My Elective Caesarean section, birth plan and FAQs

I wrote this post some times ago, and have revised it for few times when I acquired new tips. Hope that the sharing is useful to expecting mothers with similar experience like me.

Thank you to the advance of medicinal sciences and technology, pregnant women like me have a tremendously increasing chance of survival. However, it is also possible that because of the advance ultrasound, we got the prediction that our baby was too big for natural vaginal birth, that resulted in me ending up for an elective C-section.

Good bye my birth plan for natural birth!
Initially, I wanted to have a natural vaginal birth without epidural. My paternal grandmother, maternal grandmother, and mother have delivered nine, four, and four babies, respectively, through natural birth and without epidural. I have prepared my mind to have no fear in enduring labor pain. However, since I am going for a C-section, the birth plan can be put aside for the time being.

Since my pregnancy was considered not to require C-section, no maternal obesity, no high blood pressure, no gestational diabetes, no pre-eclampsia, our baby is not in breech position, I have prepared for the best. I only read up about natural birth, we watched videos about natural birth but not Caesarean at all. OK, I read a little bit about Caesarean.

Our baby was underweight all the way, then he started to have normal weight. That’s good. Then, in the last 2 weeks, he gained about 0.5 kg per week. Well, our baby is a late boomer.

On my 39th week 3rd day (in the evening), the ob-gyn recommended me to go for an elective Caesarean the next day or the day after. We did not have any mental preparation.

The C-section was scheduled 2 days before our baby’s EDD (expected due date). Until the day before the C-section, I had no major contraction, no bloody show. I only suffered from back pain from growing tummy, and could only sleep on left side, with a little pillow to support my belly (with baby inside).

Since the operating theaters were not available the next day after we saw the ob-gyn, I had a day extra to find out more about C-section.

To quote Marie Curie, "nothing is to be feared, only to be understood." I think and feel that the more I understand, the more prepared I will in facing challenges in lives. That is what happened when I prepared myself mentally and physically for tandem skydiving, paragliding, many academic examinations in the past, delivering talks, and venturing into the foreign countries on my own. In addition to my birth country where my parents took care of me, I have lived and survived on my own in five foreign countries, learning the systems from the scratch, making new friends, finding ways to my accommodation. To learn about making peace, I have also traveled to war torn site where soldiers with gun pointed at our bus. I have nothing to be fearful of except God.

In the evening we saw the ob-gyn, we decided to follow the ob-gyn’s advice. He told us that he was worried that the baby may have shoulder dystocia or injured nerves as he might be too big to pass through my birth canal. The ob-gyn even did not bother to check if my cervix was dilated. Shoulder dystocia affects less than 1% of birth, but our baby might have an increased risk.

As of the 39th week 3rd day, our baby has not reached the criteria of macrosomia (big baby syndrome). Note that fetal weight estimations late in pregnancy are pretty imprecise.
Perhaps, the ob-gyn thinks that our baby is big, I am small (though not small by Asian standard). I still remember my Spanish girlfriend remarked that I looked slim while pregnant, without a big belly. She teased me "I hate you". Well, now my belly looks big, I agree with the ob-gyn that our baby is likely to be a big size but I was hopeful that I can deliver him naturally.

The ob-gyn prefers the election C-section instead of an attempt of natural labor followed by emergency C-section with high risk in between. Emergency C-section has increased risk of surgical and anaesthetic complications. Post-surgical remark : I think my anesthetist was cool! He estimated the right birth weight of our baby with a difference of 0.002 kg. I may consider anesthetist as a career, if I had a chance to go to a medical school.

For the safety of our baby, we consented for an elective C-section. It was difficult to book an operating theater at our hospital of choice, they seemed to be unwilling to give us a slot, until the ob-gyn personally spoke to the hospital staff. The latter thought that we chose an elective C-section for horoscopic purpose. Actually, we did not care about the timing, as long as our ob-gyn feels comfortable and not in rush, of course we understand that he wants to see patients at his clinic at particular time slots. The most important thing is the safety of our baby. When I tried to think positively about the hospital, I come out with a positive explanation (as advocated by Martin E. Seligman): they perhaps reserve the operating theater for emergency C-section for mothers who have not succeeded to try to deliver naturally.

"My attitude is Que sera sera. Accept things that I cannot change. Now, we can only make decisions based on our limited knowledge."

Our baby was still moving happily in my womb on the day -1 of C-section. Soon, I will be able to see and hug the little one whose tiny feet and knee often protrude on my belly. However, I was concerned with the slower recovery from C-section, how I was going to take care of our baby. Post-delivery note: it turned out to be a huge challenge! Since my left hand was poked with medication, I have no strength to bring my baby to my side to breastfeed him.

FAQs (note: you should always consult your healthcare provider):

Q Why did our baby suddenly grow so much?
1. Since I complained about abdominal pain and my cervix was relatively short as compared to normal, I was prescribed 200 mg of Utrogestan daily to prevent premature delivery, for a period of 2 weeks (until the safe date for our baby’s birth). I did not took it for the last 2 days of prescriptions. I was also asked to rest more, which I enjoyed as I love reading, gazing at the park nearby, and freed me from the need to commute to work. I love to work, but I find that fighting for a space in public transport is like a daily battle and I had to be extremely careful of irresponsible people who run to rush for the train.
2. Honestly, I ate some chocolate cakes, though I do not think that I ate excessively based on my normal weight gain. The ob-gyn told me that my baby weight has nothing to do with my diet.

Q: How do I know if our baby is really big?
A: A friend had a baby measured using ultrasound for 3.5 kg, but the baby girl arrived weighting only 2.8 kg. That is why they said that the ultrasound weight prediction is imprecise. Both father and mother of our baby are not fat genetically, how can our baby be so big? Perhaps he is lengthy, and the weight measurement of ultrasound is based on the length.

Q. If I have a short cervix, will it be a shorter path for our baby to pass through, then why I cannot attempt a natural vaginal birth?
A. In my consent form, the reason for elective C-section is Cervical dystocia.
What is cervical dystocia? difficult labor and delivery caused by mechanical obstruction at the cervix.
I also read that "In preparation for childbirth, the woman’s cervix shortens."
I am confused.
No matter what, we are grateful that our baby did not end up as a premature baby.

Q: How do I know my cervix is dilating?
A: " if my cervix was in fact dilated, then I’d be able to feel something hard on the other side of it"
www.babycenter.com said that a pelvic exam can result in too much stimulation and more dilation of cervix.
Self-check may be dangerous / unhygienic, risk of breaking water bag, feel for the "hole in the donut".
"you could go 3 weeks more without going into labor after you have become effaced or started dilating"

Q: Does short cervix cause cervix dystocia?
A: I cannot find answers to this.

Q: Is C-section less painful than natural birth?
A: No, this is a misconception. The pain that is experienced because of surgery is greater than that of labor and therefore requires a more intense nerve block. It seems that I was going to endure more pain but the effect was minimized through anesthesia, but for the subsequent days I had to endure more pain as compared to natural birth.
It seems to me that
natural birth: short-term severe pain, long-term mild pain.
C-section: short-term mild pain, long-term severe pain (with the risk of longer recovery).

Post-surgical note : I heard that some women opt for elective C-section to preserve their vagina, in order to keep their husband happy.

Q: What are the risks of C-sections?
A:
postoperative adhesions.
incisional hernias: may require surgical correction.
wound infections.
placenta accreta.
emergency hysterectomies.
postnatal depression.
newborn mortality before 39 weeks.
C-sections for subsequent pregnancies & deliveries.
Emergency C-sections have additional risks:
anaesthesia risk: due to stomach not empty.
severe blood loss.
postdural-puncture spinal headaches.

Q: Will C-section reduce the chance to conceive / have the subsequent baby?
A: There will be an increase risk of
1. placenta accreta (only 0.13% after two Caesarean sections, but increases to 2.13% after four and then to 6.74% after six or more surgeries).
2. emergency hysterectomies.
40% or more of women having three or more C-sections will experience the complications of heavy bleeding and needing hysterectomy.
"By the time a woman gets to her third cesarean, she’s at serious risk for life-changing and even life-threatening complications," says Bernstein.

Q: Can one have a vaginal birth after a previous C-section?
A: Yes, but there will be a risk of uterine rupture which is catastrophic. We had a heart-to-heart discussion and decided that we are happy with 2-3 children, even if just 2 children.

Q: Should I choose between GA (general anaesthesia) or epidural?
A: Regional anaesthesia (e.g. using epidural) is preferred as it allows the mother to be awake and interact immediately with her baby.
You may still feel some pressure or a tugging sensation at some point during the surgery.
A catheter is then inserted into your urethra to drain urine during the procedure, and an IV is started (for fluids and medications including antibiotics) if you don’t have one already.

Q: Does one have to shave for C-section?
A: The top section of your pubic hair may be shaved (http://www.babycenter.com). My ob-gyn prefers full shave.

Q: What are the types of C-section, their pros and cons?
A:
1. VERTICAL / Longitudinal incision. Con: more complication. Pro: more space to deliver baby. Used in emergency C-section to allow a quicker access to baby.
2. HORIZONTAL / lower uterine segment section / a transverse cut just above the edge of the bladder. Pro: less blood loss.
The procedure involves an incision through the skin, abdomen, muscle, and then into the uterus. From start to finish, including pre- and post-op, a typical C-section lasts 3-4 hours.

Q: Should I request for antacid medication?
A: You may be given an antacid medication to drink before the surgery as a precautionary measure. If an emergency arises, you may need general anesthesia, which puts you at risk for vomiting while you’re unconscious and inhaling your stomach contents into your lungs. The antacid neutralizes your stomach acid so it won’t damage your lung tissue.
For me, since I suffered from gastric pain in the past, I would prefer to request for an antacid.

Q: Can my birth partner attend C-section?
A: Your partner, freshly attired in operating room garb, may take a seat by your head.
Sometimes no for emergency C-section, in which GA is used.

Q: What Bible verses can help to prepare Christian mothers for C-section?
A:
2 Corinthians 12:9,10 "My grace is sufficient for you for my power is made perfect in weakness. … For when I am weak, then I am strong."
Psalm 103:1-5 "… who forgives all your sins and heals all your diseases, who redeems your life from the pit and crowns you with love and compassion, …"
Proverbs 31:10-31 "A mother’s love is like a beacon burning bright with faith and prayer. Through the changing scenes of life, we can find a haven here. A mother’s love is something that no one can explain — it is made of deep devotion and of sacrifice and pain."

Q: How expensive is C-section?
A: Caesarian is $500 + $925 = ~ $1,500 more expensive than normal delivery.
Note that this calculation has not included:
room charges.
equipment usage fee.
medication fee.
anesthetist fee.
baby’s stay.
pediatrician fee.
doctor’s daily visits (even just to ask "are you ok?").
Eventually, several thousands $ are required.
Personally, I try to save money by sharing a room. I can still have privacy of view thanks to the curtain, but patients have limited privacy of sound. My first night roommate heard my family’s and relative’s conversations, and by default I have to listen (& get to know my second and third night roommates because some (I think many of) their relatives speak loudly). An ear plug is a rescue.

Q: How is placenta removed during C-section?
A: The ob-gyn will do it.

Q: How is the suture done?
A: The stitches used for your uterus will dissolve in the body. The final layer – the skin – may be closed with stitches or staples, which are usually removed three days to a week later (or your doctor may choose to use stitches that dissolve on their own). Closing your uterus and belly will take a lot longer than opening you up, usually about 30 minutes.

Q: How to breastfeed after C-section?
A:
1. you and your newborn lie on your sides facing each other.
2. football / rugby position.
To minimize discomfort, place a pillow over the incision while holding your baby.

Q: How is lochia removed after C-section?
A: According to Mayo Clinic, “Expect a bright red, heavy flow of blood for the first few days after the C-section. It might contain a few small clots. The discharge will gradually taper off, becoming more watery and changing from pink or brown to yellow or white. To reduce the risk of infection, use sanitary napkins rather than tampons. Contact your health care provider if your bleeding soaks a sanitary pad each hour for two hours, you pass a clot larger than a golf ball, the discharge has a foul odor, or you have a fever of 100.4 F (38 C) or higher.”

Q: How to recover from C-section?
A:
As soon as the anesthesia wears off, your doctor will encourage you to get up and walk around, which reduces the risk of a dangerous blood clot (pulmonary embolism) forming. Post-surgery note: I only remember a voice telling me to move my legs after the surgery, even though I was immobile.
Avoid strenuous work (e.g., lifting objects over 4.5 kg, running, walking up stairs, or athletics) for up to six months.
Rest as much as you can.
Talk less.
Wait ~ 18 months before attempting to conceive another baby.
According to babycenter, pee often, even if you don’t feel the urge to go. In the first few days after you give birth, your bladder may be less sensitive than usual, so you may not feel the need to urinate even when your bladder is quite full. In addition to causing urinary problems, a full bladder makes it harder for your uterus to contract, leading to more after pains and bleeding.

Q: What are food precaution after C-section?
A: My mother: do not eat hard food (e.g. rice) immediately after surgery, but drink something warm or eat porridge. If the porridge is cold, do not eat.
Do not eat TianZiWang.
Do not eat fried food.
My mother in law: do not to eat poultry within 12 days after C-section because today poultry is heavily injected with hormones.
My confinement lady: Do not eat ginger and wine within 12 days after C-section.
My confinement lady: Do not do post-natal abdomen massage, but hand, foot, back massage are ok after 12 days of delivery. A friend A of CW who also delivered via emergency C-section went for the post-natal abdomen massage, and felt uncomfortable after it. Personally, I think foot massage has risks too because of the linkage of acupressure points.
See also my notes on confinement.

More details:
www.webmd.com
www.mayoclinic.com
www.babycenter.com

Things I did on day -1 of my elective LSCS:
Read, watched, learned about C-section.
Drank a lot of water because I felt so thirsty.
Drank red date tea.
Paid all my outstanding credit card bills. I did not know how long it would take me to recover.
Requested the father of our baby to help us take photos of my tummy with the baby at the park.
Trimmed my eyebrow and fringe.
Clipped my nails to prevent scratching our baby.

New birth plan for my elective lower segment C-section (LSCS):
To ask healthcare provider:
Will my IV contain antibiotic?
Will I be given antacid? to request.

Before I head into the operating room, let my doctor know that I would like to see our baby as soon as possible after the delivery (as long as he is healthy).
Tips: if you have myopia, you will not be allowed to wear your soft lens, so bring your spectacles with you (and do not let any nurse to take them away). If they insist, pass it to your birth partner. Like me, you want to see your baby clearly.

If the ob-gyn allows, ask the father of our baby to play soothing music. Post-surgical note: I forgot to request. Then, I tried to console myself that music may distract my ob-gyn.

After C-section, to confirm with the ob-gyn if I do not have vertical incision.
If there was vertical incision, uterus is more likely (8 – 10%) to rupture during a vaginal birth after cesarean (VBAC).
Note: outside incision may be horizontal, but invisible inside incision may be vertical.
My ob-gyn said I have horizontal incision.

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