The operation, it's risks and complications

Caesarean Section (CS) is an operation where a baby is delivered through an incision (cut) in the uterus and abdomen.  Approximately 30% of babies are delivered by a caesarean section.  CS is usually undertaken when delivery through the birth canal is considered unsafe for the mother, baby or both.  In most cases a transverse cut is made in the lower part of the uterus and this is known as a lower segment caesarean section (LSCS).  However, in some cases (i.e. if there is extreme pre-maturity) the cut in the uterus has to be made vertical involving the upper part of the uterus (known as a classical caesarean section).

 

Elective Caesarean Section

An elective caesarean section is preformed when the problem is known before the labour starts.  These usually include:

• Breech (bottom first)
• Placenta Preavia (low placenta)
• Growth restriction in the baby
• Cephalo-pelvic disproportion (baby too large, high head, small pelvis) is recognized before labour
• Poorly controlled medications such as diabetes or preeclampsia
• Previous CS and where patient does not want to have the trial of vaginal delivery or trial can not be offered due to a reason.
• Patient request.

 

Emergency Caesarean Section

Emergency caesarean sections are often only preformed for these main reasons:

• Foetal distress
• Failure to make adequate progress in labour
• Placental problems as abruption (placental separation before the baby is born)
• Bleeding of uncertain origin
• Active genital herpes infection

 

Preparation for Surgery

If you are having a planned CS you will be booked in a surgical theatre like any other surgery.  This means that a booking form will be filled in by me, you will sign consent a few days before the operation and will take this form to the Diagnostic Centre (suite 210, Level 2 in RPAH Medical Centre).  You may be booked for a pre-admission consultation where various options of anesthesia and the risks and benefits may be discussed.  You will also have necessary blood tests.  The Diagnostic Centre will inform you about the time and date of presenting to the hospital and will complete other formalities.

However if you have an emergency C-Section, the labour ward anaesthetist will see you and discuss risks and complications.

 

Anaesthesia

Caesarean sections are usually preformed under epidural or spinal anaesthesia.  Sometimes, particularly in an emergency a general anaesthesia may be required.

 

The Procedure

A 10 cm bikini line incision is made in the lower abdomen and various layers of skin are opened.  A transverse cut is made in the uterus and the uterine muscles are divided.  The baby is delivered and the placenta is delivered by a controlled cord traction.  A dose of antibiotics is given.  The uterus and various layers of abdomen are closed with dissolving sutures.  The skin is then closed with dissolving sutures as well.  There are at least 6-7 people in the theatre at any given time, including the anaesthetist and assistant, the surgeon and assistant, nurses, paediatric staff and sometimes medical students.  If you have had epidural or spinal anaesthesia your partner or support person can be present in the theatre as well.  You will have an IV drip, urinary catheter, and occasionally an infusion for pain relief (PCA).  Occasionally a drain is left in the abdominal cavity to drain any blood or fluid that may be present.

 

Risks and Complications

A caesarean section is a major surgery and although it is a common operation, there is a potential for complications.  With modern surgical techniques it is rare to develop any long term or life threatening surgical complications.  However, it is important to consider the following list of potential risks before undergoing surgery.  On an average, 5% of patients undergoing major surgery will experience a significant complication despite the best medical and surgical care.

Risks include:

• Intra-operative/post operative bleeding - Blood loss of up to 500mL is common in a caesarean sections (as is in vaginal delivery).  However, excessive bleeding may occur and you may require a blood transfusion.  In some cases, blood loss may occur days after the operation and necessitate return to theatre.  Some drugs if taken within two weeks or surgery can increase the risk of bleeding at the time of the surgery.  These include warfarin, aspirin, voltaren, celebrex, other arthritis or stroke medications and Chinese and other natural herbs.  Please discuss with me if you take any medication or herbs.  In very rare cases, hysterectomy may be required due to uncontrolled bleeding.  There is also a risk of uncontrolled bleeding after a vaginal delivery.
• Infection - Infection of lungs, bladder, wound and abdomen may occur after surgery.  All precautions are taken to reduce the risk of infection by using sterile techniques, antibiotics if required and ensuring you mobilise soon after the surgery.  In some cases, an infection of the wound can lead to wound dehiscence (separation), requiring re-suturing.
• Damage to organs and blood vessels - Due to the close proximity of the abdominal and pelvic organs, damage can occur to bladder, bowel, ureter, large blood vessels and other structures.  Most of these injuries are recognised at the time of surgery and will be managed appropriately.  Trauma to the bowel is usually repaired with simple closure however in some cases this may require a colostomy/ileostomy (bowel bag).  If this does occur it is usually temporary.  Trauma to the ureter and bladder may necessitate prolonged catheterisation after surgery.  Occasionally the damage is not recognized at the time of surgery and may be apparent only a few days/weeks later.
• Thrombo-embolism (clotting) - Clots in the legs (DTV) and lungs (pulmonary embolism) may occur in patients undergoing pelvic/abdominal surgery.  Precautions are taken to reduce the incidence of clots by using special stockings and in some cases blood thinning agents after the operation.  Early mbilisation after the surgery reduces the incidence of clotting.  Smoking significantly increases your risks of developing clotting.
• Effects on future child bearing/long-term complications - Long term complications may include pelvic pain, adhesion formation,urinary or bowel symptoms and risk of placental problems in future pregnancy (i.e. low placenta or morbid adhesions of placenta increase with every c-section).
• Smoking and other life style factors - Smoking, obesity, excessive use of alcohol, etc all increase operative and anaesthetic risks significantly.  Please try to avoid these factors.
• Anaesthetic Complications - The anaesthetist will discuss in detail with you potential anaesthetic related problems.

 

Epidural Anaesthesia

An epidural, as it is commonly called, is an injection of pain relieving drugs in an area of the spinal cord called the epidural space.  The procedure is preformed by an appropriately trained doctor (usually an anaesthetist).  A special hollow needle is inserted through the skin into the epidural space (in the lower part of your back), a fine plastic tube called a catheter is threaded through it, the needle is removed and pain relieving drugs (i.e. anaesthetic) can be given through the catheter.  Epidural anaesthesia is a very effective way of relieving labour pain.  It can make the experience of labour and delivery more satisfying, not only for you but also for your support people.  You may be in a better position to enjoy your birth experience and feel in control.  However, if there is no medical indication for advising you have epidural, it would only be preformed at your request.  There are medical reasons for having an epidural which include: high blood pressure, multiple pregnancies, or where an assisted delivery or caesarean section may be required.  In some medical conditions, epidural may carry more risks.  If you have a medical condition including heart or lung disease, back problems, blood clotting problems or have a severe infection it may be contraindicated.

Risks and complications of epidural anaesthesia - Epidurals provide a low risk method of relieving pain, however, the following are some possible side effects you may experience:

• Some stinging and discomfort when the local anaesthetic is injected to numb your skin.
• A mild drop in blood pressure thus the need for a ‘drip’.
• Temporary muscle weakness in your legs.
• Shivering, although you won’t feel cold.
• Itchiness, which can be treated if severe.
• Some tenderness at the site of injection/insertion.
• Nerve damage (which is extremely rare)
• Headache.

At RPA Hospital there is an anaesthetic on site 24 hours for obstetric services.  However, there can be a delay sometimes if there is an emergency and they are busy with another patient.