VBAC (Vaginal birth after C section)
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Amma Kyei-Mensah
Consultant in Obstetrics and Gynaecology. Lead obstetrician in maternal medicine at The Whittington Hospital in London.
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Birth and labour

What happens in a planned and emergency caesarean section?

You and your medical team may know beforehand that you need a caesarean section. This is called a planned or elective caesarean section. There are also situations in which emergency caesarean sections are required.
In Short

Elective caesarean section is the preferred method of delivery:

If you have had 2 previous CS deliveries.

If you have had a CS with a vertical incision in the uterus – a classical CS.

If your first baby is presenting by the breech at term.

If you have twins there are often more reasons for CS.

If you have triplets or a higher multiple pregnancy.

If your baby is lying sideways in the uterus.

If your placenta is completely covering the cervix.

If you have a medical problem preventing safe normal delivery.

Emergency caesarean delivery may be needed:

If labour is very prolonged and normal delivery is unlikely.

If the baby becomes distressed at any time in labour.

If the mother develops any problems such as severe high blood pressure or sudden onset of bleeding during labour.

Preparation for caesarean section

Swabs will be taken from your nose and groin some days before your operation to check that you do not carry the resistant bacteria MRSA.

If you do carry MRSA, you will be given a kit to sterilise the skin before the operation.

Blood tests to check for anaemia and your blood group will be taken up to 3 days before your operation.

Your doctor will discuss the reasons for planned caesarean and also the risks of an operation. You will be able to ask questions about the procedure.

You and your doctor will then sign a consent form for the operation.

You will also be seen by anaesthetist do discuss appropriate pain relief during and after caesarean section.

On the day of the operation, you will be asked to fast for 6 hours before the planned operation time. You will also be given a tablet to reduce stomach acid.

Most hospitals require women to attend at least 2 hours before the planned operation time to admit you and review tests and paperwork.

Pain relief for caesarean delivery

Epidural and spinal analgesia

Epidural and spinal analgesia are the methods of choice for pain relief at CS. They both involve injecting local anaesthetic in the lower lumbar region around the spinal cord.

Epidurals are used in labour with weak local anaesthetics and provide excellent pain relief. If the epidural is already in place for labour, it can be topped up to give stronger pain relief for the CS.

For elective or emergency CS, spinal analgesia can be used as dense pain relief can be established quickly.

Women can still feel touch and pressure during the operation but should not feel pain. The anaesthetist will check for this before the operation can begin.

Using epidural or spinal analgesia allows you to be awake during surgery so:

  • Your partner can be with you in the operating theatre.
  • You will be able to hold your baby and put them to the breast soon after birth.

General anaesthetic

This is only used if the woman cannot have an epidural or spinal for medical reasons e.g. previous spinal surgery or a bleeding tendency.

It may be used in extreme emergencies when heavy bleeding occurs e.g. bleeding from a low-lying placenta.

Your partner will not be in the theatre with you if you have a general anaesthetic.

Even if you have a general anaesthetic, it is safe for you to breastfeed your baby as soon as you feel able. Your partner can care for your baby and have skin to skin time with them while you recover. They may also need to help you hold and position the baby if you are still feeling a bit drowsy.

What happens at a caesarean section?

You will have a team of healthcare professionals looking after you in the operating theatre. So we can work efficiently, usually, only one companion is allowed into the theatre to support you.

  • Anaesthetist who administers the pain relief – epidural or spinal
  • Anaesthetic practitioner
  • Obstetrician who performs the CS.
  • Obstetrician acting as surgical assistant.
  • Midwife who will attend to the baby after delivery.
  • Scrub nurse who passes the instruments to the obstetrician.
  • Theatre orderlies who help in theatre.
  • Paediatrician if the baby needs specialist input

Epidural insertion

The anaesthetist will insert an IV cannula in your forearm to deliver fluids and any required medications during the operation.

Epidural insertion occurs either with you sitting sideways and leaning forward on the operating table or lying on your left side. A fine needle is inserted into the epidural space between the lower lumbar vertebrae and local anaesthetic is injected.

You then lie flat on the operating table, which will be slightly tilted to the left to prevent the uterus blocking the main vein to the heart which would cause dizziness and faintness.

The anaesthetist will check that the pain relief is effective using a cold spray. When the pain relief is effective, you will not feel the cold spray over the abdomen. This can take up to 15 minutes. The anaesthetist will then give the go-ahead for the obstetricians to begin the CS. At this stage, a single IV dose of antibiotic is administered as this has been shown to dramatically reduce postoperative infective complications.

Before the surgery begins, you will have a catheter inserted to drain urine from the bladder. This will stay in place for at least 24 hours.

Your abdomen will be cleaned with an iodine or alcohol solution and you will be covered in sterile drapes which will be pinned to stands so you do not have to see the operation taking place.

The skin incision is usually across your bikini line, which will be shaved beforehand to ensure thorough cleaning prior to the operation.

A straightforward CS takes about 60 minutes.

The baby is often delivered quickly in 5 – 10 minutes after the surgeon has made an incision in your abdomen and uterus.

If you have a high BMI or have had previous abdominal surgery or several previous caesarean sections, it may take longer to reach the baby due to tissue scarring.

The uterine incision is usually made laterally, along your bikini line.

If the baby is lying sideways or your baby is very premature or the lower segment is blocked by a low-lying placenta or a large fibroid, a vertical uterine incision (classical CS) may be required.

You can request that the drapes are lowered so that you can see your baby being lifted from the abdomen. This will be done if there are no problems encountered during surgery and if the baby is well.

The World Health Organisation recommends delayed cord cutting – not earlier than 1 minute after birth – for improved maternal and infant health. The doctors will do this if it is appropriate. It may not be feasible if your baby is distressed and needs immediate resuscitation or if there is a maternal problem that requires rapid delivery and completion of surgery.

Your partner may wish to cut the cord and a pair of cord scissors can be passed to him to do this. To avoid unnecessary contamination we recommend that they wear sterile gloves to do this.

If your baby is well at birth he can be passed straight onto your chest for skin to skin contact. Your head and shoulders may need to be raised a little so you can cuddle your baby while they finish the operation. You can ask the anaesthetist to make sure to place any electrodes away from where your baby will be lying. The placenta is removed and the uterus is sewn up in layers. All the stitches on the inside are dissolvable. The skin is usually stitched with a dissolvable suture unless you have a tendency to keloid formation.

Skin to skin contact

You can request skin to skin contact after elective and emergency CS.

Skin to skin contact straight after birth triggers the release of the hormone oxytocin which:

Calms baby’s heart rate and breathing

Enhances maternal bonding

Stimulates milk production and starts breast-seeking behaviours

The close contact of either parent begins the process of colonisation of the baby’s skin and gut with healthy bacteria.

Postnatal care after caesarean section

After the operation, you will be taken to a recovery area for 1 – 2 hours. The epidural catheter will be removed before you return to the ward. The IV line will stay in place for 24 hours. If there are no problems you will be transferred to a postnatal ward a few hours after delivery.

Pain relief is always prescribed and is often needed for 7 days. Strong analgesics are prescribed for the first few days to encourage mobilisation which is always beneficial. They will be compatible with breastfeeding.

You may be quite gassy after CS so peppermint water and plenty of fluids are recommended.

The urinary catheter will stay in place for at least 6 – 9 hours until you can safely walk unaided to the toilet.

Similarly, eating is encouraged after 4 hours once you feel up to it.

All pregnant women have thickened blood as part of the adaptation to pregnancy. This increases the risk of making blood clots in the legs (deep vein thrombosis, DVT) which could travel to the lungs (pulmonary embolus, PE).

To reduce the risk of DVT and PE:

The midwives will get you up out of bed certainly by 12 hours after the operation because good mobility reduces the risk of making clots.

You will wear TED stockings to improve blood flow to your legs whilst you are in hospital.

You will receive blood-thinning heparin injections for 10 days after delivery. This may be extended up to 6 weeks if you have any risk factors such as being overweight or complications of delivery such as infection.

Baby care post delivery

Your baby can stay with you after CS unless special care or investigations are needed.

Your partner can accompany your baby with the paediatrician to the special care baby unit (SCBU) or neonatal intensive care (NICU) if that is needed.

On the postnatal ward, the midwives will carry out daily checks on your baby.

All babies must have the formal Newborn Initial Physical Examination (NIPE) within 72 hours of birth. This can be carried out by a paediatrician or suitably trained midwife.

Discharge from hospital

Most women go home 1 – 2 days after their caesarean section.

If you have had an emergency CS, one of the doctors will come to explain the reasons for the operation before you leave. This is called a debrief. You will have another opportunity to ask questions at your follow up appointment which is usually set for 6 – 8 weeks postpartum.

Usually, only women who have had emergency CS need hospital follow-up. Women who have had a planned CS are reviewed by their GP.

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This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Essential Parent has used all reasonable care in compiling the information from leading experts and institutions but makes no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details click here.