Caesarean section

Dr. David Kiragu Explains Why And How The Operation Is Done

Undergoing a Caesarean section just a few years back was something so rare, that those who delivered this way, did not speak publicly about it.

Many people have argued that giving birth naturally, brings more satisfaction to mothers (when one is able to push her baby out without any assistance). However, some women cannot go that route because of various factors. Many women undergo a Caesarean section without really knowing what happens to their bodies, during the process of delivery by this method.

What is a Caesarean section?

A Caesarean section or C-section, is an operative procedure for delivery, in which the baby is removed through an incision made in the mother’s abdomen. The incision can be vertical in the midline from the navel down to the hair line, called a sub-umbilical longitudinal incision. It could also be horizontal just above the pubic hair line, called the pfannenstiel incision.

Horizontal or vertical incision?

Most women and doctors prefer a horizontal incision, because it heals faster than a vertical one. The scar is also stronger and cosmetically more acceptable than the vertical scar. Its relative strength is as a result of being cushioned by strong anterior abdominal muscles after healing. The patient is less likely to develop a hernia (out-pouching of the anterior abdominal wall), or a scar rupture.

On the other hand, the vertical incision is technically simpler, easier and faster to perform. It is usually preferred in hospitals where doctors deal with many patients, or where previous surgery was done through this incision.

How is a C-section carried out?

The operation is performed under general anaesthesia, or regional (local) anaesthesia. In general anaesthesia the patient is fully asleep and unconscious. In regional anaesthesia or spinal anaesthesia, the patient is awake and only her lower body is paralysed.

Spinal anaesthesia has more advantages. This includes substantially being lower in cost, and on average having fewer complications than the general one; which has a higher cost and greater anaesthetic risk.

Like any other surgical procedure, the skin is cleaned with a disinfectant and covered with sterile linen, to prevent germs from infecting the area where the cut is to be made. This is done while the patient is awake. After anaesthesia is given- in the case of general anaesthesia, the surgeon proceeds to make the incision through the abdominal skin, underlying tissues, and finally opens up the lower part of the uterus. In other forms of anaesthesia, the anaesthesia may be given before the patient is positioned for skin cleaning. The rest of the procedure is the same.

The surgeon then removes the baby through the incision, and hands it over to the midwife or paediatrician, as the case might be for resuscitation. The placenta is also delivered manually through the incision. The uterine incision is then repaired. The various layers of the abdomen walls are stitched up, starting from the innermost advancing outwards up to the skin. The internal repairs are done with absorbable sutures, that is; stitches that do not require to be removed later as they usually dissolve on their own.

Dressing is applied on the repaired skin with waterproof-dressing material, to enable that the patient can take a shower the following day. Finally, the surgeon wipes the birth canal, which may have blood clots that have trickled from the cervix during the operation.

What are the main reasons behind a C-section?

There are many and varied reasons for doing a C-section. Some are definite (absolute), while others are relative. Absolute reasons are where there is no option but to undertake a C-section. Relative reasons are reasons where C-sections are not absolutely necessary, but are undertaken as a better option to overcome the presenting risk. As such, two doctors may reach two different decisions for the same problem. One may decide to be a bit patient and give the pregnant mother more time. Another may be cautious and decide to do a C-section straightaway. Relative conditions to a large extent, explain the different rates of this operation in different institutions. Institutions that handle difficult referral cases will also tend to have higher rates of C-sections.

A C-section is done to save the life of the mother, or the baby, or both. This depends on the clinical phenomenon one is dealing with. It may be a planned (elective), or an emergency operation.

The major common cause for a C-section

The major common cause for a C-section, is foetal distress. This is a condition where the baby is not receiving an adequate supply of oxygen. This can lead to foetal death, if the baby is not delivered urgently. Foetal distress can arise from several reasons, for instance; the cord coiling around the baby’s neck.

C-section can also be due to many other reasons. As much as possible, it is important for the mother to be informed about the reason for a C-section, before the operation commences.

Women who have had two or more previous C-sections, must be delivered through the same method. This is because their scars are weak and can easily open up when the uterus starts contracting, leading to internal bleeding and death.

Where labour is progressing poorly and the cervix is not opening up at an acceptable rate, or the baby’s head is not descending appropriately, a C-section may be done. In labour, progress is generally monitored using a standard chart in the labour ward; which informs and guides the doctors on the appropriate course of action, depending on the progress. If the labour process is not advancing well, it is termed as poor progress.

What complications arise with a C-section?

To start with, it is a fact that normal or natural delivery is safer than C-section. Some of the complications associated with a C-section include:

•  Infected wounds after surgery, which can cause anaemia.
• Surgical errors that can lead to injury to body organs like the bladder, although this is rare.
• Formation of blood clots in the legs and pelvis and development of pneumonia. Blood clots form due to slow circulation when the patient is sleeping, and the patient’s limbs are not actively moving. The patient gets hypostatic pneumonia, due to accumulation of secretions in the chest when resting.
• Death resulting from some of the complications mentioned above.

What care is given after surgery?

Patients are generally advised not to feed orally for a minimum of six hours after surgery to avoid abdominal complications. Thereafter, feeding is gradually introduced from fluids, to a light diet, and then normal feeds.

Patients are encouraged to walk around as early as the second day after the operation. This is done to avoid blood clots forming in the legs and pelvis, and to improve the recovery process.

Antibiotics are given, to prevent infections at the wound site.

When should a C-section patient be discharged?

If no other complications are detected, the patient is discharged on the fourth day.

How long does the wound take to heal?

The rate of healing depends on one’s general health status. If a patient has an infected wound, reduced immunity, poor health or is anaemic, healing slows down. It is also slower in repeated C-sections, due to the state of tissues at the healing site.

In general, the wound shows advanced healing by the end of the first week. At this time, the outer stitches on the skin break off and an antiseptic agent (it can be a spray, cream, or solution) is applied. No other medication is needed unless there is a complication. The patient should rest for about three weeks. After a week, primary healing has occurred and the wound is completely closed. Complete (tertiary) healing is achieved after 90 days.

Upon discharge, after the fourth day, the mother may take a shower but should not scrub the wound site until her condition has been reviewed by the doctor two weeks later.

Can one deliver naturally after having a C-section?

Yes. Most women can deliver naturally after one previous C-section, but they should be professionally assessed, to determine the safety of a normal delivery.

How many children can one have by C-section?

There are no hard and first rules about this. However, it is advisable for a mother to stop having babies after the fourth C-section. This is because maternal risks become significant, exposing her to real danger of developing complications, particularly spontaneous rapture of the uterine scar.

Next birth after C-section: what you must know

After a C-section, a patient should stay at least two years, before giving birth to another baby. The next delivery must be planned, and the mother assessed for delivery and follow up in the antenatal clinic. To space your children, a birth control method of choice should be used.

Dr. David Kiragu is an obstetrician, based at KAM Health Services in Nairobi.

END: PG4/41-42