What Exactly Does a Caesarean Section Involve?
A caesarean section involves delivering your baby through a cut in the abdomen. We go through a similar process whether it’s a planned caesarean or an emergency caesarean. Most caesarean sections are done under epidural or spinal anaesthetic, meaning you’re awake but can’t feel any pain. You will feel movement – that’s normal. You won’t be able to see the actual surgery, but your obstetrician will talk to you throughout so you know what’s happening.
We start with a sideways cut low down on the belly, just above the bikini line. We go through several layers of tissue to reach baby. The initial layers include the skin, subcutaneous fat, and rectus sheath (a sheet of tough tissue that helps support the abdominal wall). We don’t actually cut through the abdominal muscles – we go around them. Next, there is a double layer of delicate tissue called the peritoneum. Once through the peritoneum, we’re at the uterus. We make a small cut on the front wall. At this point, we’ll drop the surgical drapes so you can watch the birth. The obstetrician will gently wiggle baby out through the incision and hold it up for you to see (and your partner to take photos!). Afterwards, we clamp and cut the umbilical cord and hand baby to the midwife.
As long as there’s no need for immediate medical attention, the midwife will bring baby up to meet you and start skin-to-skin contact. Depending on how baby is looking, he/she might be taken over to the warmer, checked top-to-toe and the Apgar scores recorded. If baby needs any assistance, a neonatologist (baby doctor) will be there to help.
While everyone else is focused on the new arrival, the obstetrician gets on with the tricky bit of the operation! The placenta is delivered. Your uterus and all the tissues in your abdominal wall are stitched back together, layer by layer. Finally, we close up the skin and put a dressing over the wound. Different obstetricians use different techniques to close the skin layer – my own preference is to use a dissolvable stitch, as most patients prefer this. Altogether, a caesarean section takes around 40 minutes.
Afterwards, you and baby will go to the Recovery Room for a couple of hours. In Recovery your vital signs, blood loss and pain relief will be closely monitored. The midwife will often be able to help you breast-feed. Once we’re happy that everything looks good, we’ll let you go back to the ward. You can expect to have a catheter (tube) in your bladder for 12-24 hours after the operation.
When is a Caesarean Section Medically Indicated?
There are lots of reasons to have a caesarean section. There are absolute reasons, where a caesarean is the only safe option. There are also relative reasons, where a vaginal birth is still possible but after careful discussion, the patient, her partner and I feel a caesarean section is the wiser choice.
A labour and vaginal birth takes time. Sometimes, it’s not safe to wait. For example, the mother might have severe pre-eclampsia, which carries a risk of seizures or stroke. There might be heavy bleeding from the placenta, putting both mum and baby in danger. The baby may have a problem and need to be delivered much earlier than expected.
Labour is also physically demanding for both mum and baby. A woman with underlying medical problems may not tolerate the physical stress of labour. A very small baby who is already showing signs of distress in the womb is also unlikely to cope with labour. A caesarean section is safer in these cases.
Other reasons are – a placenta that covers the cervix, a baby lying breech or sideways in the womb, a labour that has stopped progressing, certain kinds of twins. I always explain carefully to a woman the specific reason I am recommending a caesarean section birth.
What Is Your Opinion On a Vaginal Delivery Versus Elective Caesarean Section?
It’s a loaded question because many people have strong feelings about this topic! I think it’s very important to maintain a balanced view. It’s also hard to generalise, because so much depends on the individual patient. Two women, of similar age, in their first pregnancies, might have very different concerns and may choose very different births.
In a perfect world all women would have totally straightforward vaginal births with no complications. But it’s not a perfect world and in reality there are risks and benefits to both vaginal birth and caesarean section. Each woman will evaluate those pros and cons differently. The balance can change from one end of the pregnancy to the other.
Many women want to avoid a caesarean section if possible, as it involves major surgery, leaves a permanent scar and affects their mobility, driving etc. in the postpartum period. Other patients are more concerned about the impact of a difficult vaginal birth on their pelvic floor, bladder control, sex life etc. and may choose an elective caesarean to try and minimise these risks; or they may want to avoid a long, difficult labour which ends up in an emergency caesarean.
I did a lot of my training in Ireland, where the hospitals are generally very pro-vaginal birth. We had much lower caesarean rates than some of the hospitals here in Australia. However, I also spent 3 years working at the Pelvic Floor Unit in St George Hospital in Sydney, treating women with prolapse and incontinence, usually related to difficult vaginal births. Hopefully, my experience helps me see both sides of the argument.
Ultimately, I feel strongly that a woman has a right to choose her own preferred mode of birth, assuming I have counselled her well and she is aware of all the risks and benefits. This includes elective caesarean as well as vaginal birth.
How Can Women Optimise their Connection with their Baby Immediately After a Caesarean Section?
First of all, I think there’s a lot of scaremongering about bonding after caesarean section. It started just over 10 years ago, when a couple of small studies suggested a difference in bonding between caesarean and vaginal births. There have been further studies, but most were small and of poor quality. Like a lot of things in medicine, the media jumped on the headlines and exaggerated the science.
In the past, skin-to-skin contact for babies born by caesarean section was not promoted. Early skin-to-skin contact is now routine in most operating theatres, unless of course there’s a medical emergency. We’ve also introduced changes like dropping the surgical drapes for mum to watch the birth and speeding up the time to the first breastfeed. But early skin-to-skin contact is the main thing mums can do.
A host of factors affect the mother-baby bond, far more than just the mode of birth. Some of the strongest predictors of bonding are social and psychological factors – how prepared the mum is for a newborn, how much support she has available in the first months of baby’s life. I’d like to see a lot more focus on those factors to help new mothers bond with their babies.
How Can Women Best Recover After a Caesarean Section?
Get moving as soon as possible! Once your anaesthetic has completely worn off, the midwives will remove the catheter (bladder tube). At this point, really try to get up and start moving around. Yes, you will be more restricted than usual, but we can give you pain medication to keep you comfortable. The sooner you start moving, the faster your recovery. It also reduces your risk of blood clots and even helps your bowels work again! I am usually happy for women to start eating and drinking again straight after the surgery with no restrictions.
The wound will be covered by a special dressing, which stays on for the first few days. It’s waterproof, so you can still shower. I normally use a dissolvable stitch that doesn’t need to be removed.
Wound healing goes through several phases. At first, you’ll notice the incision is still visible, pinkish and sometimes has tiny scabs. The new skin forming is delicate and tender. You might need to put a dry pad over it, to stop it rubbing on your clothes. You’ll also need some high-waisted underwear so the elastic isn’t pressing on the wound. Avoid using any creams, oils or salt compresses at this stage of healing.
After a couple of weeks, the wound will have completely closed over. It looks smooth and pink. You can start regular massage, which has been shown to help wound healing. You can use any moisturiser or oil – it’s the massage that helps more than the actual cream! Some women buy a silicone dressing to use over the wound – this keeps the scar tissue hydrated and reduces the chance of a keloid (raised) scar.
Remember that your abdominal wall also has deep stitches. It takes time to heal and recover strength. For the first six weeks, don’t lift anything heavier than your baby. It will be at least four weeks, sometimes six, before you are healed enough to drive. Having said that, gentle physical activity like walking is strongly recommended for both physical and psychological health. Do only what is comfortable; the slow and steady approach is best!
Finally, pelvic floor exercises are a must! Your future self will thank you. It’s surprisingly hard to get the right technique though, so I do recommend seeing a Women’s Health Physiotherapist so that you can learn the right technique and be given a structured programme to follow.
Bio:
Dr Colin Walsh is an Obstetrician, Gynaecologist and accredited Maternal-Fetal Medicine specialist. He has advanced qualifications and extensive experience in high-risk obstetrics and female pelvic floor disorders, having completed major fellowships in both these areas. He undertook his specialist training in Dublin, New York, Cambridge and Sydney, finding this international experience invaluable in his practice today. Before entering full-time private practice, he ran the Medical Disorders in Pregnancy Clinic at Royal North Shore Hospital for five years. He has published more than 90 scientific papers, written chapters for major medical textbooks, acted as a reviewer for international medical journals and holds a PhD from the University of New South Wales.
Colin provides comprehensive antenatal care, birth and post-natal care for both low-risk and high-risk women. Contact Colin at:
Email: info@drcolinwalsh.com.au
Phone: 1300 460 111
Social: @drcolinwalsh