At the antenatal visit prior to your planned surgery, you will be given two tablets (called Omeprazole) which reduce the amount of acid in your stomach. One tablet should be taken the night before your operation (10pm) and one on the morning of the operation (6am). You will also be given two pre-operative carbohydrate drinks to bring home and take on the morning of your surgery. Store these in the fridge the night before your operation. If circumstances change, and you do not use these drinks, please bring them back to reception unopened on your admission to hospital.

The day before your caesarean section, you will receive a phone call from a member of theatre staff telling you what time you should come to the hospital the following day. The person contacting you will remind you the time to stop eating and drinking before surgery depending on whether your operation is scheduled for the morning or afternoon.

Please check that we have your correct phone number and that of your partner, so that we can make contact with you to give you these details. Please also ensure your phone is not on silent so you are aware we are calling you.

At the antenatal visit prior to your planned surgery, you will be given tablets (called Omeprazole) which reduce the amount of acid in your stomach. One tablet should be taken the night before your operation (10pm) and one on the morning of the operation (6am).

You should have a shower or bath every day for seven days prior to your caesarean section. Please pay particular attention to the groin and skin fold sites. No routine hair removal at the incision site is needed before your operation and most importantly this should not be undertaken in the 7 days before your caesarean section to reduce the risk of wound infection.

On arrival in theatre

• You and your partner will be brought to one of our theatre reception areas.
• A member of staff will check you in to theatre. They will check your medical/obstetric history and consent for your operation.
• You will be given a small drink to take which neutralises the acid in your stomach.
• The anaesthetist will speak to you about the anaesthetic and your choices. They will check your medical history, previous anaesthetics and that you have fasted for long enough
• You will be guided by your midwife/nurse into theatre, while your partner will be shown to the change area to change into scrubs.
• Preparation for your operation will take about 20 minutes. Your partner will wait in the reception area while the preparation takes place. A nurse and anaesthetist will be with you during this time. A drip or intravenous cannula will be placed in your arm/hand. You will be given fluids and antibiotics through this drip. The theatre team will attach some routine monitoring devices to your arm, finger and chest to check your blood pressure, heart rate and rhythm – these devices do not hurt. The team will also run through a routine safety checklist recommended by WHO (World Health Organisation) prior to starting.
• Following the anaesthetic, a nurse will place a catheter (plastic tube) in your bladder to drain urineA protection screen will be placed on top of your tummy so that you and your partner do not see the surgery. Just prior to commencing surgery, once the anaesthetic has been checked and working effectively, your partner will be brought into theatre and given a seat next to you, opposite the anaesthetist.

Anaesthesia (pain relief) for your caesarean section
The most common anaesthetic for a caesarean section is a regional anaesthetic. This is often called a ‘spinal anaesthetic’ and means you will be awake for the birth. In some circumstances however, women may be offered a general anaesthetic and will therefore be asleep. This happens if a regional anaesthetic is not suitable (due to blood clotting disorders or abnormalities of the back/spine for example) or rarely, if you experience pain during the surgery.

A spinal anaesthetic involves an injection of local anaesthetic and strong painkillers into the back using a very fine needle. The medicine goes into the fluid around your spine that contains your nerves which normally gives sensation to your tummy and legs.

What to expect from regional anaesthesia?

• Once in the operating theatre, you will be asked to either sit, slouching over a pillow or lie on your side, curling your back
• A nurse will spray your back with a cold antiseptic cleaning solution
• The anaesthetist will inject local anaesthetic into the skin of your lower back to numb your skin
• From this point onwards, you should just feel pressure or pushing on your back
• When the anaesthetic medication is being injected, you may feel a tingling sensation going down one leg. It is usually nothing to worry about, but you should tell the anaesthetist if this happens
• The procedure will take a few minutes but if it is difficult to find the right position for the needle, it may take longer
• Your bottom and legs will begin to feel warm and heavy or may start to tingle
• After approximately 5 minutes, the anaesthetist will check that the anaesthetic is working correctly before the operation starts. They do this by checking your ability to feel cold sensation over your legs and tummy with ice.
• Sometimes your blood pressure can fall after a spinal anaesthetic. This may make you feel nauseous or sick. Please mention this to the anaesthetist as it can be treated very easily with medication.

What happens during the operation and how long will it take?
If you are awake for your operation, it is normal to feel pulling and pressure but you should not feel any pain. If you do feel pain, tell the anaesthetist who will be by your side. They can give you more pain relief, which can include a general anaesthetic if required. Birth of the baby can take only minutes but it will take longer if you have had previous operations.

The baby will be held up so that you and your partner can see them and find out if you have had a boy or girl. The midwife will then place the baby on a warm bed close to the operating table. The baby will be dried and examined from head to toe by the midwife and/or a paediatrician, if necessary.

If all is well, we encourage skin to skin with your baby; the midwife will place your baby on your chest while surgery continues. Skin to skin is encouraged for as long as possible provided there are no health problems with you or your baby. Sometimes we may have to delay skin to skin contact and or feeding your baby. The most common reasons are:

Mother

• nausea/vomiting
• bleeding
• general weakness or tiredness
• low temperature

Baby

• need for oxygen, suctioning
  and observations
• requires admission to the NICU
• low temperature

The midwife will put an identification bracelet and security tag on the baby’s arm and leg and with your consent will give the baby an injection of vitamin K.

After the birth, the obstetrician will remove the placenta and close the wound. This can take about another 30 minutes or more to complete. When the surgery is about to finish, your partner will be taken to the reception area of theatre with your baby. Your partner may continue skin to skin contact with your baby until you get to the recovery room. If your plan is to bottle feed, your partner can feed the baby. We ask partners not to walk around the reception area of theatre with the baby or use their mobile phone as these can interfere with theatre equipment. It is ok to use your phone to take pictures of the baby.

• Enjoy your baby and try breastfeeding if that is your preference
• Continue to drink more and eat some food
• Control nausea – ask your midwife for anti-sickness medications if needed
• Control any pain – ask your midwife for additional painkillers if your pain is not controlled with the regular painkillers
• Start to move around in the bed as your legs gradually recover from the spinal anaesthetic. Movement reduces your risk of developing a clot (DVT) by working your calf muscles. You will wear the surgical stockings while you are in the hospital. At 6 hours after your spinal anaesthetic, your midwife will assess whether or not you are ready to get out of bed. Do not worry if you are not quite ready, the staff will check again at 8 hours.

The assessment to get you walking
The midwife/nurse will do an assessment 6 hours after your spinal anaesthetic, or approximately 4 hours after your arrival on to the postnatal ward.

The assessment consists of the following:

1. Getting you to raise each of your legs straight up in the air while you are lying on your bed
2. Standing for a minute beside the bed to check for balance
3. Supervised walk to the toilet

Once you have passed this assessment, you will be allowed and encouraged to walk on your own.

Removing your urinary catheter
It may be safe to remove your urinary catheter 6 hours after your spinal anaesthetic particularly if the caesarean section was done early in the day and you are able to walk to the toilet safely. If you do not wish to have your urinary catheter removed 6 hours after your spinal anaesthetic, it can be removed the next morning at 6am.

Before removing the catheter, we must ensure that:

• Your observations are normal i.e. blood pressure, heart rate etc
• Your pain is reasonably well controlled
• Your nausea is well controlled
• You are able to drink water and will monitor your fluid intake and urine output once the catheter is removed from your bladder
• You have passed the assessment and are able to walk to the toilet independently

Once the catheter is removed
It is important that you manage to pass urine by yourself within 4 to 6 hours after the catheter is removed. To help with this, we advise you to drink to thirst. Keep a note of how much you have drank and communicate this to the midwife looking after you. Let your midwife know if you have not passed any urine by 4 hours so you can be monitored more closely for the next 2 hours.

• You will be asked to pass urine into a jug for the first couple of times you go to the toilet so that we can measure how much you pass – it should be at least 200mls each time.
• Let the midwife know if your bladder does not feel empty after passing urine, you are incontinent of urine or if the stream of urine feels irregular.

Before you go home, we want to ensure that:

• Your pain is under control
• You can walk and move around easily
• You are drinking plenty and eating healthy meals
• You can pass urine
• Your baby has been examined by the paediatrician
• Your doctor or midwife say you are well enough to go home
• You have a prescription for painkillers and understand when and how to take your medication at home

Early discharge
If both you and your baby are well, you may be eligible for early discharge. Early discharge is dependent on the above criteria being met and your home address being in the geographical catchment area for our community midwifery led follow up. For some women, early discharge may still be possible despite not living in the right catchment area for community midwifery care follow up, provided they have adequate support at home from family or friends.

Wound care
It is important not to touch your wound unless absolutely necessary and to ensure your hands are washed regularly, particularly before and after toilet use. The dressing should stay in place for 72 hours unless it is soiled. If you have a PICO (vacuum-type) dressing this will be removed after 5-7 days. Light showering is allowed with the PICO dressing, but the pump must be disconnected first as it cannot get wet. Ensure that the end of the tubing attached to the dressing does not get wet – keep it facing down so that the water does not get into the tube. Our midwives will explain this again at the time.

You will be told if your wound was closed with sutures or clips, and when these need to be removed.

At home
Recovery from a caesarean section is a gradual process over a period of about six weeks. Your public health nurse will visit you at home following your discharge from hospital or from the community midwifery team.

Pain management
It is important you take the painkillers prescribed when you need them. The majority of women going home will be advised to take regular Paracetamol (1g four times a day) and a non-steroidal anti-inflammatory like Ibuprofen (400mg three times a day), unless otherwise advised. This may be needed for at least 5 days after your operation. Keeping the pain well controlled will allow you to look after your baby. For example, we suggest taking the Paracetamol at approximately 6 am, 12 mid-day, 6 pm and 10-12pm and the Ibuprofen at 6am, 2pm and 10pm.

It is very important to walk around at home to help prevent a clot developing. Some women may need blood thinning injections for ten days or longer to prevent a blood clot. The midwife will show you how to give yourself the injection before you are discharged and will give you a special box for disposing of the needle and syringe.

Contraception advice
Fertility can return as early as three weeks after birth, so ensure you have appropriate contraception when you resume sexual activity. You will be given contraception advice prior to discharge.

Driving
If you drive, it is best to check with your insurance company if there any restrictions to driving following a caesarean section. Some companies require your GP to certify you fit to drive. Many women wait until after the six-week check.

Exercise
Your body will have undergone significant changes during the pregnancy and birth and will need time to heal and recover. You should get as much rest as possible, take gentle exercise and have a well-balanced diet. You should follow the postnatal exercise handout and information you receive while in hospital. These exercises focus on the pelvic floor and core abdominal muscles. These are very important to prepare your body for more strenuous exercise later on. Start gentle walking as pain/discomfort allows, gradually increasing your distance then your speed up to 30 minutes of a walk each day. You can start swimming at 6 weeks following your caesarean section. For the first 6 weeks avoid lifting anything heavier than your baby, including housework or other strenuous activity. Heavy or more strenuous exercise should wait until 3 months after birth to allow the pelvic floor to recover.