Step-by-Step Admission to Recovery Room - Cesarean / C-Section Birth

By: Aunt Doula (11/06/2022)

In the United States, the current national average of cesarean section births is just about 1 in 3 births. This varies state to state, county to county and even hospital to hospital when just across the street. Every surgeon has their own c-section rate tied to them, and it is good to know and your right to ask what your doctors c-section rate is. Sometimes, it is an understandable higher rate such as for doctors who attend primarily high-risk pregnancies that require c-sections more often to keep everyone safe and healthy. Other times, it is not so clear why one doctor has a higher rate than his fellow colleagues, and so it can provide a very telling data point if your doctor has a higher or lower rate than the other doctors within the same practice.

There are many reasons a c-section may occur, however there are three primary scenarios: Scheduled, labor dystocia and emergent. Scheduled c-sections are planned usually well in advance of the due date for a host of reasons that will be covered in another post and linked here when finished. C-sections as a result of labor dystocia (also known as failure to progress in an attempted vaginal deliver) is decided upon usually without distress or urgency. Emergent c-sections are due to a situation that is life or death for the mother or the baby and move very quickly, are not planned or expected situations and can unfortunately be extremely traumatic if there isn’t preparation prior to labor for what situations can lead to an emergency c-section. This too will be covered in another post and linked here when finished.

In this post, we will be going over the step-by-step progression from admission to the recovery room of a scheduled c-section birth. This will be an uncomplicated and straight forward broad-stroke overview – this is not medical advice or a promise of how your scheduled c-section will go. This is intended to give you an idea of how things will likely occur so you can be better prepared for it and be able to ask directed questions of your team prior to the surgery. It is also intended to educate you on the process so there are fewer surprises and empower you to know when something may be going far off script so you can speak up and understand what's going on.

Admission Procedures

When you arrive for your induction, you may have pre-registered and already signed paperwork, if not you will begin that process. You will then likely be taken to your postpartum room where you will come back to after the surgery. If this is not available when you arrive, you will be taken to the pre-op admission area to get changed into your surgery gown, hair net, fashionable leggings and a nurse will start an IV. If you have a preference, they may be able to accommodate it, however it is ultimately up to the anesthesiologist if you need the IV in a particular place. Depending on your risk status, they may also start a back up IV. The nurse will likely examine your abdomen to determine the current positioning of the baby, but this will be repeated in the operating room. If you have a labor partner with you that you want to be present in the operating room, they will be given a set of clothing to change into along with their own hair net, face mask and fashionable booties to go over their shoes.

Each facility may have slightly differing intake tests and procedures they follow that may or may not include a cervical exam, a 30-minute test with two stretchy bands wrapped around your belly to record the baby’s heart rate and determine if you are having any contractions (these may remain on when you go into the operating room), the placement of a urinary catheter, and you may received fluids through your IV while you wait to enter the operating room. It is good to ask at an appointment near you surgery date if any or all of these things will happen so you are prepared.

Operating Room Procedures

Once you are prepped and ready, you will be wheeled to the operating room. You will be transferred from the bed to the surgical table. The room is likely to be a busy place while they are finishing preparations for everything they need. Depending on the facility, you may be wheeled in by yourself initially to receive your spinal epidural – this will be a one-time administration of anesthetic into the spine and there will not be a catheter that remains like a labor epidural. It lasts typically 3 to 4 hours, plenty of time for the surgery and closing the abdomen. Depending on facility your partner may be allowed into the operating room with you immediately, so again it is best to ask what their procedures are so you can be prepared for when you may have to wait for your partner to join you.

Once the spinal epidural is administered and all preparations have been made, you will be on your back with your arms out to the side like an airplane. It has been standard that your arms be gently strapped to the table during surgery, however it is your right to request one or both hands free. Depending on hospital policy they will do their best to accommodate your request and this is something to include on your c-section birth plan.

At this point, surgical preparations of your abdomen, pubic area and vagina will begin. This is often after a drape is up and you may not be fully communicated with each phase of this process - it is 100% your right to ask what they plan to do and are doing and to be asked for your consent! Your entire vulva (external genitals) will be scrubbed to remove risks of infection, especially when a catheter is going to be inserted. Your vaginal canal (internal genitals) will be washed and scrubbed with an antiseptic cleaning liquid on a sponge that is inserted the full length of your vaginal canal and may take multiple insertions to complete. The uterus is connected to the vaginal canal via the cervix, and as such this is an infection route. Your pubic mound will likely be shaved and your abdomen from your ribcage down and across your pubic mound will be cleaned with multiple steps of antiseptic and scrubbing materials. This is usually not something that can be opted out of for your safety and surgical sterile procedures, however if you want to know what is happening you can ask to be kept aware of each step of their preparations. It can be an exceptionally traumatic experience to have vaginal soreness or irritation, a shaved pubic area, or see later on your chart that something happened to you and you didn't know, so as with every empowerment post here, remember that this awareness is to prepare you, not scare you.

The anesthesiologist who administered your spinal epidural will be situated at the head of your surgical table and be attending to the medication needs (if any) and monitoring your vital signs during the surgery. Your partner will also be at the head of the surgical table and a vertical drape will cross just below your breast line to keep the surgical field sterile. You can request that this drape be clear for viewing your baby as soon as possible.

Once everything is set, the surgeon will ensure that you are numb – they will pinch a number of places on your abdomen and if you feel any pain, it is your job to speak loudly and firmly that you can feel the pinching or especially if you feel pain at any time! You may feel a pulling pressure, but you should not feel any pain during this check or during the operation. You may be numb on one side and not the other – Say So if that is the case. If at any point you are feeling pain, look your anesthesiologist in the eye and say “I am feeling pain, not pressure, I need more anesthesia". This is not a contest to endure pain, there is no prize for suffering – speak up, speak loudly and make yourself known. Have a word that you have agreed to with your partner so they can advocate for you that something is wrong. Ideally this is a word you don’t normally use in every-day life such as kumquat or sassafras – whatever your word is, it is for emergencies and to communicate with your partner that you don’t feel right, and it is their job to tell the anesthesiologist that you don’t feel right and to pay attention. Always tell your team what is happening as it is happening and be as specific as you can be. Anxiety and nausea are extremely common, and the anesthesiologist can give you medication through your IV to combat these. Be clear in your birth plan if you want drugs that have the least amount of memory-impairment if possible so you can recollect your birth.

The Surgery

Once you are confirmed numb, there will be what's referred to as a “time out” (this may have happened earlier in the preparation anytime from when you were wheeled in – It should happen before they get to the c-section, but it only needs to happen once. Different facilities perform the time out at different stages.) where they confirm who you are, what you are there for, and state for the record that everyone is ready for your surgery.

You again should not feel any pain, you may feel tugging sensations, pressure, or a strange sensation you can't quite describe, but pain should not be on the list. You may hear a variety of sounds such a suctioning, a buzzing sound with beeps or a possibly a splash when the amniotic sac is broken. You may smell a slight burning odor - this is from an ‘electrocautery’ tool that is used to stop blood vessels from bleeding and sounds like a beep and a buzz when it is applied. There are many tools that are used, and doctors will request them out loud from their surgical nurse, they may ask for a number of items and typically it is all routine. Try to focus on your partner and keeping your breathing low, slow and controlled to the best of your ability. Conscious surgery can be very surreal, keep a focal point on your partner and stay in communication with them as much as you can to stay present and grounded.

The time from the first incision to the baby being born is typically about 10 minutes. Recently, the term “gentle c-section’ has been being used to describe the set of choices ideally followed such as baby being birthed slower out of the incision to mimic a vaginal delivery as much as possible, delayed cord clamping, observing a quiet moment so the first voice the baby hears is the parents and skin to skin is immediate and the golden hour preserved. It has become more and more common especially with scheduled c-sections to request a ‘gentle c-section’ and most providers are becoming aware of these requests. Once the uterus is exposed and the incision made, the amniotic sac will be ruptured and baby will be birthed whichever part is “up” nearest the incision, as slowly and as safely as can be permitted per your wishes if a gentle c-section has been requested and if you have requested delayed cord clamping you can request that they place baby on your chest while they wait. As soon as baby is out, they will be dried, stimulated gently to encourage fluid to leave their airways and at 1 minute and 5 minutes baby will be assessed for their “APGAR” score. Assuming baby cries and is well, baby can remain on your chest or in your partners arms if you have designated so on your birth plan.

Should anything indicate an issue with your infant, a dedicated team of neo-natologists (just-born baby doctors) will be in the room ready to attend to any needs of your baby. This is a separate team to your surgeons who will remain focused on your care while the baby team is focused on your baby’s care if needed. It is common for babies not to cry immediately after a c-section as they don’t have the same hormonal and mechanical pressure signals as they do coming through the vaginal canal during a vaginal birth, however they compensate generally well, so don’t worry – you have everyone around you that you and your baby need to respond to any issues that may arise. Your baby may need some extra back rubs or heel pinches, but ideally they would keep baby attached to the umbilical cord as this has proven to be beneficial especially for babies who do not cry immediately – they are receiving oxygenated blood from the placenta for up to 5 minutes – be ready to advocate that they do not clamp the cord and take baby away to the warmer right away unless it is absolutely necessary – they have a direct line when connected to you of oxygenated blood and that is better than any neo-natology team can provide in the first 3-5 minutes of birth.

Closing the Abdomen & Recovery Room

Once baby has been delivered and if you have elected, the delayed cord clamping period has passed, doctors will clamp the umbilical cord and then remove the placenta from your uterus. They will then check that all of the placenta and amniotic sac has been removed from your uterus and begin the process of closing the abdomen. There will be many sounds of suctioning, they will be examining and talking amongst themselves - this can feel very disconnected especially if their conversations take an interpersonal note. If you feel like you need to know what is happening, ASK! Your comfort is important and while doing this surgery is their normal, it's not yours and this is your birth experience to know and be involved in as much as you want and need. All of this will happen likely without your notice, especially if you have elected to have immediate skin to skin. This can take anywhere from 30-45 minutes. In your birth plan I recommend considering requesting double stitching for all relevant layers of closing as this ensures the strongest recovery and shouldn’t be an issue. Many surgeons for planned c-sections already do double stitching as a routine practice, however there is no harm in ensuring you receive the gold standard. This may extend the time in the operating room, however it is not a significant delay and is extremely beneficial. It may extend your time in the operating room by 5-10 minutes. Staples are on their way out as a skin closure option for c-sections, but it is important to elect if you do not want them clearly in case that is still a practice at your birthing facility.

Once you are completely closed and the surgical team is satisfied with your vitals and abdominal closure, a wheeled bed will be brought in and you will be transferred to it along with your baby in your arms and wheeled to your post-surgical recovery room, or your postpartum recovery room (depending on facility – ask before you go!)

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If you kept your baby with you on your chest during the completion of surgery, baby will have a number of things that they need to have administered once you reach the recovery room. The golden hour should be protected time and you may have to advocate for it and put in your birth plan that you want it. It may not be convenient for your nurses, but this is your baby and your birth – ask for what you want. The measurements, vitamin K injection and eye ointment can wait until you have had your first vital hour with your baby skin to skin.

Variations on this process may occur, but this is the general overview of a planned c-section from admission to recovery room and I encourage you again to discuss it with your doctor well before your c-section any questions you have about the process and procedures that you may encounter. The more you know, the less anxiety you are likely to encounter and the better educated you are about what's going to happen, the more empowered you can be to speak up when something doesn’t feel right.