Planned Caesarean Birth

Planned Caesarean Birth 

Your planned caesarean has been booked in for:
_____________________________________
Please arrive on the labour ward between 07:30-08:00 and bring your hospital bag(s) with you.
Please attend the maternity day assessment unit for your pre-operation blood tests on
_________________________at_____________
Your caesarean is a planned operation and there may be one or two planned for that day. In exceptional circumstances we may need to move your caesarean date prior to the day or may need to delay it on the day due to emergencies from the labour ward arising which do take priority. We will inform you of any changes and may be able to offer you a drink or
snack while you are waiting. If you are second on the list, we will give you a drink on your arrival to avoid a long time without fluid. If you have any concerns or signs of labour such as your waters break, you are experiencing contractions, any vaginal bleeding or your baby’s movements have changed or reduced then please call us immediately on 01722 425185

Introduction

This leaflet gives you information about your caesarean birth including anaesthetic which we hope will help you to understand and prepare for it. We support enhanced recovery which involves using techniques that prepare you well for surgery and get you back to normal as soon as possible. This will mean your stay in hospital will be shorter, and your recovery overall should be improved. We describe the usual plan of care followed at Salisbury District Hospital, but we cannot cover every situation. If your situation needs something different from the usual plan, the doctors will discuss this with you. Please look at the diary section to see the planned progress for your care.

Before your Caesarean
You will usually have signed your consent form in antenatal clinic when your caesarean is booked. If this has not been completed, then this will be done with you on the day of your caesarean. The antenatal clinic will have given you a box of omeprazole tablets to take home (this reduces the acid in your stomach before your operation).
You will have been given an appointment in the maternity day assessment unit (24-48 hours before your caesarean) in order to perform blood tests to assess your blood count levels and to save a sample of blood (known as a group and save) which has tested your blood group and antibody levels.
The full blood count provides information about your haemoglobin levels to assess if you are anaemic. Occasionally mothers who have become anaemic during pregnancy will need iron tablets or an iron infusion in the weeks leading up to their caesarean.
The group and screen sample is stored in the lab for 72 hours. This is required if you require a blood transfusion. Your stored sample will be used check the blood products we plan to give you if a blood transfusion is indicated to ensure that your blood does not react with the donor’s blood. A midwife will contact you prior to your caesarean if there are any concerns with your blood test results.

Preparing For Your Caesarean
We recommend that you shave any pubic area in the area that the doctor will be making your incision at least 24 hours before your caesarean. Shaving the area less than 24 hours before your caesarean has been shown to increase the risk of infection. Showering with soap and water before you come into hospital reduces the risk of infection.
The NHS website provides useful advice for what to pack in your hospital bag:
Hospital bag checklist - Best Start in Life - NHS

You can wear slippers and a dressing gown over your hospital gown on the way to theatre if you wish. You may wish to bring a camera/phone to take photographs in theatre. We are unable to support photographs of the operation itself. We also have a Bluetooth speaker in theatre should you wish to connect this to your phone to play music. Please bring a nappy and hat for your baby into theatre. 

The Night Before/Morning of Caesarean
Please do not eat anything after midnight on the day of your caesarean. Please take two omeprazole tablets (40 milligrams total) before you go to bed. You can continue to drink 250ml per hour of clear fluid (water, diluted squash, tea or coffee without milk) up until you go to theatre. Please take the other two omeprazole tablets (40 milligrams total) at 06:30 with a glass of water. We recommend drinking plenty up to 06:30 so you can come to hospital well hydrated.

Admission to Labour Ward
When you arrive on the labour ward, we will take you to your bed which is likely to be in a 4- bedded bay. You will be seen by a midwife who will prepare you for theatre and answer any questions that you have. The midwife will check your blood pressure, pulse, respiration rate, oxygen saturations and temperature as well as feeling your tummy and listening to your baby’s heartbeat. She will gently shave the top of your pubic hair to expose the planned site for surgery if you have not already done this. The midwife will apply wrist bands with your information and provide you with a hospital gown to change into and surgical scrubs for your birth partner. Please note that only one birth partner is permitted to come into theatre with you. The anaesthetist will come and see you to discuss the spinal anaesthetic as well as the obstetrician who will perform the operation. If you are having a caesarean because your baby is not presenting head down (e.g. breech presentation) then you will be offered a scan to assess which way your baby is presenting. If your baby is presenting head down, then the obstetrician will discuss your options with you.

Transfer to Theatre
Most caesareans take place in the maternity theatre on labour ward. If your caesarean is going to be performed in the main hospital theatres for any reason this will be discussed with you prior to admission. The midwife will accompany you and your birth partner into theatre. Theatre staff will be present including the anaesthetist, operational department practitioner/anaesthetic nurse (supporting the anaesthetist), scrub nurse and theatre care assistants. The midwife will also request the presence of a neonatal (baby) doctor if this is required. The two obstetric doctors performing the operation will
arrive in theatre once your anaesthetic has been given. Your midwife will remain in theatre for the duration of your caesarean. The team will introduce themselves to you as part of the surgical checklist that is completed.

Spinal Anaesthetic
A spinal anaesthetic is the most common way of ensuring your comfort for a planned caesarean birth. However, in uncommon individual circumstances, a caesarean can also be performed using an epidural, combined spinal and epidural or with you asleep under a general anaesthetic. If any of these alternative techniques are being planned for you it will always be explained and discussed with you in advance before your caesarean. A local anaesthetic drug is injected through a needle between the bones of your back into the fluid that surrounds the spinal cord. The anaesthetic acts to numb the nerves that supply sensation to your body from the level of your chest down to your feet. It will make you numb for at least 2-3
hours. Furthermore, painkillers added to the injection that will provide additional pain relief for
several hours beyond this. Spinal anaesthesia can have several advantages over other forms of anaesthetic to allow the birth
of your baby:
• You can avoid a general anaesthetic and will be awake to meet your baby straight away
• You will also avoid the common side effects of a general anaesthetic such as sleepiness and nausea
• You will avoid potential complications of a general anaesthetic such as breathing difficulties
• Because you are awake your birthing partner can be present with you
• Faster return to eating and drinking after the procedure
• Less need for strong pain-relieving drugs such as morphine

Preparing For Your Anaesthetic
The anaesthetic assistant will assist with applying a blood pressure cuff, an oxygen saturation probe and heart monitoring stickers in order to monitor your observations. The anaesthetist will use a needle to insert a thin plastic tube (cannula) into a vein in your arm or hand. Please let the anaesthetist know if you have any concerns such as difficulty with needles and they will support you as much as possible. Fluids will be given to you through the cannula to reduce the risk of your blood pressure dropping. The anaesthetist will also use the cannula to give you antibiotics when the caesarean starts and medication to help deliver your placenta and reduce bleeding. They can also administer medication through your cannula to treat low blood
pressure and anti-sickness medication if you are feeling sick. Please continue to talk to the anaesthetist about how you are  feeling so that they can support you with any symptoms you may be feeling.

Insertion of Spinal Anaesthetic
The spinal can be performed with you either sitting or lying on your side. You will be helped into the correct position once you are comfortably on the theatre table. The anaesthetist will explain to you what they are doing to your back at all times. They will firstly clean your back with a very cold cleansing solution. Local anaesthetic will then be injected under
the skin to numb the area through which the spinal need will be inserted. The spinal injection itself can take several minutes to be undertaken and your midwife and a member of the theatre team will be with you to support you at all times.
A spinal injection is generally no more painful than having a cannula inserted or a blood test performed.
• Often as the injection goes in you may feel a warm sensation or tingling in your bottom and toes
• If you feel any shooting pain or ‘electric shock’ sensations try to stay still and tell the anaesthetist
• A range of sensations are very common and normal to experience. These may include warmth in the legs and body, tingling and then numbness to touch.
• The injection tends to take 5-10 minutes to take full effect (though it can take slightly longer) but very quickly you will notice that your legs have started to go numb and heavy
• When the injection is fully working you will be unable to move your legs and your body will be numb to approximately the middle of your chest

Testing the Spinal Block
The anaesthetist will always check and ensure that your spinal is working effectively before the caesarean is undertaken. A range of simple checks are performed including:
• Making sure your legs are heavy (“Can you list your legs off the bed for me?”)
• Ensuring that the effects of the spinal have spread across a wide enough area. This can include spraying a very cold liquid onto your skin from your feet up to your chest. Once the spinal block has started taking effect you will lose the sensation in your bladder. Due to this, the midwife will insert a catheter into your bladder which will stay in place until the day after your birth. The catheter will keep your bladder empty to reduce the risk of damage to your bladder during the caesarean. The catheter usually stays in until at least the evening or morning after your birth to ensure that you are fully mobile and the sensation to your bladder has fully returned.
The anaesthetist will not allow your caesarean birth to be started until they are completely
happy that the spinal is working as it should be.

Side Effects and Complications from Spinal Anaesthetic
Common
• Low blood pressure – this is very common after a spinal and your anaesthetist will treat it with a combination of fluids and medication through your cannula. A common symptom of blood pressure is feeling nauseous or faint.
• Itching – this occurs due to a morphine-type pain killer that is commonly put in spinals. If the itching becomes troublesome it can be treated.
• Shivering – this is a very common and harmless side effect of a spinal.
• Urinary retention - because you will not be able to feel the sensation of needing to pass water, you will have a catheter in place after the caesarean until your normal sensation has returned. Occasionally mother can have some trouble passing urine after the catheter is removed. Midwives will ask you to measure your urine twice following the removal of your catheter to ensure you are emptying your bladder properly.
Rare and Serious
• Headache – there are many causes of headache after an operation, including the anaesthetic, behind dehydrated, not eating and anxiety. Most headaches get better within a few hours and can be treated with pain relieving medicines. A severe headache can occur after a spinal injection. In young women having a spinal for childbirth it happens in around 1 in 200 spinals. If this happens to you, please let the maternity unit know for an assessment to be arranged with an anaesthetist.
• Nerve injury – this is a rare complication of spinal anaesthesia. Temporary injury occurs roughly once in every 1000 spinals. Symptoms include a loss of sensation, pins and needles and sometime muscle weakness which may last for a few days or even weeks, but almost all of these make a full recovery in time. Permanent nerve damage is rare (approximately 1 in
50,000 spinals). It has about the same chance of occurring as major complications from having a general anaesthetic.
• Infection – severe infections involving the spine after a spinal are extremely uncommon (less than 1 in 50,000 spinals). You will be continued to be monitored closely after a spinal and any signs of infection will be acted on quickly.
• Haematoma - a blood clot affecting the spine at the site of the spinal. This is very rare; about 1 in 168,000.
• Paralysis - this is a complication that many people understandably worry about. Fortunately, it is very rare – about 1 in 100,000. More information can be found at labourpains.org: Caesarean birth advice and information - Labour Pains

Caesarean Birth
Once your anaesthetic is working the midwife will check your baby’s heartbeat, and you will then be cleaned with antiseptic. A sterile drape will be placed over it and brought up to form a screen so that you cannot see the operation being performed. Your birth partner will be sat next to your head and the anaesthetist will continue to be present to monitor you and provide support. The midwife will be preparing for baby’s birth.
The spinal will remove sensations relating to pain and sharpness; however, it is completely normal to still be aware to a degree of touch and pressure. The sensations can feel very strange, mothers often describe it as being like “someone doing washing up in your tummy”. The anaesthetist will talk you through what you may feel, but during your operation please tell the anaesthetist about any sensations you are unsure of or finding difficulty and they will ensure you are comfortable. The caesarean surgery takes approximately an hour to complete, your baby will usually be born within the first 10-15 minutes. The obstetrician will lift your baby up over the screen so that you and your birth partner can see your baby. If you do not know the sex of your baby and wish to find this out yourselves then please let the midwife know. The baby’s cord will be left for one minute of delayed cord clamping, this cannot be extended due to how cool it is in theatre and because of the risk of infection to yourself. Your placenta will be delivered by the doctor, if you wish to see it or take it home with you then please let the midwife know. The obstetrician will clamp and cut the cord and pass your baby to the midwife. Your baby will be
checked over by a midwife or neonatal doctor to ensure they are healthy and breathing normally, this will usually take place on a resuscitaire (an equipment table for checking babies and providing breathing support if required). Once they are happy that your baby is breathing normally you will be asked if your birth partner wishes to do the final cutting of the cord, and the midwife will apply a cord clamp. Your baby will be brought over to you dried and wrapped to keep them warm, and you
can initiate skin to skin contact straight away if you wish.

Immediately After the Caesarean
Once your caesarean is completed you will be transferred on to a bed where you will be cleaned and incosheets and a sanitary pad will be placed in between your legs as you will still bleed after your birth. You will be transferred to the recovery area where you will be monitored by a midwife for 30-60 minutes to ensure that your observations and bleeding remain normal. The midwife will give you something to drink and check that you are not feeling sick or unwell. We recommend that you continue your skin-to-skin contact, and you can also initiate breastfeeding if you are planning to breastfeed. The midwife will be able to support you with this. If you are planning to formula feed and your baby is showing signs of hunger, then we will ask your birth partner to get your formula milk to feed your baby. You will then be transferred back to the bay you arrived in for the rest of your recovery on labour ward. The midwife will be able to bring you something to eat and will continue to monitor your observations, bleeding, wound and your urine output in your catheter. They will also offer to complete
a top to toe check on your baby, weigh, measure and apply identification labels to your baby. The midwife will discuss whether you would like your baby to be given vitamin K. You will usually remain on the labour ward for a total of 6 hours following the birth, however this may be longer depending on how much blood you lost during the caesarean, or you have certain risk factors for developing complications.

Pain Management
Your spinal anaesthetic will contain a long-acting painkiller which continues to work after the numbness has worn off. This is usually 4-6 hours after the spinal anaesthetic was given. We ask that you bring some paracetamol and ibuprofen (if you are able to take these normally) into hospital with you. You will have regular pain relief prescribed as well as extra pain relief if the regular medications are not enough. We will encourage you to self-administer your own pain relief, but please let the midwives know if you are in pain. All drugs prescribed for you will be safe to take whilst breastfeeding. The better control of your pain, the sooner you may be able to mobilise, therefore aiding your recovery.

Some of the stronger pain relief (morphine based, including dihydrocodeine and oral morphine) are present in breast milk in small amounts. Although this should not stop you breastfeeding, do be aware and alert your midwife if you feel, or your baby seems, excessively sleepy. If you feel lightheaded, nauseous, sleepy or dizzy after taking dihydrocodeine or oral morphine, tell your midwife or doctor straight away and don’t breastfeeding until you have had advice. When you go home you will be discharged with dihydrocodeine if you have been taking it in hospital. The most common side effect of medications such as dihydrocodeine and oral morphine is constipation in yourself. If you are discharged home with dihydrocodeine then we will also discharge you with a laxative to take. We encourage you take this at home alongside drinking plenty of water and eating a fibrous diet. This will help with keeping your stools soft and reduce pain when you open your bowels. Once your pain is more manageable we would advise you to reduce and then stop the dihydrocodeine first, whilst continuing with paracetamol and ibuprofen.
We recommend you have access to paracetamol and ibuprofen (providing you usually take these) at home as you will not be discharged home with them.
Once you are at home, if you are finding that the pain relief you are taking is not helping then please contact us in maternity on 01722 425185.

Moving Around
You may try to walk with help from the midwives and maternity care assistants when:
• The sensation in your legs and bottom feels back to normal
• You can lift each leg from the hips while keeping your knee straight

Please let a midwife know if this is not possible by six hours post birth. Early mobilisation is important in achieving a swift recovery after any operation. It reduces postoperative complications such as pneumonia, blood clots in the legs and pressure injuries (bed sores). We therefore encourage all women to mobilise as soon as they are able. This can include moving yourself around whilst still in bed or sitting out and eating your meal in a chair. Walking around the ward is also encouraged, and you can do this even if your catheter is still in place – it is easy to pick up the bag and carry it with you or hook it into your pyjama waistband.

Wound Care
The dressing on your caesarean will usually be removed the following day. For some women it may be left on longer depending on the advice from the obstetrician who performed the surgery, and the type of dressing used. The midwife will check for any signs of infection but if you are concerned about your wound, tell the midwife who is looking after you.
In most cases your scar will run horizontally across your lower abdomen just along the line of your pubic hair. It is usual to use a single stitch which will dissolve, or a thin non-dissolvable stitch which will need to be removed by the midwife on the fifth day. The midwife or obstetrician will discuss this further with you.
It is important that you look after your wound and monitor it for signs of infection. We recommend that you shower as soon as you feel able but do not put soap or toiletry products on your wound. You should make sure that you wash your hands before touching your wound. If your tummy is covering your wound, try to lift it gently and shower underneath and ensure it is dry afterwards. Your wound should be dried by gently patting with a clean towel and not rubbing it. We advise
wearing loose fitting, high waisted underwear to prevent rubbing of the wound.

What are the visiting hours in maternity?
We support one birthing partner to be with your caesarean birth. If you notice any symptoms of infection in your wound then please let the midwife know or contact maternity if you have been discharged. Symptoms of infection include: the skin around your wound is red or sore, it feels hot or swollen, it has a fluid discharge which is often green or yellow pus, your wound opens or you feel unwell or have a temperature.
One birthing partner can stay with you overnight during your admission including after the birth. We will ask that a behaviour agreement is read and signed by anyone staying with you overnight on the Beatrice Maternity Ward either before or following the birth. Other friends and family are welcome on the Beatrice Maternity Ward following birth between 08:00 – 21:00 with a maximum of 3 visitors (including birth partner) at the bedside. Please note that no children may visit other than the mother’s own. Fresh flowers are unfortunately not permitted on the ward due to infection control guidance.

How does parking work?
There is a limited number of patient parking spaces available in entrance A (maternity). There is a larger patient car park in car park 8 at the back of the hospital.
Parking will be charged for and is not capped at 24 hours. There are pay machines in the maternity car park, the main entrance and in car park 8. You can pay for your parking at the end of your parking episode by cash, card or contactless on your phone at the machines. No change is given from the machines.
Blue Badge holder parking is free, please display your blue badge on your dashboard. You will need to register your blue badge online before your hospital stay at https://bluebadge.apcoa.co.uk/ or validate it using the tablet at the Main Entrance Enquiries desk.
People on certain benefits may qualify for discounted parking, please see our website for more information.
If your baby is admitted to the neonatal unit, you will qualify for free parking.

Length of Stay and Discharge
This depends on how quickly you recover from your caesarean; with good pain control and
motivation to get up and about, you may only need one night in hospital. Medical and midwifery
staff are routinely available to discuss your care with you and answer any questions.
The midwife and doctor will assess you as fit for discharge providing:
• Your observations are normal
• You are passing urine normally
• There are no concerns with your wound
• Your pain levels are managed with pain relief
• You are happy to go home
• Your baby is feeding well and is not requiring any observation
Your baby will be offered a newborn infant physical examination (NIPE) check within 72 hours of birth. If you wish to go home before this is completed, then the midwife can arrange for this to
be completed in the hospital or in the community after discharge.
When you go home from hospital the midwife will go through a discharge checklist and safety advice with you including things to look out for in yourself and your baby, when to contact us
with concerns and how to contact us 24 hours a day on 01722 425185.
The midwife will arrange your discharge medication. You will be discharged with pain relief (if required) and other medications that you may be discharged with include laxatives, antibiotics, iron tablets or blood thinning injections. The midwife will explain how often to take your medications and for how long.
If you wish to discuss contraception options then please discuss this with the midwife as there are options available that the midwife can arrange for you before you go home. We recommend
waiting at least a year before trying to conceive again after a caesarean to allow your body time to heal. An interpregnancy interval of less than a year is associated with an increased risk of
preterm birth and low birthweight baby. Your fertility can resume as soon as 3-4 weeks post birth, though this may be delayed if you are breastfeeding exclusively. Further information
regarding contraception after birth can be found from the NHS at:Sex and contraception after birth - NHS

Your community midwife team will contact you the day after you go home from hospital to plan your postnatal care. Your postnatal appointments will usually be a mix of telephone checks, home visits and/or clinic visits. At the weekend postnatal care will generally be offered in a clinic at Salisbury District Hospital. The community team will usually see you on days 3, 5 and around day 10 for routine postnatal checks, however this will be personalised based on your needs. If you reside in the Bournemouth/Poole, Southampton, Bath, Swindon or Winchester catchment areas then you will usually be discharged to the community midwives at that Trust. If you wish to continue your postnatal care with the Salisbury midwives who have been caring for you in your pregnancy, then please let your midwife and the ward staff know. Your postnatal care will need
to be in our clinics as we are unable to provide home visits to women who are out of area.

Recovery at Home
• You should continue taking pain relief at home
• Avoid putting too much strain on your tummy muscles while they are healing; gentle activities which cause you no pain will do you no harm
• Ask for help with housework such as ironing and vacuuming
• You should avoid driving for 6 weeks. Rules will differ between car insurance companies, so this is worth checking with them. You should also check with them if you are taking strong pain relief.
• Sexual intercourse may be resumed when you feel ready. We recommend waiting until your bleeding has stopped, and you are no longer requiring pain relief.
• Avoid strenuous exercise like cycling, aerobics and riding until after your 6-8 weeks postnatal check with your GP which you will need to arrange
• Exercise should be started gradually and is important:
   o Pelvic floor exercises can be started straight away. The midwife will discuss these with you during your postnatal care
   o Leg and foot exercises should start as soon as you have movement back
   o Abdominal exercises can be started after a few days when you feel more comfortable

Further information about exercise can be found from BSW at: Pelvic Health - Maternity

This leaflet is to give you general information about caesarean birth, most of your questions should be answered by this leaflet. It is not intended to replace the discussion between you and your midwife or doctor but may act as a
starting point for discussion. If after reading it you have any concerns or require further information, please discuss this with a midwife or doctor.