Four categories, not one emergency

NICE's caesarean birth guideline sets out a "standardised scheme to document the urgency of caesarean birth and aid clear communication between healthcare professionals". Quoted in full:

Category 1. "Immediate threat to the life of the woman or fetus (for example, suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia)."
Category 2. "Maternal or fetal compromise which is not immediately life-threatening."
Category 3. "No maternal or fetal compromise but needs early birth."
Category 4. "Birth timed to suit woman or healthcare provider."

Only the first two are what most people mean by an emergency caesarean. A Category 3 is unplanned but unhurried. A Category 4 is an elective.

The decision-to-birth targets

These are the numbers you may hear called across a room, and NICE's wording is careful. For Category 1: "Perform category 1 caesarean birth as soon as possible, and in most situations within 30 minutes of making the decision." For Category 2: "Perform category 2 caesarean birth as soon as possible, and in most situations within 75 minutes of making the decision."

Note "in most situations". These are audit standards, not deadlines that define safety. NICE adds a third recommendation that pushes directly against treating them as a race: "Take into account the condition of the woman and the unborn baby when making decisions about rapid birth. Be aware that rapid birth can be harmful in certain circumstances."

NICE also requires that the time the decision to expedite birth is made is recorded, that the team is informed of the degree of urgency, and that someone talks with you and your birth companion "about why the birth needs to be expedited and what the options are."

Why it is happening

NICE lists the common reasons as "slow progression of labour or concern about fetal condition". The NHS adds that a caesarean may be done in an emergency if a vaginal birth is thought too risky, giving examples including a baby not getting enough oxygen, labour not progressing, or excessive vaginal bleeding.

Some emergencies begin as a planned caesarean that could not wait. Others begin as a failed assisted birth: RCOG says that if neither forceps nor ventouse is effective, "your healthcare professional will recommend an emergency caesarean birth."

What is different from a planned caesarean

Structurally, the operation is the same. What changes is pace, preparation and staffing.

Preparation is compressed

The HSE puts it plainly: "You may have an emergency caesarean if there are complications before or during labour. There may be a sense of urgency and things may move fast. You may still have blood tests and be asked to sign a consent form." In a true Category 1 it may not be possible to sign anything: "In cases of extreme emergency, there may not be time for you to sign a consent form. Your obstetrician may need to act quickly in the best interests of you and your baby."

The anaesthetic may change

NICE still prefers regional anaesthesia — you awake, your partner with you. But the NHS notes that "occasionally, a general anaesthetic (where you're asleep) may be used, particularly if the baby needs to be delivered more quickly." If you already have a working epidural it can often be topped up for theatre, which is faster than starting from scratch.

If a general anaesthetic is used, NICE requires pre-oxygenation, cricoid pressure and rapid sequence induction to reduce the risk of aspiration, and asks every maternity unit to hold a set of procedures for failed intubation. Afterwards, a professional with airway skills carries out continuous one-to-one observation until you have regained airway control, are stable and can communicate, followed by observations every half hour for two hours.

More people are present

NICE requires "an appropriately trained practitioner skilled in the resuscitation of newborn babies" to be present for any caesarean under general anaesthetic or where there is evidence of fetal compromise. The NHS notes that "a baby born by emergency caesarean because of foetal distress may be taken straight to a paediatrician for resuscitation" rather than straight to you.

Cord blood may be tested

NICE asks for "paired umbilical artery and vein measurements of cord blood gases after caesarean birth for suspected fetal compromise, to allow for assessment of fetal wellbeing and guide ongoing care of the baby." This is routine after a caesarean done for concerns about the baby, and it is not a bad sign in itself.

A caesarean late in labour is a harder operation

This is worth knowing before you are in the situation, because it changes how a choice between forceps and theatre looks. RCOG states it directly: "A caesarean in the late stage of labour is a more complex operation than a planned caesarean and in some circumstances may increase the risk of harm to both you and your baby." The HSE says the same — surgery "can be difficult if you are fully dilated and in the second stage of labour", with excessive bleeding among the risks.

NICE reflects the same reality when it tells teams to advise women declining an assisted birth that "your choices may be limited by clinical safety or degree of urgency (for example, if a caesarean birth is no longer an option because the baby's head is too low in the pelvis)." For the impacted fetal head at caesarean birth, NG192 points teams to RCOG's scientific impact paper rather than specifying a technique.

How likely is it?

RCOG gives figures for women who have not had a caesarean before: "The chance of you needing an emergency caesarean birth is 1 in 3 if you are a first time mum in the UK (1 in 5 including women who have given birth before)." NICE's own patient-facing figure for caesarean birth overall is that "around 25% to 30% of women have a caesarean birth", while the NHS states that "around 45% of babies born in England are delivered by a caesarean" — planned and emergency combined.

NICE's tables on planned place of birth give unplanned caesarean rates per 1,000 low-risk women: for a first baby, 69 planning a freestanding midwifery unit, 76 alongside, 121 in an obstetric unit. For a later baby the figures are 8, 10 and 35.

Afterwards

Skin-to-skin still applies. NICE's recommendation to "offer and facilitate early skin-to-skin contact between the woman and her baby" is not limited to planned caesareans, and support to start breastfeeding should be offered as soon as possible. If you are not well enough, NICE's intrapartum guideline asks that your birth companion have skin-to-skin contact instead.

Ask for a debrief. RCOG notes that discussing a difficult birth with a healthcare professional to understand what happened may help, and that "many complications that happen during one birth do not, or are unlikely to, happen again."

Emergency Caesarean: What Happens