By Dr. Derrick Thompson (Obstetrician &Gynaecologist)
A planned elective cesarean section is usually performed under spinal anesthesia. If you have been taking low-dose aspirin during your pregnancy, you will be advised to stop this medication preferably 10 days before the due date of you cesarean section. If you have been on heparin therapy, the administration of heparin is ceased the day prior to your cesarean section and will be recommended after delivery. It is recommended you fast for at least 6 hours prior to your operation. This means you are not allowed food and fluids, you are not allowed to smoke, you are not able to suck lollies or lozenges, or chew gum.
If a cesarean section is being performed during labour and an epidural catheter has already been inserted, the epidural is topped up. This means extra anaesthetic solution is inserted into the epidural space.
Occasionally the woman might need a general anesthetic, for example, in the following circumstances;
- for an emergency cesarean section where the procedure needs to be performed without delay
- if the anesthetist is unable to insert the spinal needle into the epidural space or spinal canal for technical reasons
- is she prefers a general anaesthetic
Most cesarean sections are performed under local anesthesia either by spinal or epidural, while you are awake and your partner is present.
Once you are placed on the operating table, your anesthetist will insert an intravenous cannula, and then position you either lying on your side or sitting bent over on the operating table, to insert the spinal needle. A urinary catheter will be inserted to drain your bladder and keep it empty during the cesarean section. Your abdomen from your navel down to your pubic area will be washed with antiseptic solution. Your lower abdomen will be draped with sterile sheets, and your obstetrician or doctor will check that the operating site is anaesthetised. A transverse lower abdominal incision (about 15-20 cm long) is made thru the skin and fatty tissue to the sheath of abdominal muscles (rectus abdominus). This is incised transversely, and the rectus muscles are separated.
If you have a scar from a previous cesarean section in this area, most obstetricians will cut along the same scar line. If your previous scar is irregular or puckered, excision of the old scar is recommended. These days it is very unusual for a vertical incision in the lower abdomen to be performed when having a cesarean section.
Most women think their abdominal muscles have been completely cut transversely when having a cesarean section. In fact, this is not the case. Because the two halves of the abdominal muscles have only been spread apart (to allow access to the uterus) and have not been cut, bending and lifting post-operatively will not affect your c-section recovery.
The internal lining of your abdomen (called the peritoneum) is opened vertically between the rectus muscles. This can explain why you often feel numbness in your lower abdomen between your navel and the incision. The tissues in this area have been separated from the overlying skin before the peritoneum is opened vertically. The peritoneum over the lower segment of your uterus is then incised transversely and the uterine cavity opened.
The sign that the uterine cavity has been opened is often marked by a large gush of fluid, which is liquor. This is often mixed with blood, and the loss can appear quite startling.
If your baby is presenting head first, most obstetricians will deliver the head using obstetric forceps. Sometimes it can be quite difficult delivering the baby’s head manually. To prevent this potential difficulty, forceps are applied to the baby’s head and the head is lifted our of the uterine cavity. The diameter of the head plus the blades of the forceps applied to the head is less than the head plus the hand of an obstetrician, and therefore the uterine incision is less likely to be torn. Occasionally, there can be some superficial bruising over your baby’s face and scalp from applying forceps, but this will be minor and will usually resolve within a few days to a week. If your baby is breech, your obstetrician will grasp the foot first, deliver the other foot, then the bottom, the tummy and finally the head.
As your baby is being born, the drapes are lowered so that both you and your partner can witness the actual birth.
- Once your baby is born, the cord is clamped, and your baby is passed to the pediatrician who will check your baby to make sure all is well. Your baby is wrapped up and handed to you or more commonly your partner to cuddle while the operation is being completed.
- To complete the cesarean section, the placenta is removed and the uterine cavity checked to ensure there is no retained placental tissue. A finger is then passed into the cervical canal to make sure membranes are not obstructing the canal. This would prevent drainage of the blood that oozes from the raw placental site and cause the uterus to fill with blood forming a haematometra.
- This builds-up of blood can become infected, resulting in the mother feeling most unwell with rigors and high fever, usually greater than 38°C. Drainage of the uterine cavity and antibiotic treatment are required.
- The uterine incision and abdominal wall are sutured in layers. Most obstetricians close the skin with self-dissolving hidden suture just beneath the incision (a subcutaneous suture). The total operating time is about 30 – 40 minutes.