Caesarean birth

Admit it — you don’t think you need to read this article, do you? Not long ago, Anna McCready would have thought the same way. Sure, the Ottawa, Ont., woman had probably heard that 25 to 28 percent of Canadian mothers give birth by Caesarean section, but those odds couldn’t apply to her — she was healthy, her pregnancy problem-free, and the women in her family “pop out babies faster than they can peel potatoes.”

“C-section didn’t even cross my mind,” Anna admits. “I didn’t know anything about it.” It wasn’t until her labour was well underway that Anna found herself wishing she did. That’s when one of her caregivers mentioned the possibility of a Caesarean: While Anna’s cervix was fully dilated, her baby (who, it later turned out, was stuck in an odd position) hadn’t begun to budge. “My husband and I panicked,” she recalls. While the couple’s story ends on an upbeat note — their daughter was born safely, and caring hospital personnel helped make the C-section a positive experience — Anna believes that being better prepared beforehand could have averted much of the anxiety that threatened to overshadow the day.

So think of the next few pages as insurance. Chances are about three in four you’ll never need the information — but if you do develop an unforeseen complication or your labour runs into a roadblock, you’ll know what to expect from surgery, and have picked up some pointers on making a Caesarean birth as serene and satisfying as possible.

In many ways, Anna is typical of first-time moms who end up having a C-section. Only a minority have planned operations due to some problem (breech position, for example) picked up during pregnancy, or have to be rushed to the OR to deal with an emergency. For first-timers, the most common reason for a Caesarean is stalled labour — which means a woman and her partner can participate and even incorporate elements they’d hoped to include in a vaginal birth. (You might want to think about what would make a Caesarean as pleasant as possible for you, and add those wishes to your birth plan.)

However, it also means that, like Anna and her husband, most parents don’t have days to deliberate. Still, it’s usually possible to make an informed, confident decision, which is one of the keys to feeling good about the birth afterward, according to Kathleen Lindstrom, a childbirth educator, doula and perinatal program manager at Douglas College in New Westminster, BC. Parents should understand why a C-section is being suggested, and how the pros and cons of surgery compare to those of attempting to deliver vaginally in their particular situation. “I felt our caregivers were making a lot of assumptions, or just thought we didn’t care — but when we did ask them for information, they were great about giving it to us,” says Anna. “Ask everyone to go away for 10 minutes and then come back to answer your questions.”

Parents might also want to take a few minutes to think about any requests they might like to make. For example, a woman might want to walk to the OR instead of being pushed in a wheelchair, and avoid having her arms strapped down if possible. “I wanted my husband to tell me what the sex of the baby was,” says Linda Brayman of Greely, Ont. Other possibilities include placing the baby on dad’s bare chest, taking photos of the grand entrance (for legal reasons, ask permission), and bringing the new arrival to mom’s side for a get-acquainted cuddle.

Once parents give the OK, they may misunderstand the abrupt change in atmosphere, Lindstrom observes. “All of a sudden, the lights come on, people are running into the room, there’s all this stuff happening. A lot of women see the people flying around and think, ‘This must really be serious.’ It’s not necessarily — it’s that OR time is at a premium.”

So let’s take a closer look at that flurry of activity. The woman signs a form acknowledging the risks of surgery, and giving consent. Blood samples are taken, and an IV is inserted (the extra fluid battles the blood pressure drop caused by the anaesthesia). She may drink an acid-reducing medication to reduce irritation in case of vomiting, and be given a rectal suppository containing a pain reliever to ease discomfort after surgery. “It sounds gross,” admits Jan Christilaw, head of specialized women’s health at BC Women’s Hospital in Vancouver, “but it works beautifully.” Women with higher-than-normal odds of blood clots in the leg (overweight women, for instance) may receive an injection of a blood thinner.

Next, the woman is taken to the operating room, while her partner or support person dons surgical scrubs. OR space is limited, so many hospitals allow only one companion — though some facilities make exceptions for midwives and doulas. She’ll meet the surgical team, at least seven people for a routine C-section, and be hooked up to a blood pressure cuff and a finger clip that tracks heart rate and blood oxygen levels.

A word about anaesthesia. In Canada, roughly 90 percent of C-sections are performed using regional anaesthesia to numb the lower body, allowing the woman to be awake during the surgery. Most Caesareans are done under an epidural because most women request one during labour and already have it in place; otherwise, a spinal may be used. Both procedures involve injecting local anaesthetic near nerves in the spine: The spinal is more foolproof (10 to 15 percent of epidurals don’t “take”), but wears off within a few hours because it doesn’t allow more medication to be added over time. In some centres, morphine is injected with the anaesthetic to help control pain after surgery; in others, both a spinal and an epidural are done — one for the surgery, the other for post-op pain control.

Often, the woman’s partner is asked to leave the room while the anaesthesia is administered — the task demands precision and concentration, and many anaesthetists prefer to have the fewest possible people present. However, some doctors will soften this stance if asked. And if the partner can’t remain, many women find their nurses’ support nearly as helpful.

The insertion itself is done this way: The woman lies curled on her side or sits hunched forward as the needle is placed between two bones in her lower back. “It sort of feels like somebody’s pushing into your back with their elbow,” Christilaw says; sometimes this is followed by a fleeting shock-like sensation. Almost immediately, the woman’s legs start tingling or feel like they’re filling with warm water. Then the nurses lie her down and place a wedge under her hip to prevent the uterus from pressing on major blood vessels. Some women briefly feel nauseated and sweaty from the medication, or short of breath because they can’t feel their breathing muscles working — though they are!

As the spinal takes effect, the mom-to-be is readied for surgery. Her arm may be folded over her chest or strapped to a board, and a catheter is inserted to keep her bladder empty and out of the way. This procedure can be uncomfortable without the spinal or epidural, so ask to have it done after you’re numb. The woman’s abdomen and upper thighs are painted with antiseptic, and towels and fabric placed around the area. In some hospitals, a screen is also erected, to block the woman’s view of her belly. The husband or partner is seated near the woman’s head to provide support. However, he’s probably just as nervous if it’s his first time in an operating room, so many couples find it reassuring to have someone explain what’s happening, and most caregivers are happy to oblige when asked.

“There are all these noises; there’s all kinds of beeping,” Anna McCready recalls. “I had a phenomenal nurse who stayed right beside me and told me what was going on. It was like having a play-by-play. She was aware of what might make me nervous, and explained it.”

Finally, the woman is checked to ensure she’s numb — first with cold, then a pinch. (The freezing extends up to the nipple line, and sometimes as far as the shoulders. If the regional anaesthesia doesn’t work or causes complications, a general anaesthetic becomes necessary — in which case, the husband or partner will be asked to wait in another room.)

By now, the big moment is only five or 10 minutes away. Normally, the surgeon makes a side-to-side incision roughly four inches long through the skin and fat just above the pubic bone. “We don’t cut the muscle because it doesn’t heal very well,” says Tracey Crumley, an obstetrician at St. Joseph’s Health Care London (Ont.). Instead, the vertical muscle is separated in the middle and pulled to either side. Another cut is made through the wall of the uterus. Usually, it resembles the outside incision, though it’s occasionally necessary to make a larger up-and-down cut.

Now, a woman may feel a lot of pressure as the physician pushes down on her belly. “We actually push the baby out,” Crumley notes. Once the baby is out, some women start shivering — this is thought to be a reaction to adrenalin, and often occurs after vaginal births too. The umbilical cord is cut, and the baby is lifted over the screen or brought around the side and introduced before being taken to another area to be checked over and dried off. Many parents choose to record this memorable moment! If the assessment is done in another room, many parents prefer the partner go too. “My husband took his shirt off and put the baby on his chest,” says Linda Brayman. “They let him hold the baby while they were doing the tests.”

Meanwhile, the surgeon is still at work. The placenta is delivered through the incision, and a hormone is given to make the uterus clamp down quickly. Most women also get a dose of antibiotics to reduce the odds of infection. “Then we close the uterus,” Christilaw says, typically in two separate layers. “There are seven layers (total) that we open and close,” adds Crumley, and “the ‘putting together’ takes a lot longer.” The entire operation typically takes between 30 and 45 minutes. The skin is often closed with surgical staples. While these initially make the wound look ugly and puckered, they actually produce a less noticeable scar than sutures, and removal is painless.

What the baby and partner do while this is happening depends on the hospital, and whether or not the new mom is still awake (it’s not unusual to fall asleep from sheer fatigue or medication-induced drowsiness). If she is, the new family may choose to remain together. “They wrapped my daughter up, and let my husband hold her near me,” recalls Karen Yee, of Oakville, Ont. Or, the parents may choose to have the partner stay with the baby. “I was very comforted to know Maya was with my husband the whole time,” says Alise deWinter, of Midland, Ont.

Nurses put a dressing on the wound, clean mom up and take her to a recovery area. Some hospitals have a separate maternity recovery room; in others, C-section moms are lumped in with regular surgical patients. In some facilities, the new family stays together here while the baby undergoes a detailed assessment and is given a vitamin K shot and antibiotic eye ointment. Then “we ask the partner if he wants to diaper and dress the baby,” says Margaret Belliveau, a perinatal nurse-educator at St. Joseph’s Health Care London (Ont.). The nurses also help initiate breastfeeding, for those moms who plan to do so. Since breastfeeding tends to get off to a slower start for C-section moms, the nurses will often help bring the baby to the breast as soon as possible — even if the mom is still asleep! “My husband told me the nurses just uncovered my breast and held my son up against me to feed,” says Melissa Knowlton, of Lachine, PQ. (Parents can ask to see a lactation consultant for advice on getting breastfeeding underway smoothly.)

The nurses continue to monitor mom for the warning signs of any potential problems like internal bleeding. She’s asked to wiggle her toes or move her ankles to make sure the anaesthetic is wearing off as expected. “We also gently check her uterus to make sure it’s firm, and make sure the blood flow from her vagina is not excessive,” says Belliveau. Both the obstetrician and anaesthetist typically drop by to see how things are going too. If everything goes as planned, after a couple of hours, mom and baby are settled into a room in the postpartum unit.

Dad or a support person is often welcome to stay too (at least in private rooms). Since rooming in is the norm in many hospitals now, many moms find the extra pair of hands invaluable. An extra person — like a doula — to spell off dad can help both parents get much-needed rest! Just ask Pam Venkataya, whose husband and mother both stayed with her the night after her first child’s birth. “It was a great help,” says the Burnaby, BC, mom. “I could not jump up with a crying newborn.” If you are on your own, don’t be afraid to ask the nurses to take the baby so you can sleep.

C-section moms are encouraged to sit up within six hours after surgery and resume walking the following day — this gets the bowels moving again, prevents blood from pooling in the legs and speeds recovery. It also involves less discomfort than you might expect, particularly for women who receive morphine. “That actually gives most people pain relief for about 24 hours,” Christilaw explains. However, the drug sometimes causes nausea or itchiness — which can usually be remedied with Benadryl.

Once mom is back on her feet, the catheter is removed, though the IV usually stays in place for 24 hours. She can also expect to feel a bit more sore around the time the IV is removed. That’s when moms think, “Right, I’ve had surgery,” says Belliveau. “They can feel really good, and then kind of hit the wall and have to sit down and rest.” An oral pain reliever like acetaminophen plus codeine can make moving more comfortable, so a mom can concentrate on enjoying her baby. However, codeine is constipating, so “take the stool softener they offer you,” urges Judy Roche, of Bowmanville, Ont. “There is nothing worse than being in pain from the C-section and not being able to push out a poop.”

Heading home

Over the next few days, swelling in the feet and ankles (from the extra fluids given during surgery) slowly dissipates, the dressing is removed, and the staples are taken out. Within 72 hours, most women head home. And while many women are pleasantly surprised to find they bounce back more rapidly than expected, the combination of a new baby and the after-effects of surgery can leave C-section moms very tired. “Let people help you,” emphasizes Megan Amisson, a two-time C-section veteran in Oshawa, Ont. Michelle Bennett concurs: “If you had some kind of liver surgery, you’d take the time (to rest),” the Toronto mom points out. For some women, grief or sadness can complicate recovery. “Some women feel that they were robbed of their birth,” observes doula Kathleen Lindstrom, who adds that simply talking to someone who will listen without judging may help.

On the other hand, Judy Roche’s experience is probably more typical. Despite the fact she felt defeated during labour because her hopes for a home birth had been dashed, she says, “once my son was born, I was so busy learning how to be a mom that I didn’t even notice how I was feeling. I was just so happy and overwhelmed and exhausted.”

How does an emergency C-section differ from its less-urgent counterpart?

First of all, there may be little time to digest what’s happening. In a centre that cares for high-risk women, “we need to be able to get a woman to section within five to 10 minutes,” says Margaret Belliveau, a perinatal nurse-educator at St. Joseph’s Health Care London (Ont.).

Sometimes, “I’m explaining things as we’re running down the hall,” notes Jan Christilaw, head of specialized women’s health at BC Women’s Hospital in Vancouver. While the husband or partner waits outside the operating room, inside, the woman is being given medication — both by mask and IV — to make her sleepy. Once she’s unconscious, a breathing tube is inserted in her throat, and surgery is started.

Once the baby is born and checked over, the husband or partner is usually given a chance to meet the new family member. When mom starts coming out of the anaesthetic, the nurses will reassure her and keep talking to her until she starts to cough or gag — these are signals that she’s ready to breathe on her own. The doctors will pull out the breathing tube and suction away any extra mucus. (She may have a sore throat or scratchy voice for a few days afterward.) The new mom is then taken to the recovery room where, if all is well, she’ll be reunited with her family.