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The Natural Caesarean

Pregnancy Dr Minke Burke Director
During pregnancy do you often think about how your delivery will go? Do you wonder whether your labour will go smoothly and as planned? Most women have a vaginal birth in mind but sometimes things change and a caesarean birth is necessary….

Changes to your delivery plan may happen during your pregnancy and some women will need a caesarean delivery, as a vaginal birth is not safe.  This is the case if the placenta is low lying, if the baby is in a breech (bottom first) position or if you have had certain forms of surgery to the uterus including a previous classical caesarean delivery.  Besides these medical indications some women may choose to have a caesarean delivery.  This may be because of a traumatic first vaginal delivery or a fear of natural delivery.

Changes to your birth plan may also happen during labour.  This affects about 1 in 5 women in labour.  Examples include obstructed labour where, despite all efforts, the labour is not progressing and a vaginal birth is not possible.  Your baby may get distressed during labour or you may become unwell and your baby may need to be delivered to speed up your babies or your own recovery.

Caesarean delivery is increasing worldwide and there are various factors associated with this – but we will blog about that another day….

What are women’s attitudes around delivery and what are their expectations?

There is little research regarding women’s expectations and preferences around how they deliver.  It seems that a minority of women choose to have a caesarean delivery over a natural birth.  There are some studies addressing women’s feelings around delivery, their experience of having undergone a caesarean delivery and attempts in making the caesarean delivery experience more woman and baby friendly.  One important finding from these studies is that irrespective of the mode, women need to have a sense of control over their delivery.  If the birth is a positive, empowering experience women will have fewer post partum complications, fewer problems with bonding or breast-feeding and their emotional wellbeing is improved.

If a caesarean delivery was not the preferred option for you, this procedure may be associated with increased anxiety and apprehension.

What happens during a caesarean section?

A caesarean delivery may be scheduled as an elective procedure, performed as and emergency or as a “crash” (super emergency) procedure.  These three types of caesareans all have similar steps but are carried out faster in an emergency situation.

For a typical elective caesarean delivery, when you arrive into the operating room the anaesthetist will administer a local block to the spinal nerves.  This takes a little while to be effective and during this time you will be positioned onto the operating table.  You will have a cannula with an IV drip in your arm, and some electrodes on your chest for the ECG (heart monitor) machine.  The operating table is narrow and not so comfortable.  Once the block is effective you will have a urinary catheter (a thin plastic tube to empty the bladder and continuously drain it) inserted into the bladder.  After your abdomen is cleaned with an antiseptic solution a surgical drape is placed in front of you and will cover your body.  Your partner or support person is then welcomed into the room and is seated next to you.  The surgical drape prevents you from seeing the actual procedure.  The midwife scrubs in to receive the baby once he or she is delivered.  There are four people around the operating table: two obstetricians (one assists), a scrub nurse and the midwife.  Other people that are present in the operating room are the paediatrician, your anaesthetist with an anaesthetic assistant, and another scrub nurse to ensure the operation being performed goes smoothly.

The delivery process of the baby is usually fairly rapid: after opening the abdomen and uterus the babies’ head is usually delivered by hand or forceps (blades gently placed around babies’ head), followed by active assistance of the surgical team facilitating delivery of the babies’ shoulders and body.  Once the baby is about to be delivered the drape is lowered and the baby is seen for the first time, and you and your partner may determine the sex of your baby.  The umbilical cord is clamped and cut and your baby is handed to the midwife.  The baby is taken to the Resuscitaire where the paediatrician makes sure that he or she is transitioning appropriately to life outside the womb.  Your partner is welcome to cut the remainder of the cord and to take photos.  Your baby is wrapped and may receive Vitamin K, and after this your baby will be placed onto your chest for a cuddle.  This is a great opportunity for photos and recruiting the anaesthetist to do this job means that the whole family can enjoy this first moment together.  The obstetrician continues to deliver the placenta and closes the abdomen.

Traditionally the operating theatre is the domain of the surgeon.  This is where he or she “calls the shots”.  Patients usually have received some sedation or a relaxation agent prior to entering the operating room and will be asleep soon after.  This means that there is not much concern for staff to attend to the patient’s emotional needs.  The focus is mainly on their safety throughout the procedure.  A caesarean delivery throws this concept out of the window as you are awake during the procedure and you have a support person with you.  The birth of your baby is without a doubt one of the most significant experiences in your life and this experience in theatre may have an influence on mother baby bonding, breastfeeding and post partum wellbeing.

We need to keep in mind that a caesarean delivery is a major surgical procedure and needs to be performed under strict guidelines to adhere to safety for both mother and baby.

Are there ways we can adjust our traditional practice to some extent to allow a more woman and baby friendly approach without compromising safety to mother, baby and surgical staff?

The authors of “Natural Caesarean”- a woman centred technique” describe their management of women undergoing a planned caesarean delivery.  Some of their deviations from the traditional caesarean are summarised below.

In preparing the woman for the caesarean delivery the anaesthetist makes some simple adjustments whilst maintaining vital monitoring and allowing skin to skin between mother and baby after birth.  This means placing the pulse oximeter (the machine that measures how much oxygen is in your blood and usually placed on a finger) on the mother’s foot and placing the ECG leads away from the mother’s chest – to accommodate baby placement after delivery.  While the mother is receiving her anaesthetic, the partner or support person is being kept up to date, as he or she is usually waiting in the anaesthetic bay.

The main difference in delivering the baby is that these authors attempt to mimic a vaginal birth; a slow process of delivering the fetal head followed by a “hands off technique” allowing auto resuscitation to occur; the baby will start to breath while still connected to the umbilical cord and the placental  circulation.  Furthermore, the hands off technique allows the lung fluid to be squeezed out through the babies mouth and nose, due to the compression of the uterus.  Baby’s body will be delivered in a combination of passive expulsion by uterine contraction and active assistance.  The mother and partner are observing the birth.

Another interesting change is their attempt for early “skin to skin” contact; the anaesthetic assistant clears the chest of the mother.  Still scrubbed, the midwife receives the baby directly from the surgeon to prevent contamination.  The mother should be warned not to reach out for her baby as this risks touching the obstetrician.  The baby is laid prone between the mother’s breasts, dried with a warm towel and kept warm with fresh warm towels.  Temperature in theatre is kept around 25 degrees Celsius, a little warmer than usual.

The partner is invited to cut the remaining cord if he or she wishes. Vitamin K administration is accomplished with the baby on the mother’s chest.  After the procedure is finished the baby is weighed and measured, and mother and baby are kept together allowing skin to skin and breastfeeding to continue.

Some of the suggested changes are easily implementable and as usual the biggest reluctance to change are the people, since they may have to change their rituals and routines.

Acknowledgement that a planned caesarean delivery is not just a surgical procedure, but much more – a birth – is paramount.  The changes mentioned above empower women and improve their delivery experience, especially in those women who had preferred to have a natural birth.  These changes are likely to improve their post partum wellbeing, bonding with their baby and breastfeeding.  Slow delivery of the babies head and body allows lung fluid to be squeezed out through the nose and this may reduce the “transient tachypnea of the newborn”, however evidence to support this is lacking.  Early “skin to skin” contact has been proven to reduce infant crying and improve bonding and breastfeeding.  Every effort should be made to try and improve this for both mother and baby.

At Alana…

At Alana, the anaesthetic and obstetric team collaborate and encourage any positive change that may improve mother’s and baby’s outcome.  Moving in the right direction, we educate you and your partner regarding the birth of your baby.  We prepare couples for a caesarean delivery by discussing the procedure in detail and recommendations to attend antenatal classes, watch a caesarean delivery DVD, and visit the operating theatre, or take a hospital tour.  This will help you feel more in control of your delivery, as the surroundings are familiar and everything is less foreign.  We also encourage couples to make a music play list so you can listen to your own music in theatre if you would like to.

In theatre, we are mindful that this is your big day and respect your privacy.  We will try and keep conversation appropriate and do our best to make you and your partner feel comfortable.  If possible we will try to create an ambience, for example keep theatre lights appropriate but to a minimum.

The Prince of Wales Private Hospital makes a real effort in trying to keep baby together with mum after the delivery, therefore recovering you on the maternity ward, rather than in the recovery ward within the operating complex where mother and baby may not always stay together depending on staffing.  These are all changes in the right direction.

Further reading

1.“Natural Caesarean”- a woman centred technique by Smith et al, published in the BJOG in 2008, describe adjustments to a traditional caesarean that are more women and baby friendly and the article

2.“Australian women’s perception of their preparation for and actual experience of a recent scheduled caesarean birth” by Lewis et al published in Midwifery in March 2014

3. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ, “Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss”. Pediatrics. 2003 Sep;112(3 Pt 1):607-19

4. Anderson G, Moore E, Hepworth J, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2003;(2)

5. DiMatteo MR, Morton SC, Lepper HS, Damush TM, Carney MF, Pearson M, et al. Cesarean childbirth and psychosocial outcomes: a meta-analysis. Health Psychol. 1996;15:303–14

6. Rowe-Murray HJ, Fisher JR. Baby friendly hospital practices: cesarean section is a persistent barrier to early initiation of breastfeeding. Birth. 2002;29:124–31.