Cat 3 EMCS - experiences and questions to ask

Aw I hope it’s today for you. One thing that surprised me was how quick it was once it got started! From the first incision to baby being born was only four minutes. It was such a lovely, relaxed atmosphere. I was so nervous before hand, but looking back, I’d give anything to do it again.

Good luck for tomorrow @Meier. My ELCS was the best day of my life. I was so anxious beforehand and posted lots of questions (under another name), which @Greybeardyalways so kindly answered for me. It was honestly such a fantastic experience and I think anaesthetists are bloody marvellous people. I’d do it again in a flash. Hope you get some sleep tonight and I shall look forward to a heartwarming update tomorrow!

'fraid not. Ideally it shouldn't be much longer than normal rules (6 hours for solids), but that can be difficult to time on LW. They possibly could have done a bit better with oral fluids during the day, but that's easy to say from here - it may genuinely have been unavoidable. If you're still not done by now they probably need to have a think about whether to call it a day and giving you some food, but it depends a bit on what the reason for the section is and what the rest of their current inpatient load is. Don't be tempted to snaffle some secret snacks/fib about it if things do go ahead tonight. For a cat 3 section it is normal to be fasted according to the standard rules (and it'd be sod's law that if you just decided to eat then theatre would become available). If things change and become more urgent then they'd normally weigh up the pros vs cons of proceeding unfasted vs waiting (and for the more urgent cat 2/1 sections usually the risk of waiting is greater but it does still make for a hairier anaesthetic).

That’s so frustrating I’m so sorry! Worth asking if they can at least give you some fluids through your cannula to help keep you hydrated?

You should have been able to carry on drinking. i’d ask if it’s likely to be in the next couple of hours and if not have a large glass of squash/water if not.

electives and emergencies are supposed to be kept separate - elective doesn’t just mean the maternal request sections - they could be really high risk. Cat 3 can be a difficult place to be.

Yes, but guidelines only changed recently, so if you're child is relatively old then it was common practice historically

(some people very quickly metabolise codeine into lots of morphine, others don't metabolise it at all... and we can't tell who is who) hence we now give dihydrocodeine to everyone as its metabolism is predictable, so we know that if mum is feeling more drowsy then baby will likely to be a bit more drowsy and needs a closer eye

The risk with codeine is that a small proportion of women metabolise it differently to the rest and if those women breastfeed them the baby is at higher risk of side effects including respiratory depression (one of the breakdown products of codeine is morphine and genetic variations mean that some people can make more morphine out of codeine than others do). For most people codeine would be fine but prompted by a well documented case of a catastrophic neonatal outcome, and the fact that there’s another option (dihydrocodeine) that is safer and possibly works better for some women, it’s been advised in the uk at least that codeine should not routinely be used for women who are planning to breast feed. Probs best to speak to a real life HCP so they can help weigh up the pros and cons.

I’m not a medic so conscious I may sound thick there…

So does that mean co-codomol shouldn’t have been prescribed if they knew I was planning to breastfeed? I’m still breastfeeding at 18 months but also now have extremely painful periods that OTC painkillers don’t even touch so still take the co-codomol I have left from my c section when the pain is really bad.

Dihydrocodeine is the default, when we don't know breast feeding choices as normal codeine can't be taken when breast feeding (a large proportion of the population don't metabolise it properly either so get no benefit from it, hence I don't prescribe it unless patients are on it at home preop and not breast feeding

As others said, a category 3 is basically the same as a normal elective. It just means it wasn’t planned for that day, but it’s still not an emergency.

I have had two c sections, one of which was a category 3. Both times they lowered the drapes as DC were being born (though it was very hard to have a good view when I was lying down), passed him to me right away for skin to skin and delayed cord clamping too.

It’s one of those things that you may need to stress several times. A friend of mine had a c section at the same trust and they took her son away to be weighed, etc before she even saw him. So because of that, I told everyone I could that’s what I want so it happened.

I was in for 3 days with my first but was due to separate issues. Went home the day after with my second. And definitely ask for pain relief and ask for it before you even need it. If you wait for the midwives to bring it to you, it might be too late and your previous dose may be wearing off, so just stay on top of it and take it regularly. And definitely get more than ibuprofen and paracetamol - I had dihydrocodrine for one and co-codomol for another.

6 hours! Yikes! I’m so grateful that my hospital didn’t do that. I was so hungry I could have chewed my own hand post section.

Also, this time they let patients drink sips of water right up until going to theatre for categories 3 and 4. It’s a new protocol since my last section, and it was a huge improvement.

Yeah definitely will be huge variation I moved to a trust and was like "youll likely be home tomorrow" and the midwife was like "no she wont" lol opps!

I've done obs in 7 trusts now and direct to chest only happens for trials. Makes sense tho..same as eating post section, some trusts can eat immediately within reason, others make the lady wait 6 hours post op

Thanks!

https://fpm.ac.uk/sites/fpm/files/documents/2021-03/surgery-and-opioids-2021_4.pdf

This is the longer version @SomethingDifferentBloomed

Yes @Destiny123 different trusts must be different as straight to chest is not unusual for us and oramorph for home is also not unheard of!

Yeah they did when I very first started too. Now most, but not all trusts give dihydrocodeine (30mg = 3mg oromorph) with paracetamol ibuprofen

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15262

This just shows how much practice varies between trusts, where I am at the moment we have window drapes and it is standard practice to pass baby straight through to mum at electives.

What are the international pain consensus guidelines? I’ve had a quick google but not been able to find anything. I’ve definitely sent people home with oramorph (both after a section and following other surgeries) if there was a reason they couldn’t have dihydrocodeine. Didn’t have any pushback from pharmacy so I don’t think it can be that uncommon.

It used to be routine practice in our trust to be prescribed oramorph to take home after a section when going home after 24 hours. Unfortunately it’s no longer routine here, but when I asked my team for it, they were understanding and supportive. I definitely was able to mobilise better with it for the first couple of days. The diclofenac also really helped and I am grateful that my recovery was very straightforward.

It’s wild that women are typically expected to have major surgery and go home the day after with a newborn to look after and just take some paracetamol and ibuprofen! Pain management is such an important part of postoperative and postnatal care.

When dc2 was born (meant to be an elective but I went into labour first), she was passed to the midwife who then gave her to me so I had her in about 3 minutes (we also had delayed cord clamping). They did her measurements/vit k about 3 hours after her arrival in recovery. Watching her come out was amazing. Do you want to see your placenta? They're fascinating although I drew the line at taking mine home but that was an option.

I found her birth to be healing after what happened in my first. It helped me understand a lot of what had happened before and this time I was listened to which made a huge difference. I originally wanted a general anesthetic and jumped through all the hoops to get it signed off but the Doctor who actually delivered her asked me to trust her. It was an absolutely amazing experience. Everyone but the Consultant cried (but she did hug me and ask for a baby cuddle in recovery), there were lots of hugs and actually I can't imagine any way in which it could have been more perfect.

As for recovery I think it really varies. Mine literally didn't hurt beyond a mild ache without pain relief (dc1 was in NICU and no one told me to go back to the ward for medication and with my 2nd, I just didn't take anything). With my first, this caused a bit of a problem and I was prodded far too much by an anesthetist in an attempt to find an issue.

One of the NICU doctors recommended scar massage once everything was healed as numbness around the scar can be an issue. It worked for me. I don't have any numbness at all now.

Wishing you an amazing experience and lots of lovely squishy baby hugs tomorrow.