(An obstetrician is a doctor who has had specialist training in the care of women during pregnancy and childbirth.)

A caesarean may be planned in advance – for example, because the baby is positioned bottom first – or it may be done at short notice as an emergency if complications develop during your pregnancy or labour.

During your pregnancy your midwife or doctor should give you information about birth that is based on the best available research evidence. You should be offered this information in a form that suits you if you have extra needs –
if, for example, you do not speak or read English or if you have a disability. It should include accurate information about caesarean section, including:
• common reasons for needing a caesarean section
• what the procedure involves
• the risks and benefits of caesarean section compared with vaginal birth
• how having a caesarean section might affect any future pregnancies
• how having a caesarean section might affect your chances of having a vaginal birth in future.

Your midwife or doctor should encourage you to ask questions if there is anything you do not understand, and discuss them with you.

Making decisions about how to have your baby
To enable you to make decisions about how to have your baby, your midwife or doctor should discuss with you the benefits and risks of a caesarean section compared with a vaginal birth specific for your situation. He or she should make a note of this discussion. If you need a caesarean section, your healthcare team should explain to you why it is necessary and record their reasons for carrying it out.
Your healthcare team should record the level of urgency of any caesarean section. They will do this using the following standard categories:
1. Where there is an immediate threat to your life or the life of your baby
2. Where there is concern about your health or the health of your baby, but your lives are not in immediate danger
3. Where there is no immediate concern about your health or the health of your baby, but you need an early delivery because of an existing condition
4. Where delivery is timed to suit you or your healthcare team.

If your doctor doesn’t think a caesarean section will benefit the health of you or your baby, he or she has the right to decline your request for one. However, they should offer to refer you to another doctor.

Effects of caesarean section on a woman’s health

The table on the next page shows the effects of caesarean section on a woman's health. These risks do not apply to all women or all circumstances. If you have a caesarean section because of a problem that develops during pregnancy or
labour, the risks will be different. Your midwife or doctor should discuss this with you. Some problems – such as needing admission to an intensive care unit – are more likely after a caesarean birth than after a vaginal birth. It is not clear whether this happens as a result of a caesarean section or because of the reasons for needing a caesarean section. Pain in the abdomen affects about 9 of every 100 women who have a caesarean section, but most of the other problems are very rare.

There is more detailed information on the effects of caesarean section on women's health in Appendix A at the end of this booklet.

You should not be offered ECV if:
• your waters have broken
• you are in labour
• you have a scar on your womb, or if your womb is irregularly shaped
• the health of your baby is at risk
• you have any vaginal bleeding
• you have an existing medical condition.

If your baby is positioned bottom first at the end of your pregnancy and you are not able to have ECV, or it has not been successful, you should be offered a caesarean section. This reduces the risk of your baby dying or being injured during birth.

If you have a first-ever infection of genital herpes in the last 3 months of your pregnancy, you should be offered a caesarean section. But if you have a recurrence of genital herpes at the time of the birth you should not be offered a planned caesarean section, unless you have agreed to take part in a research programme. There is not enough evidence to tell us whether caesarean section cuts down the risk of passing the herpes virus on to your baby if you are having a recurrence at the time of birth.

If your babies are due to be born, you are healthy and have not developed complications in the pregnancy, and the first twin is in the head-first position (the normal position for birth), you should not routinely be offered a planned caesarean section, unless you have agreed to take part in a research programme. It is not certain that planned caesarean section improves the health of the second twin in these circumstances.

If you are expecting twins and have had no problems with your pregnancy you should not have a caesarean section before the 38th week of your pregnancy. Having a caesarean section any earlier than this increases the chances of the babies having breathing problems when they are born.

Some things are known to cut down the chances of needing a caesarean section. They may also affect other aspects of your labour or the birth that are not considered in this guideline.
• You should be aware that having another woman with you for support throughout your labour reduces the chance of having a caesarean section.

• If you are still pregnant after 41 weeks of pregnancy, you should be offered induction of labour (to have your labour started off). This is safer for the baby and reduces the chance that you will have a caesarean section (for information about induction of labour, see the NICE guideline Induction of labour;
• The use of a chart called a partogram to follow the progress of your labour also makes a caesarean section less likely. At 4-hourly intervals, your midwife or doctor will offer to do a vaginal examination to measure how far your cervix has opened up (dilated), and feel your abdomen to see
how the baby is moving downwards. If the progress of your labour lags more than 4 hours behind the average they should discuss with you what your options are (including whether you can go ahead with a vaginal birth), and take action as appropriate.
• Having a consultant (senior) obstetrician involved in decision making about caesarean section reduces the chances that a woman will have a caesarean section.
• In some cases, the midwife or doctor will need to monitor the baby’s heartbeat and contractions throughout labour, using electronic devices that are attached to the abdomen. This is called cardiotocography, or CTG for short. The trace may make your doctor or midwife suspect there is a problem, when in fact your baby is fine. If they suspect your baby is not coping well with labour, further action may be taken. This could include immediate caesarean section, but
usually another test should be offered before the decision is made. The test is a ‘fetal blood sample’. This is done by passing a small tube through a speculum (a metal instrument which is inserted into your vagina) to take the sample from a pinprick on the baby’s scalp. This sample will be tested to see if the baby is coping well with labour. Having this test may avoid an unnecessary caesarean section. (For more information about monitoring the baby’s heartbeat see the NICE guideline Electronic fetal monitoring;

Reasons for needing an emergency caesarean section.

 You may need an emergency caesarean section because:

• there is concern that your baby’s health is compromised
• your labour is not progressing
• you have vaginal bleeding during pregnancy or labour
• you go into labour before the date of your planned caesarean section. 

In some situations your baby may need to be delivered very quickly (within half an hour).

If you have an emergency caesarean section, you are at risk of vomiting during the operation. If this happens, fluid and food particles from your stomach may pass into your lungs (this is known as aspiration) and can cause potentially serious inflammation (known as aspiration pneumonitis). You should be aware that eating during labour may increase the amount of food and fluid in your stomach, and this may increase the risk of aspiration if you have an emergency caesarean section. Drinking drinks that have the same concentrations of salt and sugar as human body fluid (known as isotonic drinks) during labour gives you energy without giving you a full stomach.

Some women have a high risk of this happening, if they have:
• heavy bleeding before labour (known as antepartum haemorrhage)
• placental abruption (where the placenta separates from the wall of the womb)
• placenta praevia (where the placenta is lying across the entrance to the womb)
• uterine rupture (a tear in the womb, often along the scar of a previous caesarean section).
If you have any of these problems, you may need a blood transfusion and you should have the caesarean section at a maternity unit with,blood transfusion services.

If you have been healthy during your pregnancy, you do not need to have:
• screening tests for blood clotting
• grouping and saving of serum (this is when a sample of your blood is taken, the blood group is analysed and then the sample is saved in the hospital blood bank ready to be used to order a blood transfusion if you need one)
• an ultrasound scan before a caesarean section; it does not cut down your risk of heavy blood loss or the risk of injury to the baby.

You should be given information about the different kinds of pain relief that you can
use after the operation, so that you can be prescribed whatever best suits your needs.If you have a regional anaesthetic for your operation, you should also be offered diamorphine, given by an injection into your spine at the same time that the anaesthetic is given. This reduces the need for other pain relief afterwards.

You will need to have a bladder catheter inserted to empty your bladder because, with a regional
anaesthetic, you will not be able to tell if your bladder is full and needs to be emptied.
If you are having a regional anaesthetic, you should also be offered a drug called ephedrine or phenylephrine, which will be given through a drip to reduce your risk of low blood pressure during the operation. 

If you have an emergency caesarean section, your healthcare team should cut down the risk of vomiting and aspiration into the lungs by:
• offering you drugs or acupressure (which involves wearing wrist bands that apply pressure to special points in your wrists) to try to prevent nausea and vomiting
• offering you antacids to reduce the acidity in your stomach and drugs to keep the amount of food in your stomach low, and reduce its acidity
• using standard emergency procedures such as giving you oxygen through a mask before a general anaesthetic, and the anaesthetist applying pressure with his or her hand at the front of your neck to block the airway and prevent particles going into your lungs.
Maternity units should follow accepted good practice when giving anaesthetics to women in labour. When a person is under general anaesthetic, a tube may need to be inserted through the mouth or nose to feed air and oxygen down to the lungs. Maternity units need to have a procedure in place
for what to do when attempts to do this fail. 

The operation. 

You have more risk of a blood clot if you have a caesarean section, so you should be offered things during and after the operation to reduce the risk of this happening, such as elastic support stockings, help to walk around soon after the CS, or injections. Your doctor should assess your risks of blood clots when deciding which of these you need.

If you are awake during the operation, a screen will be placed across your abdomen so that you
do not see the operation being done. You may be able to choose to have the screen lowered, so that you see the baby being born. You may also be able to have music playing, or have silence in theatre so that your voice is the first the baby hears. If you are interested in any of these things, you should discuss them with your midwife or doctor.

During caesarean section, the operating table will be tilted sideways to an angle of at least
15°. This reduces your chance of getting low blood pressure and feeling sick during the operation, because it takes the weight of your womb off major blood vessels in your abdomen.

Whenever possible, the obstetrician will make a horizontal cut across your lower abdomen (just below the line of your pubic hair) to reach your womb. This opening along your ‘bikini line’ will cause you less pain afterwards and look better than an ‘up and down’ scar. Sometimes the baby’s skin may be cut while the opening in the womb is being made. This happens to about 2 of every 100 babies.

You should be given the drug oxytocin by slow injection into a vein once your baby is born to
encourage your womb to contract and cut down blood loss.
You should be offered antibiotics at the time of your caesarean section because they cut down
the risk of getting an infection afterwards.

Your healthcare team should encourage you to have skin-to-skin contact with your baby
as soon as possible. This tends to improve how women feel about their baby, their mothering skills and their chances of successfully breastfeeding. It also tends to reduce the amount a baby cries. 

If you have had a caesarean section, you may have more difficulty starting to breastfeed your
baby. Therefore, you should be offered extra support and help to do this. Once you have

started breastfeeding, you are as likely as other women to be able to carry on.

Unless you have an infection that needs treatment, you do not need to continue to
have antibiotics after your caesarean section. You should be offered pain relief that you can control yourself with drugs such as morphine (called patient-controlled analgesia or ‘PCA’). However, these can make you drowsy and nauseous, so you should also be offered non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, if they are suitable for you. Taking NSAIDs can cut down the amount of morphine-like painkillers (such as diamorphine) that you might need.

If you are recovering well and you have no problems after your caesarean section, you
should be able to eat and drink if you are thirsty or hungry. Your bladder catheter will be removed once you are able to walk and at least 12 hours after the last ‘top-up’ of your epidural.

Your wound dressing will be removed after 24 hours. Wound drains do not cut down infection or the risk of bruises, so they should not be used as a matter of routine in caesarean section. Wound drains do reduce the chances of infection for women who are very overweight, however, and should be offered to them.

If you have had a caesarean section, your healthcare team should give you the opportunity to discuss the reasons for it and any other related issues at an appropriate time. They should keep a record of the reasons for carrying out a caesarean section.

Current good practice for the care of your baby after a caesarean section should follow the accepted care for any newborn.

In addition to routine postnatal care, you will need advice about recovering after a caesarean section and possibly about other complications if you had these during pregnancy or childbirth.
When you go home, you should be given regular pain killers to take for as long as you need them. For severe pain you, should be offered co-codamol and ibuprofen; for moderate pain, you should be offered cocodamol; and for mild pain, you should take paracetamol.

You should be given advice about how to look after your wound. Advice should cover wearing loose, comfortable clothes and cotton underwear, gently cleaning and drying the wound daily, and looking out for possible wound infection (such as more pain, redness or discharge) or fever.

You should tell your midwife or doctor if you have symptoms such as pain on passing urine,
or leaking urine. You should tell your midwife or doctor if your vaginal bleeding increases, or becomes painful. After caesarean section, this is less likely to be due to retaining part of the placenta, and more likely to be due to infection in the lining of the womb. 

You should tell your midwife or doctor if you develop a cough or shortness of breath, or swelling and pain in your calf, so that they can make sure that these symptoms are not due to a blood clot.

After a caesarean section, you will not be able to do some activities straight away such as driving a car, carrying heavy things, exercise or having sex. You should only start these once you feel that you are able to do so and when they do not cause you pain. If you are unsure, you could discuss this with your midwife.

If you have a caesarean section, you are not more likely than other mothers to have any of the following: difficulty breastfeeding, postnatal depression, pain during sex or difficulty
controlling your bowels.

If you want to have a vaginal birth, your healthcare team should support you in this
decision. You do need to be aware that some rare but serious complications are increased with vaginal birth after a caesarean section. These possible complications include your scar tearing apart or the baby dying. For these reasons, during your labour, you should be offered electronic fetal heart rate monitoring, and be cared for in a maternity unit where a caesarean section can be done very quickly if needed, and where there are blood transfusion services. This is even more important if your labour is induced, because the risks of some complications, such as the scar tearing apart, are higher.

Studies have shown that pregnant women who have had both a previous caesarean section and a previous vaginal birth are more likely to have a vaginal birth than those who have had only a previous caesarean section.