Caesarean section

What it is

Birth of a baby through a cut in the lower abdomen and in the lower segment of the uterus, usually under a spinal or epidural anaesthetic so that the person is awake and a birth partner can be present. The operation is the same for trans men and non-binary people who give birth. It is one of the commonest operations carried out in the UK and accounts for a substantial proportion of births. A planned (elective) caesarean is booked in advance, normally after 39 weeks; an unplanned one is done during pregnancy or labour, and its urgency ranges from an immediate threat to the life of the woman or the baby, when the baby is delivered within minutes, to a decision that can wait for the next available theatre. Urgency is graded in four categories, from an immediate threat to life through to a caesarean timed to suit the woman and the team.

Why it is done

• The baby lies breech or across the uterus, or turning the baby by external cephalic version has not worked or is not suitable
• The placenta covers or lies close to the cervix (placenta praevia), or is abnormally attached to the scar of an earlier caesarean
• A twin or higher-order pregnancy where the first baby is not head-down, or where labour is not thought to be safe
• Concern about the baby during labour, such as an abnormal heart rate pattern, bleeding from the placenta or a cord prolapse
• Labour that does not progress, or a baby in a position that cannot pass through the pelvis
• Maternal conditions such as severe pre-eclampsia, and some infections that could be passed to the baby during a vaginal birth
• A previous caesarean, where a planned repeat operation is chosen rather than a vaginal birth after caesarean, or a request for a caesarean birth after the risks and benefits of both routes have been discussed

Before the procedure

• A discussion of the reasons, the risks of caesarean and of vaginal birth, and what the recovery involves, with written consent
• A blood count and a group and save sample, with anaemia treated beforehand where there is time; an ultrasound to confirm the position of the baby and the placenta
• Fasting and a medicine to reduce stomach acid, because of the small risk of acid entering the lungs under anaesthetic
• A spinal or epidural anaesthetic in most cases, with a general anaesthetic kept for the most urgent operations or when a regional block is not possible
• Antibiotics before the skin is cut, clot-prevention stockings, and a catheter passed once the anaesthetic is working

Step by step

1. The anaesthetic is tested to make sure the abdomen is numb, the skin is cleaned and draped, and a screen is placed so that the birth can still be watched if the parents wish
2. A transverse incision is made a little above the pubic bone and deepened to the rectus sheath, which is opened and lifted; the rectus muscles are separated in the midline, keeping clear of the inferior epigastric vessels at their outer edges, and the peritoneum is opened
3. The fold of peritoneum over the lower segment of the uterus is incised and the bladder is gently pushed downwards out of the way
4. A small transverse cut is made in the lower segment and opened out with the fingers; the membranes are ruptured and the head, or the breech, is delivered with a hand and pressure on the fundus, occasionally helped by forceps or a vacuum cup
5. The cord is clamped, after a short delay when the baby is well, and a drug that contracts the uterus is given so that the placenta separates and is delivered by controlled traction on the cord; the cavity is checked to be empty
6. The uterine incision is closed, normally in two layers, bleeding is checked, swabs and instruments are counted, the sheath is closed and the skin is closed with a suture or clips
7. A vertical (classical) incision in the uterus is used only occasionally, for example at very early gestations or when the lower segment cannot be reached safely, and it changes the advice about future births

Afterwards

• Skin-to-skin contact and the first feed usually start in theatre or in recovery, with help to find a position that keeps the baby off the wound
• The catheter comes out once the anaesthetic has worn off and walking, eating and drinking start early; regular pain relief is given and clot-prevention injections continue for a period after discharge
• The dressing is removed after a day or two and the wound is kept clean and dry; clips or non-absorbable stitches are taken out by a midwife
• Vaginal bleeding (lochia) continues for a few weeks, as it does after any birth; bleeding that becomes heavy again or passes large clots, offensive-smelling discharge, fever, a severe headache with visual disturbance, calf pain or breathlessness are reported to the maternity unit or NHS 111 straight away

Recovery

Most people stay in hospital for one to two days and feel a little stronger each week over about six weeks. Driving restarts when an emergency stop can be done comfortably, and lifting anything heavier than the baby is avoided at first. The scar sits low and fades over about a year; numbness around it is common and usually improves.