Benefits

The overwhelming reason for CS is obviously to prevent mortality and morbidity in mothers and babies. The WHO (1985) believes that a CS rate of around 10–15% reflects appropriate intervention.

• CS may be the only means of delivering a baby in truly obstructed labour. The alternative is fetal, and ultimately maternal, death.

• There may be a reduction in cerebral palsy. However, only around 10% cerebral palsy appears to be birth related, and CS appears to make no difference (NICE, 2004).

• CS may reduce some (but not all) urinary incontinence and uterovaginal prolapse. It makes no difference to faecal incontinence (NICE, 2004).

• Prevention of perineal pain (NICE, 2004) unless the woman has a CS following failed instrumental birth. Abdominal scar pain is of course unavoidable.

• Some women have a morbid fear of childbirth, which counselling may not dispel. CS may give them a sense of control and reduce fears.

• Some may perceive that elective CS offers them a sanitised birth experience: witness the ‘celebrity cult’ of elective CS. These women are labelled in the popular press as the ‘too posh to push’ brigade.

• A small number of women with pelvic problems, e.g. congenital hip dislocation, may benefit from CS, but most can be helped to have a normal birth.

• Convenience (if elective CS): the parents know the date of their baby’s birth. This may be relevant for parents who wish to avoid a baby being born on a dead sibling’s birthday.

• CS can assist in the resuscitation of a mother who has experienced cardiac arrest (see Chapter 17).

• Perceived protection of clinicians from litigation: believing they will be judged to have done their best if a CS is performed, even if the outcome is no better, or even worse (see Chapter 22).

Risks

CS carries risks to mothers and babies particularly in the second stage of labour (see the Appendix for NICE CS algorithm). CS is more likely than vaginal birth to result in (NICE, 2004):

• Abdominal pain. Some unlucky women who have a failed instrumental delivery may also have perineal trauma to cope with.

• Bladder and ureter injury, hysterectomy, but no difference in genital tract injury.

• Increased length of hospital stay, readmission and return to theatre.

• Implications for further pregnancies are placenta praevia uterine rupture and antepartum stillbirth. Women are less likely to have more children following CS than after vaginal birth.

• Thromboembolic disease, intensive therapy unit admission.

• Maternal death. CEMACH (2004) states: ‘Further research is needed to estimate more robustly what, if any, is the increased risk of maternal deaths associated with CS, particularly those undertaken without a clinical indication.’

• Neonatal morbidity: babies may have adverse respiratory outcomes particularly after elective CS, and low blood sugar and poor temperature regulation (NICE, 2004; Kolas et al., 2006). Babies of mothers undergoing elective CS are twice as likely to be admitted to neonatal intensive care unit than following vaginal delivery (Kolas et al., 2006).

• It has been speculated that elective CS in particular results in lower maternal hormone levels (oxytocin, endorphins, catecholamines and prolactin) which can affect postnatal mood, self-esteem and breastfeeding (Buckley, 2005).

• Post-traumatic stress disorder can result from any birth (Kitzinger & Kitzinger, 2007), but there are many accounts of post-traumatic stress disorder following emergency CS (BTA website). This ‘anecdotal’ evidence may be dismissed by some clinicians. It may not be so much the CS itself, but the sense of loss of control and poor support that causes psychological trauma.

• CS (including postnatal stay) costs double that of instrumental delivery and 2–3 times more than spontaneous vaginal birth (Henderson et al., 2001). For every 800 births conducted as CS instead of normal birth without complications, the NHS spends an extra £1 million, costing the NHS £2 billion a year.

There is a wide-ranging debate about the reasons for the current steep rise in the CS rate (Odent, 2004; NHS Institute, 2007). Numerous birth initiatives aim to stem this epidemic including the RCM campaign for normal birth (Royal College of Midwives (RCM), 2007) and the National Service Framework (DoH, 2004). The NHS Institute has published Pathways to success – a self-improvement toolkit (NHS Institute for Innovation and Improvement, 2007) aimed at enabling trusts to assess their performance and make practice changes to reduce CS rates and offer better care to those women who have CS.

CS may be reduced by the following:

• Home birth (NICE, 2004).

• Supporting women who choose vaginal birth after caesarean section (VBAC) (NICE, 2004): giving women who have had previous CS unbiased, factual information improves uptake of vaginal birth (see Chapter 11).

• Offering continuous support in labour (Hodnett et al., 2004).

• Offering induction of labour after 41 weeks gestation (NICE, 2001) (see Chapter 18).

• Use of a partogram with a 4-hour action line (NICE, 2004) but this is controversial (for more information on partograms, see Chapter 8, p. 109). Inappropriately early diagnosis of ‘slow progress’ may lead to intervention, which may in fact increase CS.

• Avoidance of continuous cardiotocograph (CTG) monitoring for low-risk women (NICE, 2007). Some would even question its value in high-risk women, since Cochrane review can find no evidence that it improves outcomes (Alfirevic et al., 2006).

• Performing fetal blood sampling (FBS) prior to CS for abnormal CTG (NICE, 2004). However, Cochrane review found no evidence of higher CS rates when FBS was not available (Alfirevic et al., 2006).

• Involving consultants in the decision regarding CS (NICE, 2004).

• Performing high quality instrumental deliveries by experienced clinicians.

• Addressing doctors’ lack of awareness of their influence on women’s decision making. Studies show the obstetrician’s experience, gender, workplace practices and whether working privately or NHS affects decision making regarding mode of delivery (Thomas & Paranjothy, 2001).

This chapter does not aim to address the debate about the appropriateness of CS in detail; hopefully much of the rest of this book, in promoting good midwifery care, will do this. Instead, this chapter aims to help the midwife assist a woman who is, for whatever reason, undergoing CS.

NICE (2004) lists the following:

• A term singleton breech (if external cephalic version is contraindicated or has failed) – however see Chapter 13 for further discussion.

• A twin pregnancy with first twin breech although NICE can offer no research to support this, but instead say it is ‘common practice’ (see Chapter 14 for further discussion).

• HIV as it reduces the risk of mother–baby transmission.

• Primary genital herpes in third trimester as this decreases neonatal infection.

• Grades 3 and 4 placenta praevia.

NICE (2004) states that CS should not be routinely offered to women with the following:

• Twin pregnancy when the first twin is cephalic at term.

• Preterm birth. There is no evidence that CS improves the already high morbidity for this group.

• Small for gestational age babies for the above reason.

• Hepatitis B or hepatitis C.

• A recurrence of genital herpes. As long as this is not a primary outbreak, there is no evidence of high risk of transmission.

• Maternal request. Further discussion recommended; offer counselling if fear of childbirth is identified.

Maternal request

The issue of elective CS for maternal request creates hot debate, with one lobby stating that a woman has the right to choose the birth of her choice while others feel that no one should have the right to choose unnecessary major abdominal surgery which absorbs scarce resources (Dimond, 1999; Dodwell, 2002).

NICE (2004) states that maternal request alone is not an indication for CS and that further clarification should be sought and counselling offered.

CS may come as a blessed relief to a woman after an arduous pregnancy and/or labour. Conversely, she may feel deeply disappointed that she has been unable to give birth naturally. If the CS is an emergency she may be frightened and apprehensive as her birth plans fall apart and events move out of her control. Choice can disappear as the quiet birthing room is invaded suddenly by noise, light and unknown people. She and her partner may even believe that she or their baby might die. Good care and support are critical in helping the woman achieve a positive experience whatever the circumstances and greet her baby with joy.

The principles of care are broadly the same whether a woman is undergoing elective or emergency CS, although the urgency of emergency CS will increase stress levels for everyone. Even if an elective CS, the woman’s decision may not have been easy, and she is likely to have the same fears as anyone else undergoing CS.

It is interesting to speculate why so few women undergoing elective CS write a birth plan. Perhaps they do not feel they have any control over this highly medicalised procedure. Although it is not common practice, it is perfectly possible for a woman to write down her preferences (Lowdon & Chippington Derrick, 2007). The process of enquiring/imagining what may happen may help her and her partner prepare for the event. A written birth plan may also be harder for staff to disregard. Responding to individual preferences may take some staff out of their comfort zone and remind them that there is a person at the centre of the proceedings, not a series of formulaic actions to be performed.

‘Women’s preferences for the birth, such as music playing in theatre, lowering the screen to see the baby born, or silence so that the mother’s voice is the first the baby hears, should be accommodated where possible’ (NICE, 2004).

Consent. Whilst some would question the quality and objectivity of information given to many women considering CS, consent for elective CS is comparatively straightforward. An emergency situation however may be quite different. A competent woman has the right to refuse CS even if she or her baby’s health would clearly benefit (DoH, 2001). The midwife may have to support a woman’s right to refuse in the face of strong opposition, occasionally even that of her partner.

Written consent is advisable, but in an emergency not essential, as long as the mother has verbally consented (or is not well enough to consent). Informed consent is not achieved when a distressed, frightened woman is forced to sign a piece of paper she can barely focus on, while a junior SHO gabbles out the risks of a CS which the woman may believe is now essential to save her baby’s life. Such ‘consent’ will have little validity in a court of law under questioning by any competent lawyer.

Question the obstetrician politely and calmly if you feel there is not a good indication for CS. If there is an abnormal fetal heart rate pattern in the first stage, FBS should be offered first, if technically possible and not contraindicated (NICE, 2004), although disappointingly FBS does not appear to affect CS rates (Alfirevic et al., 2006) or neonatal outcomes (NICE, 2007). Junior/middle grade doctors should not be making the final decision. A consultant obstetrician should be involved in any decision to offer a CS which will depend on evidence of clinical benefit to mother and baby (DoH, 2004). (In practice this ‘consultation’ can consist of a quick phone call to a consultant saying ‘I’m doing a CS, Are you happy?’) Be sensitive to the difficult position the obstetrician may be in: pressure from parents (and sometimes midwives!) to perform a CS, along with fears of an adverse outcome, criticism and litigation, can make their job very hard.

Give emotional support. If CS is elective, or occurs for slow labour progress, women usually have time to prepare emotionally. The woman may feel relieved that things are finally drawing to an end and/or distressed that she has been unable to have a vaginal birth. All women need support, but an emergency CS for ‘fetal compromise’ can be particularly frightening. Hold the woman’s hand, give her eye contact and show her warmth: let her know that her baby will be here soon, that she is doing her very best in difficult circumstances, and that the birth will be a triumph no matter what. Birth partners can be tired and emotional too – don’t forget to support them. Partners may appear angry. Sometimes they say ‘I knew this was going to happen’; following vaginal birth they may forget these transient negative thoughts, but when emergency CS occurs, they feel the bad experience was almost foreseeable.

Accept your own feelings. Midwives may feel disappointment in realising their care has not been enough to achieve a vaginal birth. You are no longer the lead caregiver and may feel disempowered and frustrated, perhaps especially so if you do not agree with the decision for CS. Do not let this affect your behaviour towards the woman: it is not her fault, and she needs your support more than ever.

Physical preparation

• Full blood count result. It is sensible to have this prior to any birth, but particularly CS, as 4–8% women lose >1000 ml at CS (NICE, 2004).

• Site intravenous cannula. A preload of crystalloid/colloid is recommended if CS under regional anaesthesia (NICE, 2004).

• Give antacids or similar drugs pre-CS to reduce gastric volume and acidity (NICE, 2004).

• A catheter is normally sited for a regional block due to potential bladder dysfunction (NICE, 2004), and possibly to ensure a full bladder does not obstruct surgery/risk bladder damage, although the routine use of catheters for CS has been questioned (Ghoreishi, 2003). 4% women develop a urinary tract infection following CS with an indwelling Foley catheter despite antibiotic prophylaxis (Horowitz et al., 2004). If there is time, ask the woman if she would prefer to have the catheter sited in theatre or in her room first.

• Shave. A lower segment CS will often be at or below the pubic hair line, so a shave is normally performed. Again this can be done in theatre or the woman’s room. An electric shaver with disposable head is probably the most comfortable option. Disposable single-use razors are uncomfortable if used dry; soap and water or shaving foam is considerate.

In theatre

Anaesthesia: The Royal College of Anaesthetists recommends that CS should usually be performed under regional anaesthesia (e.g. spinal/epidural). Thomas and Paranjothy (2001) found 77% emergency CS and 91% elective CS are performed under regional anaesthesia in the UK. If the mother is having a GA, her birth partner may not be allowed in the theatre. It is not clear why this is often the case, and this archaic practice is being challenged in more progressive hospitals where staff recognise that it should be up to the couple to decide what is best for them and their baby. Whether the partner is present or absent for the birth, he may wish to cuddle the baby at the earliest opportunity and perhaps offer skin-to-skin contact (SSC) until the mother is awake.

Environment. Do not be intimidated by the number of other staff in theatre and avoid picking up on anyone else’s negativity. Sometimes when the team is stressed, individuals may appear irritable, withdrawn or cold. Do not let this become infectious. Keep a relaxed and warm manner towards the woman, even if yours is the only smiling face in the room. She may like to have music playing, a running commentary, or silence so her voice is the first her baby hears. She may want the lights dimmed briefly for the moment of birth and/or photographs taken. These things are easier to plan and implement for an elective CS, but even in an emergency many choices can still be fulfilled. Blithely ignore any staff who cast their eyes to heaven at your strange requests: the mother is the centre of events and the staff are there for her, not the other way around.

Temperature. Make sure the theatre is warm. CS babies are more prone to hypothermia (NICE, 2004). Theatres are large rooms with a constant airflow and staff often notice that they are cold (Ellis, 2005). Put on the resuscitaire as soon as possible (its heater will also help warm the room), although hopefully it will not be needed, as SSC is advised, and a well baby will not need to be separated from its parents.

A screen may protect the mother and partner from seeing too much, but some parents wish to watch their baby being born. Always ask: never assume.

Scrubbing to assist. Some hospitals require midwives to scrub to assist the obstetrician, but others have theatre staff to do this. Midwives may have views on this, feeling they are there to be ‘with women’, not ‘with obstetrician’; if scrubbing is necessary, try to ensure that there is someone free to be with the woman. Anaesthetists are, however, usually very good at connecting with woman and their partners. It is not so much the quantity of staff, but the quality of care that is important.

Prophylactic antibiotics are recommended after CS (NICE, 2004).

Cord blood analysis. Paired venous and arterial samples will be required following emergency CS (see Chapter 23).

Resuscitation. If fetal compromise is suspected, or following general anaesthesia, a practitioner trained in advanced newborn resuscitation should be present (NICE, 2004) (see Chapter 17).

Skin-to-skin contact. SSC can be achieved with the baby delivered immediately onto the mother’s chest (see Chapter 1 for benefits). If the mother is feeling unwell or does not want this, partners may wish to offer initial SSC; babies given SSC with their fathers following CS cry less and appear calmer (Erlandsson et al., 2007). There should be no rush to weigh and measure the baby – this special time is important. Erlandsson concludes:

‘The father can facilitate the development of the infant’s prefeeding behaviour in this important period of the newborn infant’s life and should be regarded as the primary caregiver . . . during the separation of mother and baby.’

Postnatal care

Recovery room. Women should be observed on a one-to-one basis until they are stable, have regained airway control and can communicate (NICE, 2004). This should be done by trained theatre staff.

Breastfeeding can be started in the recovery room. CS mothers are less likely to start breastfeeding in early hours after birth, but once established they are just as likely to continue as other mothers (NICE, 2004). Delayed mother–baby contact can result in lower postnatal mood for up to 8 months (Rowe-Murray & Fisher, 2001).

Observations. Regular observations can identify any problems early. Check halfhourly for the first 2 hours then ‘hourly thereafter’ (NICE, 2004): usually around 2 hours if all is well. Local guidelines may apply. Obviously report any problems to an obstetrician.

• Pulse, BP, respiratory rate

• Pain and sedation. Ensure the woman is comfortable. Opioid analgesia can oversedate some women.

Also:

• Observe lochia and wound site.

• Check urine output. Ensure the catheter is free draining and the tubing not kinked.

Analgesia. Women may vary greatly in their needs. Opioid drugs and non-steroidal anti-inflammatories (NSAIDs) (check for contraindications) give good pain relief following CS (NICE, 2004), with paracetamol for milder pain. NSAIDs reduce the need for opioids, so should be used as an adjunct to any analgesia (NICE, 2004).

Check analgesia has been prescribed and given. Advise the woman to ask for further analgesia early, as pain is easier to control before it has built up; regular analgesia is usually sensible for the first few days as pain can be debilitating for a new mother with a baby to care for.

If patient-controlled analgesia is used, check it is working properly: overdosage can be serious.

Beware of drugs written on anaesthetic charts but not transferred to prescription sheets: this may result in drug errors.

Thromboprophylaxis. Thromboembolism is the most common cause of direct maternal death; 80% of women who died had identifiable risk factors for pulmonary embolism (CEMACH, 2004). Thromboembolic stockings +/− low-molecular-weight heparin should be prescribed for post-CS women particularly if other risk factors are present, e.g. high body mass index (RCOG, 2004). Ensure she is wearing stockings and that any necessary thromboprophylaxis has been prescribed.

Eating and drinking can be resumed when the woman wishes if she is recovering well with no complications (NICE, 2004).

General support. Women will need lots of assistance particularly in the first few hours. Make sure that she is comfortable with plenty of supportive pillows and a drink and the call bell is accessible. Reassure her that she can ring at anytime for help with the baby. Tuck the baby in with her if she wishes, and is awake enough: ensure the baby is safe. Try to anticipate her needs as well as respond to them.

Postnatal discussion. Women who have emergency CS should be offered the opportunity afterwards to discuss the reasons for it and the implications for future pregnancies with a knowledgeable professional (NICE, 2004; Murphy et al., 2005) (see Chapter 11). She may wish to tell her story endlessly at first, particularly if the CS was an emergency; give her space to do this. Referral to a support group may help.

Tell a woman that she has been very brave to undergo major abdominal surgery for the sake of her baby.

• The steep rise in CS has not improved maternal or neonatal health.

• Good midwifery care and avoiding unnecessary interventions reduces CS.

• Women requesting elective CS should have a full discussion of risks and benefits.

• Consider a birth plan for elective CS.

• Politely challenge a CS which you believe is unnecessary.

• Give maximum emotional support to the woman and birth partner.

• Ignore negativity: make the woman the centre of attention.

• Physical care: