A caesarean birth is one in which the baby is delivered through an incision made in the mother's uterus (womb). This information handout covers the specific question that is sometimes asked “I know there is no medical reason for it but I want to have a caesarean section”.
WHAT DOES SURGERY FOR CAESAREAN DELIVERY INVOLVE?
Caesarean delivery involves administering either a regional or a general anesthetic, making an incision either vertically or horizontally in the lower abdomen to expose the uterus, then making another incision in the uterus itself to allow removal of the baby and placenta. Other procedures, such as tubal ligation (sterilization), may also be performed during caesarean delivery. Because caesarean delivery involves major abdominal surgery, recovery generally takes longer than for vaginal delivery.
CAN I REQUEST A CAESAREAN DELIVERY FOR NON MEDICAL REASONS?
Yes. The concept of caesarean delivery on maternal request, also referred to as "patient choice caesarean at term" or "elective prophylactic caesarean delivery," is relatively recent. It is currently accepted in most Western countries that a pregnant woman has the right to make choices regarding her treatment, including method of delivery. Some experts have published opinions stating that an informed mother has the right to assume the extra risks of caesarean delivery if she chooses.
If you want to consider an elective caesarean delivery, discuss this with me. It is the doctor's responsibility to provide you with the facts about each method of delivery, the risks and benefits associated with each, both in general and in your particular case, and to offer his or her own assessment. You should also know that you can change your mind at any time.
WHAT ARE THE ADVANTAGES OF PLANNED CAESAREAN DELIVERY?
The advantages of a planned caesarean delivery include:
It allows parents to know exactly when the baby will be born, which makes issues related to work, childcare, and help at home easier to address.
It avoids some of the possible complications and risks to the baby that are present during a vaginal delivery.
It avoids the possibility of post term pregnancy, in which the baby is born two or more weeks after its due date.
It helps ensure that a pregnant woman's obstetrician will be available for the delivery.
It may offer a more controlled and relaxed atmosphere, with fewer unknowns such as how long labor and delivery will last.
It may minimize injury to the pelvic muscles and tissues and the anal sphincters. These injuries sometimes occur during vaginal delivery, and predispose to urinary and anal incontinence.
Researchers have not been able to establish reliable statistics regarding the percentage of fetuses that reach maturity in utero (in the womb) and who then experience a catastrophic event leading to neurological damage or death. Estimates range from 1:500 to 1:1750. Hypothetically, a planned caesarean delivery, which can take place anytime after the fetus reaches maturity, would avoid these events. There are, however, no studies in actual patients to use in making such as decision.
The benefits of planned caesarean delivery must be weighed against the risks. Caesarean delivery involves major surgery for the mother, and thus incurs the usual risks associated with such procedures.
WHAT ARE THE DISADVANTAGES INVOLVED IN CAESAREAN DELIVERY?
(COMPARED TO VAGINAL DELIVERY)
Because caesarean delivery involves major surgery and anesthesia, there are also risks associated with this method of delivery. Some of these include:
Is associated with a higher rate of injury to abdominal organs (bladder, bowel, blood vessels), infections (wound, uterus, urinary tract), and thromboembolic (blood clotting) complications than vaginal delivery.
Decreases the opportunity for mother-infant interaction in the delivery room.
Recovery may take longer than with vaginal delivery.
A higher risk of abnormal attachment of the placenta in subsequent pregnancies, which can lead to serious complications, such as bleeding.
Incising the uterus to deliver the baby weakens the uterus, increasing the risk of uterine rupture in future pregnancy. This risk is small, but not zero, and depends on the type of uterine incision.
WHAT SORTS OF COMPLICATIONS CAN FOLLOW CAESAREAN DELIVERY?
The major complications related to caesarean delivery are infection, hemorrhage (excessive bleeding), injury to pelvic organs, and thromboembolic (clotting) disorders.
The risk of postoperative uterine infection (endometritis) varies according to several factors, such as whether labor had started and whether the fetal membranes were ruptured. Endometritis is treated with antibiotics, rarely further surgery to drain an abscess or remove the infected uterus is necessary.
Wound infection, if it occurs, usually develops four to seven days after surgery, but sometimes appears during the first day or two. In addition to antibiotics, wound infections are treated by opening the wound to allow drainage, cleansing with fluids, removing infected tissue if needed, and close attention to subsequent wound care.
One to two percent of all women having caesarean deliveries require blood transfusion because of hemorrhage. Excessive bleeding may be due to uterine atony (lack of uterine contraction postpartum), retained pieces of placenta or fetal membranes, or lacerated vessels. Excess bleeding usually responds to medications that cause the uterus to contract. Sometimes surgery, such as curettage (scraping the uterine cavity through the vagina) is needed; a hysterectomy is rarely required if all other measures fail.
Injuries to the urinary or gastrointestinal tract are uncommon, occurring in approximately 1 percent of caesarean deliveries.
The leading cause of maternal mortality associated with caesarean delivery is deep vein thrombosis (DVT) leading to pulmonary embolus: blood clots forming in the deep veins of the legs that break off and travel to the lungs, causing respiratory distress or failure. This complication occurs more frequently after caesarean than after vaginal delivery. Prevention of DVT involves adequate pain relief and early ambulation (walking). Women at high risk of DVT may be given anticoagulant medication.
WHAT ABOUT RISKS TO THE BABY IN CAESAREAN DELIVERY?
There are fewer fetal than maternal risks from caesarean birth; the procedure is usually performed for the benefit of the fetus. These risks include prematurity and birth trauma; the latter occurs in 0.4 percent of caesarean deliveries. Transient respiratory problems of the newborn are more common after caesarean birth because some mechanisms to reabsorb lung fluid don't occur if the baby is not squeezed through the mother's birth canal. Another reason may be that the fetus is not fully mature.
WHAT KINDS OF ANESTHESIA ARE AVAILABLE FOR PLANNED CAESAREAN DELIVERY?
There are two types of anesthesia used during caesarean delivery: general (asleep) and regional (awake). For an planned caesarean delivery, both options can be considered, but regional anesthesia is the most frequently used. Regional techniques include spinal, epidural, and combined spinal epidural (CSE):
With epidural anesthesia, the anesthetic is injected into the epidural space surrounding the fluid-filled sac (the dura) around the spine. This partially numbs the abdomen and legs.
With spinal anesthesia, the anesthetic is injected into the subarachnoid space in the lower back. The space contains the cerebrospinal fluid, so the anesthetic causes complete numbness, but the patient is still awake.
General anesthesia induces unconsciousness. This means that the mother will not be able to experience the childbirth process. General anesthesia also carries greater risk of serious complications because an endotracheal (breathing) tube must be placed in the upper airway and the chances of aspiration, that is gastric contents getting into the airway, are higher.
Regional anesthesia is generally preferred because it allows the mother to remain awake so she can experience the birth and have immediate contact with her infant and because it is safer than general anesthesia. Many practitioners prefer spinal or CSE to epidural techniques because of more rapid onset and better blockage of pain. Your meeting with the anesthesiologist allows you to ask specific questions about anesthesia, and allows the anesthesiologist to identify any medical problems that might have important implications for the anesthetic plan. This meeting is particularly important for women with known disorders that affect administration of anesthesia, such as coagulopathy (clotting disorder), obesity, restriction or abnormality of the spine, or cardiovascular or respiratory disease.
HOW WOULD I PREPARE FOR A PLANNED CAESAREAN DELIVERY?
One of the most important factors in scheduling a planned caesarean delivery is making certain that the fetus is mature. In general, caesarean deliveries are not scheduled before the 39th week of gestation for this reason. However, there may be times when earlier delivery is recommended (eg. The placenta is failing).
Shaving. Please perform a mini shave of the pubic hair 1 week before a planned Caesar. This allows the incision to be easily placed in the hair line. Shaving before (rather than the day of surgery) reduces the risk of infection.
Anesthetist. Generally the anesthesiologist will recommend a Spinal or epidural block. If you have more complex problems, you may be advised to meet with the anaesthetist some weeks before the birth, otherwise he/she will discuss your options on the day of delivery.
Fasting. As with any surgery, you will need to fast beforehand, no food or drink for 6-8 hours prior to the procedure.
Admission. You will be admitted to the hospital ward some hours before the surgery.
Antacid. You will be given an oral dose of an antacid, usually sodium citrate, to reduce the acidity of the stomach contents.
Bladder. Please empty your bladder just before being taken to the theatre complex.
In the Theatre complex. An intravenous line will be inserted into your hand or arm, and before anesthesia is begun an electrolyte solution will be infused. You may also be given intravenous antibiotics to reduce the risk of postoperative infection, although these are often begun once the baby has been delivered and the umbilical cord cut and clamped.
Epidural/Spinal. If you are having a regional anesthetic, it will be inserted. You will begin to feel its effects within a minute or so. Your partner may be with you for the birth.
Monitors. When you are taken into surgery, monitors will be placed to keep track of your blood pressure, heart rate, and blood oxygen levels.
General Anaesthetic. If you are having general anesthesia an injection will be administered to begin anesthesia; you will fall asleep within 10 to 20 seconds and a tube will be placed to help you breathe. Generally, your partner may not be with you for the birth.
Bladder Catheter. I generally try to avoid catheter placement. Emptying your bladder just before going down to the theatre complex helps to avoid a catheter. On occasion, previous surgery or other factors may dictate that a catheter is placed in your bladder; if so it is generally removed within 24 hours of the procedure.
WHAT KIND OF INCISION WILL BE MADE IN MY ABDOMEN?
There are two basic types of incision: horizontal (transverse) and vertical (midline). A transverse incision is made below the pubic hair line. The advantages of this type of incision are:
Less postoperative pain during movement and breathing
A strong wound closure with low rates of wound dehiscence (separation)
A good cosmetic result. Transverse incision leaves what is often called a "bikini scar."
A vertical incision is made in the midline of the abdomen (up and down rather than sideways). I use this incision only occasionally when the delivery is anticipated to be complicated. I will tell you if I intend to perform a vertical incision.
WHAT ABOUT THE UTERINE INCISION?
The uterine incision can also be either transverse or vertical. The type of incision depends upon several factors, including the position and size of the fetus, the location of the placenta, presence of fibroids, and development of the lower uterine segment. The main consideration is that the incision must be large enough to allow delivery of the fetus without causing trauma.
The most common uterine incision is transverse. This offers the advantages of less blood loss, lower risk of bladder damage, easier repair with a faster closure time, and a lower incidence of uterine rupture during subsequent pregnancies.
I use a vertical (classical) uterine incision only occasionally when there are major complicating factors (eg. Fibroids or other pathology in the lower uterine segment preclude a transverse incision, the bladder is densely attached to the uterus, the placenta is attached to the lower front of the uterus, etc). I will let you know if it is my intention is to perform a classical incision.
HOW LONG DOES IT TAKE TO DELIVER THE BABY?
Once the uterine incision is complete, the baby is usually removed within a minute or two. After the baby is delivered, the umbilical cord is clamped and cut and the placenta is removed. Baby is then shown to you and passed to the Midwife for checking.
WHAT HAPPENS AFTER BABY IS DELIVERED?
You or your partner may hold the baby in the delivery room soon after the birth. After that, dad will go with baby to the nursery while you are sewn back up.
WHAT KIND OF SKIN STITCHES WILL BE USED?
The uterine and deep portions of the abdominal incision are closed with stitches. Generally I use a hidden self absorbing stitch (ie. No need for later removal). On occasion (eg. After removal of a previous thick scar) it may be preferable for the skin to be closed with staples.
WHAT HAPPENS DURING POSTOPERATIVE CARE?
After surgery is completed, you will be monitored in a recovery area for evidence of uterine atony (lack of uterine contraction), excessive vaginal bleeding, bleeding at the incision site, adequate urine output (oliguria), as well as routine vital signs (blood pressure, temperature, breathing).
You will also be provided with adequate medication for pain. Initially this is likely to be a PCA (Patient Controlled Analgesia) which is a drip containing pethidine. You press a button when you feel pain and a small amount of pethidine is delivered to you. Pethidine is a good analgesic but may cause some light headedness and nausea. When used in combination with Voltaren, most patients need the Pethidine for less than 24 hours
You will also be started on non-steroidal anti-inflammatory agent such as Voltaren as a regular suppository twice a day. Using the Voltaren twice a day regularly for three days is an excellent form of pain relief. It is best to use a pain killer before you experience pain, rather than waiting for the pain to build up. Using the voltaren regularly as a suppository is an excellent form of pain relief and allows most women to recover quickly.
You may begin breastfeeding the baby anytime after the birth. A pediatrician will examine the baby and speak with you within the first 24 hours of the delivery. Hospital discharge is typically within a 4-5 days of the delivery.
Your abdomen will heal over the next few weeks. During this time you may have mild cramping, light bleeding or vaginal discharge, wound pain, and numbness in the skin around the incision site. For several weeks after the birth, you should not place anything in your vagina, lift heavy objects, or do any strenuous activity. Most women will feel well by six weeks postpartum, but incisional numbness and occasional aches and pains can last for months. Massaging the wound with sorbolene for 10-20 mins per day after a few weeks may hasten resolution of wound numbness.
WHEN CAN I DRIVE?
The main factor is whether you can apply sufficient braking force without reflexly pulling your foot off the brake pedal because of wound pain. For some patients they may be able to drive after 2-3 weeks, for others it may be six weeks. When you are ready to drive I suggest test yourself out by applying sudden firm pressure on the brake pedal whilst sitting in the driveway of your home.
ONCE I'VE HAD ONE CAESAREAN DELIVERY, WILL I HAVE TO DELIVER THIS WAY IN FUTURE PREGNANCIES?
Although decades ago it was assumed that one caesarean delivery meant caesarean delivery for all future pregnancies, this is no longer the case. Most women who have had one low-transverse caesarean delivery can attempt vaginal delivery in subsequent pregnancies; 50 to 80 percent result in successful vaginal birth.
The American College of Obstetricians and Gynecologists published a set of guidelines that are useful when considering whether a women with a previous caesarean delivery should attempt vaginal delivery. Considerations include:
The woman should have had only one or two prior caesarean deliveries
The woman should have a clinically adequate pelvis, meaning bone structure that allows for successful vaginal delivery
No other uterine scarring or previous ruptures should have occurred
A doctor who is capable of monitoring labor and performing a caesarean delivery should be available throughout active labor.
Personnel required for an emergency caesarean section, including an anesthesiologist, should be available.
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