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Background
A caesarean section is an operation to deliver a baby through the wall of the abdomen, as an alternative to delivering through the birth canal (vaginal or “natural” birth). Caesarean section is now the most commonly performed major surgical procedure in the world.
Indications
Caesareans are usually classified as elective or emergency. Elective caesareans are generally planned. They are performed for reasons such as placenta praevia (where the placenta is in front of the birth canal), breech presentation, twin pregnancy, and for large babies, such as in diabetes.
Caesareans may be performed as an emergency, especially where the labour is not progressing normally, or there are signs that the baby is not tolerating the labour (“fetal distress”), or in the presence of vaginal bleeding. Sometimes the caesarean may be required as a semi-emergency, such as when your blood pressure is uncontrollably high (severe pre-eclampsia).
Timing of Caesarean
The best time for caesarean section is usually 39-40 weeks. The NSW Health Department has stipulated that elective caesarean section should routinely be performed after 39 weeks. This is in contrast to previous practice, when caesarean section was performed at 37 or 38 weeks. Doing the caesarean section near to the due date has significant benefits for the baby, including a 50% reduction in admissions to the special care nursery with breathing difficulties, or fluid on the lungs.
The latest evidence also shows significant improvement in brain development in babies born later. If your baby needs a caesarean prior to 37 weeks then it is recommended that you have two steroid injections to help the baby’s lung development. This halves the rate of unnecessary nursery admission, although the results of any long-term effects on the baby are not yet known.
Consent for Caesarean
You need to give consent for caesarean, whether it is elective or an emergency. That consent should be freely given, once you understand the risks and benefits of caesarean and the alternatives, and have been given the opportunity to discuss any concerns. The consent form must be signed by you, and nobody else can sign on your behalf. It must also be signed by me, after discussing the risks, benefits and alternatives with you.
Pre-operative Assessment
Prior to caesarean you will need to have blood taken for cross match, in case you need a blood transfusion. We normally check your blood count, and sometimes iron stores, at the same time. The anaesthetist will see you before the caesarean. Some anaesthetists like to meet you the day before, but others meet you on the day of the caesarean. At POWPH a midwife will see you to perform your hospital preadmission. At RHW this is usually done at the time of admission.
Anaesthetic
You will require an anaesthetic for a caesarean section. You can be put to sleep (general anaesthetic) or have a needle in the back that makes you numb from the waist down (regional anaesthetic). General anaesthetic is not usually preferred in pregnancy for safety reasons, so most caesareans are performed under regional anaesthesia, which means you are awake. There are various types of regional anaesthetic – spinal, epidural or combined spinal and epidural. All involve a needle into the back. A spinal anaesthetic is a single injection that immediately gives a heavy numbness and lasts for around 4 hours. An epidural injection is into the tissue around the spinal cord. It takes longer to start working, but lasts longer, and can be topped up via a tube taped onto your back. It can be used for labour and topped up for caesarean if required.
Each anaesthetist has a preferred type of anaesthetic and it is important to allow the anaesthetist to perform the type of anaesthetic they prefer.
Surgical Preparation
Please ensure that all jewellery is removed prior to going to the operating theatre. Caesarean section is a surgical procedure, so it is performed in a cooled operating theatre, under sterile conditions. The surgeon, assistant surgeon and scrub nurse all have to perform a sterile scrub and wear sterile gowns and gloves to prevent infection. Prior to commencing the operation you will have the upper portion of your pubic hair clipped, and a urinary catheter tube will be inserted to empty your bladder. Studies have shown that clipping of hair is associated with fewer infections than shaving with a razor, however having a bikini wax in the days prior to surgery is also a good option. You will then have antiseptic solution, such as Betadine, painted onto your abdomen to help prevent infection. Sterile drapes will then be put up to create a sterile field. Please do not touch the sterile drapes at any time. Please let me know if you are allergic to Betadine or to tape.
The Procedure
An incision about 12 cm long is made with a scalpel on the bikini line. I then cut down through the major tissue layers until I reach the womb. The bladder lies over the lower part of the womb, and needs to be pushed down out of the way to reach the thin part of the womb – the lower segment – where I make an incision in the womb big enough to deliver the baby.
I then break the waters, and you may hear the gurgling of the fluid being collected in the suction tube. I then need to deliver the baby through the incision. It is often a tight fit, and often I use forceps to guide the baby’s head out gently, which reduces the pressure needed from above.
The umbilical cord is then clamped and cut. I generally like ti delay clamping of the cord by one minute, even at caesarean. Because we are working in a sterile field the initial cut must be made by me, or my assistant, but we generally allow enough cord for your partner to do the final cut. There is a midwife in theatre to make sure that the baby is fine, and to make sure you have a cuddle in theatre. Sometimes your baby has a little fluid on the lung, or needs some minor resuscitation. If you have a caesarean in labour or your baby is pre-term or breech, or if there is any concern about the baby I will arrange for a paediatrician to be present at the caesarean.
People Present for Caesarean
There are often several people present for caesarean, in addition to you and your partner/support person. I require a surgical assistant, sometime another obstetrician. The anaesthetist requires an anaesthetic assistant. There is a scrub sister and scout sister as well as a midwife and often a paediatrician. For preterm babies or twins extra staff members will need to be present.
Recovery from Caesarean
At the completion of the operation you will usually go to the recovery ward for around 30 minutes for observation and monitoring. During that time your baby will usually be brought to you by the caesarean midwife, for “skin to skin” contact and for initiation of breastfeeding.
Occasionally you will not be able to feed in recovery, in which case at the end of the operation your partner or support person will leave the operating theatre with the baby and return to the ward. That is a great time for your partner to do “skin to skin” with the baby. Expressed breast milk can be given if necessary. Occasionally elective caesarean may delay your milk supply, in which case frequent feeding or expressing in the first few days may help the milk come in.
For the first 24 hours following caesarean you will generally rest in bed. If you are at POWPH you can leave your baby in the nursery for a few hours during the night, and I recommend you to make use of this excellent service, firstly to get some rest and secondly because you cannot twist and lift the baby. For the same reason I advise you to keep visitors to a minimum in the first 24-48 hours. If you have a single room it may be a good idea for your partner or mother to stay with you to help.
Your bladder catheter will usually be removed on the morning following the procedure. If you have had an epidural anaesthetic the epidural catheter will be generally removed after 24-48 hours, although some anaesthetists like to remove it at the end of the procedure, having given you some epidural morphine or pethidine. Your intravenous cannula (“drip”) will be removed when you are drinking adequately and your epidural catheter has been removed.
After the first 24 hours it is good to get up and start to walk around. This helps your lungs to re-expand, helps your bowels to re-start, and reduces the risk of blood clots (DVT). You may need extra pain medication before walking around. By the time you leave hospital you should be fully mobile and should be able to manage stairs slowly.
You will generally be in hospital for four or five nights following caesarean section. If you are planning to breast feed then this time is valuable for becoming confident with feeding and settling, which is often a major challenge for first time mothers. If you are booked at POWPH and wish to go down to the Crowne Plaza, as part of the Little Luxuries programme, then you will usually spend three nights in hospital and then two nights in the hotel. It is important to ensure that any difficulties with breast feeding are addressed prior to going to the hotel.
Your recovery time is around 6 weeks. I advise you not to drive for the first three to four weeks, or until you can safely perform an emergency brake. You should not perform any heavy (more than 10kg) lifting for around 3 months. You should avoid sit-ups or crunches for 3-6 months following either natural or caesarean birth, to allow the abdominal muscles to knit.
Complications of Caesarean
Caesarean section is a very commonly performed operation and it is extremely safe for both you and your baby. It is, however, a major operation, and no operation is entirely without risk. The most common risk is infection, either in the skin, under the wound, in the lining of the womb (endometritis) or a bladder infection. Some bleeding occurs at all births, but is typically heavier following caesarean than natural birth. Sometimes the bleeding can be so heavy during caesarean section, that you require blood transfusion and special procedures to stop the bleeding.
Other risks include the risk of blood clots (DVT) in legs and lungs, for which you will be given surgical stockings and daily injections of a type of Heparin, known as Clexane, to thin your blood until you leave hospital. Following the procedure scar tissue will form in the skin and in the tissue below. The skin scar can become thick and heaped up, known as keloid. The deep tissue scar can make future operations more difficult. In general each caesarean becomes a little more difficult, in contrast with natural birth, which generally becomes easier after the first birth.
Uncommon complications include the possibility of injury to bladder or bowel or the ureters – the tubes from the kidneys to the bladder. In rare cases, such as where the placenta is abnormally stuck to the wall of the womb, the haemorrhage can result in the need for an emergency hysterectomy (removal of the womb). This is only performed as a life-saving procedure.
You should call the Delivery Suite if you experience fevers above 38 degrees, any obvious infection, worsening pain or bleeding, chest pain, breathlessness, calf pain and swelling, or difficulty emptying your bladder within 6 weeks of the operation. You will need to come in for assessment. That will be to Delivery Suite or to the Emergency Department.
Following caesarean you should generally wait at least nine months before conceiving again. If you have had a caesarean it is usually fine to plan for a vaginal birth after caesarean (VBAC) next time if you want one, depending on circumstances. There are, however, issues to be discussed, including a very small risk (under 0.5%) of your caesarean scar tearing in labour.
Fees for Caesarean
In private medicine the fees are set by the provider, but you should have informed financial consent, which means you should know in advance approximately what they will be. My fee is unchanged.
The fees for caesarean are generally similar to the usual obstetric fees, except you will need to pay for a surgical assistant. The surgical assistant fee can vary greatly. The usual surgical assistant fee is around $500-$600 and you generally get back around $120 from Medicare and your fund.
Many professional fees vary greatly, and also change from time to time, so it is difficult to give you a precise figure but a guide to your out of pocket expenses is as follows:
- anaesthetist from $500 to $1,500;
- surgical assistant from $400 to $500 usually, but can be as much as $1000;
- paediatrician around $500.
Please note that if you require an emergency caesarean after hours or at weekends then these professional fees may be increased, although my fees remain the same.
If you have an epidural for labour and then an emergency caesarean you will receive two anaesthetic bills.
Hospital fees, including tests and medications, may be covered by your fund, depending on the cover you have.
Please check these costs with your fund prior to booking into the hospital. Please also check that your baby will be covered in the event of an admission to the neonatal nursery.
Dr Rahul Sen, 2017