Cesarean birth during Covid-19 Outbreak
One in three women in major London maternity units are now delivered by the abdominal route. The indications range from permissive maternal requests though to conditions where vaginal delivery is prohibitive or not recommended such as placenta preavia, breech presentation, previous caesarean sections.
If you exclude the 20 percent of low risk women delivering in Midwifery Led Units or at home , you will be forgiven for thinking the postnatal ward is akin to a general surgical ward .The difference is not just the sound of crying babies, exhausted mothers who are both recovering from surgery and tending to newborns and then there are the rampant hormones. We know we need there needs to be better at understanding some of women’s more subtle needs at this time. For example, in women delivering vaginally, the first labour is often the toughest but the benefit is each subsequent delivery gets easier enabling women to be back in home clothes and up and about within an hour or two of birth of baby number 3-4. Women delivering vaginally can if need be ask for a six hur discharge from hospital.
The converse is the case for cesarean, where the first operation is often the easiest to recover from, with subsequent CS being slightly more complicated. Women can have a more prolonged recovery time with not just a newborn to care for but other young children at home
Now add the backdrop of the Covid-19 outbreak. Everyone at this very unprecedented time is scared, confused and worried. This world wide pandemic that has dominated our screens, our news and disrupted our lives. Pregnant women have been self isolating even before coming into hospital having been classified as a vulnerable group. They have been kept out of hospital as much possible antenatally. It has been tough weighing up when one needs to go in to hospital for routine visits or symptoms of potential concerns. Virtual telephone appointments have become the new norm. So during this antenatal period with isolation, one can be reassured about evidence that pregnant women are at no greater risk than other individuals that are healthy esp when strict lock down has been observed.
However, now with a planned CS or even Emergency CS , women will naturally now worry not just about having an operation but having this surgery and recovering in hospital during this Covid-19 outbreak.
C-section during pandemic: how to enhanced recovery and reduce length of time in hospital
What can be done to optimise care at every stage in order to allow enhanced recovery from C-section, reduce length of time in hospital and allow timely return to full family life following childbirth?
Antenatal Period: Avoid Anemia
Avoidance of anaemia and optimisation of Haemoglobin in anticipation of the increased blood loss at Caesarean section compared to vaginal delivery. Therefore, good iron rich diet, prenatal vitamin supplements containing iron and blood check for anemia at 34 weeks can help.
Women with good blood levels before surgery can weather blood loss of up to 2 litres without need for a blood transfusion which will complicate delivery and prolong hospital stay.
If levels are low due to poor absorption of oral iron tablets then an iron transfusion can be given antenatally which will help boost the Haemoglobin levels and does not have blood products in it like blood transfusion.
Timing of Planned (Elective) CS
There is a small risk of Transient Tachynpnoea of the Newborn (TTN) if elective delivery is booked before 39 weeks. TTN is breathing difficulties in baby’s because they do no clear fluid off their lungs which usually occurs with labour (contractions) or if the baby is being squeezed through the birth canal.
You do not get TTN with Emergency CS and hardly ever after 39 weeks. It is therefore not ideal to deliver women before 39 weeks unless by risk assessment this is the lesser risk. This means that there may be say other risk of baby not growing in the womb, or risk of blood pressure that is greater than risk of TTN so delivery may need to be earlier. So avoidance of TTN will stop unnecessary admission of a baby to the SCBU at 38 weeks because of earlier elective delivery. This will clearly prolong hospital stay.
Cesarean birth: the surgical delivery of a baby
Birth as a special occasion can still be reproduced even under the sterile, bright lights and high tech operating theatre environment.
Even in Covid times, your partner can be right there with you, and this is particularly important. He may be required to wear a mask and in some units, in addition to the screening questions about covid symptoms, a temperature may be taken on the day. It is likely that for planned CS it will not be long before both mother and partner may have swab tests before to see if they are positive. This will help the staff manage care in the right ward area and with the right Personal Protection Equipment (PPE) and help reduce any chance of infection of others.
With over 95% of operations performed under regional anaesthesia (epidurals/spinals), dedicated obstetric theatre staff have mastered the skill of trying to normalise a clearly surreal setting for parents. The option of women bringing in their personalised play list to listen to during the surgery can be relaxing. The lowering of the separating drapes between the surgeons and parents at time of delivery is a true ‘magical moment and one that the theatre staff never tire of cooing over.
Antibiotics in theatre help reduce the risk of wound infection and bladder infections that can delay discharge.
The ability for mum to have skin to skin with your baby minutes afterbirth even whilst the uterus (womb) is being closed can be special. Mums usually leave the operating theatre with baby tucked in under the gown ‘Koala style’ for the short journey to the recovery unit.
Covid outbreak or not this time in theatre is all about mum and baby. The operation and theatre is probably the one area that feels completely the same as Pre Covid times with no major change except in few women who are positive or unwell with Covid-19.
Post operatively cesarean birth
There are two priorities for new mums with Caesarean sections:
1. Effective, generous, preemptive pain relief medication to enable women to be able to care for and feed their babies whilst recovering from significant surgery. This leads to early mobilisation (moving around) and enhanced recovery. This is even started at the end of the operation in theatre so that by the time the epidural starts wearing off there is already pain relief on board
2. Blood clots (legs and lungs) is a risk in women who have caserean operations and at minimum all women wear anti thrombosis socks and low molecular weight heparin injections to thin the blood. These are started in hospital and many women go home with daily injections to reduce the risk of thrombosis.
Enhanced Recovery and Discharge
With planned earlier discharge of women from hospital some of the early post operative symptoms may now be an issue at home.
Some of these include the following:
1. Shoulder tip pain resulting from some residual blood in the abdomen irritating the lining of the abdomen. This is nuisance value and can be uncomfortable but will pass usually in 24 hours as the blood is absorbed.
2. Wind that can be so severe that women can be in marked discomfort and fear something serious is going on. Telltale signs including abdomen being quite distended and drum like with , no history of passing wind or burping. This is usually on the second post operation day this can be aggravated by relieved by peppermint tea or peppermint water or chewing gum. The bowel which is a bit lazy will then wake up and start gurgling and women will never have felt so relieved to pass wind! .
3. Another source of concern to women is often post operation swollen legs . This is usually related to position in bed, their fair share of IV fluids in the drip. Reassuring features are normal blood pressure which the midwife who comes to see you will confirm , no protein in the urine and women are otherwise well. Be reassured that this can take a few days to resolve is often required and continuing use of anti thrombosis socks is helpful. Most likely route of getting rid of the excess fluid retention is from night sweats that can occur in the first couple of weeks.
Many units are now not allowing partners to stay for long after the actual birth. The objective is to keep women safe in hospital in special designated areas for the minimum but safe length of stay. All areas are demarcated to segregate women according to risk. In all areas staff wear masks, gloves and aprons or gowns as required . This is to keep you safe and to protect themselves. You soon get used to this.
Enhanced recovery pathway is a state of mind. Most units should prepare you for this and particularly now during the Covid outbreak to be ready for discharge safely but early.
The preparation starts antenatally when you have your preoperative visit before your planned caesarean. If you are suitable then the discussion can begin.
Not all women are suitable for enhance recovery as there may be other issues that require a longer hospital stay. Key is regular pain killers, prompt removal of your catheter, verbal and written information about when to contact your midwife or hospital for after discharge if concerns, midwives visiting and supporting care at home. Physiotherapists will visit to help advice on how to move , exercise and look after yourself safely. There are some very informative apps like mother and baby app that have lots of useful supportive information.
So look forward to the new addition to the family irrespective of the mode of delivery.
Birth is still a very special time in maternity units and the absolute priority is safe care and delivery of mother and baby.
This article has been written by Miss Gubby Ayida Consultant Obstetrician at The Women’s Wellness Centre.
Our Consultants and Specialists at The Women’s Wellness Centre offer care and reassurance from conception to birth, providing everything you need to have a healthy and happy pregnancy. If you wish to know more about our Private Pregnancy Care please contact us on 020 7751 4488 or book an appointment online here.
Consultant Obstetrician and Gynaecologist MA FRCOG DM (Oxon)
Gubby’s guiding philosophy is based on a respect for pregnancy as a state of health, and childbirth as a normal, healthy physiological process. Her obstetric care respects the diversity of women’s needs and the variety of personal and cultural values that women bring to pregnancy and birthing. Gubby Ayida is also Founder/CEO of the Women’s Wellness Centre over the years has grown, developing a strong established brand. Miss Ayida was listed in (2007/2013) Tatlers Guide to Britains ‘s 250 best private Doctors.