Birth by caesarean section is increasingly common: in some parts of the UK, as many as 30 per cent of births are caesareans, so it is unwise to assume that ‘it won’t happen to me’, or ignore the possibility that your baby could be born this way.
Find out as much as you can
A caesarean can be an extremely positive experience, when mothers feel confident that it was the right choice for them and that their wishes were respected. It may be planned in advance, called an ‘elective’ caesarean or it may have to be agreed at short notice, especially during labour, when it is termed an ‘emergency’ caesarean.
For some women the suggestion of a caesarean, or the decision to carry out the operation, will come as a welcome relief. The circumstances of each situation and the information that a woman has been given will combine to reassure her that a caesarean birth is definitely right for her and her baby at that time.
For other women, the prospect of a caesarean can be disappointment or distressing. If a woman has not been given enough information, or she is not convinced of the need for or the ‘rightness’ of a caesarean, then she may feel that she has no option but to agree, despite her misgivings. Under these circumstances a caesarean can, sadly, be a traumatic experience.
If you do not feel you have been given sufficient information, or you do not understand your circumstances as well as you would like to, do ask for more information. You have a right to a second opinion, and if there is time (for example, if it’s an elective caesarean) you can seek further information from elsewhere such as caesarean support organisations or the Internet.
When would a caesarean be recommended?
A caesarean may be recommended at any time during pregnancy or labour. In some cases there is clear evidence that a caesarean is needed to save life or to safeguard the health of mother or baby. However, in many cases the best option isn’t clear (see below).
Obstetricians can read the same evidence in different ways and hold differing opinions on the need for one.
You may have different priorities when making decisions. There are occasions when the choice is left to the parents – who may feel they have insufficient information on which to base an informed decision.
Why might I need a caesarean?
There are occasions when a caesarean is needed, other situations where the evidence is less clear cut.
You need a caesarean if you have:
- Placenta praevia: when your placenta lies across your cervix, the opening into the vagina (see ‘Low-lying placenta’ for more information)
- Placental abruption: when the placenta comes away from the wall of the uterus
- Pre-eclampsia: which can develop into a serious medical condition of pregnancy (see ‘Health problems and pregnancy’ for more information).
- Your baby is lying in the oblique or transverse position (see ‘‘Best’ baby positions for birth’ for more information)
- Medical conditions of the baby.
Indications are less clear if:
- Your baby is lying bottom down (see ‘Breech baby’ for more information)
- The progress of labour is considered to be too slow (failure to progress)
- The baby is believed to be in difficulty (fetal distress)
- You have a history of previous caesarean deliveries
- You are carrying more than one baby.
Can I choose not to have a caesarean?
As with all interventions in labour and pregnancy, you have to give your consent before you can have a caesarean. However, if you are uncertain about the need for a caesarean it can be very difficult to disagree with your medical professionals, particularly is you are in labour.
Not all ‘emergency’ caesareans are dire emergencies. The urgency of a caesarean (elective or emergency) has been graded into four categories:
- There an immediate threat to the life of the mother or baby
- Mother or baby are in difficulty, but it’s not immediately life threatening
- Mother should be delivered shortly, but neither mother nor baby are in difficulty
- Delivery timed to suit the mother and the staff.
Unless the circumstances of your caesarean fall into one of the first two categories, there should be time for you to seek more information to help you understand your situation and come to your own decisions.
It may be helpful at such moments to have a strategy for making decisions when medical help is offered. A strategy which many women have found helpful is the ‘BRAIN’ analysis:
Benefits: What are the benefits of the intervention?
Risks: What are the risks both to the baby and me?
Alternatives? What other options are there?
Instincts? What do your instincts tell you?
Nothing: What if you don’t do anything?
Asking yourself, your midwife, and/or your doctor these questions, and thinking through the answers will help you make decisions that are right for you.
What are the main risks of having a caesarean?
Although a caesarean is generally considered to be a ‘safe’ operation, it is still major abdominal surgery and there are some risks to both you and your baby.
- Vaginal birth is about four times safer for you than having a caesarean section, but in both cases the risk is very small (an elective caesarean is thought to be safer than an emergency one)
- The mother is at risk of haemorrhage (severe bleeding), wound infection, or small blood clots (thrombosis)
- Recovery will take longer than a vaginal delivery, and varies considerably from woman to woman.
- One of the long-term effects of the operation is that you will have a scar on your uterus, which may affect future fertility, pregnancies, and births, and complicate any later gynaecological surgery. A few mothers who have had caesareans have been known to suffer long-term pain.
- The major risk to babies born by caesarean is that there’s a higher chance of them having breathing difficulties that continue for a while after the birth. The birth process helps a baby to breathe once he is born as labour prepares the baby’s lungs for breathing. Babies born by caesarean – particularly elective – do not go through this and may be more likely to need to be taken to the neonatal baby unit after birth.
- Breathing difficulties due to prematurity can be reduced by waiting until at least 39 weeks of pregnancy to have a caesarean.
What sort of anaesthetic will I have?
If you are having an elective caesarean, you will be given the opportunity to meet the anaesthetist to discuss your anaesthetic options.
These days the majority of caesareans are done with spinal anaesthesia. This is a one-off injection in the lower spine that works quickly and gives sufficient anaesthesia for the length of the operation.
When an epidural has been used for pain relief in labour, this can usually be topped up to provide the anaesthesia required for an emergency caesarean. An epidural is sometimes used for elective caesareans but is becoming less common.
Around ten per cent of caesareans – both elective and emergency – are performed under general anaesthetic. If you have a general anaesthetic you will not be aware of anything going on around you. General anaesthetics are less safe than regional anaesthesia, but may be used for various reasons. For example, you may wish not to be awake during the operation, or you may have a medical problem that prevents the use of a spinal or epidural.
Preparation for the operation
The exact procedure varies with different hospitals and obstetricians, but in all cases you will be asked to sign a consent form, without which the operation cannot legally take place.
For an elective caesarean
If you are having an elective operation, you will have some routine blood tests done beforehand. You will be asked to go into hospital the night before or early on the morning of the operation, and to take an antacid medicine to neutralise your stomach contents.
Before your operation, the final preparations will take place. These will involve: changing into a hospital gown; having a bikini shave if necessary; removing nail varnish, glasses or contact lenses, and jewellery. The nursing staff will put a name-band on your wrist. You may also need to take some clothes to the operating theatre for your baby.
You will then be taken to the operating theatre. If you are having a spinal or epidural anaesthetic, your birth partner will be able to stay with you during your caesarean, but will have to change into theatre clothes. If you are going to be having a general anaesthetic, your birth partner will usually be asked to stay outside the operating theatre.
For an emergency operation
If you are having an emergency caesarean, the same process applies. However, the degree of urgency will determine how much time is available.
What about the operation itself?
The procedure is similar whether the caesarean is elective or an emergency. There are likely to be a large number of people in the operating theatre with you. The medical staff may include: a midwife, the obstetrician, and an assistant; a theatre nurse and an assistant; an anaesthetist and his or her assistant; and probably a paediatrician (doctor specialising in children).
If you have a spinal or epidural anaesthetic, and you are awake, a screen will be placed near your head so you can’t see what is happening. You shouldn’t feel any pain at all during the operation though you may be aware of some sensations. Some women describe the feeling as like ‘someone is doing the washing up in your tummy’. If you have had a general anaesthetic, you won’t be aware of anything until you wake up.
Your baby will be born very quickly, during the first five minutes, followed by the delivery of the placenta. It will then take around half an hour to have your wound stitched. There are several layers will dissolve by themselves. Your skin will usually have one continuous stitch with beads at either end, or special skin staples that need to be removed later.
When will I see my baby?
If you are awake and your baby is well, he will be handed to you straightaway. If you have had a general anaesthetic, he can be given to your birth partner outside the operating theatre. If your baby needs any help breathing, or has other problems, he may need to be taken to the special care baby unit.
Your baby should be able to have skin-to-skin contact with either you, or your birth partner, as soon as he is born and some mothers have even breastfed their babies while still in theatre.
What happens after the birth?
Again, exact procedures will vary between hospitals and obstetricians. Typically, you would be moved out of the operating theatre to another room called a recovery room. A midwife will monitor you to make sure there are no problems until you have recovered sufficiently to be taken to the postnatal ward. If you have had a general anaesthetic, your birth partner and baby should be there with you when you wake up.
After the operation, it is usual to be given a painkiller that lasts for several hours. It is also usual to wear tight stockings and/or be given medication to reduce the risk of getting blood clots (thrombosis).
Are there any choices I can make for myself?
Many women are surprised by the scope of options available, even though a caesarean is surgery. Women who have had time to think about what aspects of birth are important to them, have often found it helpful to think through what they might like to have during their operation and state their preferences while discussing choices at the time.
Your health professionals may be wary of discussing caesarean preferences until they realise these are not medical requests, but just environmental ones. For example, some women have chosen to have a commentary during the birth, to have music playing, or complete silence; to take photographs or record the birth on a camcorder; see their baby born via a lowered screen or with a mirror; be the first person to greet their baby; discover the sex of the baby themselves or decide who they would like to give them this information.