Caesarean section

Caesarean section

Introduction

A caesarean section is an operation to deliver a baby. It involves making a cut in the front wall of a woman’s tummy (abdomen) and womb.

The operation can be:

  • planned (elective) procedure – when a medical need for the operation becomes apparent during pregnancy or if it’s requested by the mother in advance
  • an emergency procedure, when circumstances before or during labour call for delivery of the baby by unplanned caesarean

A caesarean section is usually carried out under epidural or spinal anaesthetic, where the lower part of your body is numbed. It usually takes 40-50 minutes, but can be performed quicker in an emergency. Some caesarean sections are performed under general anaesthetic.

Read more about how a caesarean section is carried out.

When a caesarean might be needed

A caesarean section is usually carried out when a normal vaginal birth could put you or your unborn baby at risk  for example, because:

  • your labour doesn’t progress naturally
  • you have placenta praevia (where the placenta is low lying in the womb and covering part of the womb’s entrance)
  • you have had two or more previous caesarean sections
  • your baby is in the breech (bottom first) position

Read more about when a caesarean section is necessary.

NICE guidelines

In 2011, the National Institute for Health and Care Excellence (NICE) published guidelines on caesarean sections. This aimed to give appropriate research-based advice to women and their families.

NICE made a few new recommendations:

  • Some women who are HIV positive and women who have had a previous birth by caesarean section should be offered the option of a vaginal birth.
  • Women should be given antibiotics before (rather than after) surgery to prevent infection.
  • If a woman requests a caesarean section because she’s anxious about childbirth, she should be referred to a healthcare professional with expertise in providing mental health support to help address her anxiety.
  • If a woman requests a caesarean section, a planned caesarean should be offered if a vaginal birth is still not an acceptable option after discussions and offers of support.
  • If the obstetrician does not wish to carry out a planned caesarean, a referral should be made to an obstetrician who is willing to perform the procedure. 

Read the NICE guidelines on caesarean section.

Risks

Like any surgery, a caesarean section carries a certain amount of risk, such as the wound becoming infected or the baby developing breathing difficulties.

Read more about the risks of a caesarean section.

Recovery

In most cases itakes longer to recover from a caesarean section than it does from a vaginal birth. You will usually need to spend three to four days in hospital after surgery, compared to one or two days after a vaginal birth.

Read more about recovering from a caesarean section.

Abdomen

The abdomen is the part of the body between the chest and the hips.

Why a caesarean section is necessary

A caesarean section is usually performed when a normal vaginal birth could put you or your unborn baby at risk. 

It can either be planned or carried out as an emergency procedure.

Planned caesarean section

Before you give birth, your midwife or doctor should discuss the benefits and risks of having a caesarean section compared with a planned vaginal birth.

Medical reasons for having a planned caesarean section include: 

  • severe pre-eclampsia – this is pregnancy-related high blood pressure and requires emergency treatment
  • position of the baby – your baby may be in an abnormal position inside the womb, such as the breech position, which makes it unlikely to fit through the birth canal
  • two or more previous caesarean sections
  • if you are expecting twins or other multiple births – the babies may be premature and more safely delivered through caesarean section; one or more of the babies may be in an abnormal breech position (bottom or feet first), or two or more of the babies may share a placenta, which means a caesarean section is necessary to avoid the babies being deprived of oxygen
  • small pelvis – scans sometimes show that the baby’s head is larger than the space in the mother’s pelvis through which it needs to travel
  • placenta praevia – when the placenta blocks the exit to the womb
  • infection – if you have certain viral infections, such as a first attack of genital herpes, you may be offered a caesarean section because a normal delivery would risk transferring the virus to your baby
  • a medical condition – for example, a heart problem may put you at risk during a normal delivery
  • restricted growth of the baby – some babies who are not growing well in the womb have a higher risk of dying or being ill around the time of birth.

Emergency caesarean

In an emergency, there may not be enough time to discuss fully the advantages and disadvantages of a caesarean section. If vaginal delivery poses significant risks to your own or your baby’s health, the midwife or doctor will decide with you if a caesarean section is the safest option.

Reasons for needing an emergency caesarean include:

  • your unborn baby not getting enough oxygen, and a vaginal delivery will take too long and put your baby at risk
  • your labour not progressing, despite your efforts to move the baby sufficiently and quickly down the birth canal (from the womb through to the vagina)
  • your labour being induced for a medical reason, but the methods used are failing to produce contractions effective enough to lead to a vaginal delivery
  • you have a lot of vaginal bleeding during your labour

In some emergency situations, a baby may need to be delivered very quickly, even within half an hour. In such emergencies, a caesarean section is the safest way to protect both you and your baby.

Older women

Statistically, women over 35 years old are more likely to need a caesarean section, because they have an increased risk of certain complications during pregnancy, such as:

  • high blood pressure
  • gestational diabetes
  • slow widening (dilation) of the cervix
  • having a large baby
  • the baby adopting an awkward position in the womb, such as the breech position
  • placenta praevia
High blood pressure
High blood pressure or hypertension is when the pressure of the blood in your bloodstream is regularly above 140/90 mmHG.
Womb
The uterus (also known as the womb) is a hollow, pear-shaped organ in a woman where a baby grows during pregnancy.

How a caesarean section is performed

Your caesarean section will usually be performed under a regional anaesthetic (epidural or spinal anaesthetic). This numbs the lower part of your body, but means you will be awake during your operation. 

This is safer for you and your baby compared to a general anaesthetic, where you are put to sleep. A small amount of caesarean sections are performed under general anaesthetic, usually if a regional anaesthetic is not possible.

Read more about anaesthesia and an epidural.

Before the procedure

Before the procedure, you should have:

  • a blood test  to check for anaemia and to keep a sample of your blood, in case it’s needed
  • antibiotics – to reduce your risk of developing an infection after the operation
  • if required, medication to help prevent low blood pressure during the operation  either ephedrine or phenylephrine
  • antacids  medication to reduce acidity in your stomach
  • anti-emetics  medication to prevent nausea and vomiting

Antacids and anti-emetics are used in case you need a general anaesthetic, because there may be a risk of food or drink entering the airway (aspiration). Read more about the risks of a caesarean section.

You will also need to have a catheter (tube) inserted into your bladder to empty it. This is because, with a regional anaesthetic, you will not be able to tell if your bladder is full and needs emptying.

The procedure

A caesarean section usually takes 40-50 minutes.

A screen will usually be placed across your tummy (abdomen) during the procedure, so you don’t have to watch the operation being done. However, you can choose to have the screen lowered to see your baby being born. You won’t see yourself, just the baby being lifted up.

During the procedure, the operating table will be tilted sideways to an angle of at least 15 degrees. This moves your womb and baby to one side, so it takes the pressure off your womb and large blood vessels in your back, reducing your chance of getting low blood pressure and feeling sick during the operation. The bed is usually levelled once your baby has been delivered.

A horizontal cut will be made to your lower abdomen, at the top of your pubic bone  this is often described as your bikini line. This allows another horizontal incision to be made in the wall of your womb, so your baby can be delivered. The low incision will cause you less pain afterwards and looks better than a vertical scar.

Once your baby has been delivered through the incision made in your womb, you should be given an injection of the hormone oxytocin. This encourages your womb to contract and reduces blood loss. The placenta soon separates and is also removed. The wall of your womb and abdomen will be closed with stitches that will safely dissolve.

The cut in your skin will be closed by either:

In some cases, it may be possible to use skin glue to close the wound, although this is rare. You may want to ask your hospital team which method they plan to use.

Your healthcare team will encourage you to have skin-to-skin contact with your baby as soon as possible.

After the procedure

You will usually be moved from the operating room to a recovery room. Once you have recovered from the anaesthetic, the medical staff will make sure you are well, and then continue to observe you every few hours. They will perform some tests, such as checking:

  • your heart rate
  • your blood pressure
  • whether you have any drowsiness or pain

You will be offered a combination of painkillers  usually paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and stronger painkillers, such as morphine.

If you are recovering well, you should be able to eat or drink normally.

You may want to begin breastfeeding your baby, and the medical staff can offer support to help you begin.

Read more about the first few days of breastfeeding.

Anaesthetic
Anaesthetic is a drug used to either numb a part of the body (local) or to put a patient to sleep (general) during surgery.
Epidural
An epidural is an anaesthetic injection given into the epidural space that surrounds the spinal cord, especially during labour, to numb the lower half of the body. 
Local anaesthetic
A local anaesthetic is a drug that is injected by needle or applied as a cream. It causes a loss of feeling in a specific area of the body.
Spine
The spine supports the skeleton and surrounds and protects the delicate spinal cord and nerves. It is made up of 33 bones called the vertebrae.

Recovery from a caesarean section

In most cases, it takes longer to recover from a caesarean section than it does after a vaginal delivery.

You should be able to get out of bed fairly soon after the operation, and your wound dressing may be removed after 24 hours. Women generally stay in hospital for two to four days after a caesarean section. However, if you and your baby are well and want to go home earlier, you should be able to leave after 24 hours and have your follow-up care at home.

In the first few weeks after giving birth, try to get as much rest as possible. Avoid walking up and down stairs too often, as your tummy may be sore. However, you should take gentle daily walks to reduce your risk of blood clots.

You should be given regular painkillers to take at home, for as long as you need them. Your midwife should also advise you on how to look after your wound to prevent infection, such as wearing loose comfortable clothing and cotton underwear, and gently cleaning and drying the wound daily.

Getting back to normal

In general, it will take about six weeks for all your tissues to heal completely. Before this time, basic activities, such as caring for your new baby and looking after yourself, should be possible.

However, you may not be able to do some activities straight away, such as driving a car, exercising, carrying heavy things and having sex. Only start to do these things when you feel able to do so. Ask your midwife for advice if you’re unsure.

If you drive, check your insurance cover for any restrictions about driving after an operation. Some companies require your GP to certify that you are fit to drive. Most women do not feel fit to drive for a few weeks after a caesarean and many wait until after their six-week postnatal check. 

Future pregnancies

If you have had a delivery by caesarean section, it does not necessarily mean you will have to have a caesarean again in the future. You can discuss future pregnancy options with your obstetrician or midwife in the hospital or community, or with your GP, who should take account of:

  • the reason for your first caesarean
  • your preferences and priorities
  • the overall risks and benefits of a caesarean section
  • the risk of tearing the wall of your womb (uterine rupture) along the scar from your previous caesarean section
  • the risk to your own and your baby’s life and health at the time of birth

If the caesarean was carried out for a health reason that will not change in your next pregnancy (for instance, if you have a very narrow birth canal), it is likely that a caesarean section will be necessary for each birth.

If you want to have a vaginal birth, your healthcare team should support your decision. However, make sure you are aware of the serious complications you may be at risk of, including your scar tearing.

During your labour, you should be offered electronic foetal heart rate monitoring to keep a constant check on your baby. You should also be cared for in a maternity unit that has blood transfusion services and the facilities to do a caesarean section very quickly, if necessary.

Risks of a caesarean section

Although it is a common procedure, a caesarean section is still major abdominal surgery. Like any operation, it carries a certain amount of risk.

Compared to a vaginal birth, a caesarean section increases the chance of needing to be admitted to an intensive care unit (ICU). However, this is still uncommon.

Risks to you

The main risks when having a caesarean section include:

  • infection of the wound
  • infection of the womb lining, known as endometritis, which can cause fever, womb pain, and abnormal vaginal discharge or heavy bleeding
  • blood clot (thrombosis) in your legs, which can be dangerous if part of the clot breaks off and lodges in the lungs
  • excess bleeding
  • damage to your bladder or ureter (the tube that connects the kidney and bladder), which may require further surgery

However, a recent change in practice means that infections should become a lot less common. Doctors now give women a single dose of antibiotics just before operating, which reduces the risk of developing an infection more than if antibiotics are given after the operation.

Aspiration

In the unlikely event you need a caesarean section under general anaesthetic, there is a risk that you will vomit during your operation. If this happens, food and fluid particles can pass from your stomach into your lungs. This is known as aspiration.

This can cause potentially serious swelling (inflammation) of the lungs, known as aspiration pneumonia.

Eating during labour may increase the amount of food and fluid in your stomach, and increase your risk of aspiration if you need to have an emergency caesarean.

If there is an increased chance you may need to have a caesarean section during labour, drinking isotonic drinks (that have the same concentrations of salt and sugar as human body fluid) can give you energy during labour, without giving you a full stomach.

Risks to your baby

Having a caesarean section has not been shown to increase or decrease the risk of your baby having the most serious complications, such as an injury to the nerves in the neck and arms, bleeding inside the skull, cerebral palsy or death. These complications are very rare and affect fewer than 20 in 10,000 babies.

Sometimes a baby’s skin may be cut when the opening in the womb is made. This happens in 2 out of every 100 babies delivered by caesarean section, but usually heals without any further harm.

Breathing difficulties

The most common problem affecting babies born by caesarean section is difficulty breathing, although this is mainly an issue for babies born prematurely. For babies born at or after 39 weeks by caesarean section, this breathing risk is reduced significantly to a level similar to that associated with vaginal delivery.

Straight after the birth, and in the first few days of life, your baby may breathe abnormally fast. This is called transient tachypnoea. Most newborns with transient tachypnoea recover completely within two or three days.

If you think your baby is experiencing breathing difficulties, see your GP or call NHS 111 straight away. Treatment with oxygen may be necessary.