Caesarian sections: the how and whys

Planned caesarian section
If during pregnancy your doctor decides that attempting a vaginal birth would be unwise for the health of either you or your child then you will be advised to have a planned caesarian. There are many reasons why your doctor might think this is necessary including:

• Placenta praevia or low-lying placenta
• You are suffering from pre-eclampsia or have very high blood pressure
• The baby is too big for your pelvis
• A multiple birth where one or more of the the babies' positioning is awkward, or where there are three or more babies to be delivered
• The baby's position is breech (bottom first) or transverse (sideways)

Emergency caesarian section
An emergency caesarian section may be necessary if you have a medical condition that rapidly deteriorates and threatens either your, or your baby's, health, such as pre-eclampsia or placental abruption. An emergency section may also be necessary once labour has actually started, common reasons include:

• If progress in labour is unduly slow and either mother or baby are becoming very tired
• If the baby becomes distressed in the course of labour and birth is not imminent
• If the mother's blood pressure becomes high and doesn't respond to drugs
• If there is abnormal bleeding
• If the umbilical cord becomes wrapped around the baby's neck and there is a risk of strangulation at birth
• If the umbilical cord emerges through the cervix and so risks being constrained as the baby comes out, so cutting off the baby's oxygen supply

Elective caesarian
C-sections are not a minor operation, they cost significantly more than vaginal births, carry a higher risk for the mother and take longer to recover from physically: For those reasons many doctors may be reluctant to allow elective sections. Some women may wish to opt for a c-section to avoid giving birth vaginally for cosmetic or convenience reasons. However, for some women there may be a deep-seated anxiety about vaginal birth, perhaps due to an unpleasant experience with a previous labour but also possibly due to psychological reasons.

The operation

Anaesthetic
Most c-sections are performed under either an epidural anaesthesia or a spinal block. Both of these involve the administering of anaesthetic to the spine via a very thin, curved needle and, in the case of the epidural, a catheter. Both allow you to be awake for the duration of the c-section so that you can hold your baby as soon as he or she is delivered. The spinal block may be chosen if time is short and an epidural has not already been administered as pain-relief as it is faster-acting than the epidural.

In an emergency a general anaesthetic is usually the favoured option, in which case you won't be awake for the operation and it will usually be about half an hour before you come around afterwards, and another half-hour until you can hold your baby.

In the case of spinal anaesthetics your partner will probably be allowed into the operating room to be with you throughout to provide support and even to witness the operation if he wants. If a general anaesthetic is required or requested then your partner will probably not be allowed into the theatre.

Procedure
Your midwife will probably accompany you into the operation to provide support and perhaps to talk you through what's happening. Even if you are not under general anaesthetic, you probably won't be able to see the operation yourself because a screen is put up across your abdomen. That said, if the positioning of the metal surgery lights might allow you a peak at the reflected goings on if you're really keen to see.

After disinfecting the area, the surgeon makes an incision in the abdomen, just above your pubic bone, to reach the uterus. This cut is commonly known as the bikini cut. The surgeon then cuts through the uterine wall in the lower section where the uterus is stronger for more effective post-operative healing and exposes the sac of fluids protecting the baby. After carefully cutting through the bag of waters, the baby is lifted out before the umbilical cord is clamped and cut. The whole thing will probably take only about ten minutes.

Once delivered your baby is given a quick health check before being handed to you or your partner for holding while your placenta is delivered and you are stitched up. You may even be able to attempt breastfeeding your baby now if you feel up to it, although you may equally want to wait until you are out of theatre. Unsurprisingly the stitching up part takes quite a bit longer than the cutting open, not only are there several layers to be stitched, but doing a really good job is important for future pregnancies.

Possible risks involved
C-sections are these days conducted with great frequency and by and large the procedure is a safe one. However, like any major operation it is not entirely risk-free and while c-sections are often carried out to decrease the risks posed for a baby, the risks for a mother are greater than those of a vaginal birth. Figures from the NHS present c-section as three times more likely to result in a fatality for the mother than a vaginal birth, however, the fatality rate is still very, very low and you need to remember that c-section is often embarked upon because of a pre-existing medical condition.

• Anaesthetics - General anaesthetic poses the greatest risk to the mother, however, it is still very safe, especially given modern monitoring aids. The greatest risk posed by general anaesthetic is inhaling stomach acid, which is why you will have food and drink restricted and given antacids before a general anaesthetic. It's important to be honest about what you have had to eat and drink when a general anaesthetic is discussed
• Deep vein thrombosis - As with other operations, c-section carries a post-operative risk of DVT, a blood clot forming in a vein or lung. Encouraging circulation through moving around will help decrease the risk
• Severe bleeding - C-sections do usually involve more blood loss than a vaginal delivery, however, your surgeon will be careful to minimise blood loss are far as possible and it's very rare that blood loss is so great that a transfusion is needed
• Injury to the bowel, bladder and uterus - in rare cases the bowel bladder or uterus may be affected by scar tissue following a caesarian and require a further operation
• Infection - As with any other operation it is possible that you may suffer an infection of the caesarian wound but antibiotics are routinely given as a preventative measure
• Disruption to breastfeeding - Some women may find that abdominal discomfort and general recovery time following the operation make breastfeeding more difficult. However, there are recommended positions for adapting to feeding after a c-section and many women find it presents no extra difficulty at all