Caesarean Section

Caesarean Delivery

Birth by Caesarean Section is common, safe and efficient. It is a valid choice for delivery and although not without its risks and complications, enjoys a number of advantages over natural birth. Everyone can be born by caesarean section whereas the same cannot be said about vaginal birth. No one who professes any knowledge of childbirth and labour should malign a choice of caesarean section and this is the one surgical technique responsible for saving more lives than all other surgery combined. Who then, could be so arrogant as to fail to revere this miracle of medicine? Whether a caesarean section is appropriate or not, is an entirely different matter. In this practice, a request for a caesar, unless strongly motivated, will be neatly deflected to the 37 week visit. I strongly believe that any decision should be based on fact and the facts are only known by 37 weeks. This is, however a private, pro-choice practice, and you will not be subjected or coerced into any procedure without your explicit consent. There are many absolute reasons for a C/section including, but not limited to, fetal distress, severe prematurity, abnormal lie, 2 or more previous caesars, a very large infant and a contracted pelvis. A caesar may be conduced electively (planned) and then generally occurs within 7 to 10 days of due date, or as an emergency (unplanned) while in labour or as a consequence of an acute event.

Preparation for an elective caesar is similar to that of laparotomy with the same preop check list and postop instructions. Nothing to eat or drink from midnight and in the hospital at 06h00. An infusion will be sited and routine medication administered. A catheter is often also sited. In theatre, your partner will enjoy a cup of tea or coffee, while the anaesthesiologist inserts the spinal (this occurs with you sitting on the theatre bed). The spinal takes 3 to 5 minutes to work, which gives the theatre sister ample time to clean and drape you. Your partner will then join you and is welcome to stay for the entire procedure. Still photography is allowed and the anaesthesiologist is generally very willing to help. Your partner is there for you!

The efficacy of the spinal will be thoroughly tested before any cutting is performed. There is always the option to give a general anaesthetic if there is excessive sensation. Movement and pressure you will still feel, but not pain. The first incision is transverse through skin and subcuticular tissue (we prefer not to call it 'fat'). Blood vessels are cauterised as we progress. An incision is made in the muscle sheath and the muscle and sheath are separated up to the belly button. The muscle is then split down the midline (we do not cut muscle). The membrane lining the inner abdomen (peritoneum) is then tented and incised. A plastic ring is inserted to keep the wound open (this is not always paid for by the medical aid, but makes a huge difference to the ease of surgery and we use it routinely). The peritoneum over the lower part of the womb is then incised and the bladder moved out of the surgical field. A horizontal cut is made in the fibrous lower section of the womb up to the amniotic sac. A forceps is then inserted (it is a thin instrument, shaped to the babies head and takes up less room than a hand) and the head delivered. A bums-first (breech) baby is delivered in a similar fashion to vaginal breech birth, but in the absence of a bony pelvis, this is a much less complex and much safer task.

The cord is allowed to pulse for up to a minute and we generally let baby breathe at its own tempo, rarely using suction. After clamping, baby goes to the midwife for a short tour to the baby-station before coming home go mama! You are welcome to nurse your baby in theatre and in general we keep the family together up to the last stitch.

The placenta is delivered and the anaesthesiologist administers medication to assist with uterine contraction, this saving valuable red blood cells. The uterus is sutured in 2 layers with the odd extra stitch for any bleeder that may escape. If a sterilisation is authorised, it is done at this time. Peritoneum and muscle are sutured followed by the sheath. A pain catheter for local anaesthetic is often sited at this time. The subcuticular tissue is plicated at the skin closed with hidden, absorbable sutures. A comfeel dressing is then placed. This is instrumental in ensuring a keloid free scar and should not be removed for at least 3 weeks.

Pain returns gradually, giving you ample time to request pain killers as prescribed by the anaesthesiologist. Most medical aids give 3 nights after a Caesar but we can negotiate after two.


Dr Douglas Seton, Obestetrician & Gynaecologist Knysna © 2017

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