DAY OF C-Section INSTRUCTIONS

The surgery will typically be done by the primary OB, who will be coming in to do it. The booking OB’s office will provide a booklet indicating the date and time of the procedure, and when to come in. This will generally be 2 hours before the start time.

Fasting is required. Women are advised to not eat or drink after midnight the night before. An exception is made for clear fluids, which can be consumed up to 6 hours before the start time. Medications can be taken with a sip of water, unless otherwise instructed. A clear fluid is completely transparent (eg. apple juice is a clear fluid whereas as orange juice is not). If in doubt, it’s best not to drink it. When women are not properly fasted, their surgery may be cancelled or delayed, in which case it could be handed off to the on-call OB if the primary OB is no longer available.

Women checking in for their planned C-section should come in through the UCC (Entrance #97). Once admitted, they will be taken to the OR area in the TACC unit through the tunnel on the 2nd floor. There is limited space in the pre-op preparation area. Belongings other than small personal items and a phone/camera should be left in the car, to be retrieved after admission to the postpartum unit. The list of things to bring is similar to that recommended for labour and delivery, minus the items specifically pertaining to comforts in labour.

Upon arrival to the pre-op area, women will be asked to change into a gown, and the support person will don OR scrubs. The nursing staff will start an IV and draw any necessary bloodwork. The Anesthesiologist on duty will introduce themselves and review the anesthetic plan. The primary OB will check in to stay hello, and the assisting resident and/or medical student will introduce themselves as well.

The C-sECTION PROCEDURE

The entire procedure will take about an hour. When the woman is brought into the OR, the support person will be asked to wait outside. In the OR, the surgical team will perform a briefing or surgical safety checklist to confirm things such as the patient’s identity and planned procedure, and discuss any special concerns.

Most procedures are done under spinal anesthesia. This involved insertion of a very thin needle into the back to inject some freezing into the spinal fluid. The procedure sounds scary, but it is relatively painless, and the numbness sets in very quickly. The Anesthesiologists at BC Women’s are highly-experienced in spinal anesthesia. The sensation is similar to that of an epidural, but the onset is more rapid, the block is more reliable. Nothing is left in the back.

Once the spinal procedure is done, the woman is placed onto her back and a Foley catheter is inserted, to keep the bladder empty during the procedure. The catheter is typically removed on the day after the operation. The abdomen area is then cleansed with an antiseptic solution, and sterile surgical drapes are applied.

At this point, the woman’s support person, who has been impatiently waiting outside, will be brought in and asked to sit on a stool near the woman’s head. The operation will not be visible because of the drape, and watching is not encouraged other than the moment of the birth itself. This is because the role of the support person is not to be a spectator, but rather to provide comfort to their awake loved-one and be there to meet the newborn.

A ‘time-out’ will be called by the team, to do a final review of the procedure about to happen, and a pinch test will be done to ensure the spinal is fully effective. Please note that pressure sensations and touch are still felt under spinal anesthesia, but there should be nothing sharp or painful.

In most cases, a bikini-line (Pfannenstiel) incision will be made horizontally above the hair line. Existing scars are usually removed and replaced with a fresh one. Delivery usually happens rather quickly, within 5-10 minutes of the start of the procedure. This step can take longer when there is a lot of scar tissue related to previous surgery. Women will feel intense pressure on their abdomen while the baby is being actively pushed out by the surgical assistant. When the baby is born, the support person may be invited to take some photographs. Video is never permitted. The support person must stay behind the blue drape, to avoid contaminating the sterile field.

If the baby is not needing immediate pediatric attention, 30 seconds of delayed cord clamping will take place. Delayed clamping is beneficial to the baby, but waiting more that 30 seconds can be hazardous for the mother, as there can be considerable brisk bleeding from the uterine incision until the placenta is removed and the uterus is closed.

If vigourous, the newborn will be handed to a nurse who will place him/her directly onto the mother’s chest while the procedure is being completed. Breastfeeding will generally not be possible, due to the limited exposure afforded by the draping. When women do not feel comfortable holding the baby, their partner can hold the newborn skin-to-skin.

A Pediatrician attends every C-section birth and is immediately available when resuscitation is required. When all is normal, they will defer their newborn assessment while the parents are bonding with the baby. When it’s time for them to weigh and examine the newborn, this will be done in the OR, with a camera positioned above so that the woman can watch on a monitor while her surgery is completed.

Suturing all of the layers takes about 30 minutes. When the surgery is done, the team will do a ‘sign out’ to review what took place, and any special considerations for the postpartum period.

In some situations, a spinal anesthetic will not be possible, and the surgery will need to be done with general anesthesia (woman is asleep). Sometimes, the spinal may stop working optimally, and a woman will need to be given general anesthesia part way through the procedure. In these instances, the support person will be asked to leave the OR and wait outside. The newborn will be brought to them after assessment by the Pediatrician.

Post-operatively, women spend 1-2 hours in the post-operative care unit (PACU) before being transferred to the pospartum ward. Breastfeeding can be initiated in PACU. No visitors other than the support person are allowed in PACU.

WhAT TO DO WHEN LABOUR HAPPENS BEFORE THE PLANNED C-SEcTION

Because most C-sections are booked at 39 weeks, it’s quite common for labour to begin before the scheduled date. There is no need to panic when this happens. If there are regular painful contractions, or if the water breaks, women should come in to the Urgent Care Centre (UCC) at BC Women’s (Entrance #97).

Women who should not labour (eg. placenta previa, prior full-thickness myomectomy) should err on the side of coming in early with any painful contractions or bleeding.

IMPORTANT

When making their way in to the hospital, women should refrain from eating or drinking, as an empty stomach for a minimum of 6 hours is generally required before proceeding with emergency repeat C-section. Women who have recently eaten may be made to wait.

On arrival, women will be assessed to determine whether they are, in fact, in labour, and rupture of membranes will be confirmed, if there is any doubt. The C-section will thenbe done as an emergency by the OB Group physician on-call. The primary OB will not be called in.

In suitable cases, women may also be given the option of proceeding with a trial of labour after C-section (TOLAC), if the circumstances are favourable. Risks and benefits of both options will be explained by the OB on-call.

Women should remind the on-call OB if they were planning to have ligation or removal of their fallopian tubes (for permanent birth control) with their planned C-section, and indicate whether or not they still wish to proceed.