Instrumental delivery and emergency caesarean section

The procedure may be needed if the baby is showing signs of distress or if the woman is completely exhausted. An instrumental delivery can only be performed if the cervix (neck of the womb) is fully dilated.

The obstetrician will decide which instrument to use. It will depend on the position of the baby, how low in the birth canal the baby is and how well the baby is coping with labour.  The obstetrician will also decide if it’s safest to deliver the baby in the labour room or in theatre.

If you need an instrumental delivery the reason for it should be clearly explained to you by the obstetrician. You should have the chance to ask questions so you can give your informed consent to the procedure.  Your midwife will stay with you and continue to support you and assist the obstetrician.

One to one care, upright and mobile positions and not having an epidural in labour, reduces your chances of needing an instrumental delivery. Although having an epidural does not mean that an instrumental delivery will be necessary. We use a ‘low dose’ epidural which ideally allows women to feel the pressure of their contractions without the pain, so that when the time comes you are able to push. An instrumental delivery is only recommended when it is the best option for the delivering the baby. If the baby is very low in the pelvis an instrumental delivery is often a much safer option for both mother and baby than an emergency caesarean.

The risk to the baby is bruising and possible small grazes / cuts to the head or face. These are usually superficial (just skin layer) and the baby will be checked over by a neonatologist and midwife after birth to decide if any treatment is required. Most bruising / cuts will go away in 2-3 days.

Some babies can be unsettled after an instrumental delivery and if you are concerned at any time please ask the midwife to check your baby over.

If your baby has a lot of bruising he or she is more likely to develop jaundice in the few days after birth. This will be reviewed by the staff and treatment given is they feel it is required. It helps to feed your baby often after birth as this helps healing and reducing the risk of jaundice.

For the mother there is risk of tissue damage to the vagina or perineum (skin between the vagina and anus) from an episiotomy (vaginal cut) or a tear. This can lead to bleeding, pain and an increased risk of infection.

Episiotomies and tears are sutured (stitched) after birth and you will be given advice on how to look after the area to minimise the risk of infection and given pain relief and anti-inflammatories.

Very occasionally an obstetrician may change from using a ventouse to using forceps if they feel the delivery is still possible using a different instrument. They should explain this to you at the time or immediately afterwards. About 3% of the time the baby cannot be delivered after using instruments. On these occasions you will require an emergency caesarean section.

The obstetrician and midwife should discuss what happened with you and answer any questions you may have. Your baby will be reviewed by a neonatologist as soon as he or she is born. You may need a catheter (urine bag) for around 6 hours after the birth. With adequate pain relief your recovery should be straightforward.

Emergency caesareans are classified into two categories:

• Category 1: immediate threat to the life of the mother or baby (performed within 30 minutes of decision)
• Category 2: mother or baby are showing signs of compromise which aren’t immediately life threatening (performed within 75 minutes of decision)

The most common reason for a category 1 emergency caesarean section is a concern about the wellbeing of the baby.  If the baby is showing signs of distress or is not coping and birth is not imminent, then an emergency caesarean section may be recommended.

There are other reasons for needing an emergency caesarean section but these are much rarer, for example heavy bleeding or the mother suddenly becoming very unwell.

The most common reason for a category 2 caesarean section would be that labour has slowed or stopped and interventions to encourage progress have been unsuccessful. Very prolonged labour may not be safe for you or your baby as it can lead to your baby becoming distressed and an increased chance you may bleed more heavily after birth.

The decision about requiring an emergency caesarean section should be discussed with you by the obstetrician making the decision.

You should understand the reason the caesarean is being recommended and be given a brief description of the process, risks and side effects of the operation. You will be asked to consent to the operation; this will usually be a written signature on a consent form but in extreme emergencies this consent will be verbal and you will be asked to sign the consent form afterwards. Your midwife will stay with you and explain the different things that are happening.

One birth partner is welcome to come into theatre to be with you once the anaesthetic has been completed (unless you have a general anaesthetic where your birth partner will wait for you in recovery). Once appropriate analgesia has been given and preparations made the surgery will start and the baby is usually born within around 15 minutes.

A neonatologist will be present when your baby is born to assess and provide immediate care if it is required. If the baby is well then he or she will be returned to you as soon as possible. We encourage skin to skin for you and your partner in theatre if this is part of your birth plan.

Once the surgery is completed you will be cared for by a nurse in recovery where you will stay for about 2 hours.

We prefer that you do not have visitors other than your birth partner until after you have left recovery area to minimise infection risks, limit the disturbance to others in recovery and to give you time with your baby. The obstetrician will talk to you about the operation and answer any questions you may have.

When the recovery nurse thinks you are ready you will be moved to the postnatal ward. Women who have had an emergency caesarean usually stay on the ward for at least 2 days.

Most women will have a straight forward recovery following their surgery. If you have any concerns please tell your midwife.

We will talk to you about the effect on your future pregnancies before you leave the postnatal ward.

Some women will not be recommended to plan a normal birth in the future due to a number of reasons, however most women who have a had one previous caesarean section will be supported and encouraged to plan a normal birth for future pregnancies.