Will I need a Caesarean section?

A  Caesarean section is an abdominal operation to deliver your baby. It is either an emergency or elective operation.

An emergency Caesarean section is done when there is an urgent complication in pregnancy or labour which significantly compromises your or your baby's well being (or both). This implies that continuing the pregnancy or labour for a significant time will be very dangerous. How quickly the Caesarean section needs to be done will vary from extremely urgent (viz immediately) to within the next few hours. 

An elective Caesarean section is a pregnancy planned event. The reason could be previous pregnancy or labour problems, maternal health issues, complications in this pregnancy and sometimes personal patient request. Some women prefer to have a Caesarean section rather than a vaginal birth.

An elective Caesarean section is booked on a date close to your EDC. In these situations it is safer to avoid labour. If you are booked for an elective Caesarean section and you go into labour before the scheduled date please advice the hospital and attend immediately. I ( Dr Sykes) will do your Caesarean section as soon as possible after you arrive at the hospital.

What happens with a Caesarean section?

The operation procedure and anaesthetics are discussed in the topic 'Caesarean Section' in the Pregnancy Care section.

While there are significant risks associated with the operation, because of improved surgical and anaesthetic techniques and new drugs the incidence of serious complications is much less than historically was the case. I will discuss these risks in detail with you in consultation. 

Isn't recovery worst after a Caesarean section than after a vaginal delivery?

That depends as there are lots of variables. If you have a normal vaginal delivery with no or minimal stitches then it is likely you will have an excellent recovery. But if you have a complicated vaginal delivery then the recovery after an uncomplicated Caesarean section is likely to be better.  Recovery after an elective Caesarean section is usually better than after an emergency Caesarean as your expectations of a vaginal delivery have not been deflated, it is less stressful as you know what to expect, it is not as rushed and you are not exhausted from labour. Also emergency Caesarean sections have more surgical risk than elective Caesarean sections.

Because of improved surgical and anaesthetic techniques and new drugs recovery is usually quicker than in the past and most women can resume normal activities sooner than in the past. In hospital stay is often no longer than after a vaginal delivery with some women wanting to go home on the third postoperative day. I advise my patients who have has a Caesarean section to take it quietly the first week at home and then resume normal activities gradually as the body allows. If it hurts or makes you to tired then slow down. A post Caesarean section patient should not drive a car until she is pain free. That means if you can brake suddenly without it hurting you then you can drive. Most women are doing all normal active before the six week post natal visit. Some have reported they are driving within two weeks after then are home!
 

Will I need a Caesarean section next time also?

Not necessarily. It depends on factors including the reason for the first Caesarean section, your preference and whether you can accept the implied risk of an attempt at a vaginal birth after a Caesarean section (also called VBAC or Trial of Scar). If you choose a VBAC then you and your baby will need close monitoring in labour. But be reassured, I have never had a ruptured uterus even though I have managed very many labours after Caesarean sections.

If the Caesarean section was done because your pelvis is too small or unusual in shape, or you have certain complicating factors this pregnancy then a Caesarean section is indicated. I will discuss this with you.

What is the biggest risk of an attempt at a vaginal birth a Caesarean section?

Having a Caesarean section does have implications for the next delivery. The biggest concern of an attempt at a vaginal birth after a Caesarean section is uterine rupture in labour. This is because scar tissue forms in the uterine wall with healing. Scar tissue is not as strong as non-scarred tissue and so there is an increased risk of uterine rupture.

The generally stated incidence of a  uterus rupturing in labour after a Caesarean section is about 1 in 200 cases, although the reported incidence in studies varies from 1 in 70 to 1 in over 300 . The implied risk will vary according to circumstances and be greater for some women than others.  Uterine rupture is very uncommon before labour. In labour it is due to the shearing forces of the contractions on the lower segment region of the uterus where the Caesarean section scar is located .

Unfortunately whether the uterus will rupture cannot be predicted, although sometimes an ultrasound in advanced pregnancy will report a very thin lower uterine segment, which implies increased risk.  Uterine rupture occurs without warning and is a retrospective diagnosis.

Extra precautionary measures are taken in a labour after a Caesarean section to try to diagnose uterine rupture early. This included continuous foetal heart rate monitoring as sudden fetal distress may be the first sign. Some obstetricians will not allow an epidural in labour as a an epidural can mask signs of uterine rupture. Sudden sharp pain over the scar is a sign and this will be missed if there is an epidural. Also there can be vaginal bleeding, a sudden cessation of contractions with the uterus tearing and the mother can become faint or even go unconscious because of low blood pressure with internal bleeding.

What damage uterine rupture causes depends on how severe the uterine tear is and where it is located. As well as a tear in the uterine wall the tear can extend and can result in trauma to major internal organs (bladder and bowel) and to major blood vessels which result in life threatening internal haemorrhage. Necessary surgery to correct damage can be major and high risk and even involve the need for an emergency hysterectomy. If the blood flow to the baby is affected by the uterine rupture, the rupture can result reduced oxygenation or cessation of oxygenation to the baby. This can result in asphyxial (lack of oxygen) brain damage to the baby or even in death of the baby.

What is placenta accreta?

A Caesarean section has implied risk of a markedly (morbidly) adherent placenta (called placenta accreta) next time. This means the placenta does not come away from the uterine wall in the normal way after delivery. The severity of placenta accreta varies. The incidence increases with the number of Caesarean sections and surgical uterine closure technique with Caesarean section. Placenta accreta is associated with risk of marked haemorrhage which can be life threatening. As well there may need to be major surgery including sometimes the need for an emergency hysterectomy. Placenta accreta can be checked for by ultrasound scan with some degree of accuracy.

To my knowledge my incidence of any degree of accreta after Caesarean sections I have personally done is extremely  low, and I have never had a patient with significant degree of placenta accreta. I  believe my low incidence reflects my surgical technique with closure of the uterine wall. As well I have noticed  a very low incidence of intraperitoneal adhesions which is less than seen when colleagues have done the previous Caesarean section. I believe this is because of my careful surgical technique with closure of the abdominal wall.