What to expect from your planned or emergency c-section
This one is for our Tiny Heart's mamas, who are having a planned c-section. But more than that, it's also for mamas who may end up having an emergency c-section. As a Midwife, I find that so many families research vaginal births so well because that's plan A. But sometimes birth doesn't go to plan, and a mama finds herself facing the possibility of an emergency caesarean, with no idea what in the world is about to happen. That's where this blog steps in because Tiny Hearts is all about helping you face parenthood without fear, right from the very start.
A caesarean section [also known as c-section or caesarean] is when an Obstetrician cuts through many layers of a mama's abdomen to reach the uterus and deliver bub. A c-section is major abdominal surgery and is certainly NOT "the easy way out". The Obstetrician makes a cut along the bikini line [in most cases] and works through the skin, the fat layers and abdominal muscles, all while trying to avoid other vital organs like the bladder and bowel. Once they get to the uterus, they will make a small cut and help deliver bub. In most cases, after bub is born, the Obstetrician will wait for one minute after birth before cutting and clamping the cord [delayed cord clamping] and then pass bub to the Midwife. We'll talk more about what happens after a c-section below, but first, let's talk more about planned and emergency caesareans.
A planned caesarean is a caesarean that is booked in advance that a mama knew about prior to the onset of labour. There is an exception to this. If a mama has a planned caesarean but requires it earlier [for example, she goes into labour beforehand], the caesarean will be brought forward. It will then be considered an "emergency c-section" because it was required before her booked caesarean date. It is usually booked for around 39 weeks in pregnancy.
There are many reasons a mama may elect to have a planned caesarean:
- You've had a previous c-section
- Bub is in a breech position
- You've had a previous 3rd or 4th-degree vaginal tear
- You're a victim of sexual abuse or trauma
- Previous birth trauma
There may also be medical conditions that require a mama to have a planned caesarean:
- Placenta previa [when part of the placenta is covering all or part of the cervix]
- Placenta accreta/ increta/ percreta [when the placenta is grown into or through the uterus muscle, and potentially onto surrounding organs]
- A mama's medical condition outside of pregnancy
- A belly bub's medical conditions [such as bub having severe fluid build up on the brain]
- Twins or triplets [note: a vaginal birth may still be an option]
What happens leading up to the elective caesarean?
Leading up to the date, you may have an appointment with the anaesthetic team, who will go through the anaesthetic options with you for your planned caesarean, such as an epidural or a spinal. In very uncommon cases, a mama may require a general anaesthetic. The anaesthetist may talk about what it means to have a spinal, epidural or general anaesthetic, including the benefits and risks, the procedure itself and how it will affect you and bub after birth. They may undertake a full medical history from you to make sure nothing will impact the type of anaesthetic you will require, feel your spine and talk about any concerns or questions you might have. You'll also have several appointments with the Obstetric and Midwifery team, who will be able to talk you through the operation, what recovery looks like, discuss how to prepare and sign your consent forms. A few days before, the hospital may call you to tell you what time to be there and where to go and may ask you to get some blood tests done beforehand.
On the day of your caesarean, you should shower in the morning, remove all jewellery and hairpins, not eat or drink from the time set by your hospital or Obstetrician and prepare yourself to meet your little one. In most cases, a Mama will be told to present to the pre-operative area. You'll be 'checked in' where a nurse will confirm your name, DOB, allergy status and the procedure that you're having today. You'll be given a theatre gown to put on [hint: nothing goes underneath it, including bra or undies], and an ID band will be placed on your arm. If you've got a support person, they'll be given scrubs to change into [and yes, they keep their undies on]. Depending on your hospital policy, you may meet your Midwife beforehand, who may listen to bub's heart rate on a doppler or CTG. They may also discuss your preferences with you, like your feeding plans for bub, if you want bub to have Vitamin K and Hep B vaccine after birth and if you want to keep your placenta. If the c-section is for bub being breech, your doctor may also do a quick ultrasound to double-check that bub hasn't moved to a head-down position. From there, you'll be given a hair net to wear, put into a hospital bed, have an IV cannula inserted, and some compression stockings applied. You'll then wait in your bed with your support person in a place called 'holding bay' or 'anaesthetic bay'. Your anaesthetist will then come and meet you, have a chat with you about what's going to happen, and you'll be wheeled in bed to the theatre where you'll meet your bub.
An emergency caesarean is a caesarean that was not planned and may have come about because of a medical emergency. Around 2 in every 5 c-sections are emergencies. They are often given a category based on how urgent they are, ranging from 1-4. For example, a category 1 c-section needs to happen immediately because there's a life-threatening condition to a mama or bub, such as a placenta abruption. A category 4 is much less serious and can happen at any time that suits a mama and the theatre team, as there is no rush at this point.
There are many reasons a mama may have an emergency c-section, including:
- A mama's medical condition such as eclamptic seizures
- Bub's heart rate recording [CTG] indicating they're not happy
- An obstetric emergency such as a cord prolapse
- Labour is not progressing
- Labour beginning when a mama requires a c-section, such as a mama who has a placenta that covers the cervix
What happens leading up to the emergency caesarean?
Preparation for an emergency c-section is similar to that of an elective caesarean, except it may happen at a much quicker rate. If there's time, you'll be changed into a gown, have an IV cannula inserted and blood sent off, have compression stockings put on, and fluids started. If you've already got an epidural going, it will be paused but remain in your back so your anaesthetist can use it to give you an extra dose for your c-section instead of taking it out and putting in a new one. If you don't, the anaesthetist may put in a spinal or epidural once in theatre if there's time and you and bub are ok. If it's a life-threatening situation for you or bub, a general anaesthetic [being put to sleep] may be strongly recommended. Your partner will be given scrubs to wear, and it's a good idea that they get changed early, grab their phone for photos of bub being born, do a wee and have a quick snack. If they're not sure what else to do, ask them to gather your things together into bags to make it easy to move to the ward once you're in theatre. Also, just a little reminder that this isn't the time to move the car! Theatre won't wait for them to get back if it's an emergency. The transportable monitor will be hooked up to bub and placed on your bed to keep a close eye on bub on the way to theatre. If you've got the hormone drip going, this may be stopped to try and stop labour. You may even receive an injection in your tummy of a medication called 'Terbutaline' which works to stop contractions too. Your bed will then be pushed to theatre for you to go and meet your little one.
What happens during the caesarean?
Once you're in the theatre, your support person will be asked to wait in the holding bay while the anaesthetist puts in your spinal or epidural.
They'll ask you to sit very still, curled over on the edge of the bed. Then they'll clean your back and insert the spinal or epidural, which will cause you to go numb from the abdomen down. The Obstetric team will put a catheter into your bladder, shave along your bikini line if it hasn't already been done, and secure you to the bed around your legs because they'll tilt it slightly to the left to keep you off your back. A drape will be hung, and your support person will be invited to come and sit near your head and hold your hand. If you're having a general anaesthetic, most hospitals don't allow a support person to come in and ask them to wait outside until the Midwife brings bub out to them after birth.
Lots of monitors will be attached to you to read your blood pressure and heart rate continually, and your anaesthetic team may start to give you some fluid to keep your blood pressure up after the medication. They may also give you an antibiotic to prevent infection from the surgery. Depending on your hospital, a Midwife may listen to your little one again to make sure they're coping after the anaesthetic too. If it's an emergency, you may still be hooked up to the monitor, which won't be removed until the last second to keep a close eye on bub.
You might notice a temporary lull in the number of people in your operating theatre. Don't worry; they haven't left- they're just scrubbing and getting their gowns and gloves on. It's important at this point that your support person remains right by your side to minimise the chance of them accidentally touch something that is meant to be sterile. While they're scrubbing, your Midwife will be busy preparing the resus cot for your little one's arrival. This is standard for every c-section, so don't be afraid that it means something is wrong, mama. If it's an emergency caesarean or bub has a known medical condition, the NICU team will be present for bub's birth.
You might be feeling pretty overwhelmed at this point. Take a deep breath, close your eyes and take a moment to soak in the last moment of this little life dancing inside of you before being brought earthside. How exciting!
Just before starting the operation, your anaesthetic or obstetric team may test your anaesthetic to make sure you can't feel any sharpness or pain. It's important to know that you will still feel pressure [e.g. pushing], but it's not normal to feel pinching or pain. If you do, or you feel like you're going to vomit, you need to let someone know straight away. Once your anaesthetic is sorted, your obstetric team will clean the area and begin the operation. If your doctor's use a scalpel, there won't be a smell, but it will smell if they use a different device called a cauteriser. Again, don't stress, mama; this is normal and expected. The Obstetrician will cut through the layers to get to the uterus and birth bub. As bub is being born, the team may drop the drapes so you can catch your first glimpse of your newest little person being brought into the world. At this point, families who don't know what they're having may also get to announce it to the theatre; a gorgeous girl or beautiful boy. Bub will have one minute of delayed cord clamping [unless they aren't coping with the transition to the big wide world] and then be passed to the Midwife. The Obstetric team will then get to work delivering your placenta, minimising blood loss and closing the layers of the uterus and tummy.
At this point, the Midwife will take your little one to the resus cot, which is usually set up in the theatre [partners are welcome to follow] and dry bub. That's because bub will come out wet and theatres are cold, meaning bub is at risk of dropping their temperature if not dried and wrapped in warm blankets. Depending on how you're feeling, how bub is transitioning and the hospital policy, bub may be brought to you for some skin to skin and/ or a breastfeed [if breastfeeding]. Alternatively, a Midwife may do a quick top to toe assessment of bub, including listening to their heart and lungs. They may also ask the support person to trim the cord, give bub their injections, weigh and measure them and wrap them in blankets and a beanie to keep them snug. At this point, if a mama isn't feeling up for skin to skin, bub will be given to the support person until a mama is ready to go to recovery. The Midwife will check the placenta, collect cord blood if required, begin paperwork, and keep an eye on bub. If it's an emergency c-section, the Midwife will pass bub to the NICU team, who will check bub over and allow the above to happen, or start resuscitation.
In some cases, bubs are taken by surprise by the transition to the big wide world and need some help. Other bubs cope well initially but need help later on due to fluid remaining in their lungs. If that's the case, a Midwife or the NICU team may start some resuscitation on bub by putting a mask on them and breathing for them, holding the mask on their face to help them keep their airways open or suctioning their mouth and nose. If bub settles and begins breathing normally on their own, they'll be able to stay with you. If bub is still needing some help, they may be taken to NICU or special care nursery for further support or observation. I know this can be devastating, mama, and I hope this doesn't happen. But it's important to know that it is a possibility, regardless of how unlikely it is.
What happens after the caesarean?
Once the doctors have closed the uterus, they will put a dressing [large bandaid] on top. They'll do a final check for bleeding and change the pads underneath you. You'll be unhooked from all the monitors and wires except for any medication or fluids going through your drip. You'll be shuffled onto a different bed where bub may be placed on your chest for the journey to recovery. Alternatively, bub can be pushed in the cot down the hallway to recovery by your support person or your Midwife. Recovery is where all people go immediately after surgery while the anaesthetic starts to wear off. It's also to make sure that you're well enough to go back to the ward after your operation. Your nurse will check your dressing, take regular observations, give you pain medication if required, check that your anaesthetic is wearing off, make sure you're getting movement back in your legs and give you something to drink [or an iceblock if you're lucky!] While this is happening, if it hasn't already happened, your Midwife will weigh and measure bub, give them their injections, check bub over and apply ID labels. Once you're ready, your Midwife will place bub skin to skin and help you initiate the first breastfeed or get the formula ready for you to feed bub. If you're in recovery for a little while for whatever reason and bub is required to have blood sugar monitoring, this can be performed here too. The Midwife will continue monitoring bub and will let you and the baby doctors know if there are any concerns. Some mama's I've cared for get nervous in recovery that if something goes wrong, there's no equipment to help bub. Don't stress, mama! If there are no permanent fixtures in recovery for bubs, a Midwife will carry transportable equipment with them for the entire journey. All you have to do is ask, and they'll be happy to show you! Like I always say to the mamas I'm caring for; I'll do the stressing, and you get to know your newest little love that you've waited 9 months to meet.
Once you're stable enough to go to the ward, you'll be transported in the bed to the maternity ward. Once you get there, your nurse will tell the Midwife on the ward all about you, including your medical history and what happened during the caesarean and while in recovery. The Midwife that attended your birth will also tell the Midwife about what happened, but they're generally more focused on what happened with bub. I recommend all mamas to listen to these handovers in case things are missed or discuss things that you weren't aware of. It also allows you to be involved in your and bub's care. Your birthing Midwife may also give you some important paperwork- the birth registration and bub's book. Keep these close by and try your hardest not to lose them!
From there, your ward Midwife will perform regular observations on you depending on your hospital's policy. In general, though, it may be something similar to every 30 minutes for 2 hours, hourly for 2 hours, then every 4 hours. If bub requires observations, your ward Midwife may also do a set of observations on bub at this point too. Once you've settled into your room, this could be a good time to offer bub another feed. If you haven't already, you can put a nappy on bub and do some more skin to skin. Your Midwife will continue to check your bleeding, wound and pads. They may also offer you a sponge bath to freshen you up until you get up for a shower [approx 12-24 hours later]. If you've got pain, SPEAK UP, MAMA!! You're not weak by asking for pain relief. We're not judging you. We want you to be comfortable, but we don't know that you're in pain unless you tell us.
If you're staying in a hospital that doesn't allow support people to stay overnight, make sure you use the buzzer if you need help. That's what we're there for, mama! Buzz away.
What happens the day after the caesarean?
The day after the caesarean, you may be seen by one of the senior doctors. They'll check your wound and dressing, bleeding, pain levels, vital signs and that things are looking normal. They may also debrief with you and your partner about the birth, particularly if it was an emergency caesarean or a traumatic process. If you've got any questions or are unsure about what happened, this is the perfect time to ask.
At some point, your Midwife will discuss with you about getting up for a shower. Yep, it's probably going to be painful. But the first time getting up is the worst, and it will only continue to get better. You'll be offered a dose of strong pain medication and given around 30-60 minutes later for it to kick in. It's a good idea to get your support person or Midwife to get clothes, towels and toiletries together before you go into the bathroom and have them ready to go. Once you're ready, your Midwife will help you get up to the shower. I recommend using the bed to sit up, and a rolled-up wrap or pillow pressed flat against your wound as a brace. Once you're sitting on the edge of the bed, put your feet flat against the floor and slowly start to stand up, bracing your wound if you need to. Once you're standing, take a few steps on the spot, making sure to sit back down if you feel light-headed. Once you're standing, slowly move to the bathroom, using the Midwife or your support person for support if you need it. For the first shower, I recommend mamas use a shower chair for sitting in case you become light-headed or feel pain during the process. Your partner or Midwife will help you to get undressed, and dry and redressed as well as changing your sheeting and getting you some fresh pads. It's amazing how much better brushing your teeth and having a shower can make you feel!
During the first day after your c-section, you'll continue to have regular observations [usually 4-hourly unless there are other concerns]. You may also have a blood test to check your blood levels and have fresh compression stockings applied to minimise the chance of blood clots. You might continue having regular medication and depending on your pain levels, you may be having less and less strong medication as time goes by. Some mamas will also be prescribed a medication called 'Clexane'. It's an injection to help prevent blood clots forming [which you're at an increased risk of due to having been pregnant and having surgery]. The injection will often go into your tummy, may sting and can leave a bruise. Again- not pleasant but something to know about before it comes to that time.
While on the ward, depending on the Covid restrictions, you may have visitors come up. While having support is so important, I always like to remind mamas that this is the time for you to be getting to know your newest little person and perfecting breastfeeding, settling techniques and getting your questions answered while you've got the support of Midwives and lactation consultants around the clock. You and bub will continue having routine checks and be monitored by the Midwives and Doctors on the ward until you go home [usually day 2 or 3 in the public system and between day 3-5 in the private system]. Before you go, bub will have a second top to toe check, a newborn screening test, a hearing test and potentially their first bath. You might receive in-depth discharge education and medications to take home and discuss what follow-up you'll receive from the hospital over the next few days or weeks.
What happens after going home?
After you've gone home, the Midwives may visit you at home to do things like take off your wound dressing, weigh bub, check in on you both and provide more education and support. Your wound dressing may come off on around day 5-7. Depending on the type of stitches or staples your Obstetrician used, your Midwife may remove some or all of these too. In most cases, a mama is recommended to make a GP appt for her bub on day 7-10 for an extra check. If you're a private patient, these appointments maybe with your Obstetrician instead. If you've got any questions or concerns in this period [such as bleeding, signs of infection or feeding problems], you should call your Midwife or Doctor until you've been discharged from the home visiting service or no longer see your Obstetrician. In saying that, the emergency department or GP is always there as another option if you're unsure too.
At around 6 weeks, a mama should make an appt for her and bub with the GP. At this appt, the GP [or Obstetrician for private mamas] will check the wound healing and discuss important things like spacing pregnancies, ongoing recovery and mental health. They'll also weigh and measure bub, give them their first dose of vaccinations and check their general health. Your GP may talk about things with you like how to know they're getting enough milk, wet and dirty nappies and normal newborn behaviours. If you had low iron or other concerns in pregnancy like gestational diabetes, your GP might organise follow up tests at this appointment.
I hope this answers all of your c-section questions. But if it doesn't, please DM us! There are no silly questions, and if Nikki can't answer them, she'll pass them onto me, and I can make a post about it. The chances are that if you're thinking it, there's probably 20 other mamas out there wondering the same thing. Good luck, mama! I can't wait to hear all about it.