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The caesarean procedure

This section deals with the beginning to end caesarean process, be that an elective caesarean or an emergency caesarean. The exception is the first section - pre-surgery which applies only to an elective caesarean.

Pre-surgery (for an elective caesarean)

You will be given a blood test up to 7days prior to your scheduled caesarean. This is to check your haemoglobin levels. It is looking for anaemia (low iron levels) and will also check the blood group. The need for transfusion is rare.

You will be advised not to have any food after your last meal the night before the surgery (certainly not beyond midnight). The recommendations vary from one hospital to another, but generally you can drink water to within two and a half hours of the surgery. Avoiding food and drink (other than water) helps to ensure that you have little or no gastric fluid in your stomach making surgery easier and reducing the likelihood of the surgeon nicking other organs. It is likely that you will be given an antacids to assist with this and you will need to take the first one of these the night before the surgery.

You will be advised to report to the hospital at a specific time. You should stick to this time, as schedules are often tight. It is worth remembering that as you are a scheduled caesarean you will take second place to any emergency that occurs on the day.

On the day

You will be given an identity bracelet to wear until you go home.

You will take your second antacid on the morning of the surgery. At this time you will also have an anti-nausea tablet to take.

You will be given a gown for theatre and in most cases you will be given knee length surgical stockings (or inflatable gaiters). These are to reduce the likelihood of a Deep Vein Thrombosis (DVT). You may also be given a blood thinning agent to assist with this.

Your pubic area will be shaved. If you have not done this in advance a nurse will do this for you. Unfortunately it is often done with a Bic razor and without shaving cream so you may want to arrange for this to be done prior to your arrival at hospital. The incision is in your bikini line so there is no way you can avoid a shaving.

You will be asked to sign a consent form (you are sometimes asked to sign this at your last check-up rather than on the day). It will ask you to confirm that you have been fully informed about the procedure and it's risks. It will probably then also ask you to recognise specific risks namely infection, bleeding, damage to bladder / bowel and clot formation. This all sounds very scary and even when you have done all the research in the world and you know that the likelihood of such things occurring is very rare, it can cause moments of doubt and panic. It is normal to feel like this - you are having major surgery.

You will be asked to remove:

Anaesthesia

IMPORTANT: we only cover the general points here, it is important that you seek full medical advice when deciding which type of anaesthesia most suits you. If you have an elective caesarean you will be encouraged to speak with an anaesthetist in any case.

As a general rule you will be given a choice between the following types of regional anaesthetic. 80-90% of women opt for one of these 15:

Regional anaesthetics act upon the nerves in a specific location and block all nerve signals to and from that area, creating a numb sensation. With this form of anaesthetic you can be awake throughout the whole procedure. You are usually able to see your baby the moment he / she is born and touch them, and in some cases hold them, within minutes of them being born. Some women have been known to breastfeed while on the operating table, however this is very rare.

For an elective, awake caesarean a spinal is becoming the preferred choice in the UK because it is a single injection. It is quicker, easier, less painful to administer and uses a lower dose of local anaesthetic yet produces a denser blocking effect 6. It is not possible to top up a spinal (it lasts at least 1.5 - 2 hours - far longer than a straightforward caesarean).

An epidural is a very fine catheter through which the anaesthetist can easily top up the anaesthetic ensuring that the numbing effect can be maintained no matter how long the procedure goes on for (hence why it is also used during normal labour).

Many women now request a combination of the two.

You should note that with a regional anaesthetic there is a risk of:

On occasions it is necessary to use a general anaesthetic. This is only typically used in some emergency situations or where the other forms of anaesthesia are not working. A general anaesthetic is administered through a drip. You will be fitted with an oxygen mask and the anaesthetist will apply pressure to your throat (this is to stop stomach acids regurgitating as you drift off to sleep). Once asleep a breathing tube is inserted into your mouth. Once the surgery is complete you will wake and feel drowsy for the next couple of hours. A general anaesthetic crosses the placenta and will make your baby drowsy. It is partly because of these rare occasions where a regional anaesthetic may need to be converted to a general that it is necessary to not eat prior to the procedure. It also presents a fractionally higher risk of bleeding and clotting for you 15. This is why it is only typically used in specific emergency situations. After the surgery you will be given a patient controlled analgesia which you can administer by pressing a button, alternatively you may be given morphine injections as required.

In order to make a decision about the type of anaesthetic you want to use you should make an appointment with your anaesthetist 4-5 weeks before the surgery to discuss options. At that time the anaesthetist should go into great detail about the pros and cons of each option. They should also give you information to take away to read. It will go on your medical notes at that time that you have had a consultation with the anaesthetist. We would suggest that even if you are hoping for a vaginal birth it is worth having such an appointment as epidurals could be very useful in a vaginal delivery or your labour may alter such that it becomes necessary to have a caesarean.

The most common position for administering the spinal or epidural appears to be sitting up, with your ankles at the foot (or over the side) of the bed, knees spread out and your body curved over a pillow or with your hands in front around your knees or holding your birth partners hands. Some anaesthetists do prefer to use a lying down position, usually right side down, as you will be tilted left side down during the surgery.

The anaesthetist should talk you through their actions so that there are no surprises. For a spinal and an epidural it's important not to move. Typically the anaesthetist will numb the area where the spinal or epidural needles are to be inserted. On inserting the spinal or epidural needle you will feel pressure on your spine and maybe a slight tingling. It is not usually painful, just pressure. The effect is quite quick and you will start to lose feeling in your lower half. You will then be helped to turn fully onto the table.

Testing anaesthetic success is obviously very important. There are strict protocols to ensure the best success. The test is usually conducted using an alcohol spray or ice, it is not simply a pinprick. First the anaesthetist will spray it on your arm or shoulder so that you can register a cold sensation, they will then spray in stages up your abdomen and onto your chest asking you to state when you can feel the cold sensation. You should only be able to feel it once it reaches your chest. Once the anaesthetist is confident the block is successful the surgeon will carry out an additional check by pinching the site of the incision using a clamp. This may feel like a dull pressure but there should be no pain at all by this point. If there is, say so.

There are a number of websites that offer far more detail on the types of anaesthesia 13. is a particularly clear one.

Set up

In the theatre there will be a number of people and a lot of technology. It is worth reminding yourself that this is all to make surgery go as smoothly as possible.

If you do a hospital visit as part of your antenatal classes it is worth asking them to show you a typical theatre prior to the procedure so that the technology in the room is not a surprise when you do arrive on the day.

People you might see in theatre:

A drip will be inserted into your arm or hand. This will be used to provide you with extra fluids during the surgery. This remains in place throughout to allow the anaesthetist to administer extra/other drugs if required. For example, a drop in blood pressure (hypotension) might make you feel sick. Tell the anaesthetist that you feel sick and they can alter your drugs to remove this sensation without affecting your anaesthetic.

Antibiotics will also be administered. This helps reduce the likelihood of infection. It is also thought to reduce the incidence of endometriosis by two thirds to three quarters as well as show a decrease in incision site infections 7.

Monitors will be attached, these will include: leads for your heart monitor and a clip over your finger to monitor blood pressure (or a cuff may be used).

You will be helped to lie flat on your back and your birth partner will be seated at your side next to your head.

A catheter is usually inserted to empty your bladder during the surgery. Occasionally it may be inserted while on the ward before you are wheeled to theatre. However in most cases you can walk to theatre and it is inserted after the anaesthetic has taken effect, if you would prefer this, say so. The catheter is likely to remain in place for several hours (this should be no more than 12 hours 27) This is to remove the need for you to try to walk to the toilet. Its removal is usually painless. While the use of a catheter is not mandatory (and there is a connection of its use with increased likelihood of urinary infections), it is advisable as it helps to reduce the likelihood of the surgeon nicking the bladder. In addition, in the first hours after your caesarean you will probably not be able to easily walk to the toilet.

Iodine is wiped all over your abdomen to sterilise the incision site.

A screen will be raised over your chest. This is to help prevent both you and your birth partner from observing the surgery. This screen will be lowered slightly as your baby is born so the surgeon can hold your baby up for you to see before he / she is taken to another part of the room to be cleaned, checked and weighed. If your baby is breathing it may be possible for your birth partner to hold your baby before he / she is taken away to be checked. You may want to check in advance that your baby will remain in theatre with you, they usually do. No matter how curious you or your partner is, it is advisable not to look over the screen while the caesarean is in progress. If you really want a record of the surgery you can describe this in the birth plan. I is unlikely that you will be permitted to video tape the surgery, but you can ask to have photos taken.

The Incision

The skin is cut in a slight curve along your bikini fold line, usually a distance of about 20cm. The muscles are not cut. A surgical knife is only used to:

Each of these cuts are then extended "bluntly" (i.e. torn) usually using a finger. There is a lot of evidence that tissue that has been torn rather than cut heals better.

Once the skin has been cut, the abdominal/rectus muscles underneath are separated, not cut. If ever it is necessary to cut muscle, this is usually done along the direction of the muscle, so that the fibres of the muscle can, on the whole, remain intact.

On very rare occasions it may be necessary to perform a vertical incision in the abdomen and here muscles will need to be cut. However this is extremely rare and only in cases where the normal incision area is inaccessible due to: large fibroids; significant dense scar tissue from previous abdominal surgery (i.e. previous caesareans); a highly vascular area due to placenta praevia; there are foetal malformations (e.g. conjoined twins); cancer of the cervix; your baby's in a transverse position (i.e. your baby's back is down) for which a lower uterine segment incision cannot be safely performed. In this latter case there are a number of activities which you can try to help turn your baby prior to the caesarean thereby avoiding a vertical incision.

Surgery

The whole procedure should take around 30-45 minutes, with your baby being delivered in the first 5-10 minutes. The remainder of the procedure is stitching you back up. However the set up time prior to this might take as much as an hour.

Once the incisions have all been made, the fluid that helped cushion your baby in the womb (amniotic fluid) is suctioned away and the surgeon will lift your baby out through the opening. At this point your baby should be lifted up and shown to you before being taken to another part of the room to be checked.

The sensations often described for the delivery of your baby are tugging or rummaging. If the anaesthetic is working properly it is no more than this. There should certainly not be any of the sharp pain that you would expect to associate with a knife cut.

You may feel sudden pressure on your lungs, this is simply downward pressure being exerted on your upper chest to help push your baby out. It will be over quickly and some women are not even aware of this. It is actually advantageous to your baby as it helps compress their lungs in preparation for breathing in a similar way to delivery through the birth canal

You will be given oxytocin to help your uterus contract so that the placenta can easily be removed. A suction tube will remove all the excess fluid that remains in your abdominal cavity. Then the surgeon will close the incision layer by layer.

Dissolvable stitches are used internally. However you can request dissolvable stitches for the outer layer too. These are commonly used in hospitals now, though on occasions surgeons may opt to use small metal staples for the outer layer and these will be removed before you leave hospital.

A pressure bandage is put over the incision. This extends across your whole abdomen and is fantastic for making you feel like everything is being held in place.

When the surgery is complete, you, your birth partner and your baby will be taken to a recovery room for around 30 minutes. Here a nurse and midwife will closely monitor you before releasing you back onto the ward.

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