Caesarean birth
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Caesarean birth (caesarean section) This leaflet considers the reasons why it may sometimes be best for your baby to be born by caesarean birth. It provides information regarding the risks of having this type of birth for both mother and baby. This information should help you to understand the reasons for a caesarean birth and help you to make the right choices in the unlikely event that this is needed. Currently at Southmead Hospital Bristol about 1 in 5 women have a caesarean to deliver their baby. This rate for Caesarean births is the same as most other units in the country1.
What is a caesarean birth? A caesarean birth is an operation that requires a cut to be made in your lower abdomen and uterus (womb) to deliver your baby. The medical term for a caesarean birth is caesarean section. Caesarean births are either planned in advance – an elective caesarean birth, or become necessary as a result of a problem occurring during your pregnancy or labour – an emergency caesarean birth. There are many reasons why a caesarean birth may be planned and these include: nn Previous caesarean birth: If you have had a caesarean birth in the past, your obstetrician (birth specialist) will discuss with you options for delivery during this pregnancy. A planned caesarean may have been arranged or you may wish to aim for a normal labour and vaginal birth. Indeed, between 6 and 8 out of 10 women who have had one previous caesarean birth, go into labour in their next pregnancy and achieve a vaginal birth2. nn Breech presentation: If your baby is lying in a breech position with its bottom and/or feet pointing downwards in your uterus at term, research has shown that it is safer for your baby to be born by a caesarean birth3. It may be 2
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appropriate for your obstetrician to suggest attempting to turn your baby into the head down position (External Cephalic Version) to avoid having a caesarean birth, but if this is unsuccessful or you decide not to have this done, then a caesarean birth would be recommended. nn Placenta praevia or low lying placenta (afterbirth): Although it is common for your placenta to be situated in the lower part of your uterus (womb) at your 20 week anomaly scan, it is rare for it still to be low by the time your baby is due to be born. If this is the case, and your placenta is covering the opening of the cervix (neck of your womb) then a vaginal birth would not be possible. nn Twins/multiple births: If you are expecting more than one baby you may be offered a caesarean birth but each case is different and not all twins need to be born by caesarean. nn Very large baby: Occasionally for some very large babies, you may be offered a caesarean birth. This is more common in mothers with diabetes. nn Problems with your previous vaginal birth: There may have been problems with your previous vaginal birth, which may reoccur, in subsequent births. If you previously had a vaginal birth but had difficulty delivering your baby’s shoulders (shoulder dystocia) or sustained a perineal tear (skin and muscle between vagina and rectum) that extended down to your rectum (back passage), it is important that you discuss with your obstetrician options for delivery this time. nn Medical conditions in the mother: There are a few medical conditions where it may be safer for a woman to have a caesarean birth rather than go into labour and/or have a vaginal birth. If you have a medical condition, your obstetrician will advise you on the best options for delivery.
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nn Request by a mother: If you have no medical conditions or problems with your pregnancy or labour that might indicate that a caesarean birth is necessary, but think you might prefer to have a caesarean birth rather than a vaginal birth, this needs to be discussed with your midwife and obstetrician. As a caesarean birth is a major operation associated with more complications then a vaginal birth, maternal request is not an indication on its own for a caesarean birth. Therefore it is important that all your reasons for this request are discussed.
What are the risks of having a caesarean birth? Despite caesarean birth being much safer these days it is still a ‘major’ operation. A caesarean birth is considered major abdominal surgery and, as with other operations, there are risks involved. The risk of a woman dying after a caesarean birth is less than 1 in 2,500 (the risk of death after a vaginal birth is less than 1 in 10,000)1. The need for further surgery, such as a hysterectomy (removal of the womb) occurs more frequently after a caesarean birth, about 5 per 10,000, compared to a vaginal birth (about 1 in 10,000)1. nn Infection: As with any operation there is a risk of an infection developing. After a caesarean, common infections include urinary tract infections, (urine/water infection - 1 in 100) and wound infections around your scar (6 in 100). Occasionally you may develop an infection in your womb (endometritis 8 in 100) or bruising deep inside your tummy (haematoma). Antibiotics are given during your Caesarean birth to reduce the chance of these infections. nn Blood loss: The amount of blood loss during a caesarean birth is about twice as much as with vaginal birth. Most women who have a caesarean birth are given iron tablets after the operation, but some women will need a blood transfusion. Major blood loss (post partum haemorrhage) is a rare but serious complication of childbirth occurring in about 1 in 100 4
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of all deliveries, but occurs more frequently in women who have had a caesarean birth1. nn Deep vein thrombosis and pulmonary embolism: Being pregnant and having an operation increases the risk of developing blood clots. These blood clots can form in the veins of your legs (deep vein thrombosis) and can travel to your lungs (pulmonary embolism) causing breathing problems. To try and reduce this risk you are asked to wear special stockings during or immediately after the operation, which will improve the blood flow in your legs. Women with additional risk factors will also be given injections to help prevent clots forming. The overall risk of clots developing is rare (about 2 in 10,000) but this occurs about four times more frequently following caesarean birth than vaginal birth1. nn Having a scar on your womb: After having a caesarean you will have a scar on your womb. Most of the time this will not cause you any problems. There is a very slight risk that the scar could tear (rupture)5 in a future labour. Uterine rupture is a rare complication, about 2 in 100,000 pregnancies, but it occurs three times more frequently in women who have had a previous caesarean birth. A scar on your womb also increases your chances of having a placenta praevia after birth situated low in the womb to about 6 in 1000, or a placenta acreta (an afterbirth that will not separate from the womb)1. nn Risk of damage to other organs1: Very rarely other organs, such as your bladder or bowel may be injured during the operation. The risk of bladder and urinary tract injuries are about 1 in 1000 with caesarean birth compared with 1 in 10,000 with vaginal birth. Birth canal injury is as likely with a caesarean birth as a vaginal birth. Faecal incontinence (not having control over passing stools) is also as likely following a caesarean birth as after a vaginal birth. This is more common if you have had a caesarean birth before, because the operation is slightly more difficult due to scarring. Caesarean Birth
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Possible risks to your baby nn Breathing problems: The risk of babies developing breathing problems is increased if your baby is born at less than 38 weeks. Therefore most caesareans are done in the 39th week. This is because most babies born at this time will have fully developed lungs. Occasionally women who are having an elective caesarean birth go into labour before the planned date. If you feel this may be happening to you please contact the Central Delivery Suite at Southmead Hospital Bristol on 0117 323 5320. You will be asked to come into the delivery suite for an assessment by the midwives and doctors, and it may be necessary to do your caesarean earlier than planned. nn Fetal injury: Although rare, the surgeon can accidentally cut the baby’s skin surface while making the incision (risk of approximately 1 in 50)1. This is usually during emergency caesareans. These cuts are usually superficial, normally heal very well and seldom cause long term scarring. nn Having an elective (planned) caesarean birth: Caesarean births usually take place a week or so before your expected due date. You will be asked to come to the hospital Antenatal Clinic the day before your caesarean is planned, usually at about midday. If your caesarean is booked for a Monday, you will be asked to go to one of the wards at 3.00pm on Sunday. A midwife will perform a routine antenatal check and then a doctor will come and see you to discuss the operation and ask you to sign a consent form. You will have some blood taken and then you should be able to go home and will be informed of what time to return the following morning. nn The decision will be made following discussion with your obstetric consultant (birth specialist) in the antenatal clinic, prior to your admission1.
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nn The doctor specialising in anaesthetics and pain control during labour and delivery will discuss the type of anaesthetic that would be best for you and which you would prefer. Various methods of pain control will also be discussed6. nn Blood and urine tests will be performed. nn You will be asked to sign a consent form for your operation and a date will be given for you to be admitted to the ward. nn You will be given two tablets to take before your operation. nn You may be asked to consent to your placenta (afterbirth) or cord being used for research, which is a valuable part of our work. You may be approached separately about this and can refuse if you wish. nn MRSA (Meticillin Resistant Staphylococcus Aureus) Screening. As your caesarean birth is an operation you will need to be screened for MRSA prior to your admission.
What is MRSA? MRSA is a variety of Staphylococcus Aureus (a common bacterium found on the skin and in the nostrils of about a third of healthy people), which has developed resistance to meticillin (a type of penicllin) and some other antibiotics that are used to treat infections. MRSA is found in both hospitals and the community. It is carried harmlessly on the skin and in the noses of many people, approximately 20% to 40% of the population,without causing infection. However, an infection with MRSA can occur when there is an opportunity for the bacteria to enter the body,for example, invasive procedures in healthcare such as an operation. Sometimes, and especially in people who are already unwell, MRSA can spread further into the body and cause serious infection. Caesarean Birth
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How Does MRSA Spread? Healthy people with healthy skin, who have good home and hand hygiene are at low risk of becoming infected. In hospital MRSA can be passed between patients - as it easily spread by touch. Careful hand washing by patients, staff and visitors is important and helps to prevent spread of infection. Visitors should not sit on beds or use patient toilets and you should not expose your wound to visitors or touch it unnecessarily. MRSA can only be found by testing in a laboratory from swabs taken from skin, wounds or a sample of urine.
What Does Screening Involve? Swabs are taken from the nose. This will not hurt and only takes a few minutes. This screening will be done at your pre-operative assessment appointment in the Antenatal Clinic. nn If you are found to be carrying MRSA you will be contacted and given a course of treatment. nn If MRSA is not found you will not be contacted.
On the day of your elective (planned) Caesarean section Your Caesarean section date is: …...........................................
Please bring your suitcase and notes along to .......................................................................................Ward. 8
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Here are a few things you need to know: nn Do not eat anything from midnight the night before the operation. nn You may drink clear water only between midnight and 6.00am and nothing at all after 6.00am. nn Take the tablets prescribed: one Ranitidine (antacid) at 10.00pm on the night before the operation and one Ranitidine at 6.00am on the morning of the operation. nn Have a bath or shower before coming into hospital. nn Please remove your nail varnish and do not wear any makeup. nn Leave jewellery at home. You may wear your wedding ring, but it will be taped to your finger before going to theatre. nn Please bring a CD with you to listen to in theatre, if you wish. nn Only one birth partner is able to be with you in theatre during the caesarean and on very rare occasions they may be asked to leave by the surgeon or anaesthetist if he/she feels it is necessary. nn Unfortunately you will not be able to use a video camera to film the birth of your baby in the operating theatre but you can bring a camera to take photos of your baby. Elective caesarean births normally take place in the morning, but if there are emergencies in the delivery suite your operation may be delayed. Whatever happens, you will be kept well informed. Very rarely a caesarean birth may not be performed on the planned day due to other emergencies. If this is the case then every effort will be made to ensure you are priority for the following day.
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Types of anaesthetic nn Regional spinal and/or epidural anaesthesia – You will be awake for your operation, which means that your birth partner can stay with you. This is the technique used for about 9 out of 10 caesarean births at Southmead Hospital Bristol. The anaesthetist will give you an injection into your back to numb the pain sensation to the lower half of your body (epidural or spinal). In most cases, this is the form of anaesthetic that we recommend, as it is better for you and your baby. Your birth partner can stay with you in theatre if you are having this type of anaesthetic. nn General anaesthesia – In some cases, it may be appropriate for you to have a general anaesthetic for your caesarean birth. The anaesthetist will ask you to breathe some oxygen through a mask, before you are given some medicine into a vein (a ‘drip’) that will make you drift off to sleep for the whole operation. You will be woken up after the surgery has finished and be able to see your baby as soon as possible. If you are having a general anaesthetic your birth partner will not be able to stay with you in theatre, but can be with you again when you are in the recovery area, next to the theatre. Whatever the choice of anaesthetic, you will be seen by an anaesthetist before the operation and they will give a full explanation of the choice of anaesthetic and the risks and benefits for your particular situation. If you are having an elective (planned) caesarean birth, you can request to see an anaesthetist in the Antenatal Clinic. The caesarean birth team who will care for you in the operating theatre: nn A midwife will remain with you in the operating theatre. nn 1 or 2 anaesthetists. nn Anaesthetic assistant. nn Obstetrician (the surgeon). nn Assistant obstetrician (the assisting surgeon). 10
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nn Midwife/nurse assisting the surgeon. nn Circulatory nurse (to get equipment for surgeon and assistants). nn Midwife (to care for you and your baby). nn Sometimes a neonatal doctor (specialises in the care of babies). nn Sometimes student doctors or student midwives may be present. If you do not want students please say so.
What happens during the Caesarean birth? nn Before the operation a catheter will be inserted into your bladder to collect urine and keep it empty during the operation. The theatre team will go through a health and safety checklist (World Health Organisation perioperative checklist) which is normal practice prior to all surgery. As you will be more than likely be awake due to having spinal anaesthetic you and your birth partner will be aware of this and can ask any questions you may have. nn Once the anaesthetist has given the obstetrician permission to start your operation, your abdomen (tummy) will be cleaned with an antiseptic lotion and a drape (sheet) applied to keep the area sterile. nn The drape forms a screen that means that you and your partner cannot see the operation. The screen can be lowered, if you wish, when your baby is born. nn You will hear various noises of people moving around in the theatre during your caesarean. If any of the noises bother you please tell us, or if you wish to have some music playing, this is possible. nn Your baby will be dried, checked over and wrapped in a blanket by the midwife before being given to you or your partner. If you would like, you will be able to hold your baby ‘skin to skin’ which helps keep your baby warm and is important if you are planning to breast feed. Caesarean Birth
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nn At the end of the operation – usually after 30 to 50 minutes, the wound is closed with stitches, of which some are dissolvable and some have to be removed. A dressing will be applied to the wound on your abdomen (tummy) and occasionally a small plastic drain (tube) is left in the wound for about 12 hours to help prevent a bruise developing. When this is ready to be removed, the midwife will gently pull it out. nn When your caesarean is completed, all drapes will be removed and you will be transferred onto a trolley or bed before going into the recovery room. nn Pain control after your caesarean will be discussed with you; tablets, suppositories (painkillers given in your back passage) and injections are used. It is important that you tell us if you are uncomfortable.
After your caesarean birth nn You will be taken from the operating theatre to the recovery area on the delivery suite. You will stay there for a few hours. The anaesthetic will slowly wear off over the next few hours. You will be closely monitored by your midwife in the recovery area during this time. Only one birth partner may stay with you in the recovery area as this is still part of the theatre suite. No visitors may come into recovery – please explain this to your relatives to avoid disappointment. nn As soon as you feel able, you will be given assistance in starting to feed your baby. You will have an opportunity to hold your baby “skin to skin” if you wish. nn You will be allowed sips of water to drink at first, and will be advised when you are well enough to eat and drink normally1. This will normally be when you are back on the ward. 12
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nn You will be transferred back to the ward when your condition is stable. nn Your care on the ward will be given by midwives (and student midwives) healthcare assistants, physiotherapists and doctors. nn You will normally be allowed home from 24 hours after your operation if there are no complications with you or your baby.1 nn If you need to have injections of medicines to thin your blood (low molecular weight Heparin) to help prevent postoperative Deep Vein Thrombosis you will be shown how to administer them and given enough to take home to complete the 7 day course. You will also need to continue wearing your anti embolism stockings. nn Stitches are removed if necessary on day 5. If you are at home your community midwife will be able to remove your stitches for you. nn When you go home your care will be transferred to your community midwife and your GP (general practitioner). nn You will feel tired and it is important that you get plenty of rest. It is important that your partner, family and friends are aware of this. You many find wearing a seat belt in a car and other daily activities uncomfortable because you have had surgery on your tummy.
When can I return to normal? Women who have had a caesarean birth should return to normal activities, including driving a vehicle, when they have fully recovered from their operation1. It is advisable to contact your car insurance company before driving for the first time.
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Your next pregnancy After one caesarean birth, if there are no indications for you to have a second caesarean, you would be allowed to go into labour with the aim of having a vaginal birth1.If this is your first caesarean you will be given a letter briefly giving the reasons for your caesarean and advising you that you should be able to have a vaginal birth (in hospital delivery suite) in your next pregnancy. A copy of this letter will also go to your community midwife and GP. If you have undergone three caesarean births, then it is advisable not to attempt a vaginal delivery. This will be discussed in detail next time.
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References and Useful Information NICE Guideline: Caesarean Section (April 2004) Available at: www.nice.org.uk [last accessed 2 Nov. 2010] North Bristol NHS Trust (September 2003,2nd edition March 2010) Birth after a previous Caesarean (VBAC) Leaflet No. NBT002055 Hannah M, et al (2000) Planned Caesarean birth versus planed vaginal birth for breech presentation at term, a randomised multi-centred trial. Term Breech Trial Collaborative Group. Lancet, 356 (21), 1375–1383 National Patient Safety Agency. January 2009. World Health Organisation (WHO) Safety Checklist Obstetric Anaesthetists Association (2009). Your Anaesthetic for Caesarean Section.2nd edition October 2009. Available at: www.oaaformothers.info [last accessed 27 November 2010] Pregnant women receiving low molecular weight heparin. North Bristol NHS Trust (2004,2nd edition March 2010) Leaflet No.NBT002062 After the birth of your baby. North Bristol NHS Trust. (July 2010) Leaflet No.NBT002175 Preparing for your surgery. North Bristol NHS Trust (May 2010) Pages 5 to 7 ONLY referring to MRSA. (the remainder of this leaflet is not relevant to Caesarean operation) National Institute for Clinical Excellence (NICE) (2008) Routine Ante natal care for healthy pregnant women: Understanding NICE guidance-information for pregnant women, their families and the public.
NHS Constitution. Information on your rights and responsibilities. Available at www.nhs.uk/aboutnhs/constitution Caesarean Birth
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How to contact us: Southmead Hospital Bristol 0117 950 5050 Assessment Unit Southmead Hospital Bristol 0117 323 6397 Central Delivery Suite Southmead Hospital Bristol 0117 323 5320 Cossham Birth Centre 0117 340 8460 Day Assessment Unit St Michael’s Hospital, Bristol 0117 928 5395 Delivery Suite St Michael’s Hospital, Bristol 0117 928 5214 Day Assessment Unit Royal United Hospital, Bath 01225 824 447 or 01225 824 847 www.nbt.nhs.uk/maternity
If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice. © North Bristol NHS Trust. This edition published May 2014. Review due May 2016. NBT002394
