Every pregnant mother hopes for an easy birth with no complications, but things don’t always turn out the way the we plan. Sometimes mothers will need a caesarean section to birth their baby (30% of births were caesareans in Australia in 2009).

It can be very frightening when you find out that you have to give birth by caesarean section, whether it is in advance (due to medical issues such as placenta previa etc) or during labour when you are taken to theatre for an emergency caesarean section. Either way, it’s a good idea to read up on giving birth by caesarean section beforehand so you know what happens in the event of needing to go to theatre to birth your baby.

Please note that in an emergency situation, the procedure explained below may be slightly different as things may be rushed to save the life of either mother or baby.

A birth by caesarean section is where the baby is removed from the uterus, by an obstetrician, through an incision in the mother's abdomen. There are two types of incisions that can be made. The first is a classical incision, which is a vertical incision from the top to the bottom of the uterus. These are rarely done these days as they can cause more complications and take longer to heal. The most common nowadays is a lower segment caesarean section (LSCS) which is where the uterus is cut across the abdomen, just above the pubic bone, it is much easier to repair and lends itself much better to future vaginal births (VBAC).

Prior to your caesarean surgery you will need to remove all jewellery (or have it taped) and remove any nail polish so your vital signs can be checked. You will be given a small drink to neutralise the acids in your stomach before entering the theatre. A catheter will be inserted and you will also be given a drip, usually this will contain fluids and oxytocin, which will help your uterus contract after your baby is born. You will have heart monitors placed on your chest and a blood pressure cuff on your arm to make sure you are doing ok during the surgery.

To start the surgery, you will be given some sort of anesthetic, there are two options. You may have a general anesthetic, where you will be asleep during the caesarean section and wake up after your baby is born. Alternatively you can be awake during the surgery and be given local anesthesia through an epidural or spinal block. With a local anesthetic you will not feel anything from your chest down and as a result will not be able to move much for several hours after your surgery.

Once you are in the theatre, a screen will be raised at your chest so you cannot see any of the surgery taking place. The anesthetist will run ice across your stomach to ensure that you have no sensation and that the anesthetic is working properly. If you are having your caesarean section under local anesthetic your partner may join you once the first incision is made. He or she will sit by your head with the anesthetist.

To start the surgery, you will be swabbed with antiseptic and a small incision is made right above your pubic bone. The doctor then cuts through the underlying tissue and fat working down to your uterus. Once your doctor reaches the muscles, they will be separated manually to expose your uterus.

During this time you will feel some tugging and movement. The sensation is very strange & I liken it to having dental work done, in that you can feel the movement but there is no pain or skin sensation. It can be a little bit scary, but as long as you are feeling no pain then it is perfectly normal. If you do feel any pain, tell your anesthetist immediately and he or she will top up your anesthesia.

At this point, if you would like to view the birth of your baby, you may request to have the screen lowered. Your partner may also choose to take photos of the birth at this time.

A final incision is made, in your uterus, and your baby is pulled out, sometimes this needs the assistance of forceps. The baby’s umbilical cord will be cut and she or he will be held up over the screen for you to see. If you partner would like to cut the umbilical cord, let the midwives know in advance and it will be left long enough for him or her to cut on the warming table after the birth.

Depending on your hospital, you may be able to have your baby placed on your chest immediately after birth and checked later. Sometimes though your baby will need to be checked straightaway depending on his or her Apgar scores.

At this point, your surgery has been going for only about ten minutes.

While you snuggle with baby or the checks are being made, your caesarean section is being completed by all the layers being sutured back together. You may have staples, stitches or internal stitches, depending on the doctor performing your surgery.

This part of surgery will take up to two hours as the doctors work at stitching everything back together. It may sound like a long time, but it goes very quickly. If you are tired after a long labour you may fall asleep as they finish the surgery.

Once the surgery is finished you will go to recovery for a period of time, this is dependent on how you are doing after the surgery and how much blood loss you have had. You may be there for half an hour if all is well or up to several hours if there are any concerns about your health. If you baby is well he or she may stay in recovery with you and you can use this opportunity to breastfeed if you’d like to.

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Many doctors consider induction necessary once a woman is past her due date or if the placenta has ceased to function.

When labour begins naturally hormones are released into the bloodstream. When labour is induced medical professionals try to obtain a similar result by flooding the system with hormones, often until they reach a level that is higher than would occur in a natural labour.Although a doctor may suggest induced labour based on reasons considered necessary, it is important that you ask and are told the details of what induction involves. You may then decide to accept or refuse the treatment on offer.    

Oxytocin drip

The most popular method of induction uses syntocinon, a synthetic hormone that mimics the action of oxytocin, the hormone that is naturally produced by the body that causes the uterus to contract. This is often referred to as an oxytocin drip. The drip can be lessened or increased accordingly. Often it is turned down or removed once 5cm dilation is reached. Some medical professionals prefer to keep the drip in place until after the third stage of labour in order to control the bleeding from the uterine wall once the placenta has been removed. If a drip is advised, you may wish to ask for a long tube so that movement is less restricted. It is common for women to complain of backache following the use of an oxytocin drip tube that was too short. You may also wish to ask for the insertion to be made into the arm that you least use.

Artificial Rupture of the Membranes

Known as ARM or amniotomy, artificial rupture of the membranes is frequently done in hospitals and has become accepted as normal routine. It should not be carried out until you are 4cm dilated and are considered to be in active labour.

ARM involves the puncturing of the membranous sac using a small tool a little like a crochet hook. In a natural labour, the membranes are allowed to rupture spontaneously, usually by the end of the first stage. Sometimes the membranes rupture when the midwife or doctor carries out an internal. Rupturing is not painful. You may feel a rush of warm liquid and once this has occurred, contractions usually intensify.

ARM can quicken labour by 30-45 minutes. It is useful in that it allows medical professionals to examine the condition of the amniotic fluid to determine the baby’s welfare. When a baby becomes distressed, it often releases merconium from its bowels into the amniotic fluid. The risk of ARM is that is disrupts the cushioning protecting the baby and directly exposes it to the pressure of the contractions. It may also increase the pressure on the umbilical cord and affect the flow of blood through it. ARM also increases the risk of ascending infection and in many cases requires the use of hormones to further accelerate labour.

Prostaglandin Gels

Prostaglandin pessaries are inserted in and around the cervix to help ripen the cervix and encourage dilation. If pessaries are inserted in the evening, labour usually starts the following morning. The advantage of prostaglandin pessaries is that you have the freedom to move about. In most cases the simultaneous use of ARM or an oxytocin drip is unnecessary.

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An assisted delivery may be carried out if your labour is prolonged or there is a delay in the second stage of labour that is causing you or your baby distress. It is estimated that either vacuum extraction or forceps are used in one in ten deliveries.

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An episiotomy is a straight cut through the muscle and connective tissue in the perineal area to enlarge the opening of the vagina. The decision to perform an episiotomy is usually made as the baby’s head begins to emerge.

It is generally done in one of two ways:

• midline cut made from the vagina towards the anus or
• mediolateral made from the vagina sloping out to one side

An episiotomy can be done under local anaesthetic although for a small episiotomy, this is not always necessary as the pressure of the baby’s head on the perineum can numb the feeling. Minor lacerations known as first-degree, are common and usually heal well.

The number of stitches required is related to the size and depth of the cut. The larger the incision, the longer it will take to heal, often causing tenderness, discomfort and swelling for days, sometimes weeks afterwards. Since the incision is made through both skin and muscle layers, careful repair of the wound afterwards can take as long as an hour, often requiring local anaesthetic. 

Repairing a midline cut can often be quicker as there is a natural division between the muscles making it a simpler process. Suturing is done with a special curved needle and if they are dissolvable stitches, they can be left to dissolve within a couple of weeks. It is advisable to check the wound daily for signs of possible infection and to make sure the stitches haven’t dropped out and become imbedded in the tissue.

Is an Episiotomy necessary?

The answer to this depends on circumstances and who you ask.
Episiotomies are not routine. They are usually carried out when there are signs of the baby becoming distressed, the birth needs to be hastened or in cases of forceps delivery. For some women, the appropriate use of episiotomy is important.

Medical professionals believe episiotomy reduces the chance of uncontrolled tearing of the perineal tissue that can be more difficult to repair. It is also believed that prolonged pushing can have a negative long-term impact on pelvic floor function and that shortening the second stage of labour is better for the baby. Though there are many arguments against episiotomy, there are always situations where an episiotomy is fully justified.

Problems arising from Episiotomy

The World Health Organisation recommends that episiotomy should only be necessary with 10 per cent of births and certainly no higher than 20 per cent. In some Australian hospitals rates are as high as 40 per cent and in the United Kingdom, the proportion is only marginally lower than this. Clearly, many are performed without necessity. Though there is no concrete evidence to back up the arguments against the procedure of episiotomy, the following thoughts are worth considering.

Episiotomy may cause:

• unnecessary bleeding if performed too early as the tissue has not thinned enough
• increased chance of further tearing the episiotomy incision
• infection of stitches requiring antibiotics
• Incontinence
• Long-term discomfort during sexual intercourse
• Pain, swelling, tenderness for days, even weeks afterwards
• Excessive stress and pain far greater than that of superficial tearing

Certain birthing positions are thought to make episiotomy and tears less likely as they encourage maximum stretching of the perineum. These include positions used in active birthing methods such as being on hands and knees, squatting, upright and using a birth stool.

Other suggestions include perineal massage during the last two months, maintaining a good diet to promote the skin’s elasticity, practising pelvic floor exercises and timing during labour. The most common cause of tearing is not allowing time for the perineum to stretch. At this time, strong sensations encourage a desire to push the baby out, though timing is crucial to allow the surrounding tissue to stretch and thin in preparation. The doctor or midwife can help with hot packs.

Aftercare

The pain related to episiotomy and tearing is primarily from swelling and inflammation. Using icepacks can help. Arnica and Bach flower rescue remedy will also aid the healing process. The sting of urine passing over the sutured area can be minimised by slowly trickling a jug of warm water over the pubic area to dilute the urine as it is passed. Soaking in a salt or lavender bath can be soothing and using pads soaked in witchazel can be helpful. Rather than towel drying the area, a hair dryer can be useful.

If you are concerned about episiotomy, it is important to discuss this subject with your doctor or midwife well in advance.      

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Caesarean is delivery of a baby through a cut in the abdominal and uterine walls. It is also called a lower uterine segment Caesarean section, a Caesar, or C/S.

Performed by a specialist obstetrician and an anaesthetist, a Caesarean section is an operation requiring considerable skill. It is usually performed only if the mother and/or baby’s health is likely to be seriously compromised by a vaginal delivery. It some cases a Caesarean can be a life-saving operation for the mother and/or her baby.

Situations where a Caesarean may be necessary

• labour not progressing at all
• baby in abnormal position
• problems within the placenta
• history of cervix, uterus or bladder surgery
• baby in distress
• toxaemia or severe hypertension
• baby too big to fit through pelvis
• umbilical cord threatening baby’s safety
• delivery of multiple birth
• very low weight baby
• women suffering from active herpes, HIV or venereal disease
• women suffering from renal disease
• following an amniocentesis revealing a damaged baby
• women suffering from gestational diabetes

Anaesthetic

An elective Caesarean can be carried out under an epidural or spinal anaesthetic allowing full consciousness throughout the delivery. Epidural anaesthetic is given at a higher dose than that administered for pain relief only. It is common to have post-operative nausea and vomiting, as is often the case with general anaesthesia.

Occasionally if there is an emergency situation, it is necessary to have a general anaesthetic. This is usually a low dose as to not affect the baby and so you are only unconscious for a few minutes. It is possible to have your partner in the room and arrange for your partner to hold the baby following birth.

A spinal anaesthesia is an injection into the cerebrospinal fluid in the lower spine to numb from the waist to the knees. It takes effect within five minutes and is therefore useful when time is short. Spinals are considered potentially dangerous because the blood pressure drops, reducing oxygen supply to the baby. It is advisable to lie flat and avoid lifting the head quickly for eight hours following delivery to avoid a post-spinal headache.

Procedure

Incisions for caesareans are either vertical or horizontal. Although the classic caesarean is a vertical cut, most are horizontal as they are believed to be less likely to break than a vertical scar and are considered more cosmetically pleasing, located in the lower abdomen near the line of pubic hair.

It is common to be given antibiotics before the operation to prevent post-operative infection. A midwife may shave some pubic hair and insert a catheter to empty the bladder. In an operating room, sterile drapes are pulled around and a half-screen is erected so you do not have to see the surgery. Your abdomen is washed with antiseptic solution.

Your anaesthetic will be administered and when this has taken effect, a series of small cuts will be made through the layers in the lower abdominal wall to reveal the uterine wall. A horizontal slit is made, accessing the bag of waters which will be pierced with a noisy gush as the amniotic fluid is sucked out. The baby will be eased out of the opening, occasionally using forceps to deliver the head. You may wish to watch. Generally from your position, you will be unable to see anything gruesome.
What you will see is your baby being born.

When a baby passes through the birth canal in a vaginal delivery, the mucus is usually forced out. Because this cannot occur naturally in a Caesarean birth, mucus is often sucked from your baby’s nostrils and mouth using a suction tube. Sometimes oxygen is given to the baby via a small tube and once your baby is breathing, it will be handed to you or your partner. If the baby is very small or show signs of difficulty breathing, it may be taken to a special-care unit. The first step takes about 10 minutes.

In an emergency, the process from the beginning of the surgery to birth may only take four minutes.

Following the delivery, you may be given an injection of oxytocin to encourage the placenta to peel away from the uterine wall. It will then be lifted out through the abdominal opening.

The suturing of the opening can take as long as an hour as each layer is stitched together separately with great precision. Sometimes a small tube is left in place to drain any oozing blood and amniotic fluid. Dissolvable stitches are used in the inner layers. The skin is drawn together and secured with nylon sutures, small metal clips or a dissolvable thread.

Lou gave birth to her son through an emergency Caesarean. She recalls "Within minutes I saw my baby's bottom rising up out of my stomach... My partner and I gazed awe-struck at the sight of our son while the doctors sewed me up". To find out more about her experience of a Caesarean delivery read her fantastic birth story.

Aftercare

A Caesarean is a surgical operation and requires a period of recovery. Whatever anaesthetic you have had, you will be drowsy. You may feel sick and weak for the first few days, however, it is important to get up and move around to help prevent thrombosis. Any movement is likely to be painful. When arising, it is best to first roll gently to one side and lever yourself to a sitting position. If you have had a general anaesthetic, fluid may have collected in the lungs, forcing a cough. It is best to spit out any fluid.

Vaginal bleeding is likely as blood pools in the pelvic region. Slow breathing may help with pain control as you move around but if the pain in unbearable you may wish to ask for pain relief. Dressings will be removed three or four days later and because a Caesarean involves cutting through layers of abdominal muscle, your tummy will initially feel large and saggy.

It is advisable not to lift anything heavy for up to six weeks following the operation. The recovery period is an ideal time for you and your partner to spend time with your new baby.

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Breech presentation is when the baby's bottom is pointing downwards towards the birth canal. Most babies settle into the cephalic presentation between 32 and 34 weeks, with the head pointing downwards ready for delivery. You can try coercing your breech baby to turn by spending a little time each day on all fours. This provides more room for your baby to move.

About three per cent of babies remain in the breech position. If a woman begins labour with her baby positioned breech, medical staff will almost always advise a Caesarean delivery, particularly if it is your first baby.

Breech deliveries are more complicated and require experienced doctors and midwives. Because many breech babies are delivered by Caesarean, less and less maternity staff have the experience of a vaginal breech delivery. If you choose to deliver vaginally, you will be offered an epidural.

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