I THINK I'M READY TO HAVE MY BABY...NOW WHAT?

WHAT TO EXPECT IF YOU ARE HAVING A PLANNED C-SECTION

Sometimes patients already know they are having a Cesarean section (C-section) before they even come to the hospital and other times it becomes necessary to change the plan of care should complications arise.   While a vaginal birth is the preferred method of delivery, sometimes a C-section may be necessary to ensure the safety of the mother and the baby. There are a variety of reasons why a C-section may be recommended, including if the baby is too large to be safely delivered vaginally, if the mother has a medical condition that makes vaginal birth risky, if there are problems with the baby's position, or if labor is not progressing as it should. Your healthcare provider will work closely with you to determine if a C-section is necessary and will discuss the risks and benefits of the procedure with you in detail. It is important to remember that while a C-section is a major surgery, it can be a lifesaving option for both you and your baby in certain situations.

If you knew before even coming in that this was your plan you would be taken to the OB OR pre-op area.  Here you would meet a nurse that would be caring for you before and immediately after your surgery, or some facilities have the same nurse follow you throughout the process.  The OB nurse could be male or female, although at most facilities they are mostly ,if not all, female, so for ease in writing we will refer to the nurse as "she," from this point on. She would make sure we have all of your records in order so we can best care for you and your baby, possibly have you repeat the shower that you performed with surgical scrub prior to coming in, have you change into a gown, start an IV (an intravenous line, in your vein, that is used to give you fluids and medication directly into your bloodstream), and have you remove all of your jewelry and metal accessories including hair pins, bras, and piercings.  The nurse will verify that you have not had anything to eat or drink according to the parameters set by your provider and that you are not wearing any makeup (which could dangerously mask changes in your condition).   She will start fluids in your IV and give you pre-operative medications, including antibiotics, anti-nausea medications, and a medicine to help neutralize the acid in your stomach.  These medicines are given to prevent issues during or after surgery.  She will frequently monitor your vital signs as well. 

You will meet with a member of the anesthesia department, either an anesthesiologist, a medical doctor specializing in the administration of anesthesia or a Certified Registered Nurse Anesthetist (CRNA) which is a nurse that has received a master's or doctorate degree in the field.  The team member will discuss with you your medical history and will collaborate with you to determine the best type of anesthesia for your situation.  During a c-section, there are different types of anesthesia that can be used. The most common options are general anesthesia, epidural anesthesia, and spinal anesthesia. General anesthesia will put you to sleep for the duration of the surgery and is usually only used in emergencies or if other forms of anesthesia are not an option.  Epidural anesthesia is typically administered through a thin tube, a catheter, that is placed into the epidural space, which is a space just outside the protective covering of the spinal cord. The medication is delivered continuously through the catheter to provide pain relief during and after the c-section. Epidural anesthesia can be adjusted to provide different levels of numbness, and is most often used for pain relief during labor if needed.  On the other hand, spinal anesthesia involves a single injection of medication directly into the cerebrospinal fluid surrounding the spinal cord by a very thin needle, which provides a more intense and immediate block of pain sensation. It is most commonly used for planned cases and does not require the placement of a catheter. The medications that will be placed in the spinal are anesthetics  such as Bupivicaine, and opiates for pain relief such as fentanyl or morphine (a brand name example you may have heard of is Duramorph).  When morphine is used in this way it may significantly alleviate pain in the first 24 hours post-operatively, and also decrease the use of oral narcotics.   All of these medications may cause nausea and vomiting, sleepiness, itching, sedation, and respiratory depression.  You will be monitored for these and will be treated appropriately if they occur.

if you know in advance that your baby is at risk for complications you may meet with a member of the NICU (neonatal intensive care unit) team.  This could be a neonatologist (a doctor specializing in the care of new babies with issues) or a nurse practitioner experienced in this area.    He or she will discuss the plan which may require your baby to leave the operating room at birth to be transported to the NICU for care.  If your baby does not have any issues that you know of in advance there is a team of providers, nurse's, and respiratory therapists from this department that are on stand-by at most larger facilities should issues arise. In other smaller facilities your baby will be cared for by the unit staff until transport can be arranged to a higher level of care at another hospital if needed.

Your provider will also meet with you to discuss the plan and help you to feel at ease since this is someone you already know well and who knows you and your history. They will leave to get ready for the surgery and scrub in .  Your nurse will coordinate to get you to the operating room when it is time to go.  You may stay with the same nurse or a new nurse may take over your case while you are undergoing surgery.  

When you enter the operating room you will meet the nurses and other personnel that will be caring for you.  This includes the surgical technologist, known as a scrub tech, who is the person that ensures your sterilized instruments are placed appropriately for the surgeons.  They ensure the operating room is ready for your case.  You will be assisted to the operating table by your nurse.  You will again see the member of the anesthesia team who will provide you with anesthesia.  If receiving a spinal or epidural you will most commonly sit on the side of the table in a traditional sitting position with your feet on a step stool.   You will be facing your nurse with your shoulders slightly rounded out and your nurse will hold your shoulders.  The anesthesiologist will place the spinal (or epidural) and you will be assisted back to lie on the table.  The nurse will place a urinary catheter (referred to as a Foley catheter) which is a sterile tube inserted in your bladder to drain your urine into the connected bag.  You will have your legs strapped to the table to hold you in place.  You may be shaved in the area of the surgery, and then will have your abdomen scrubbed and a sterile drape placed by the scrub tech.  You may or may not have one or both of your arms strapped to the table for your safety.  While all of these preparations are made to get you ready other staff will be with your support person helping them to get dressed in a jumpsuit, cap, and shoe covers for required for entering the OR to reduce contaminants and, therefore,  the risk of infection.  Your support person will enter and sit next to your head and may hold your hand.  The surgeon will ensure that you are numb and then begin.

 The surgeon will make an incision in your lower abdomen and then in the uterus, this involves slow controlled cutting of several layers with the bladder and intestines safely out of the way. The baby will be delivered through the uterine incision and it is normal to feel a lot of pressure as this occurs. Another nurse will enter to the room as the baby is delivered to assist since there are now two separate patients in the room!  The umbilical cord will be cut and the placenta will then be removed from the uterus, and in most cases the uterus or the top part of it is removed from your abdominal cavity and is inspected, massaged to control bleeding, and cleared of excessive clots or blood,  then the incision will be closed with sutures (stitches).  You may feel pressure and tugging sensations as the baby is delivered and the uterus is returned to the abdominal cavity.  It is important to communicate with your medical team about any sensations you experience during the procedure.  It usually takes about 45 minutes to an hour, and you will be closely monitored by medical staff throughout the process to ensure your safety and well-being. 

Traditionally right at delivery the baby was taken to the warmer, dried, examined, and weighed with the support person accompanying.  There is a newer trend on how Cesarean births are performed, providing patients with an option called a gentle or natural Cesarean section.  This does not mean the surgeon is physically more gentle but that the the process of needing surgery to deliver your baby is done with a more family-centered approach.  Often parents feel that they have missed out on the bonding and involvement in decisions that usually accompany a traditional vaginal delivery so this type of Cesarean delivery aims to create a more positive and personalized birth experience for both the parents and the baby. In a gentle C-section, the surgical procedure itself is similar to a traditional Cesarean, but the care philosophy and the environment is different.  During a gentle C-section, the medical team aims to create a more calm and peaceful environment by reducing noise and lights in the operating room and playing soothing music. The mother may also have more control over the birthing experience, such as choosing delayed cord clamping and exercising the option to have skin-to-skin contact with her baby and possiby even breastfeed immediately after birth while the surgeon is still completing her repair.  In addition, the medical team may use a clear surgical drape, lower the drape, or use a mirror so that the mother can see her baby being born. The baby may also be delivered more slowly allowing for a smoother transition into the world.  The goal of a gentle c-section is to promote a more natural and family-centered birth experience, while still ensuring the safety and well-being of both the mother and baby.  In either type of cesarean the baby will have two bands applied immediately after birth, one on the wrist and the other on the ankle.  The bands come  in a pack of 4 (two adult and two baby) with preprinted numbers on them that are unique to that set.  the remaining adult bands are placed on the mother and the support person.    This will allow the baby to be matched with the parents

However you choose to experience your C-section you and the baby (if all is well) will be brought into the recovery room, which may be the same room you had just prior to surgery, when the surgery is completed.  You will remain in recovery getting frequent vital signs. and checks.  The top portion of the uterus is called the fundus and it is important to ensure it is firm and where it should be located to reduce the risk of hemorrhage (excessive bleeding).  The nurse will verify this with frequent fundal checks by pressing with her hand and rubbing your abdomen near your belly button while also checking the pads near your vagina for the amount of bleeding you are having.  You will also be receiving IV fluids containing Pitocin.   The fluids help with your hydration and Pitocin is a synthetic version of a hormone your body naturally releases which helps control your bleeding.  You may also receive medications to assist with any nausea you may be experiencing.  The nurse will also be checking the bag connected to your urinary catheter to ensure you are producing enough urine.  Your baby will be getting vitals signs, usually every 30 minutes if things are going well, which can happen while you are still doing skin-to-skin if you chose to do so.  After the initial hour is completed your baby will be weighed and given medications (if you elected them) which will be discussed in later sections.  You may have a second, or even third, hour of recovery but eventually will be transferred to the Mom and Baby unit, or Postpartum unit as it is called in some facilities.  After the section regarding Labor and Delivery we will discuss what happens when you arrive on the Mom/Baby unit. 

If you are a vaginal delivery you may have already been out of bed and attempted to void (urinate) with the nurse on Labor and Delivery, but if you weren’t ready yet or had a C-section we will help you here.  You will learn the best way to move yourself to the edge of the bed so as not to increase soreness in your perineal laceration or your abdominal incison.  It is important to know in the case of C-section not to have your partner pull on you trying to assist you out of bed as they may unintentionally cause to you move in a way that is painful or harmful.  It is best that you use your arms and legs to move to the edge of the bed under your own power, only using another person to support you.  As you are at the edge of the bed we will encourage you to just sit there momentarily to ensure you are not dizzy when you are ready to stand up.  For a C-section try to move not by pulling from your abdomen as we usually do but use your arms to  push off the bed as you use your muscles in your thighs to push yourself up.  You may experience a significant burning pain in your abdominal incision as you do this but push past the burning and come to a normal standing position.  For either type of delivery, as you stand do not start walking towards the bathroom until you know that your legs and feet feel stable under you.  If they don’t we are still able to help you to the bathroom but may need to utilize a piece of equipment (such as a sara stedy) to ensure your safety.  As you arise or start walking you may feel a significant gush of blood coming from the vagina.  This is a normal experience but may feel scary if you were not prepared for it.  It is the reason we encourage you not to wear your beautiful white slippers your first time out of bed, instead opting for the provided non-slip hospital socks or your wipeable slides. It is also why we ensured you had additional pads in your panties and possibly even carried a disposable chux under your bottom enroute to the toilet.  Your nurse will be sure it is not too much bleeding and will possibly check your bleeding again after you are finished.  

As you carefully lower yourself to the toilet you may notice a urine collection pan there.  Just ignore this and empty your bladder normally and the urine will go into it.  The nurse will be sure that you are producing enough urine and then further measurements will be discontinued.  We usually only need to do this one time and if you have produced at least our facility’s minimum standard (usually 100-200 ml) we will discard the container.  Your nurse will help you by filling your bathroom water bottle (often referred to as a peri bottle) with lukewarm water and advise you to wash your perineal area (vagina to anus) with the stream of water from front to back.  This is known as performing peri care and it may have been done for you until you were able to get out of bed.  You will then take the toilet tissue or washcloth the nurse provides and dry yourself (carefully in the case of a vaginal delivery; we recommend patting dry).  You will change your pad and underwear.  If you had a vaginal delivery you may also use a numbing spray (such as Dermoplast) in the event you had a laceration or episiotomy.  An ice pack can help with swelling and bruising (we use frozen diapers at my facility) and witch hazel pads (such as Tucks) can also help with swelling, bruising, or with hemorrhoids.  You can use both together or separately if desired.  C-section patients should remember to use their arms and thighs to push up to standing.  Wash your hands and if you are stable maybe take a quick walk around the room.  If you had a C-section it is amazing how much better you feel after getting up for the first time.  I always tell my patients that they will feel like a different person coming out of the bathroom than they did before going in. The first time up is the most difficult and now that is out of the way!  

You should attempt to empty your bladder at least every two hours while awake, whether you feel like you need to go or not.  As your bladder fills with urine your uterus is pushed to the side (usually the right side) and cannot as effectively contract to control your bleeding.  You also may have a decreased sensation of needing to go, or an inability to go, due to pressure on the bladder and pelvic floor during vaginal delivery, swelling or bruising of the urethra (the tube that you pass urine through), or because you had a urinary catheter in place, among other reasons.  It is a common finding that patients will call for the nurse stating they feel shaky or flu-like and when questioned as to when they last used the bathroom they realize it has been quite some time.  As soon as the bladder is emptied they feel so much better.  If you are unable to void within six hours of delivery or catheter removal you will need to have a catheter placed.  The catheter can be placed for just minutes allowing for the bladder to empty and then be removed (a process referred to as straight catheterization), or a foley catheter connected to a collection bag can be replaced for a length of time before the process is attempted again.    

One test your baby will undergo in the hospital is for jaundice, a common condition in newborns that causes the skin and eyes to appear yellow. It occurs when there is a build-up of bilirubin, a yellow pigment, in the baby's blood.  Bilirubin is a waste product that is formed when red blood cells are broken down, which we all do on a regular basis. The liver is responsible for processing bilirubin and eliminating it from the body through bowel movements.  However, in newborns (especially those born prematurely), the liver is not yet fully developed and may not be able to eliminate bilirubin as efficiently yet as it should. This can lead to an increase in bilirubin in the baby's blood, causing jaundice.  Other factors at birth may increase the issues in eliminating bilirubin from the body, such as bruising sustained by the baby during the birth process, resulting in more red blood cells that are broken down at one time.  Additionally, jaundice can occur when a baby has a different blood type from their mother. When a baby's blood type is incompatible with their mother's, the mother's body may produce antibodies that attack the baby's red blood cells, causing them to break down and release bilirubin into the baby's blood (read more in the positive Coomb’s test section).  Another possible concern is breastfeeding.  While breastfeeding is certainly encouraged for newborns for optimal nutrition and immune protection, it is essential to work with your nurse and/or lactation consultant to ensure that you are producing an adequate supply.  Low oral intake can lead to fewer bowel movements and increased reabsorption of bilirubin in the intestines.  

We will check your baby for jaundice by performing a non-invasive test called a transcutaneous bilirubin.  This just means that a small specialized instrument will be placed on the baby’s skin and will emit several flashes of light to obtain an average reading.  There is no pain or discomfort caused by this screening, although your baby may stir due to the change in temperature or pressure that he or she senses.  Facilities may vary on how often this test is performed but it is commonly done every 12 hours after birth.  If the results of this test indicate there is possibly an issue then the baby will have blood drawn to obtain a more accurate result as the skin test serves only as a general guide.  The pediatrician will use this result to determine if there is a need for treatment.  Mild cases of jaundice usually resolve on their own within a few weeks, but other times it may require further intervention.  This may be phototherapy, where the baby is placed under artificial sunlight via a light source placed over the crib or a special blanket (referred to as a bili blanket) that gives off this light.  Sometimes both are utilized together.  The baby is placed in the crib with just a diaper and a mask to protect the eyes while this light reaches the skin and alters the bilirubin to a form that is more easily broken down by the body.  Your baby can typically stay in the room with you while undergoing this treatment but it is very important to keep the baby under the lights as much as possible.  While it is tempting to remove the baby from under the lights frequently it will only lengthen the amount of time the therapy is required and may further delay discharge from the hospital.  We understand that the babies don’t like it as they are used to being swaddled or held which makes it hard on families, but your nurse will work with you on how to soothe a baby undergoing phototherapy and how to feed while still benefiting from this light therapy.  Rarely, in more significant cases, it may necessitate having the baby move to a higher level of care (such as going to the neonatal ICU, or NICU as it is commonly known) to undergo a special blood transfusion.  This is called an exchange transfusion which quickly decreases the bilirubin from the previous dangerously high level.  

If your baby requires treatment or not we will continue to watch for any signs of jaundice and work with you to decrease any risk to your baby while you are at the hospital.  We will also educate you on the signs and symptoms of jaundice to be alert for in the early period of arriving home such as yellowing of the skin and eyes, poor feeding, and lethargy.

Infant blood screening, is a crucial but simple blood test performed at least 24 hours post-delivery to identify a large range of inherited disorders thus allowing for timely intervention.   This is a bedside procedure in which the nurse collects several drops of blood on a card that is then sent to the state laboratory.  Since it is not run in the hospital it will likely be the only test you will not have results of prior to being discharged.  The state does not usually contact families individually to report normal results due to the large volume of tests.  Instead, your provider will be able to check on the state’s website to ensure the test was processed and is within normal limits.  If there is a problem detected your provider will be notified immediately, so you will want to have a pediatric provider selected prior to the test being performed.  States may vary which tests they include (from 33 to 60+) on what but generally screen for the following categories.  

Metabolic Disorders: These are genetic conditions that affect the body's ability to process certain substances, such as proteins, fats, and carbohydrates and require treatment with dietary changes or medications.  One example of a metabolic disorder is Phenylketonuria (PKU). PKU is an inherited metabolic disorder that affects the body's ability to break down the amino acid phenylalanine. Early detection through metabolic screening enables the implementation of dietary modifications, such as a low-phenylalanine diet, which can prevent intellectual disabilities. Another example is Galactosemia, an inherited metabolic disorder characterized by the body's inability to break down galactose, a sugar found in milk. Early detection through newborn screening facilitates the timely initiation of a lactose-free diet, preventing complications and ensuring healthy development.

Endocrine Disorders: These are conditions that affect the endocrine system, which is responsible for producing and regulating hormones in the body. One example of an endocrine disorder is Congenital Hypothyroidism. It occurs when the thyroid gland fails to produce sufficient thyroid hormones, essential for proper growth and development. Early detection through metabolic screening allows for early intervention with thyroid hormone replacement therapy to prevent irreversible intellectual and physical disabilities.

Hemoglobin Disorders:  These disorders are genetic conditions that affect the production or function of hemoglobin, a protein in red blood cells that carries oxygen throughout the body. One example of a hemoglobin disorder is Sickle Cell Disease, an inherited disorder characterized by abnormal hemoglobin production resulting in misshapen cells that can cause blockage of the blood flow in circulation as well as an insufficient number of functional blood cells.  Early detection through newborn screening facilitates early intervention and ongoing medical management to minimize symptoms and improve the quality of life for individuals with sickle cell disease.

Cystic Fibrosis (CF):  This is a genetic disorder that primarily affects the lungs, pancreas, and other organs. It results in the production of thick, sticky mucus, leading to respiratory and digestive complications. Early detection through newborn screening allows for the timely initiation of treatment and management strategies to minimize respiratory and digestive complications, improving long-term outcomes and extending life expectancy.

Severe Combined Immunodeficiency (SCID): Severe Combined Immunodeficiency (SCID) is a rare genetic disorder that affects the immune system, leaving infants highly susceptible to severe infections. Early detection through newborn screening enables prompt intervention, such as a bone marrow transplant, which can prevent life-threatening infections and improve the immune system's functionality.

The ability to detect these disorders early allows for targeted interventions, minimizing complications, and ensuring better long-term health for infants. As medical knowledge and technology continue to advance, the scope of disorders that can be screened for continues to expand, underscoring the importance of this critical screening tool.

The CCHD (Critical Congenital Heart Defect) test is a screening procedure performed on newborns to detect potential heart defects shortly after birth. Critical congenital heart defects are  abnormalities of the heart that are present at birth which affect the heart structure or blood flow through the heart and can cause serious health issues or death if left undetected and untreated.  Early detection of these anomalies through the CCHD test is essential because it enables prompt medical intervention. Timely diagnosis allows healthcare professionals to initiate appropriate treatments, surgeries, or interventions to improve the baby's health and potentially prevent complications or life-threatening situations.

The CCHD test is a non-invasive and painless procedure that measures the oxygen levels in the baby's blood. It involves using a pulse oximeter, which is a small device that uses light sensors to measure the amount of oxygen saturation in the baby's blood. You will most likely have had this used during your labor as well, although the sensor utilized for adults is slightly different than for newborns.  The oxygen level is measured on the baby’s right hand and compared to the level on one of the feet. If there is a large difference between those two numbers or either number is less than the threshold (usually set at 90% or higher) then further evaluation may be necessary.  The test is usually conducted between 24 and 48 hours after birth, allowing enough time for the newborn's circulation to stabilize. During this period, oxygen levels in the blood should be within the normal range. However, in infants with critical heart defects, the oxygen levels may be lower due to poor oxygenation or circulation problems.  Additional diagnostic tests such as an echocardiogram, which uses ultrasound waves to create images of the heart and blood flow, may be performed to confirm the presence of a congenital heart defect.  Your baby may also have an exam by a pediatric cardiologist as well if there was any abnormality in the test results.   

While the CCHD screening is very useful at detecting critical congenital heart defects in many newborns it may not detect all babies with such a problem.  This is yet another reason to continue to have regular exams by your pediatric provider after discharge from the hospital.