfeeding. No, it doesn’t.

• Having a caesarean makes you a worse mother. Bollocks.

Follow Up After Caesarean

I like to organise follow-up appointments in my rooms two weeks and six weeks after the birth to check there are no complications and that your wound is healing nicely.

Warning Signs of Problems

There are some things that can occur after a caesarean that might suggest that a complication is occurring. Please contact me immediately on my cell phone if any of the following symptoms occur:

• A fever
• Redness or excessive pain around your wound
• Any discharge from your wound
• A significant increase in your vaginal bleeding (remembering that the bleeding normally tends to wax and wane a little)
• An offensive vaginal discharge
• Any leg pain, redness or swelling and
• Any chest pain or shortness of breath.

Costs of Caesareans

The way I charge you reflects the complexity of your pregnancy and birth, not the manner in which you give birth. This approach reflects Medicare’s view and the item numbers allocated to childbirth (see my schedule of fees). So for example I charge less for an elective straightforward caesarean than I do for a complicated labour and vaginal birth.

Obviously your anaesthetist will bill you for your anaesthetic and again the complexity of the situation, the time involved and the time of day (or night) influence anaesthetic billing.

If you have a caesarean section in Australia we require another doctor to assist me by holding retractors and cutting sutures etc. This is compulsory and not avoidable and indeed if complications arise during your caesarean I am always grateful for assistance. If you have your caesarean at the Royal Hospital for Women we use the junior medical staff already employed in that institution to help and they cannot bill you for assisting at your caesarean. If you have a caesarean at Prince of Wales Private Hospital we have to contract a doctor who is a professional surgical assistant to help. This doctor will bill you directly for his or her services. Your health fund will refund approximately $200 of this fee.

If you have any questions or concerns about caesarean delivery, I would be happy to address them with you at your next visit.

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