C-section(or Caesarean Section)
What is a c-section?
Caesarean section, also known by the American term c-section, is an operation where a baby is delivered through an abdominal wound. There are variations on how a c-section can be performed. This is because the uterus has two parts: the muscular upper part of the uterus, and the elastic lower part.
The muscular upper part of the uterus tends to heal poorly after it is cut, and the scar that forms is not very strong. The contractions of a subsequent labour, or even just the practice contractions of late pregnancy, can break this scar tissue.
The elastic lower part of the uterus heals much more effectively, and is less likely to tear during another labour. Most c-sections are performed through this lower segment.
Indications for emergency c-section include
Failure to progress during labour
Obstructed labourCan overlap with failure to progress. If the labour progresses poorly or reaches the point of absolute obstruction, c-section is indicated.
Foetal distressThe baby can be seen to be at risk during labour and demands urgent delivery.
Antepartum haemorrhageBleeding before labour from a normally or abnormally placed placenta.
Failed assisted deliveryIf we plan assisted vaginal delivery, we expect to succeed. But if there is any doubt, an assisted delivery is best done in theatre. This way, there is immediate access to an emergency c-section if required.
Failed inductionIf we induce labour, but labour does not occur.
Indications for elective c-section include
Repeat c-sectionA previous caesarean delivery is the most common reason for an elective c-section. There are risks associated with attempting a vaginal delivery after a previous c-section, although vaginal delivery is still possible.
Breech positionIf a baby has its bottom (breech) rather than head entering the pelvis, and it is hard to turn.
Transverse lieTurning is usually not an option when the baby is lying sideways in the uterus.
Placenta praevia / vasa previaThe placenta may be low in the uterus, so when the cervix dilates in labour it can trigger severe bleeding. If the placenta is known to be low, it may lead to a c-section before labour.
TwinsIt is possible to deliver twins vaginally but is an uncommon practice these days.
Stress incontinence or fistulaSometimes, as a consequence of past delivery, there are significant pelvic floor problems. In this case, it may be risky to aggravate those injuries with repeat vaginal delivery.
Growth restrictionA baby that has grown poorly will often not cope well with labour, and c-section is preferred.
MacrosomiaIf the baby is clearly very large, c-section may be indicated. Our capacity to predict the size of the baby, even with the best scan, is still not that accurate. That said, it may be possible to deliver even a big baby vaginally.
Maternal requestI strongly believe it is the woman’s right to choose how she wants to deliver. If that is by c-section, I support it. I will always ask why that decision is being made, because it may be based on erroneous information.
How long does a caesarean section take?
The actual operating time for a caesarean section is usually around half an hour. The baby is commonly delivered in less than five minutes for a first c-section. For a second c-section delivery, the timing is only a little longer.
The total time in theatre at SJOG Murdoch is usually around two hours. This includes the pre-op holding bay, administration of anaesthetic, operation, and recovery.
Elective c-section recovery
There are a few things to consider with c-section recovery:
The skin wound will seal itself within the first 24 hours. I take a proactive approach to try to avoid keloid scarring:
- I use a removable nylon thread suture that can easily slide out five days after the operation.
- After the stitch is removed, I use a long-term dressing to exert vertical pressure on the wound and to take lateral tension off the wound.
Bleeding after c-section
An advantage of c-section delivery is the opportunity to check that the cavity of the uterus is empty of any tissue from the pregnancy. This is something that you cannot do after a vaginal delivery. As a consequence, “lochia”, the normal bleeding that can last for weeks after delivery, is shorter.
Heavy bleeding after delivery is a common obstetric problem. Statistically, it is recognised as more common during and after c-section. There are two reasons for this:
- Large blood vessels are cut when opening the lower segment of the uterus. The time it takes your doctor to close the wound influences blood loss.
- When the c-section is decided upon for failure to progress, the labour has been going for a long time. The uterus is exhausted by the time the c-section is carried out, which influences blood loss.
With an elective caesarean section is done outside of labour, heavy bleeding is uncommon.
Swelling after a c-section
The healing process after a c-section will usually produce a modest amount of local swelling around the wound.
The abdomen is swollen after the delivery. This reflects how the pregnancy itself stretches the abdominal wall. The muscles of the abdominal wall will have poor tone after the delivery, but time and exercise will improve this.
Because of the way the abdomen is opened at caesarean section, the muscles are still strong immediately after the operation. There are no limitations on your activity and you can exercise how and when you like after the operation.
While the wound may be strong, it is sore and will become more so with activity.
The anaesthetist will provide medication for pain relief after the operation. My preference is for patient-controlled epidural anaesthesia for a day or two after the operation. This provides excellent pain control while minimising the amount of strong pain medication in circulation. Therefore, you will have minimal pain and minimal side effects.
In every c-section, I will always try to make the smallest wound that I can. I also use a particular stretching method to open the wound, that requires minimal cutting and therefore less trauma.
With a strong abdomen and little pain, early return to normal activity and exercise is very possible.
One of the significant advantages of c-section is that it causes minimal damage to the pelvic floor. Prolapse, therefore, is less likely to be a problem.
Risks of c-section
There is some risk associated with c-section, although it is low. An elective caesarean section is the procedure with the lowest risk and most predictable delivery outcomes. A half-hour operation with well-controlled pain, and a very good outcome for both mother and child.
Vaginal delivery may be much better — but it may also be much worse — depending on how your labour goes.
Risks to the mother include
BleedingInfection can occur as a delayed event in the uterus after any delivery. It is less common after a c-section because we can check that the uterus is empty. Wound infection is always possible. However, it is uncommon and usually superficial and trivial.
InjuriesThere is a risk of injury to other internal organs. The most common is bladder injury, particularly in repeat c-section. If recognised and managed, this usually means that catheter use extends from the usual 24 hours to up to a week after a c-section. Long-term problems are rare.
ClotsClots in the legs, which can potentially lead to clots in the lung, are a potential risk of any surgery. We take steps to minimise that risk throughout the time of the operation. You also play an important part by mobilising yourself early after the operation.
InfectionBleeding is a common result of a c-section. Contributing factors include the specific situation of the c-section and who performs the operation. It is very uncommon to see major bleeding problems in my patients with an elective c-section.
Subsequent labour riskThe scar on your uterus, even in the lower segment, is at risk of tearing during subsequent labour. Rupture is not common, but is potentially dangerous, primarily for the baby.
AccretaAfter a c-section there is an increased chance that, in a future pregnancy, the placenta will implant in the area of the old scar in the uterus. If this happens, it will often attach to the scar and create a complicated pregnancy. This may result in a complicated delivery. In this case, there may be need for a hysterectomy to manage the placenta that has invaded the uterus. This remains a very uncommon event.
Risks to the baby include
Labour causes some acute stress response in the baby that turns on the hormones that mature its lungs. Elective caesarean section is usually done around a week before the due date. Because the delivery is a little early and without labour, the baby can have some problems with its lungs after birth.
Most commonly, there is no effect at all. On rare occasions, however, the baby will require transfer to a neonatal nursery for ventilation. Even in the most severe situations, it is very unlikely to have any long-term effects. It may simply mean that the baby spends up to a day in the St Mary’s nursery.
InjuryThe baby may suffer some trauma during delivery. There may be minor bruising of the face from moving the baby through the abdominal wound. Rarely, the baby may be cut when opening the uterus, but this is more common when the baby is breech.
Long-term health issuesSome publications raise questions about the long-term health of babies born by c-section. This includes a possible increase in the risk of asthma. The reports are inconsistent and the changes reported are small. This position may become clearer over time.
Are you not sure if you should choose a c-section?
The decision to have a c-section can be very complex. Often the events of the pregnancy or labour will dictate the necessary outcomes and decisions.
We will consider all of the complexities during your pregnancy care. Together, we will make the best decision we can.