Special delivery: understanding Caesarean sections

BAVINA SOOKDEO

CAESAREAN sections (C-sections) are the most common surgical procedure worldwide, with approximately 21.1 per cent of births occurring this way. Rates vary regionally, with Latin America and the Caribbean reporting as high as 42.8 per cent of births via C-section.

A C-section is a surgical procedure that allows the delivery of one or more babies through an incision in the mother’s abdomen and womb.

April is C-section Awareness Month, during which the complexities, benefits, and challenges of this widely performed surgical procedure are highlighted.

Dr Reiaz Mohammed, a medical doctor with 24 years of experience and a member of the Royal College of Obstetricians and Gynaecologists since 2008 said a C-section is performed when vaginal delivery poses a higher risk to the mother or baby. It can be elective (planned before labour) or an emergency procedure.

“Elective reasons include if the baby is in the wrong position, is too big, multiple pregnancy, if the placenta is too low down, if there is any obstruction to the cervix (for example, from a fibroid) and if the mother has certain medical conditions or infections that will make a vaginal delivery riskier.”

He said the most common reasons for an emergency C-section are when the baby is in distress or if labour is not progressing as it should.

“A small but increasing number of Caesarean sections are also done for 'maternal request', in the absence of a medical indication,” he noted.

Mohammed, a UWI graduate, works out at Gulf View Medical Centre in La Romaine. Since performing his first Caesarean in 2003, he has successfully carried out hundreds of these procedures throughout his career.

He said there are two types of anaesthesia used in C-sections – general, where the patient is asleep; and regional, where the patient is awake but is administered an injection into the spine through the back. Regional anaesthesia is generally preferred as it reduces blood loss and minimises breathing problems in the baby.

“It also has the advantage that the patient is awake to witness the birth of the baby and breast feeding can start earlier.

“The patient is also pain free for a few hours after the surgery until the effects of the anaesthesia wears off. General anaesthesia can be done more quickly than regional anaesthesia, so in certain cases when the baby needs to be delivered immediately, this type of anaesthesia may be used.

"Each patient and each case is different, so the anaesthetist will guide you as to which form of anaesthesia is safer for you.”

The procedure

A C-section takes place in an operating theatre under sterile conditions and involves:

- Insertion of an intravenous line and urinary catheter. The catheter is removed about 24 hours after the surgery.

- Cleaning and draping of the abdomen.

- A ten to 20 cm transverse incision (left to right) in the lower abdomen is made, in some cases a mid-line vertical (up and down) incision may be needed to gain access to the baby. “Several layers of tissue are cut through before the uterus becomes visible. The urinary bladder which is located in front of the uterus is carefully dissected and kept away from the operating field to minimise the risk of bladder injury.”

- Once the uterus is open the amniotic sac becomes visible and it is then ruptured. “The surgeon’s hand is placed into the uterine opening to locate either the baby’s head or legs. The baby is then delivered with the aid of some pressure applied to the top of the womb, known as 'fundal pressure.' Patients who are awake may experience some discomfort (but not pain) at this point.”

- The umbilical cord is clamped, and the baby is handed over to medical staff.

“Special instruments are used to help decrease the bleeding from the womb and it is repaired in two layers using dissolvable sutures. Careful inspection is then done to ensure that there is no bleeding. The layers that were opened are now closed, with the last layer being the skin. Some surgeons use dissolvable sutures for the skin, while other use non absorbable and will require removal ten to14 days post-op. The entire procedure takes about 40 minutes to one hour.”

There is a very small increased risk that babies delivered via C-sections may develop asthma later in life – one in 55 versus one in 67 with vaginal birth.

“There is also a higher incidence of childhood obesity (one in 22 versus one in 25 after vaginal birth) and an increased risk that the baby can die in the first 28 days of birth (one in 2000 versus one in 3300 after vaginal birth).”

And, as with any type of surgery, there are advantages and disadvantages.

“It is important for the patient to have the information necessary to make an informed decision to provide consent for the procedure.”

Advantages

• C-sections minimise the need of forceps or a vacuum to assist in the delivery of the baby.

• It eliminates the possibility of tears to the vagina or perineum (the area between the vagina and anus).

• The incidence of urinary incontinence is lower in women who have had C-section – 28 per cent versus 49 per cent in women who have had vaginal delivery.

• A planned C-section also allows couples to plan the date and approximate time of delivery.

“This can be useful for religious reasons or scheduling for work.”

Disadvantages

• Post-operative pain and limited mobility

• Infection risk (two to seven per cent of cases)

• Increased risk of hysterectomy due to heavy bleeding (one in 670 versus one in 1,250 for vaginal births).

• Risk of injury to the bladder or bowel, especially with repeat C-sections

Preparing for a C-section

“Traditionally, in cases of elective C-sections, patients have been advised not to have anything to eat or drink from midnight. Most recent protocols have suggested that patients be allowed solid food up to six hours before the surgery and clear fluids up to two hours before the Caesarean.”

Individuals should also avoid using makeup, lotions and nail polish. All jewellery should be removed prior to the procedure.

“One of the most important factors for a patient to be mentally prepared is to be aware that all pregnant patients, even if they have had a prior vaginal delivery, can need a Caesarean section.

“Being aware of the procedure and what to expect can make the experience less daunting. Lamaze classes are a good resource to help you prepare for either type of delivery. It is quite common to feel fear, anxiety, disappointment and even guilt especially if you had hoped for a vaginal delivery. It is important that you discuss these feeling with your partner, family, friends or a therapist.”

Post-Caesarean expectations

• Regional anaesthesia effects: Temporary numbness in the legs

• Pain management: IV or injection pain relief

• A catheter will drain the bladder

• Vaginal bleeding: Normal after a C-section

• Abdominal cramps: Due to uterine contractions, especially while breastfeeding. You will likely have a bandage on your lower abdomen where the incision was made.

• Recovery monitoring: Regular checks of vital signs and womb contraction.

“Mentally, there is no ‘correct’ way to feel after a Caesarean, and no mother should feel guilt about her emotions.”

He said hospital stays last two to three days and it takes about six weeks to feel completely better.

Factors that may slow recovery include:

• Midline incisions (more painful than transverse cuts)

• Obesity or diabetes

• Lack of post-surgical support.

When it comes to dietary and lifestyle modifications to help the recovery process, Mohammed insisted that individuals keep hydrated.

“Aim for two to three litres of water per day. This helps prevent blood clots, aids in milk production, lowers the risk of constipation and speeds up the recovery process.”

He urges new moms to ensure they have a high protein, high fibre, low sugar diet.

“You may also be recommended vitamins to help with recovery and breastfeeding.”

He said gentle activity is recommended as it aids circulation and boosts recovery.

“Avoid heavy lifting and weight bearing exercises.”

Trying to get enough rest can be a challenge with a newborn, but it is an important factor in the healing process.

“If possible, you should try to have some help at home at least for the first two weeks, this is also very important for your mental well-being. If you are diabetic, it is important that your blood sugar levels are well controlled.”

Painkillers are prescribed based on discomfort levels and allergies. Mohammed advises using the medication around the clock as prescribed by your doctor. “Don’t wait for the pain to come on and then use the medication, as this will result in a lot of discomfort while you wait for the medication to work.”

He said one of the most common misconceptions surrounding C-sections is that the new mother will have to be on bed rest for six weeks.

"Although rest is important, light physical activity is important and encouraged as it helps with the recovery process. Some patients falsely believe that you won’t be able to breastfeed. After a Caesarean, breastfeeding is encouraged and patients who have regional anaesthesia can start breastfeeding as soon as the surgery is over."

Inability to go up stairs is another common misconception.

"As long as you take your time and have support there’s no reason to avoid stairs.”

Future pregnancies

If a woman has a C-section, will all her future deliveries have to be via C-sections?

“Not necessarily," Mohammed said.

Women with a lower segment Caesarean may opt for:

• Vaginal birth after Caesarean (VBAC) which has a 72-75 per cent success rate (85-90 per cent if they previously had a vaginal birth)

• Elective repeat Caesarean section (ERCS), typically scheduled one to two weeks before the due date.

VBAC carries a 0.5 per cent (one in 200) risk of uterine rupture, while ERCS slightly increases the risk of placental abnormalities in future pregnancies.

“With each surgery the risk of adhesions developing also increases, resulting in a higher incidence of injury to the bowel and bladder. If you have had a classical Caesarean section in the past, you will be advised to have an ERCS.”

The number of maternal-request C-sections is growing due to factors like fear of labour (tokophobia) and the ability to schedule birth, and Mohammed said, “If the patient is fully informed and opts for a C-section, her decision must be respected.”

Asked about a link between C-section and postpartum depression, Mohammed said C-sections do not increase the risk of postpartum depression. Postpartum blues (mild sadness) and depression (severe and prolonged symptoms) can affect any mother, regardless of delivery method.

Mohammed said childbirth, whether vaginal or via Caesarean section, can be highly unpredictable.

“Although you may prefer a vaginal delivery, circumstances may change during delivery and a Caesarean section may become the safest option for both you and your baby. No matter how normal your pregnancy has been or even if you had a normal delivery in the past, there is still a possibility that you may need a Caesarean section.

"Each mode of delivery has its own risks and benefits. All mothers regardless of how they deliver need understanding, respect and support. It doesn’t matter what route your baby took to enter this world, what is important is the well-being of both you and your baby.”