“By definition, a caesarean section is the delivery of the fetus, placenta and membranes through a surgical incision in the abdominal wall and uterus” (Henderson & MacDonald, 2008). A caesarean may be planned (elective) if there is a reason that prevents the baby being born by a normal vaginal birth, or unplanned (emergency) if complications develop and delivery needs to be immediate. This may be before or during labour. Several reasons as to why your obstetrician may recommend an elective caesarean section, may include; previous caesarean sections, breech position (vaginal breech may not be recommended), placenta is low lying and partly or completely covering the cervix, baby is in the transverse position (lying sideways) or twin pregnancy (your obstetrician has not recommended a vaginal birth) (AIMW, 2018).
The World Health Organisation (WHO) recommends a population caesarean rate of 10-15% to ensure mortality rates are kept low for mothers and babies. Of the 309,000 babies born in 2015 in Australia, 33% were born by caesarean section (AIMW, 2018). It has been suggested that the rising age of first-time mothers is contributing to this rate but a recent study by Dahlen et al. suggests that the private sector is also playing a significant role in the increase.
There is no doubt in my mind that a parent’s main concern is their child’s health and wellbeing following the birth. For many of us the ‘way' our child is born is not a major factor, however it is important to acknowledge that for some, having a vaginal birth plays are big part in defining the birthing experience and furthermore the postnatal journey. It is important to respect that for some women having a caesarean section may ignite a variety of emotions; such as, disappointment, guilt or sadness. As a midwife I aim to create a beautiful, empowering birthing experience no matter the outcome.
So what should you expect?
To prepare for your caesarean section, you will need to fast. That means no food or drink, including water, for at least six hours before a planned caesarean. If you are having an emergency caesarean, if possible, your operation will be timed on when you last ate and drunk. Bloods are usually taken prior to the operation.
Firstly, you will have intravenous lines inserted into your arm to deliver fluid (hydration) and medicines. You will then receive pain relief, such as a spinal anaesthetic, which numbs the lower part of your body. This means you will be awake throughout the operation. This process usually takes 10 minutes. General anaesthetic is not common for a caesarean section and preferred method is either by epidural or spinal anaesthetist. Following the anaesthetist, your abdomen (stomach) will be cleaned with antiseptic and covered with sterile cloths to reduce the risk of infection. In many hospitals, the pubic hair is shaved so that it is easier to clean. (Note: Many women will wax prior to a planned caesarean – it is up to you?) You will have a catheter (plastic tube) inserted into your bladder so that it remains empty during the operation and this will stay in until the following morning, as you will be in bed for approximately 12 hours and unable to go to the toilet. NOTE: The procedure will not start until the anesthetist and patient are satisfied and comfortable with pain relief.
The obstetrician will make a cut through the wall of your tummy, usually low and across near the pubic hair line. (…and yes you will certainly be able to wear a bikini and no one will see the scar) The doctor will then cut through the layers of fatty tissue and muscle, and finally cut through the uterus. If you are awake you will feel tugging and pulling but not pain, and you will also hear fluid being suctioned. A screen will be put across your chest so you cannot see what is happening. However, if you would like to see the birth a mirror can be used. Your partner or support person can also stand up and see the birth at any point and also take photos at the appropriate times.
The baby is delivered through the surgical cut. From first cut to your child being born is usually within 5-10 minutes. It is surprisingly quick. A common misconception is that there is only one layer of skin cut before the baby is born, however it is actually seven layers. The layers of muscle, fat and skin will be stitched back together and a dressing will be applied over the wound. If you are awake they will hold your baby up so that you can see. An injection will be given to help minimise bleeding postnatally and help contract the uterus. Antibiotics are too given to help reduce the risk of infection post-surgery. The operation takes about 30 to 40 minutes.
Caesareans are safe and common. Your anaesthetist and obstetrician will discuss risk and potential complications prior to the operation. Depending on whether you are admitted into a public or private maternity hospital, your stay in hospital will be 3-5 days. Granted if you are not recovering well you stay may be extended.
Through my years of experience, the most common questions or concerns I get asked are;
- Many couples don’t expect the amount of staff present in theatre for the birth. I always like to acknowledge the amount of people present as a way to provide reassurance for the family. It is important to understand that each individual has a specific role and there is not necessarily a reason for concern. Expect the following; obstetrician (performs the operation), assisting surgeon, anesthetist (administers the anaesthetic), scrub nurse (assists both obstetrician and assisting surgeon), scout nurse (assists the scrub nurse), anesthetic nurse (assists the anesthetist), paeditrician (doctor that looks after your newborn), midwife – receives the baby once born and cares for them postnatally) and a theatre technician.NOTE: A paeditrician may not always be present for an elective caesarean if there are no foreseeable concerns. In this instance your midwife will care for your newborn immediately following the birth.
- A common misconception is that caesarean section patients will not bleed vaginally following the birth, this is completely inaccurate. Quite simply you will bleed after the birth; this is from the uterine lying. It may take up to 6 weeks for the bleeding to stop. At first (1-3days) it will be quite heavy – like a heavy period. It will then become light by day 5-7. You will need to wear maternity pad for the first 1-2weeks and from then a panty liner will be sufficient. If you feel your bleeding is increasing or frequent clots pass also discuss this with the midwife staff, obstetrician, GP or Maternal and Child Health Nurse.
- Pain relief is expected in the first couple of weeks following the birth, regardless of what type of birth you have. However, with a caesarean section it is normal to have more regular and stronger medication initially. This is simply because… you have had major abdominal surgery. Pain relief is to assist your recovery; this will as a result help you tend to your baby more readily. It important to also discuss your pain relief options and ensure it is safe for breastfeeding (if this is your chosen feeding method).
- Caring for your wound is important for recovery. In hospital your midwives will check your wound daily and show you the techniques to keep clean and dry when heading home. Initially your wound will be covered by a waterproof dressing/tape so it is absolutely safe to go into the shower and get it wet. Showering daily is encourage and safe to do. (TIP: Always ‘pat’ dry with a towel, as rubbing the wound may feel tender and/or uncomfortable). On your morning of discharge usually this dressing is removed. It may take up to 4-6 weeks for the wound to heal, in this time try to lift nothing heavier that the ‘weight of your newborn’ and gain assistance with heavier duties. It is recommended you don’t drive for up to 6 weeks following the birth to allow for recovery. Some insurance policies will not cover you for the first 6 weeks. Just double check with yours!
- One of the most frequent questions I get asked is, "Can I breastfeed after my caesarean?” And quiet simply YES, absolutely! There is also no reason why you can’t breastfeed successfully after a caesarean. In some hospitals the baby is placed skin-to-skin contact with the mother while she is still on the operating table. With this a breastfeed can follow. If this is not possible, your baby may be able to be skin-to-skin with you in the recovery room. Positioning of your baby on the breast is very important to help establish breastfeeding and prevent nipple soreness. Whatever hold you use, make sure your baby's body is close to you, chest to chest, chin to breast and nose away from the breast. Positions you may find useful after a caesarean birth are sitting with a pillow on your lap to support your baby and protect your wound; lying down on your side; or with your baby in the underarm (‘football’) position, with their feet towards your back (ABA, 2018). No matter how your baby is delivered, night feeds are important for your child to receive the colostrum and to begin learning to breastfeed. Night feeds help to prevent breast engorgement and to establish your milk supply. While it's ideal for a mother and baby to be in skin-to-skin contact straight after birth and for a baby to breastfeed within an hour of birth, not every caesarean mother can start breastfeeding immediately. You may have needed a general anaesthetic or your child may need to be admitted to an Intensive Care Unit to stabilise their condition. While early breastfeeding is helpful for baby and mother, there is one important thing you can do while waiting and that is to express your colostrum. Colostrum is like 'super' breast milk and contains more concentrated protein and immunity factors than mature breast milk. It acts as a natural laxative for the meconium, your baby's first bowel movement. Your midwife will show you how to hand express on the ward.
- Partners are encouraged to be present in the operating theatre, to share the birth of their child. Your partner can be an important source of moral and physical support and be involved with your baby from birth. Your midwife will also ensure your partner (or support person) is cared for, as the operation may be overwhelming for them too.
- Although, a caesarean section is a surgical procedure it too can be beautiful, gentle and certain elements can be natural. Talk to your obstetrician about playing music or burning oils to create a relaxed and familiar enviroment. If you are unaware of the gender of your child, request your partner announce it. It may also be a option for you to witness the birth of your child this can be done with a mirror. Discuss this with your obstetrician or midwife to see if this is doable.
Tips to help with recovery in the first six weeks include:
- Ask family or friends to help, or organise paid help if you can afford it. One way that family and friends can help is by preparing meals that can be frozen and heated up. If you feel you need extra support at home, talk with the doctor or midwife, or maternal and child health nurse. Additional help will enable you to have additional rest.
- Take a gentle walk every day. This can have physical and emotional health benefits. Be kind to yourself.
- Do your pelvic floor exercises. Regardless of the type of birth you have had, your lower abdominal muscles and pelvic floor muscles will have weakened after pregnancy, and need strengthening. Your hospital physiotherapist can teach you how to do pelvic floor exercises.
- Eat a healthy, high-fiber diet and drink plenty of water. Do this every day to avoid constipation.
- Use warmth on your wound. Warmth can have a soothing effect. Try a wheat bag or hot water bottle.
- While some women like loose clothing, many prefer firm, high-waisted compression underwear or control briefs to offer abdominal support. This can reduce pain and be worn for comfort for the first six weeks.
- Avoid sex until you feel comfortable. It is quite normal to for it to take weeks, even months, before you are ready to have sex.
- Numbness or itching around the scar is normal. This can last several months for some women.
Regardless of whether your caesarean is elective or emergency for some women having a caesarean section can be overwhelming to process and difficult to accept. I encourage you to discuss how you’re feeling with your obstetrician and/or midwives firstly. Of course debrief with your family and friends, you may find it useful to discuss with other mother’s that have had a caesarean section. The Maternal and Child Health will also be a good sounding board and if after sometime you feel there are some unresolved feelings in relation to the birthing outcome discuss this with your local GP and explore further.
I wish you a safe and positive birthing experience.
Cara x
References
Australian Breastfeeding Association (2017) Breastfeeding after a caesarean birth, viewed 1 May 2019. Retrieved from https://www.breastfeeding.asn.au/bf-info/breastfeeding-after-caesarean-birth
Australian Institute of Health and Welfare 2018. Australia’s Health 2018. Australia’s health series no. 16. AUS 221. Canberra: AIHW.
Better Health Channel (2018). Caesarean Section. Viewed 1 May 2019, retrieved from https://www.betterhealth.vic.gov.au/health/healthyliving/caesarean-section
Dahlen, HG, Tracy, S, Tracy, M, Bisits, A, Brown, C, & Thornton, C 2012, ‘Rates of Obstetric Intervention Among Low-Risk Women Giving Birth in Private and Public Hospitals in NSW: A Population-Based Descriptive Study’, BMJ Open, vol. 2, no. e001723, pp. 1-8, viewed 25 May 2019, http://bmjopen.bmj.com/content/2/5/e001723.full.pdf+html
Henderson, C & MacDonald, S (2008) Mayer’s Midwifery. A Textbook for Midwives p. 977. Bailliere Tindall, China.