Enhanced recovery pathway after planned caesarean section

On the morning of your caesarean section you should:

• not have anything to eat after 2am if you caesarean section is in the morning. If it is in the afternoon you may have a light breakfast before 8am.
• you can continue to drink water until you are on your way to theatre
• shower

Please arrive at Sara ward reception, level 3, The Rosie Hospital at 7am / 11am on the date given on your admission letter. Unfortunately we are not able to confirm the time of your caesarean in advance.

When you arrive your midwife will assess your wellbeing by checking your blood pressure, pulse, temperature and urine sample, as well as checking your baby’s heartbeat and position. You will be given your theatre gown and your partner will be given clothes to wear in theatre.

It is a good idea for you to have your baby’s clothes ready for after the caesarean section, for when your baby is not skin-to-skin, please include a vest, babygro and nappy. Your anaesthetist will discuss your anaesthetic and pain relief options, and answer any questions you may have. Your obstetrician will go through the consent form with you and ask you to sign it. Finally, the theatre team will talk you through a checklist before taking you to theatre.

In theatre

Once in theatre you will have a cannula (a thin plastic tube) inserted, usually into a vein in your hand or forearm. This allows your anaesthetist to give you fluids and medications (including antibiotics) quickly. The anaesthetist will then give you your spinal anaesthetic. Once you are comfortable, your midwife will insert a catheter (plastic tube) in to your urethra to empty your bladder and drain your urine. Your operation site will be checked and if necessary special clippers will be used to remove any hair along your bikini line. The obstetrician will then begin the caesarean section.

When your baby has been born

Once your baby has been born, if it is appropriate, we routinely offer deferred cord clamping (DCC). Your obstetrician will wait for up to two minutes before clamping and cutting your baby’s umbilical cord. This process allows blood to flow from your placenta to your baby. This stabilises your baby’s blood pressure and increases their iron levels (reducing their risk of anaemia), both of which help your baby to adapt to life outside of you.

During this important process, your baby will lie on your legs and will be held and kept warm by the obstetric team. The cord will then be cut and you will be asked if you would like to hold and cuddle them against your skin. This type of skin-to-skin contact has been shown to offer benefits including helping to regulate baby’s temperature, heart rate and breathing, and to help support breastfeeding. Even if you don’t plan to breastfeed, you and your baby will still benefit from skin-to-skin contact.

If it is not possible to have skin-to-skin in theatre for any reason, your birthing partner may wish to do this instead.

Your care immediately after the caesarean section

After your caesarean section, your wellbeing will be assessed through regular monitoring of:

• your blood pressure, pulse and temperature
• whether you have any pain or discomfort
• how well you are able to tolerate fluids and food
• how well you are able to move around

You will be offered support as you feed and care for your baby. You and / or your partner will also be encouraged to continue skin-to-skin contact with your baby. This care is usually undertaken within the recovery area.

Eating and drinking

After your caesarean section you will continue to be given fluid directly into a vein to ensure you remain hydrated until you feel able to drink fluids normally. While you are in recovery, you will be offered a light snack, such as a toast, and a drink. When you are transferred to the postnatal ward you will be encouraged to drink freely (although you are advised to avoid fizzy drinks). You should aim to be eating normally on the evening of your operation.

On the morning of your caesarean section you should:

• not have anything to eat after 2am if you caesarean section is in the morning. If it is in the afternoon you may have a light breakfast before 8am.
• you can continue to drink water until you are on your way to theatre
• shower

Please arrive at Sara ward reception, level 3, The Rosie Hospital at 7am / 11am on the date given on your admission letter. Unfortunately we are not able to confirm the time of your caesarean in advance.

When you arrive your midwife will assess your wellbeing by checking your blood pressure, pulse, temperature and urine sample, as well as checking your baby’s heartbeat and position. You will be given your theatre gown and your partner will be given clothes to wear in theatre.

It is a good idea for you to have your baby’s clothes ready for after the caesarean section, for when your baby is not skin-to-skin, please include a vest, babygro and nappy. Your anaesthetist will discuss your anaesthetic and pain relief options, and answer any questions you may have. Your obstetrician will go through the consent form with you and ask you to sign it. Finally, the theatre team will talk you through a checklist before taking you to theatre.

In theatre

Once in theatre you will have a cannula (a thin plastic tube) inserted, usually into a vein in your hand or forearm. This allows your anaesthetist to give you fluids and medications (including antibiotics) quickly. The anaesthetist will then give you your spinal anaesthetic. Once you are comfortable, your midwife will insert a catheter (plastic tube) in to your urethra to empty your bladder and drain your urine. Your operation site will be checked and if necessary special clippers will be used to remove any hair along your bikini line. The obstetrician will then begin the caesarean section.

When your baby has been born

Once your baby has been born, if it is appropriate, we routinely offer deferred cord clamping (DCC). Your obstetrician will wait for up to two minutes before clamping and cutting your baby’s umbilical cord. This process allows blood to flow from your placenta to your baby. This stabilises your baby’s blood pressure and increases their iron levels (reducing their risk of anaemia), both of which help your baby to adapt to life outside of you.. During this important process, your baby will lie on your legs and will be held and kept warm by the obstetric team. The cord will then be cut and you will be asked if you would like to hold and cuddle them against your skin. This type of skin-to-skin contact has been shown to offer benefits including helping to regulate baby’s temperature, heart rate and breathing, and to help support breastfeeding. Even if you don’t plan to breastfeed, you and your baby will still benefit from skin-to-skin contact. If it is not possible to have skin-to-skin in theatre for any reason, your birthing partner may wish to do this instead.

Your care immediately after the caesarean section

After your caesarean section, your wellbeing will be assessed through regular

monitoring of:

• your blood pressure, pulse and temperature
• whether you have any pain or discomfort
• how well you are able to tolerate fluids and food
• how well you are able to move around

You will be offered support as you feed and care for your baby. You and/or

your partner will also be encouraged to continue skin-to-skin contact with

your baby. This care is usually undertaken within the recovery area.

Eating and drinking

After your caesarean section you will continue to be given fluid directly into a vein to ensure you remain hydrated until you feel able to drink fluids normally. While you are in recovery, you will be offered a light snack, such as a toast, and a drink. When you are transferred to the postnatal ward you will be encouraged to drink freely (although you are advised to avoid fizzy drinks). You should aim to be eating normally on the evening of your operation.

Pain relief

During your caesarean section you will be given a dose of paracetamol directly into your vein and at the end of the surgery you will be offered a pain relieving suppository (Diclofenac) in your back passage (rectum).

After the surgery we will talk to you about your pain levels and in most circumstances you should take regular paracetamol and ibuprofen, both every 6 hours. If you experience pain, please let the midwife or recovery staff nurse looking after you know as additional pain relief (dihydrocodeine) can be offered if you need it. All the pain relief you are offered will be safe to use while breastfeeding.

Good pain relief will help you to remain mobile and care for your baby, as well as reduce the likelihood of you experiencing breakthrough pain. Breakthrough pain is the term used to describe recurrent pain or pain that occurs before your next dose of pain relief medicine is due.

You may request pain relief at any time and a midwife will be happy to advise you. If clinically appropriate, you will be able to choose between taking responsibility for storing and taking your pain relief at the prescribed times (known as self-administered medication[SAM]), or asking the midwife to do this for you.

If you would like to SAM, you will be provided with a locker for safe storage, and additional medication if required. Self-administered medication after a caesarean is not appropriate for every woman, however. For more information about self-administered medication, please speak to your midwife.

You are advised to ensure you have paracetamol and ibuprofen at home to use for pain relief once you leave hospital. Your midwife will discuss the frequency and dose with you before you go home. If required, we can supply dihydrocodeine tablets to take home with you.

Getting out of bed and walking

You will be encouraged and helped to get up as soon as possible and should aim to be out of bed 4 hours after your operation. The numbness from the anaesthetic will take a few hours to wear off completely so you should only get out of bed for the first time when your midwife or a maternity support worker (MSW) is with you, in case your legs are still weak. You will be encouraged to continue walking around the ward, and once your catheter is removed, walk to the toilet. Once you’re happy that you can walk around without feeling faint, your cannula can be removed. Mobilising not only aids your recovery but helps to reduce the risk of blood clots (please see below for more information). On the morning after your operation you will be encouraged to walk around the ward in readiness for your discharge home.

Blood loss after birth

It’s normal to lose lochia (a combination of mucous, tissue and blood) after birth until the uterus renews its lining. After your caesarean section, you will 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. However, you may find that your lochia appears to increase when you first stand up. If you are concerned about the amount of blood you are losing, please speak to a midwife or member of the recovery team. Please refer to the ‘After your baby’s birth – information booklet for mums and families’ for additional advice. This is accessible on the Rosie website

Catheter

Once your urinary catheter is removed, you will be encouraged to drink plenty of fluids. When you wee 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, we will give you a pot to wee in to. This will allow your midwife to assess your bladder function. You should discuss this further with your midwife, who will also be able to give you information about pelvic floor exercises which are important after having a baby.

Blood clots (deep vein thrombosis and pulmonary embolism)

Blood normally flows quickly and uninterrupted through our veins. However, sometimes clots can form that either reduce the blood flow or stop it completely. A deep vein thrombosis (DVT) is a blood clot in a vein, usually in the leg or pelvis, and its most common cause is immobility (not moving around enough, for example after surgery). A pulmonary embolism (PE) can occur if part of the blood clot breaks off and travels to the lung. In severe cases, PE can cause a collapse and may prove to be fatal.

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. After your caesarean section, you will be fitted with anti-embolism stockings to help reduce the risk of developing blood clots in your legs. It is also important that you keep hydrated and active. You should continue to wear the stockings for at least 10 days. They are to be worn day

and night, with a maximum 30-minute break each day. Please ask your midwife for a second pair of stockings before you go home. This will enable you to wash one pair while wearing the other.

You may need a daily injection of an anticoagulant (a medicine that reduces your blood’s ability to clot). This will continue for a minimum of 10 days and you will be taught how to give yourself the medication by the midwives.

Symptoms of a blood clot (DVT)

• pain in the calf or thigh associated with swelling of the limb – this may be worse when the foot is bending upwards towards the knee
• heat or redness, particularly in the back of the leg, below the knee
• you may find it difficult to put weight on the affected leg (DVT usually affects one leg).

Symptoms of pulmonary embolus (PE)

• difficulty in breathing or shortness of breath
• coughing up blood-stained sputum (a thick fluid produced in the lungs)
• chest pain that is often worse when breathing in
• collapse

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

the maternity day assessment unit on 01223 217217 for advice. If your symptoms are severe, please call 999 or attend your nearest emergency department immediately.

Reviewing your wellbeing

Once the doctors and midwives have assessed the wellbeing of both you and your baby, they may decide that it would be better for you if you do not follow the enhanced recovery programme anymore. This is likely to be because you need longer in hospital to recover. If a longer hospital stay is recommended we will discuss this with you, and you will be given the opportunity to ask any questions you may have.

The enhanced recovery pathway aims to have you fit and well enough to go home the day after your caesarean section, so you should organise your transport home in advance. If you’re travelling home by car, you must have a suitable car seat for newborn babies.

You will be given a summary of your notes and information for the midwives and maternity support workers that provide your postnatal care. You will also be asked to confirm your address and contact details for your postnatal visits and appointments.

Your midwife will discuss your pain relief and any other medications you are to take home. Information about what to expect over the forthcoming days in terms of yours and your baby’s health, including information about breastfeeding support groups, if required, may be found on the CUH maternity page. If you have any concerns or are unable to access this information, please speak to your midwife.

Midwife support at home

Arrangements will be made for you to receive a visit from a midwife or a maternity support worker the day after discharge. Unfortunately we cannot guarantee a time for this visit. The frequency and location (at home or in a postnatal clinic) of your future visits and appointments will be discussed during this visit, and will depend on the wellbeing of you and your baby. The health visitor will usually contact you ten days after the birth of your baby. Their role is to help you care for your new baby and family, in order to stay well and avoid illness.

12 Enhanced recovery after elective caesarean section Information for women and birth partners 13.

You can always phone to speak to a midwife if you have any concerns or would like some advice, please contact the area you were discharged from.

Lady Mary Ward: 01223 217667

Delivery Unit: 01223 217217

Wound care

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.

Your wound will be covered with a dressing. You are advised to wear loose, comfortable clothing and cotton underwear, and keep the dressing clean and dry. The length of time the dressing should stay in place will depend on the type of dressing used, with some being removed after 24 to 48 hours and others staying in place for up to a week. Your midwife will discuss the type of dressing and length of time it should stay in place with you and answer any questions you may have.

Please discuss care of your wound and infection prevention with your midwife. Your midwife or maternity support worker will review your wound if you have any concerns.

Please let your midwife or GP know if:

• your wound becomes hot, swollen, weepy, smelly or very painful
• your wound starts to open
• you develop a temperature and / or flu-like symptoms

If you experience any of these symptoms, you may be developing an infection and need treatment with antibiotics.

Headaches

A headache can often be the result of tiredness, dehydration, or lack of sleep. If your headache does not clear after using pain relief (such as paracetamol and ibuprofen), or if you feel the headache is severe or is associated with other symptoms such as drowsiness or nausea, please telephone the maternity assessment line on 01223 217217 for advice.

Lifting

You are advised not to lift anything for six weeks. After six weeks, a gradual return to your normal household patterns and lifting can be started.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, as toddlers are too heavy to lift after a caesarean birth (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 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 after surgery. Try to eat three meals a day, containing plenty of protein such as meat, cheese, nuts, milk, fish, grains and pulses, tofu and soya products to aid healing.

Bowel care

You probably won’t poo for a few days after birth, but it is important to drink plenty of fluids, and eat fibre rich foods such as fruit, vegetables, beans and nuts. This will help prevent constipation. When you go for a poo, it can be helpful to roll up a towel and hold it firmly against your tummy so you feel more comfortable. If you feel constipated, please inform your midwife who can advise on gentle laxatives. Also tell your midwife or GP if you’re leaking poo, or pooing when you didn’t mean to.

Driving

You may start driving when you feel comfortable, although you should check with your insurance company that you are covered to drive after 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.

Postnatal exercises

Your abdominal and pelvic floor muscles will take time to recover after pregnancy and a caesarean section. However, there are some safe, easy and effective exercises you can do which will help you feel better and avoid future health problems. Please discuss postnatal exercises with your midwife while you are in hospital.

Alternatively, you may wish to refer to the ‘After your baby’s birth – information booklet for mums and families’. This is available to download from the CUH maternity page.

Gentle sports, such as swimming, can be started when your wound is healed.

It is not advisable to undertake energetic exercise until you feel comfortable.

Postnatal appointment

It is important that you attend a six week postnatal appointment. 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.

Sexual intercourse

Sexual intercourse can be resumed when you feel comfortable. It will not damage your wound, but some positions may feel uncomfortable.

Your fertility can return quickly after having your baby, so if you need to consider contraception then your midwife or doctor can discuss your future 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 a future pregnancy and / or labour. Scar separation is rare, however it is more common in those in active labour due to the additional pressure placed on the scar by uterine contractions. It affects 1 in every 98 (0.98%) of those aiming for a vaginal birth. There is a 1 in 1000 (0.1%) chance of developing placenta accrete, a complication that causes severe bleeding. You are advised to discuss these risks with your obstetrician or midwife.

Although having one caesarean section increases the likelihood of you having another caesarean section, 72-75% of those who have had a previous caesarean section are able to give birth vaginally in subsequent pregnancies. Your midwife or obstetrician will also be happy to answer any questions you may have.