A client is rh-negative and has given birth to her newborn. what should the nurse do next?

• A caesarean section is a surgical procedure in which a baby is born through a cut made in the mother’s abdominal wall and uterus.
• A baby will need to be born by caesarean section if there are serious problems that prevent the baby being born by a normal vaginal birth.
• Caesarean section is a relatively safe operation; however, possible complications include infection, damage to your internal organs, an increased risk of respiratory distress for your baby and complications with future pregnancies.

A caesarean section (c-section or ‘caesarean’) is a surgical procedure in which a baby is born through an incision (cut) made in the mother’s abdominal wall and the wall of the uterus (womb). Your baby will need to be born by caesarean section if there are problems that prevent the baby being born by a normal vaginal birth.

A caesarean section may be planned (elective) if there are signs that a vaginal birth is risky, or unplanned (emergency) if there are problems during labour.

If you have no serious problems with your pregnancy or labour, a vaginal birth is usually the safest way for your baby to be born. Most women have vaginal births (about 2 in every 3 births).

You have a right to be involved in and to make decisions about your care. A caesarean can only be performed if you give your written permission. Your partner or next of kin can give written permission if you are not able to.

Reasons for a planned caesarean section

There are several reasons why you and your obstetrician may decide on a planned (elective) caesarean birth.

These include:

• You have previously had a caesarean section.
• Your baby is positioned bottom or feet first (breech) and can’t be turned.
• Your cervix (opening to the womb) is blocked by the placenta (this is known as placenta previa).
• Your baby is lying sideways (transverse) and is not able to be turned by the doctor.
• You have a twin pregnancy, with your first baby positioned bottom or feet first.
• You are having 3 or more babies.

Not all women have or need to have caesareans in these circumstances. The decision will be based on a combination of your particular situation and, in some cases, your preferences.

Reasons for an unplanned caesarean section

Some of the reasons for an unplanned (emergency) caesarean birth include:

• Your baby's head does not move down or ‘fit’ through your pelvis during labour.
• Your labour does not progress – your contractions are not strong enough and your cervix opens too slowly or not at all.
• Your baby shows signs of distress or their health is being compromised.
• The umbilical cord, which provides important nutrients and oxygenated blood to your baby, has fallen down (prolapsed) through the cervix and into the vagina after your waters have broken.
• A health problem, such as high blood pressure, is making labour riskier for you and your baby.

Before you have a caesarean section, talk to your doctor or obstetrician about:

• your general health, including any health problems, as some things may affect your doctor’s decisions about surgery and anaesthetics
• possible risks and complications
• any bleeding problems and whether you bruise easily
• any allergies you may have or any medication you are taking
• tests you need to have – these include blood tests to check if you are anaemic and to find out your blood type to make sure there is some blood available in case you need it during or after the caesarean section.

Some hospitals are providing ‘enhanced recovery’ strategies for planned caesarean (called ERAC or ERAS) to help women manage their pain better, eat and drink earlier, move around earlier, care for their baby more readily and go home earlier. You will be informed at the time of booking the caesarean if your hospital is providing this type of care.

Anaesthetic for a caesarean section

There are 3 types of anaesthetic you may be given so that you do not feel any pain during your operation: They include:

• Spinal anaesthetic – the most common anaesthetic for a planned caesarean. A needle will be inserted between the bones in your spine and local anaesthetic will be injected though the needle. This will block the pain from your chest downwards. You will be awake and able to breathe normally. As your baby is being born, you may feel tugging and pulling sensations, but no pain. In some cases, a pain-killing medicine (morphine) is given at the same time as the spinal. This can last for the next 24 hours and helps with your recovery as you are less drowsy and able to eat, drink and walk around earlier. Ask your doctor if this is offered at your hospital.
• Epidural anaesthetic – often used to lessen the pain of labour. If you have already been given an epidural during labour, and it is working well, the epidural can be topped up for an emergency caesarean. The epidural is a plastic tube that will be inserted into a space around the lining of your spine. Local anaesthetic will be injected through the tube, which will block any pain sensation from your waist down. You will be awake and able to breathe normally. As your baby is being born, you may feel tugging and pulling sensations, but no pain.
• A general anaesthetic may also be given if your baby needs to be born very quickly. You will breathe oxygen through a mask and you will be given medicine through a drip, which will make you drowsy and put you to sleep. You will sleep through your baby’s birth.

The Royal Women’s Hospital (The Women’s) has a fact sheet called Regional anaesthesia (spinal or epidural) for caesarean section which compares the types of anaesthetics used for a caesarean section.

Types of caesarean sections

Caesarean sections differ in terms of where the cuts (incisions) are made to the uterus. After your caesarean, ask the obstetrician what kinds of cuts were made. This will be useful information when you are making decisions about future births.

The 2 types of cuts that can be used when you have a caesarean section are:

• A lower segment incision – will be used wherever possible. This is a horizontal (across) cut through the abdomen (stomach) and a horizontal cut through the lower part of the uterus, sometimes known as a ‘bikini line’ incision. These cuts heal better, are less visible and are less likely to cause problems in future pregnancies.
• A classical incision – refers to a vertical cut on the uterus. The cut on the abdomen may be horizontal or vertical. This type of incision is usually only used for extreme emergencies or in specific situations, such as if the placenta is lying very low, if your baby is lying sideways or if your baby is very small. It can increase the chance of having problems in later pregnancies and births.

Preparing for a caesarean section

To prepare for your caesarean section:

• You will need to fast. That means no food or drink, including water, for up to 6 hours before a planned caesarean. In some cases, you can drink clear fluids up until 2 hours before your admission. Your doctor will advise you about fasting times required for your operation.
• If you are having an emergency caesarean, the doctor will ask you when you last had any food or drink so they know how to proceed with your operation.
• You will have blood tests taken.
• You may have a support person with you, unless there are serious complications or you need a general anaesthetic. It is generally possible for someone to take photos of your baby being born, so ask your support person to bring a camera if they have one.
• Don’t be afraid to ask questions or to tell the doctors or midwives if you are feeling worried.
• If you have any special preferences, talk to your doctor or midwife beforehand, so they can try to support your choices. Some doctors – offer ‘maternal assisted’ caesareans so that you can be directly involved in the birth of your baby. Ask your doctor if they offer this option.
• If the doctor believes you are at increased risk of blood clots, you may be measured for compression stockings to wear during the operation.
• The theatre team will clean your abdomen with antiseptic and cover it with sterile cloths to reduce the risk of infection. In many hospitals, the hair around the area to be cut is shaved so that it is easier to clean. You will have a catheter (plastic tube) inserted into your bladder so that it remains empty during the operation.

During a caesarean section

The actual operation usually takes between 30 and 60 minutes. It will involve:

• The doctor will make a cut in your abdomen and your uterus (both about 10 cm long).
• Your baby will be lifted out through the cut. Sometimes the doctor may use forceps to help lift out your baby’s head.
• Your baby will be carefully checked.
• You will be able to hold your baby soon afterwards. Skin-to-skin contact can strengthen your early bond with your baby and make breastfeeding easier.
• If you cannot hold your baby in the operating theatre, your support person will most likely be able to hold your baby instead.
• The umbilical cord will be cut and your placenta removed.
• An injection will usually be given to make your uterus contract and to minimise bleeding.
• Antibiotics will be given to reduce the risk of infection.
• The layers of muscle, fat and skin will be stitched back together and a dressing will be applied over the wound.

After a caesarean section

A number of things will occur after you have a caesarean section, including:

• You will be cared for in the recovery room until you are ready to go to the ward.
• If you have had a general anaesthetic, you will most likely wake up in the recovery room. You should be able to see your baby once you are awake.
• You will be encouraged to breastfeed. The earlier you start to breastfeed, the easier it is likely to be for both you and your baby. Having a caesarean section can make breastfeeding harder to start, so ask for all the support you need. Breastfeeding is the best possible food to help your baby grow healthy and strong, and the midwives are there to help you. Some hospitals encourage women to breastfeed their baby in the recovery room if there is a midwife to assist.
• Tell your midwife or GP (doctor) when you are feeling pain so they can give you something to ease it. Pain-relieving medication may make you a little drowsy.
• You may have a drip for the first 24 hours or so, until you have recovered from the anaesthetic.
• You can start to drink as soon as you feel able.
• The midwife or doctor will tell you when you can eat again. In some cases, early eating and drinking is encouraged and chewing gum is offered to help with your appetite.
• Your catheter will stay in until the anaesthetic has worn off and you have normal sensation in your legs to walk safely to the toilet. This may not be until the next day.
• Walking around can help with recovery. It can also stop blood clots and swelling in your legs. A midwife will help you the first time you get out of bed.
• You may also have an injection to stop blood clots.
• You may need antibiotics after the operation.
• You may have trouble with bowel movements for a short time after the operation. It should help to drink plenty of water and eat high-fibre food. The doctor or midwife can give you more advice.
• When your dressing is taken off, you will be instructed to keep the wound clean and dry. This will help it to heal faster and reduce the risk of infection.

Special care for your baby after a caesarean section

Some babies born by caesarean are more likely to have breathing problems and be admitted to the special care nursery for a period of time (although they are usually ready to go home when you are). If you have no complications that mean your baby needs to be born early, a planned caesarean should be carried out around 39 weeks of pregnancy. If your baby does need to be born earlier, your doctor may recommend that you have an injection to reduce the risk of breathing problems (steroids).

If your baby is premature or unwell, they may also need to go to the special care nursery. Your partner or support person can usually go with the baby. When you are well enough, and as soon as it is possible, the midwife or nurse will help you to see your baby. The midwives or nurses can help you with expressing breastmilk for your baby.

Risks and complications of a caesarean section

In Australia, a caesarean section is a common and relatively safe surgical procedure, but it is still major surgery. As with all surgical procedures, there are risks for both you and your baby.

Some of the more common risks and complications include:

• above-average blood loss
• blood clots in the legs
• infection in the lining of the uterus
• a longer stay in hospital (3 to 5 days, or 72 to 120 hours, on average)
• pain around the wound (you will be given pain relief)
• problems with future attempts at vaginal birth
• a need for a caesarean section for future births
• complications from the anaesthetic.

Some women develop serious problems after a caesarean section. You should always talk with your midwife or doctor about any problems you are experiencing, so they can assess whether or not it is serious and provide you with the treatment you need.

Some problems you should look out for include:

• pain in your abdomen or wound that is getting worse and that doesn’t go away after you take pain-relieving medication
• ongoing or new back pain, especially where you had the epidural or spinal injection (muscular aches and pains are normal)
• pain or burning when you pass urine or inability to pass urine
• leaking urine
• constipation
• inability to pass wind or bowel motions
• increased vaginal blood loss or bad-smelling discharge from the vagina
• coughing or shortness of breath
• swelling or pain in your calf (lower leg)
• wound edges pulling apart or looking infected.

First 6 weeks after a caesarean section

After a caesarean section, women usually stay in hospital between 2 to 5 days. This can vary between hospitals or if there are problems with your recovery. Postnatal care in the home by a midwife is available to all women who birth in a public hospital. Some hospitals have a ‘hospital in the home’ option for women who have a planned caesarean and who go home early (the day after the birth). Ask the nurse or midwife about what your hospital offers.

Tips to help with recovery in the first 6 weeks include:

• Get as much rest as you can.
• Ask family or friends to help or organise paid help if you can afford it. One way that family and friends can help is by preparing meals that can be frozen and heated up – this is more useful than giving flowers. If you feel you need extra support at home, talk with the doctor or midwife, or maternal and child health nurse.
• Do not lift any weight that is heavier than your baby. Be careful of your back when you lift and don’t lift anything that causes you pain.
• Take a gentle walk every day. This can have physical and emotional health benefits.
• Do your pelvic floor exercises. Regardless of the type of birth you have had, your lower abdominal muscles and pelvic floor muscles will have weakened after pregnancy, and need strengthening. Your hospital physiotherapist can teach you how to do pelvic floor exercises, or you can find out more from The Women’s website factsheets ‘Improving your recovery after birth’ and ‘Pelvic floor exercises’ .
• Eat a healthy, high-fibre diet and drink plenty of water. Do this every day to avoid constipation.
• Use warmth on your wound. Warmth can have a soothing effect. Try a wheat bag or hot water bottle.
• In accordance with your midwife’s or your doctor’s instructions, take pain-relieving medication regularly to begin with to prevent pain. If you are breastfeeding, check that any medication you are using is safe for your baby too.
• Keep your wound clean and dry. Look for signs of infection (such as redness, pain, swelling of the wound or bad-smelling discharge). Report these to your doctor or midwife.
• While some women like loose clothing, many prefer firm, high-waisted compression underwear or control briefs to offer abdominal support. This can reduce pain and be worn for comfort for the first 6 weeks.
• Avoid sex until you feel comfortable. It is quite normal to for it to take weeks, even months, before you are ready to have sex.
• Numbness or itching around the scar is normal. This can last a long time for some women.
• Join a new mothers’ group. Talking with other mums who have had a similar experience to you can be very helpful.

Some women feel very positive about having a caesarean section, while others feel disappointed or sad. It can be very helpful to talk through any feelings of disappointment with your partner, family, friends and carers. The nurse or midwife can also refer you for counselling if you are feeling very low.

Looking after a new baby is hard for all women, but it can be harder when you are recovering from a caesarean. Be kind to yourself. It may take a few weeks or even longer to recover, particularly if you have had complications.

Avoid driving a car until your wound has healed (usually about 6 weeks). Talk with your doctor about when they think would be a safe time to start driving again.

You can get advice on improving your recovery after a caesarean section from The Women’s physiotherapy information and fact sheets ‘Improving your recovery after birth – Physiotherapy advice ’ and ‘Your health after birth – exercise ’.

Long-term health outlook after a caesarean section

It is unlikely that you will have the same problem again with future pregnancies or births. However, the fact that you have had a caesarean section can cause different problems for future pregnancies or births.

If you become pregnant again, you will need to talk to your doctor about whether your next birth will be a caesarean or a vaginal birth.

Vaginal birth after caesarean section

Many women who have previously had a caesarean section can safely give birth vaginally. This is commonly referred to as 'vaginal birth after caesarean section' or VBAC.

The benefits of VBAC are:

• lower risk of developing complications than with repeat elective caesarean section
• avoiding other risks associated with surgical procedures (such as infections, deep vein thrombosis, increased blood loss)
• faster recovery
• generally less risk for the baby (for example, there is a decreased risk of your baby being admitted to a special care nursery for respiratory problems).

One of the risks associated with VBAC is rupture of the uterine scar. About one in every 200 VBACs attempted results in rupture of the uterine scar. For those women who do have a uterine rupture, there is an increased risk of hysterectomy and stillbirth.

If you have had a previous caesarean section, to make an informed decision, it is recommended that you:

• read the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) patient information pamphlet ‘Vaginal birth after caesarean section ’
• discuss and clarify the information with your doctor or midwife, and ask what types of care and support your hospital offers for women choosing VBAC.

Where to get help

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