Planned Caesarean Birth at Worcestershire Royal Hospital with Enhanced Recovery – Information Guide for Mothers, Birthing People and Birth Partners

Planned Caesarean Birth at Worcestershire Royal Hospital with Enhanced Recovery – Information Guide for Mothers, Birthing People and Birth Partners.

CONTENTS:

Introduction to Elective Caesarean Birth at Worcestershire Royal Hospital

A caesarean section is an operation performed to deliver the baby through a cut in your lower abdomen (usually just below your bikini line).

You will be given this information on the day you decide with your obstetrician to have a Caesarean birth. It will serve as a guide and reference throughout your pregnancy, birth and recovery in hospital as well as at home.

Our part will be to:

1. Ensure that you have safe and efficient care.
2. Make sure we communicate well and ensure you understand exactly what this process involves.
3. Make you feel safe and able to cope at home with your new baby.

Your part will be to:

1. Read this information carefully so that you understand what we will be expecting along your birth journey.
2. Attend hospital appointments when required and work with staff to make your birth as safe and efficient as possible.
3. Ask as many questions as needed to ensure you are as prepared as possible to deliver and look after your baby at home.

Please read it all the way through. If you then have any questions, the team will be available for contact throughout your pregnancy as well as at your final pre-operative assessment appointment at Worcestershire Royal Hospital.

Section 1: Being prepared before your Caesarean Birth

A. INITIAL BOOKING APPOINTMENT:

• If you and your consultant decide that a Caesarean Birth is the right way to deliver your baby/babies we will give you this booklet, to introduce you to the idea and principles involved in the Enhanced Recovery Programme. It is also available on your Badgernet.
• Unless your consultant recommends that you have further tests or appointments, or you need to have any further discussion about the mode of delivery, the next time you need to come to hospital will be your final pre-operative assessment appointment. This will be 2 to 3 days before your planned caesarean.

B. GIVING YOUR CONSENT FOR THE PLANNED CAESAREAN BIRTH:

• You will have discussed the option to have a caesarean birth with an obstetrician. If you decide that is the right way to deliver your baby/babies you will be asked to sign a consent form before a date is set for your caesarean.
• The consent form is a legal document outlining the discussion you have had regarding the risks and benefits of the procedure. It states that you give your permission for the operation to take place and you should have a copy to take home.

C. PRE-OPERATIVE ASSESSMENT APPOINTMENT

• Two to three days before the date of your elective caesarean you will be invited to attend a pre-operative assessment appointment at Worcestershire Royal Hospital. This appointment is essential to enable us to ensure your day of surgery runs as smoothly as possible.

During this appointment we will:

1. Answer as many of your questions as possible so that you are as prepared as you can be for the big day. You might find it helpful to write any questions down, so you don’t forget.
2. Ensure all your paperwork is in order.
3. Check your height, weight and basic observations (blood pressure and heart rate).
4. Measure you for surgical stockings. These help prevent blood clots (known as deep vein thrombosis or DVT) from forming in your legs.
5. Take any necessary blood tests and review the results.
6. Give you routine anti-acid tablets and instructions on when to take them.
7. We will confirm if you are on the morning or afternoon theatre list for your caesarean. we will tell you what time you need to attend the hospital on the day and where you need to go.

D. YOUR ANAESTHETIC

• An Anaesthetist (specialist doctor) might meet you in your pregnancy if you or your doctor think you need this appointment. Otherwise, they will meet your anaesthetist on the day of surgery. This will be before your caesarean birth. They will explain how you will be kept comfortable during and after your delivery. They will discuss with you the risks and benefits of using a Spinal anaesthetic and other options if a spinal anaesthetic is not possible.
  
• A ‘Spinal’ is an injection in your lower back which allows you to remain awake during your caesarean birth, without feeling any painful sensation in your lower body. This is nearly always safer for you and your baby, and, allows you and your birth partner to experience the delivery of your child together. This is how most elective caesareans are performed.

This webpage on Having your baby – planned delivery gives you an idea of what to expect during a spinal anaesthetic in Maternity at WRH.

E. EATING AND DRINKING (the night and morning before surgery)

• One of the key principles of Enhanced recovery is to interrupt normal eating/drinking habits as little as possible and keep you well nourished. There are many negatives to denying you food and drink before planned surgery and so the following advice is important to follow:

1. If your Caesarean is in the morning you can eat food up to 02.30 am (the night before surgery)
2. If your Caesarean is in the afternoon you may have a light breakfast (eg. cereal, toast) but you must finish eating before 07.30
3. Please drink freely up until we ask you to come to theatre for your Caesarean
   – Clear fluids such as squash, water or non-fizzy energy drinks
   – Tea/Coffee with a small amount of milk/sugar is allowed
4. If you are diabetic you can use non-fizzy, low/no sugar squash and tea/coffee as required to manage your blood sugar levels in the morning before surgery. A plan should be made for your diabetes management with your Diabetic nurse and confirmed by your pre-assessment midwife before the day.

F. REGULAR MEDICINES

• If you take regular medications, please bring them to hospital on the morning of your caesarean. It is important that you bring them in the original packaging or containers. If there are any medicines you need to stop before the operation this should have been discussed by your midwife or obstetrician, however we will confirm these plans at your pre-operative assessment appointment.

G. ANTI-ACID MEDICATION (OMEPRAZOLE CAPSULES)

• To reduce the level of acid in your stomach during the operation we routinely give patients Omeprazole capsules to take before coming into hospital. This will be discussed with you at your preoperative assessment appointment. As instructed please take:
  • 1 Capsule (20mg) at 22.00 (10pm the night before) and 1 capsule (20mg) at 07.00 (7am on the morning of surgery) with a large glass of water.

Section 2: What to expect on the day of delivery

H. FIRST THING IN THE MORNING:

• You should take your Omeprazole capsule and follow the eating/drinking guidance above.
• If your caesarean is in the morning please arrive at the Delivery Suite reception or postnatal ward at 7.30am.
• If your caesarean is in the afternoon please arrive at the Delivery Suite reception or postnatal ward 12pm for afternoon delivery (You will have been told the place and time for admission at your pre-assessment appointment).
• Your Birth partner can arrive and stay with you during this time.
• Leave all large bags in the car, but do bring a small bag with a set of baby clothes, nappy, dressing gown and slippers up to the ward.

I. WHEN YOU ARRIVE AT THE HOSPITAL:

• To find Delivery Suite reception. Enter the hospital through the main entrance. Once inside, turn left past Costa then turn first right towards ante-natal clinic and Delivery suite. The entrance is the second door on the left.

• Ring the buzzer and a midwife will collect you and take you to your bed. If you are supposed to be admitted to postnatal ward, they will sign post you to it.
• Your midwife will then check your blood pressure, pulse, temperature and ask for a urine sample. She will routinely assess your baby’s heartbeat and position.
• You will be asked to change into your theatre gown and your midwife will check you have your Anti-Embolism stockings (TEDS) on correctly.
• You will meet the obstetrician performing your caesarean section to confirm your consent form and your Anaesthetist who will be able to answer any remaining questions you may have.

J. THEATRE TIMINGS

The weekday operating plan would usually progress as follows (Monday to Thursday):

Outside these times there are theatre staff available for emergency cases.

K. DELIVERING YOUR BABY:

• When the time comes, you should have your theatre gown on and your Midwife will walk with you and your birth partner to the operating theatre.
  
• If you are having a spinal anaesthetic your partner will be able to join you in theatre. Your partner will be given some suitable theatre ‘Blues’ to change into whilst the theatre team are performing their safety checks once you arrive to theatre.
  
• You will meet the theatre team and they will introduce themselves to you, you will usually have your midwife, the surgeon and their assistant, the anesthetist and their assistant, the scrub nurse and at least two more staff members to confirm the count of instruments and provide extra help if required. There might also be a paediatric doctor to assess your baby if required.

• Your Anaesthetist will then insert a cannula or plastic tube into the back of your hand before performing the Spinal anaesthetic.
  
• Once your lower body is numb, you will have a urinary catheter inserted to empty your bladder and we will perform vaginal cleansing which has been shown to reduce your risk of postnatal infection.
  
• The theatre team will do a final safety check confirming with you, your name and date of birth before starting your caesarean.

• The caesarean itself should routinely take between 45mins to 1 hour but your baby has usually been delivered within 10 minutes of starting.
  
• Your baby will remain connected to you for 1 minute (“delayed cord clamping”) to receive as much blood as possible from you before the cord is cut, unless there are any concerns either with the surgery or your baby that would prevent this.
  
• Your partner can then trim the umbilical cord once the baby has been briefly assessed by your midwife.
  
• Your midwife will take your baby across the room for a moment to check they are well. Once your baby has been checked and weighed you or your partner will then have the opportunity to enjoy skin- to-skin contact for as long as you wish to.

The team looking after you in theatre is very experienced.

Most Caesarean deliveries are performed in a very similar way, if you have any particular requests, please discuss them with the team at your pre-operative assessment appointment and confirm them with your midwife and surgeon on the day of caesarean. We will do everything we can to ensure the experience is tailored to you.

There are different options that you might like to consider during your caesarean birth. Please discuss them with the team at your pre-operative assessment appointment and confirm them with your midwife and surgeon on the day of caesarean. We will do everything we can to ensure the experience is tailored to you:

1. Would you like staff to be as quiet as possible during the birth, would you like them to describe what is happening, or would you like them to chat to you about other things?
2. Would you like to choose own music? You can bring a playlist on your phone.
3. Would you like to have ECG dots (heart monitor) on your chest or shoulders? Having them on your shoulders can make skin-to-skin with your baby easier.
4. Would you like the surgical drapes lowered so that you can see your baby being born or would you prefer for them to stay raised during the delivery of your baby?
5. Would you like your partner to trim the cord.
6. Optimal cord clamping.
7. Would you like staff to take photos for you, your partner and your baby?
8. Would you like discovering the sex of the baby yourselves (you or your partner).

L. WHERE DO I GO AFTER MY OPERATION?

• Following the completion of the procedure, your baby and your partner will be moved around to the recovery unit.
• We will check your vagina for any bleeding and give you a pain killer as rectal suppository. You will then be transferred to join your baby and your partner in recovery.
• In recovery, you will be looked after by midwives and theatre staff for approximately 15-30 minutes.
• We will be monitoring your: blood pressure, pulse, temperature and level of comfort.
• You will be encouraged to drink and eat if you wish at this stage, and your midwife will offer support as you feed and care for your baby.
• Your midwife will then take you to the postnatal ward.

M. HOW LONG CAN MY PARTNER STAY?

Your partner can stay with you in the recovery area immediately after your operation. Partners also have 24-hour access to the postnatal ward.

N. WHEN CAN I EAT AND DRINK?

• After your caesarean section you will be encouraged to drink normally as soon as possible.
• If your observations are stable, you will be offered something light to eat as soon as you return to the Postnatal ward. If there is something light that you know you would like to eat, then please bring it with you and tell your midwife.
• If you have allergies or special dietary requirements, please let us know so that we can order the right meal for you
• You should aim to be eating normally on the evening of your operation.

Section 3: What to expect after surgery

O. PAIN RELIEF

• Caesarean section is a major operation and providing you with the right pain relief is a really important part of ensuring that you recover quickly and fully over the days, weeks and months afterwards.
• All the pain relief you are offered will be safe to use while breastfeeding.
• For most mums and birthing people delivering at Worcestershire Royal Hospital you should be receiving:

Paracetamol 1gram, 4 times a day
(TWO 500mg tablets to be taken four times a day).

Ibuprofen 400mg, 4 times a day
(TWO 200mg tablets to be taken four times a day).

These are maximum doses in a 24 hour period and must NOT take any more than this.

It is important that these medications are taken at regular intervals even if you are feeling comfortable as gaps in pain relief can make it less effective.

How long you need these drugs does vary from person to person but is likely to be up to 1-2 weeks for most people. These regular medications will help you to remain mobile and care for your baby, as well as reduce the likelihood of you experiencing breakthrough pain.

Codeine or Tramadol should not be used for pain relief if you are breast feeding.

If you are at home by the second day after delivery, you will receive a phone call from one of the Anaesthetic team.

The call will be to check you have recovered well from your anaesthetic and that the painkillers you have are adequate. If you need any breakthrough pain relief once at home, we can help organise this through your GP.

P. GETTING OUT OF BED AND WALKING

• Once the numbness from the anaesthetic has worn off and you have someone with you for support, you will be encouraged and helped to get up and about as soon as possible.
• You will be encouraged to continue walking around the ward, and once your catheter is removed walk to the toilet. This not only aids your recovery but helps to reduce the risk of blood clots.
• In some cases, urinary catheters remain in for longer than is planned – this does not mean you have to stay in bed or stop you going home.

Q. POSTNATAL PHYSIOTHERAPY

• You will be seen by the Postnatal Physiotherapy team the morning after your delivery.
• They will go through specific exercises to strengthen up your pelvic floor and abdominal muscles and provide advice on movement and activity after surgery.
• Now is the time to ask any questions about returning to normal activity.

The following links will help re-enforce the advice given by your physiotherapist:

Postnatal Exercises and Advice

R. BLOOD LOSS

• It’s normal for women to lose lochia (a combination of mucous, tissue and blood) from their vagina after birth until the womb renews its lining.
• Usually, it will not be more bleeding than a heavy period. You will need to use maternity pads for the bleeding.
• Following your Caesarean, you may be given a drug called Syntocinon (a synthetic version of the naturally occurring hormone Oxytocin) through your cannula into your vein. This will encourage your uterus to contract, helping it to shrink back to its normal size and reducing your blood loss.
• You may find that your lochia appears to increase when you first stand up.

S. BLADDER CATHETER MANAGEMENT

• Urinary catheters will routinely be removed 12 hours after they have been inserted. If it has not been removed by 12 hours, please ask you midwife why this is the case.
• Once your urinary catheter is removed, you will be encouraged to drink plenty of fluids. When you pass urine, you will be asked if you had normal sensation (feeling) at the time.
• You will also be asked to measure the amount of urine you passed during your first two visits to the toilet and you will have a scan to your bladder to check for any remaining. This will allow your midwife to assess your bladder function.
• This is an important step to getting you back to normal and your midwife will talk to you about this process after are back on the Postnatal ward.

T. BLOOD CLOTS: DEEP VEIN THROMBOSIS (DVT) AND PULMONARY EMBOLISM (PE)

• During pregnancy, swelling and discomfort in both legs is common and does not always indicate a problem. However, it’s important that you are aware of the symptoms of DVT and PE so that you know when to seek medical advice if you are concerned.
• To help reduce the risk of developing blood clots in your legs after your caesarean section you may be offered a daily injection of medicine to thin your blood (Enoxaparin).

If you have any of these symptoms while in hospital, please inform your midwife. If you have been discharged home and have any of these symptoms, please call maternity triage on 01905 733196.

• It is also important for you to continue wearing your surgical stockings for at least seven days, please request for a second pair to go home with.

They need to be worn day and night with a maximum 30-minute break each day.

BLOOD THINNERS (ENOXAPARIN SODIUM)

• Your midwife will explain how to administer any blood thinning drugs your obstetrician has asked you to take after your delivery.
• You will need to give the drug to yourself as an injection, but It can be somebody else if they are trained and happy to do so (partner, friend or a family member).

Section 4: All about going home

• The Enhanced recovery programme aims to have you fit, well and confident enough to go home the day after your caesarean section, so you should organise your transport home in advance.
• Please ensure that whoever is taking you home has baby’s car seat available to safely transport your baby home.
• Your midwife will discuss your pain relief and any other medications you are to take home but please make sure you have enough Paracetamol and Ibuprofen at home to at least see you through the first week. If you then need more, you will have had enough time to buy some.

What needs to happen before I go home?

You will be asked to access the following video with postnatal discharge information:

Your baby will need a NIPE examination by a midwife, this is part of a screening tool to check your baby over and may need referring to a paediatrician if anything is highlighted.

Your baby will also need a hearing test completed by one of the hearing screeners, the hearing screeners come to the ward daily but this can be done after discharge.

A useful guide to the steps required to enable you to get home is given below, a patient diary.

What needs to happen before you go home list:

Ways of knowing how well your recovery is going:

Things about your baby:

Things about your discharge arrangements and follow up:

You will be asked to confirm the address and contact details for your postnatal visits.

Before you go home, your midwife will ensure you have the following information:

1. A summary of your notes and delivery details will be available on our BadgerNet system to your community midwives who visit you at home. Your GP and health visitor will also receive an electronic copy of this summary.
2. Information on what to expect over the forthcoming days in terms of you and your baby’s health:

• www.mothersguide.co.uk/ – Mothers + Others Guide (free paper copy for you on discharge).
• www.gov.uk/government/publications/screening-tests-for-you-and-your-baby-description-in-brief – Screening tests for you and your baby (language translation options).
• www.gov.uk/government/publications/cervical-screening-description-in-brief – NHS cervical screening – Helping you decide (language translation options).
• www.worcestershire.gov.uk/info/20315/births/68/registering_a_birth – How to register your baby or babies’ birth.

Information on how to access breastfeeding support:

• www.worcsacute.nhs.uk/images/How_to_prepare_a_powder_milk_bottle.jpg – A step-by-step guide to preparing powdered formula feed
• A contact telephone number for ANY questions regarding:

Your Caesarean delivery, immediate recovery or pain relief – call maternity triage on 01905 733196 or your midwife or GP.
Baby or feeding concerns – call the Transitional Care Unit on 01905 760663.

Midwife support at home

• Your Community Midwife will visit you on the day after your discharge home.
• At this stage you will discuss how things are going and make a plan for the next week.
• They will usually visit you two or three times during your first ten days at home. Unfortunately, we cannot guarantee a time for this first visit, but it should be in the morning of your first day.
• The health visitor will usually contact you within ten days after the birth of your baby and their role is to help you care for your new baby.

Wound care

• Your wound will be covered with a dressing which should stay in place for about 5 days after your caesarean section according to the type of dressing.
• You are advised to wear loose, comfortable clothing and cotton underwear, and keep the wound clean and dry.
• After 5 days, you should remove the dressing after having a shower (as it will be easier to remove if it’s wet).
• Some mothers may require a vacuum dressing after their Caesarean to prevent infection. If that is the case then your midwife will discuss how to manage this at home.
• Please ask the midwives if you would like this to be checked.
• For information about scar massage visit: https://squeezelifthold.co.uk/caesarean-section-scar-massage-july-2023/

Stitches stop any bleeding from the wound and join the skin and muscle together. The thread used is dissolvable so they do not have to be removed. The stitches start to dissolve after about ten days and have usually completely disappeared after six weeks.

Please discuss the care of your wound and infection prevention with your midwife. Your midwife will review your wound if you have any concerns. In some cases, we may need to use non-dissolvable stitches, then we will let you know about that and plan for removal.

Headaches

A headache can often be the result of tiredness or stress. If this does not clear after using pain relief (such as regular paracetamol and ibuprofen) or if you feel the headache is severe or is associated with other symptoms such as drowsiness or nausea, please call maternity triage on 01905 733196.

Lifting

You are advised not to lift anything for six weeks. You may begin light housework and lifting after this time but avoid heavy lifting for three months. The exception to this is lifting your baby. If you already have older children or toddlers at home you will need to ask for extra assistance from family and friends to begin with, because toddlers are too heavy to lift (although they can have plenty of cuddles for reassurance).

If you are shopping, try to carry equal loads in each hand, not one heavy bag. It is worth remembering that car seats and prams can be quite heavy, so remember to ask for help when you require it.

Rest

Try to rest for at least one hour every afternoon. You will need someone to help you at home for at least two weeks. Where possible, make arrangements with family and friends who may be able to assist with daily household tasks.

Diet

It’s important to eat properly. Try to eat three meals a day, containing plenty of protein such as meat, cheese, nuts, milk or fish to aid healing and help build you up. Also include fibre such as fruit, bran and vegetables to prevent constipation, which will cause strain on your abdominal muscles.

Driving

You may start driving when you feel comfortable, although you should check with your insurance company that you are covered to drive following major surgery. Before you start and before you put the keys in the ignition, try putting your foot on the brake while the car is stationary, as if you were doing an emergency stop. If this is painful you should wait a few more days and try again. Try to start with short journeys as you may get tired quickly.

Activities

The Physiotherapy team will discuss postnatal exercises with you either before you go home and following these instructions will aid your recovery considerably. Gentle sports such as swimming can be started when your wound is healed.

It is not advisable to undertake high-intensity exercise such as aerobics until you feel comfortable. If you would like further advice or more information you can:

1. Contact the Maternity physiotherapist on: 01905 760622
2. Refer to the Postnatal exercise and advice leaflet and video below:

Postnatal Exercises and Advice

It is important that you attend a six-week postnatal check appointment with your GP. This follow-up enables your doctor to check that everything is healing well and that there are no problems.

This is usually with your GP, but you may be asked to come back to the hospital if there were complications that need to be discussed with the obstetrician. If you are thinking of going back to work, this is a good opportunity to discuss it with your doctor.

Sex

Sexual intercourse can be resumed when you feel comfortable. It will not damage your wound, but some positions may feel uncomfortable. Contraception is important because fertility can return quickly. Your midwife or doctor about this can discuss your future contraceptive needs with you.

Future pregnancies

It is advisable to leave a 12-month gap between pregnancies. This enables your body to recover from your caesarean and reduces your risk of scar separation during pregnancy and/or labour (2 in every 1,000 women).

Your caesarean section may also put you at increased risk of the placenta growing in the wrong place on the wall of your womb in a future pregnancy. This could lead to difficulties at the time of delivery or excessive bleeding. These are uncommon complications affecting between 4 and 8 women in 1,000.

Although having one caesarean section increases the likelihood of you having subsequent caesarean sections, 75% of women (3 in 4) with one previous caesarean have a subsequent vaginal birth (NICE 2007). You are therefore advised to discuss the implications of your caesarean section with your midwife or obstetrician.

Support for you

We hope this has been a useful resource to support your Caesarean Delivery. If you have any feedback for us about either this information or your care, please let us know by either speaking to a member of the team looking after you or using the feedback survey we would ask you to complete on leaving hospital.

The following links will give you a better idea of what to expect. Please have a look at as many of these as possible before the day, especially the clip following a routine Caesarean delivery:

• Enhanced recovery webpage
• Physiotherapy advice on exercise/activity following Caesarean delivery
• Caesarean birth advice and information – Labour Pains – General advice about Caesarean section with translation to multiple languages

The following links will help reinforce the advice given by your physiotherapist:

• Activity and exercise after Caesarean delivery (video clip)
• Postnatal exercise and advice (leaflet)

Further information

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999. 

Patient Experience

We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you.

Feedback

Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made.

There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)

If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly.

If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS

Telephone Patient Services: 0300 123 1732 or via email at: wah-tr.PALS@nhs.net

Opening times

The PALS telephone lines are open Monday to Friday from 8.30am to 4pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.

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