Pearl obstetrics | gynaecology


Caesarean section | C-section

  • Cesarean section birth
    C-section
    The view you get if you choose to have the screen dropped during the delivery.
  • After the Caesarean
    After your C-section
    Your new baby.

Caesarean section – Glengarry Private Hospital, Duncraig, Perth

Elective Caesarean section – Summary

There are many different reasons for having an elective Caesarean section. The commonest reason is where a woman has had a previous C-section.

1. An elective C-section avoids labour.
2. Most women, who actively choose how they birth enjoy meeting their new baby.
3. There is no evidence that elective C-section is riskier for the mother.
4. In birth, there are no risk-free options.
5. Breastfeeding rates after C-section are similar to vaginal birth.

This page is about elective Caesarean section, NOT emergency Caesarean section performed during labour, where the risks of the surgery are greater, recovery is longer, and dissatisfaction is more likely.

We support women who want natural birth, women who want a C-section (after detailed discussion & assessment), and those who want VBAC (after detailed discussion & assessment).

Any surgical or invasive procedure carries risks. Before proceeding, you should do your own research. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner. For instance, your GP’s opinion will be very helpful.

Call us to arrange a consultation • Perth (08) 9448 9822

 

 

Medical reasons for a C-section

Some women have medical reasons which means delivery by elective or planned Cesarean Section (C-section) is recommended. Examples would be fibroids, previous surgery, previous traumatic birth, heart problems, neurological problems etc. An elective C-section is safer than a vaginal birth when the baby is breech or transverse, often when there are twins, or when baby is compromised because of poor growth or placenta. When babies grow very large, an elective Caesarean may be the recommended method of delivery, avoiding bad tears and stuck shoulders.

 

Repeat Caesarean section birth

Many women will have had a Cesarean before and wish to have an elective C-section. In Perth, this accounts for many private elective C-sections. An important reason for the choice is the small but definite risks with rupture of the womb associated with an attempt at vaginal birth (VBAC). There are also all the other reasons why someone might want an elective Caesarean.

 

Private elective maternal request C-section

The main reasons for this choice are to avoid damage to the maternal tissues and to avoid labour and natural birth.

 

 

Disadvantages & risks of an elective C-section

  • A Cesarean section is major surgery.
  • Whilst the overall risk of significant complications for the mother is the same as attempted vaginal birth, the complications are different. You swap the risk of some type of complications for others.
  • Recovery from a C-section is longer than from an uncomplicated normal birth.
  • You don’t have the satisfaction of birthing the baby yourself with a Cesarean. For many women this is very important.
  • There is an increased need for help with baby’s breathing after an elective Caesarean. This risk is reduced to about 3% if the Caesarean is done at 39 weeks gestation. A CS at 39+ weeks has a rate not dissimilar to the rate seen at vaginal birth.
  • The bikini-line scar. Scars can sometimes heal poorly.
  • If you want a large family (3 or more children), usually normal births are best. Any reduction in bladder weakness is lost with more than 2 pregnancies, the scars become more dense, and rare complications can occur like invasive placenta.
  • Scarring inside after the Caesarean section can cause adhesions which can make later surgery more difficult. For instance a hysterectomy operation in later life is made trickier with a Caesarean scar on the womb.
  • You may be judged on your mode of birth.

 

Pain after different modes of birth

Page 45, NICE national guidelines, UK
Caesarean section (update). Clinical guidelines, CG132

http://www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf

 

Breastfeeding after C-section

NICE national guidelines, UK
Caesarean section (update). Clinical guidelines, CG132

http://www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf

 

Safety of elective C-section

Baby

http://www.ranzcog.edu.au/doc/cdmr.html

Clin Perinatol. 2008 June; 35(2): 361–vi

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2475575/

Mother

http://www.ranzcog.edu.au/doc/cdmr.html

Evidence for complications comes from the Term Breech trial, which compared vaginal birth with Caesarean.

 

References on Caesareans & maternal tissues & bladder weakness & other symptoms

http://www.ranzcog.edu.au/doc/cdmr.html

Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S. Urinary incontinence after vaginal delivery or cesarean section. New England Journal of Medicine 2003;348(10): 900–7

Farrell SA, Allen VM, Baskett TF. Parturition and urinary incontinence in primiparas. Obstetrics & Gynecology 2001; 97:350–6

Nygaard I. Urinary incontinence: is cesarean delivery protective? Semin Perinatol. 2006;30(5):267-71

MacArthur C, Bick DE, Keighley MR. Faecal incontinence after childbirth. Br J Obstet Gynaecol. 1997;104(1):46-50. 12

Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med. 1993;329(26):1905-11

Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ 1994;308:887–91.

Sultan AH, Stanton SL. Preserving the pelvic floor and perineum during childbirth – elective caesarean section? British Journal of Obstetrics and Gynaecology 1996;103: 731–4.

Sultan AH, Monga AK. Anal and urinary incontinence in women with obstetric anal sphincter rupture. British Journal of Obstetrics and Gynaecology 1997;104:754.

MacArthur C, Glazener C, Lancashire R, Herbison P, Wilson, D on behalf of the Prolong study group. Exclusive caesarean section delivery and subsequent urinary and faecal incontinence: a 12-year longitudinal study. BJOG: an international journal of obstetrics and gynaecology 2011;118: 1001–7.

http://www.iscgmedia.com/uploads/6/0/9/7/6097060/levator_trauma_after_vaginal_delivery.8.pdf

http://sydney.edu.au/medicine/nepean/research/obstetrics/pelvic-floor-assessment/Pelvic_Floor_Assessment/Publications_files/levdef%20prolapse%20BJOG%202008.pdf

 

 

Ethics & national guidelines on maternal request Caesarean section

RANZCOG, Australia

Caesarean Delivery on Maternal Request

http://www.ranzcog.edu.au/doc/cdmr.html

NICE national guidelines, UK

Caesarean section (update). Clinical guidelines, CG132

http://www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf

 

 

Discussing your birth

Discussion of the advantages and disadvantages of the various types of birth enables positive choices to be made, whether that’s a normal birth, C-section or VBAC.

 

Family size & C-section

If you’re going to have a large family eg. 3 or more babies, then the risks of Caesareans increase and the benefits decrease. Provided there are no problems then vaginal births are usually best.

 

Can I have my elective Cesarean section at 38 weeks?

This is sometimes asked. Generally speaking we prefer to do elective Caesarean sections at 39+ weeks. The main reason for this is that babies occasionally retain fluid on their lungs if the Caesarean is at 38 weeks. This can make the baby distressed and need extra oxygen, usually in an incubator. Occasional babies can unfortunately need help with breathing by a tube for a few days.

The risk of this breathing issue is about 6% at 38 weeks, and 3% at 39 weeks. There is a risk of breathing issues of about 3% in vaginal birth, so the 39+ week C-section risk is similar to vaginal birth.

However, there are sometimes medical reasons for having an elective Caesarean at 38 weeks, and here the benefits to the baby may outweigh the risks. If you really need a Caesarean at 38 weeks, then a reasonable compromise is to do the c-section a few days over 38 weeks, and perhaps use some steroids to help the baby’s lungs mature.

There is a chance of going into labour early if we book your C-section for 39 weeks. This risk is around 5-10%.

 

What happens in a Caesarean section at Glengarry Private Hospital, Duncraig, Perth?

Preparation

In the week leading up to the C-section birth, you’ll have your final antenatal appointment in our rooms near Glengarry Private Hospital in Duncraig, where our checks are completed and you get your plan for the day of birth. You’ll discuss in detail, & sign a consent form that describes the process, and risks of a Caesarean.

In the days before your elective Caesarean, you’ll have a blood test to check your blood count and check you haven’t developed any antibodies. You will have a face-to-face or telephone consultation with your anaesthetist. The night before your planned Cesarean, you’ll take a medication called ranitidine to reduce stomach acid.

On the day of your Caesarean, you’ll have another tablet of ranitidine in the morning. If the C-section is in the morning, you can’t have anything to eat or drink ie. You’re “nil by mouth”. If the Cesarean is in the afternoon, have a light breakfast at around 7am, with plenty of fluids, then nothing further – “nil by mouth” afterwards.

Come in to Glengarry Private Hospital at 7am for a morning elective Caesarean, or mid-morning for an afternoon elective C-section, where you’ll be checked-in. Don’t eat or drink anything.

The C-section itself

Most women have a combined spinal-epidural for their C-section. This usually gives excellent numbness for the operation, that can then be topped-up afterwards. We often leave it in for a day or two after the Caesarean, and this usually gives good pain relief, controlled by yourself.

epidural-spinal

Once you’re numb, we’ll lie you back on the table, clean your abdomen with antiseptic and place sterile drapes over you. Antibiotics are given. We always check to make sure you’re properly numb before starting. Occasionally the epidural is not effective; we stop the operation and top up. The anaesthetist will discuss with you beforehand what will happen in this instance. Occasional women will need a general anaesthetic, but this is rare in elective C-sections.

The C-section then starts. A 10cm incision is made horizontally on the bikini-line. The rectus muscles are not cut; we push in and stretch between the muscles to get to the womb.

The womb is incised on the outside and then stretched open with fingers. The scalpel does not usually come near the baby in an elective C-section (it can in a difficult emergency Cesarean when the womb is very thin and there is no fluid around the baby.)

Then comes the pushing on your upper tummy. This can be surprisingly strong, so be prepared. Once the baby is out (you can see the baby coming out if you wish), he or she is cleaned and wrapped up and handed over to you for a cuddle as quickly as possible.

Whilst you’re getting to know your new baby, we stitch everything back in place. Any excess bleeding is controlled. An under-the-skin stitch is usual, so there are no stitches or staples to remove. You’re cleaned and a dressing is placed on the incision (which is left on & designed to stop germs getting in.)

Note: sometimes in surgery, things don’t go to plan. The above is the most usual scenario by far, but everyone is different. Some women have difficult epidurals/spinals. Some have difficult surgery (especially if there has been surgery before). Sometimes, even at C-section, it’s difficult to get the baby out. We’ll discuss these possibilities with you in your appointments leading up to the birth, not to scare you, but to keep you informed.

Recovery after your Caesarean at Glengarry Private Hospital, Duncraig, Perth

Breastfeeding and skin-to-skin can start in theatre during the C-section, as long as it is safe, or immediately afterwards in your room.

The epidural is often left in place if you wish & it is safe, and you control your pain relief with a button. This means you can usually lift your baby. You’ll stay in hospital for a few days (most often 4 or 5 days), but you can go home earlier if you want, if all is well. The choice is yours.

The recovery period is variable and depends upon many factors. Women who have emergency Caesareans after long labours take longer to recover, as they have to recover from the labour and the surgery.

Pain relief after a Caesarean section

There are many options for pain relief after your C-section. Often women will choose to have a combined epidural and spinal anaesthetic put in for the Caesarean. This usually makes the operation comfortable; allows you to be completely awake and welcome the new baby; and gives the advantage of using the epidural for a day or two afterwards for effective pain relief. After the epidural is removed, painkillers like ibuprofen and Panadeine are usually used. Other options include strong painkillers directly into your vein through your drip.

 

 

Driving after your elective C-section

If recovery has been normal, many women can drive about 1-2 weeks after an elective Caesarean. Go to a quiet area and try an emergency stop from 50km/hr. If you can do this, and turn around to check your blind spot, then you’re safe to drive. Recovery after a C-section is variable. If you’re safe to drive, we’re very happy to supply you with documentation for your insurance company. However this isn’t usually required.

Exercise and Caesareans

Start your pelvic floor muscle exercises soon after the birth.

You need to build up exercise gradually after a C-section. You should be able to go on some short walks a week or so after your Caesarean. Listen to your body and build duration and briskness of the walks gradually.

Do some central “core” abdominal exercises while you’re standing. Hold yourself straight up – don’t stoop – and tighten your tummy muscles. The scar may “pull’ a little – this is OK.

Exercise that makes you out of breath like jogging, swimming or cycling can be very slowly introduced after about 3 weeks, but go easy. If it’s too much, wait and try again after another week or so.

Avoid strenuous exercise, weights, and sit-ups etc until after 6 weeks or so, and once again, introduce these exercises gradually and listen to your body.

C-section scar – bikini-line scar

The C-section cut is made in your natural skin crease just on the bikini-line (a Pfannenstiel incision). The Caesarean scar is usually about 10cm long. Initially, the scar will be red, and you should use sunblock if you’re out sunbathing. Occasionally, some scars become thickened. If this happens, silicon gel applied early can help – we can prescribe this silicon scar gel – it’s not very expensive. There is a new type of medical grade silicon gel available that can be applied even before healing takes place, for those at higher risk of a thickened scar. This new gel can be started a couple of days after the C-section. After 2 weeks, you then convert to the standard silicon gel. If we feel that you’re at very high risk for a thickened scar, we can inject some small doses of steroid directly into the scar at the time of the Caesarean which can help. This works by “dampening down” the body’s attempts to “overheal”. If you have another C-section, we usually use the same incision, and we can remove any thickening then if necessary.

 

 

Overall

The majority of women who have a private elective C-section have a good experience meeting their new baby. But, any surgical or invasive procedure carries risks. Before proceeding, you should do your own research. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner. For instance, your GP’s opinion will be very helpful.


Caesarean section

Give us a call for an appointment to discuss the risks & benefits.


PEARL obstetrics | gynaecology

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