A more friendly kind of c-section…

First off, let me say that the caesarean section (CS), as a piece of technology, impresses me.  Greatly.  It has saved countless moms and babies from death and significant disability.  Without the CS, my husband wouldn’t have been born alive and his mom would most certainly have died (placenta previa).  It doesn’t take long to realize the significance of the CS when you look at the dismal mortality and morbidity (disability/ harm) stats from countries where they are not readily available…oh, like Afghanistan for example.

However, only a minority of pregnant women want to end up in the OR.  I don’t think its too much of a stretch to say that women who go into labour spontaneously or are induced tend to picture a vaginal birth outcome.  Women that end up in the OR for a planned CS for some kind of complication like a placenta previa or breech or transverse presentation sometimes started their pregnancies envisioning a vaginal birth outcome too.  Sometimes when I’m looking after women in the OR their disappointment and anxiety is almost palpable.  And it hurts.  I understand how it can hurt.  And trust me, I don’t want it to hurt.  I want the birth of their child to be a wonderful, memorable event…even if it doesn’t occur just the way they originally pictured it.

So what can we do in the OR to make a caesarean section a better experience for women?  There is a move towards what is being called the “natural c-section.”

Essentially, simple and easy modifications can be used to decrease the disruption of technology into the birth experience…

put the IV and all the monitors on the non-dominant arm so that after the baby is born she can have one arm absolutely free to touch, hold her baby etc

place the EKG monitoring stickers on the woman’s back so they are out of the way

some OBs are happy to drop the drape but given that surgical wound infection is a very troublesome complication of a CS, others prefer to maintain sterility by using a clear upper drape so that the parents can watch the birth without mom being exposed to a higher risk of infection

have an individual in the room to facilitate skin to skin and breastfeeding with mom if desired (I can’t do this as my responsibility is looking after the anesthetic and the mother however I can facilitate it by making sure that I promptly treat and side effects of the anesthetic like low blood pressure or nausea or shivering so that the woman feels well).  This means that the top portion of the drape needs to be placed somewhat lower than has been traditional (many OBs place the top of the drape just under the breasts).

Ensure support for the mother (where I practice the midwives have hospital privileges and they remain with their clients throughout a c-section, even after a homebirth transfer, I am also happy to invite doulas into the OR as well as the woman’s partner or primary support person but unfortunately that isn’t the norm yet)

delay the infant exam until a time acceptable for the parents for infants that obviously have great apgars.  Some parents want their baby to be weighed and checked out in the OR, some prefer to wait until later.

Arrange the OR so that the baby isolette is visible to the mother.  Seriously, that baby should not be out of her sight even for a moment.  And even if the child comes out in poor condition, there is reasonable evidence that witnessing resuscitation efforts is comforting to parents.

Family recovery –

Easy peasy right?  Other suggestions?  I haven’t discussed things that are in the domain of the OB like delayed cord clamping, slow extraction to mimic vaginal squeeze etc as I’m trying to focus on things that I can facilitate as an anesthesiologist.

Have you had a CS or a “natural c-section?”  What did you find most comforting or reassuring during your experience?  What do you wish hadn’t happened or had been done differently?

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20 comments

  1. Excellent post. I’m curious as to what you think are the biggest obstacles to these types of changes? For instance is it more that many OBs/hospitals/administrators do not really give much thought to or place much value on the benefits or a family’s desires? Or more likely a tendency to continue established routines and policies even when they lack a safety or medical justification because it’s often simpler or more familiar to providers?

    1. Great question…personally I think it comes down to habit and established procedure. One of the ways that we have tried to decrease medical error in the hospital is to protocolize everything. Change during a CS would require education of all staff (still after 4 months can’t seem to convince the nurses that I really do want the BP cuff on the same side as the IV….sigh) and practice with the new system. For things like the newborn exam, well, there are protocols and paperwork and a policy that that stuff has to be completed prior to leaving the OR. Well, you can imagine all the changes that would be required in procedures, paperwork and workflow to support a “natural c-section.” Change is slow but it will come. It will require some strong leadership and persistance tho.

  2. Great post – Lacy, I wonder if it’s because when a planned vaginal birth turns into a cesarean, often there isn’t time or there just hasn’t been a if cesarean plan, although it sounds like many of these things could be standard procedure.

    I had a great cesarean in September – while it didn’t incorporate everything in the video, many of the features were included. It was nice that my husband was allowed to videotape my son’s entrance into the world and the atmosphere was very relaxed and happy.

  3. I love the idea of being able to watch the baby get weighed ect. I was always impatient to see the baby and frustrated that I had to wait while my husband could watch the whole thing.

  4. Alison Wines · · Reply

    Great ideas here. I had an emergency (though not unexpected) c-section and my anaesthetist convinced me to let him hold up a mirror so I could see my daughter coming out. The idea made me feel weird but when I saw it happen I felt like it really was the miracle of birth – no matter which way it happened.
    My regret was only getting to hold her for a microsecond before she was whisked away and they sewed me up and sent me to recovery for an hour. All I wanted was to hold my baby.

    1. A mirror is a great idea! Thanks for the tip.

  5. I had what you would call a natural elective C-section and i was impressed by how much effort was made into making me and my husband feel at ease it. I found it helped that from the start the nurses and doctors were joking with us, trying to get us to relax and told us what they were doing. They pulled the drape down when pulling my son out while he was sitting in my tummy and it was a bit strange but i loved being able to see him. I found they were very quick with the newborn testing and i had him in my arms or my husband did as they were stitching me up. I got to hold him the whole time and everyone in the surgery room was still talking to us about baby names, baby weight etc etc. It made a huge difference to me as i was not sure what to expect and had been told about all the horrible C-sections but my experience was hugely positive.

    my inside my tummy but it

  6. I remember being told, when we went on our maternity ward tour at St. Paul’s, that if our baby was delivered by c-section, I would be in recovery for an hour and not able to see/hold the baby during that time. I forget what the rationale was, but it was something along the lines of them not being equipped to handle potential newborn complications in the recovery room (perhaps you can shed some light on this?). It struck me as strangely old-fashioned, given that the rest of their birthing policies and procedures in that hospital are quite progressive and mom/baby-centred. I would think that more than anything, a mom and baby who have just undergone an emergent or emergency c-section would benefit greatly from being able to have immediate access to one another, assuming no complications. An unintended c-section can be a very disappointing turn of events for a woman, but I think that having the rest of the birth experience unfold as planned can go a long way towards helping her come to terms with it.

    1. Its funny how different hospitals have different policies about this…I’ve working in places where mom and baby are separated in the recovery area, where they are together in the recovery area and even in places where mom is wheeled from the OR back to the birthing suit to be recovered in her private room by a LDR nurse. I personally much prefer the third option if there have been no complications but it meas that the LDR nurses have to have some extra training and there has to be an anesthesiologist available if an emergency happens…and that means you have to have a dedicated obstetrical anesthesiologist because the in-house anesthesiologist may not be able to leave the OR to run to LDR if there is a recovery complication…its much easier to step across the hall to the recovery room.

      As for not being able to handle a newborn in the recovery room…I think we can do better than that. The odds of a baby starting to do poorly in the recovery area when it’s already been cleared by peds seem pretty low to me.

      1. supermouse · · Reply

        I am not a health care provider in any way, and I may be misunderstanding, but I thought that sometimes babies were kept separate from mothers for an hour or so after Csection because the mother might not be able to hold the baby (If she is coming off of GA, or if she is dopey on morphine).

        Fwiw, I didn’t have a Csection, but I did have 36wk twins. They were immediately seen to by the pediatric people, and they were fine (no NICU) and my husband stayed with them while they were weighed, etc. I only needed a few stitches, but I was shaking uncontrollably and was exhausted, but I think it was maybe 2hrs before I held the babies and saw my husband again. This didn’t bother me because I wasn’t in any state of mind to be handling a newborn immediately after the birth. (Also, my memory of my childrens’ birth four years ago is unreliable wrt to timeline, so it may have been only 1/2hr before I held them, but I do think it was longer. )

        1. For moms who are coming out of GA that totally makes sense and I wouldn’t suggest otherwise…but moms who have had a CS under spinal anesthesia are generally perfectly lucid and able to hold their children. Exceptions occur if there is a significant problem with side effects like nausea or even itching. The vast majority of mothers are perfectly capable of self-assessing their abilities in the recovery area. If their partner is allowed to stay with them and the baby then allowing the baby to be present does not appreciably create more work for nursing staff.

  7. veritasmater · · Reply

    I didn’t make any requests for my cesarean, it was an emergency pre-labor cesarean for absent fetal movement/fetal distress. They had the OR set up so I could see the warming table they brought the baby to, and a nurse even asked my husband to move when he was in my way. As soon as baby was stable he was brought to me, but I wasn’t comfortable holding him while lying flat, so my husband held him near me. Then we went back to the LDR room for recovery and did skin-to-skin there. He was never out of my sight once he was born.

  8. Staceyjw · · Reply

    While I appreciate these changes, I want to make a note of one thing thats been happening that’s NOT so positive:
    Forced rooming in, forced immediate constant contact and BF with baby, with little to NO help at all. sure, its suppose to be “choice”, but just know that once these things get popular, theres often no choice in it any longer.

    It may sound so mean when we are all on the Internet, healthy and clear headed, but sometimes Mom just needs to be left alone to recover. I am always hearing how CS is is “major surgery”, but then they same people push for rules and procedures that ignore this fact. You will have your baby forever, but you can only heal up properly once.

    I know that after my CS (after a ridiculous long labor), I was in no shape to be with my son. None. I got to touch him in the OR while my DH held him, it was beautiful. However, directly after this, they put him on right me in recovery. I couldn’t even keep my eyes open, let alone hold him, or bother to try to BF, or anything. Thankfully, they were able to take him to the nursery, but many places no longer have one, in their efforts to appease the BF patrol/NCBers. (aka “baby friendly”- nothing friendly about it).

    A few hours later, I had sent my DH home, after he went 56+ hours without sleep. Still barely able to keep my eyes open, and totally immobile, I thought I would sleep some more. Nope! I looked up to my son being rolled in. No night nursery! So what if I had a so called major surgery a few hours earlier, I better be up to caring for this tiny, helpless infant, all alone to boot. Wonderful.

    They left him with a mother incapable of doing anything at all, me. That’s wise. The night nurse finally felt bad for all the screaming, and took him on her rounds, against the rules. However, is was not a great solution- what if she had others who needed her? I hate to say I was relieved when they took him to the NICU: you know how awful it feels to say such a thing? You know how hurt and helpless you have to feel in order to want your sweet new baby far away from you?

    I know this isn’t within your job duties, but I wanted to mention it anyway. I am not the only one who has had this experience either. I want a Cs to be more comfortable, but I don’t want the pendulum to swing so far to the other side where Mom is totally disregarded in order to follow some philosophy.

    1. My take on this, and it isn’t popular because it costs money (*gasp*) is that after birth, both mom and baby are admitted patients in the hospital. As such, it is the hospital’s duty to care for them. If they do not merit hospital care, then they should be discharged.

      So hospitals have to figure out this “baby friendly initiative” stuff with this in mind. If they refuse to maintain a night nursery and a new mother could refuse to look after her infant on the grounds that she is too ill after a difficult or long or traumatic delivery…and then the hospital is going to have to step up or discharge the infant. Those are the only two choices.

      I am aware that in the third world family members often have to do everything other than the actual doctoring for their hospitalized family members (feeding them, bathing them, dressing them etc) but in the first world…come on. Refusing to care for the needs of an admitted patient strikes me as simply ridiculous and could invite some liability.

      Thankfully I didn’t deliver in a baby-friendly hospital and there was a nursey available if I wanted one. I think that especially when it comes to the second or subsequant births its not realistic to expect a woman to have a partner able to stay over night…there are kids at home that need looking after too and hospitals absolutely should not (again, my strongly held personal opinion) get rid of the night nursery.

      The things I mention in the post should be “optional.” Available if the mother is interested, not a substitute for adequate care and with alternatives available. They are also better suited for elective c/s than unplanned or emergency ones…simply because elective c/s women are more rested and generally less stressed and typically have an easier and faster recovery (so can do more) than women after a trial of labour.

  9. Can you have a natural C-section if you have a complete placenta previa? My understanding is that the OB will have to cut through the placenta to deliver the baby. I am guessing they will want to do that quickly? When I visited the hospital, I asked the nurse if baby could stay with me while I get stitched back up and she said no because the OR is too cold. That made me very disappointed. At least they said I can go back to my own room after to recover with the baby.
    Anyway, the c-section should be in about 3 weeks and I am very nervous about it.

    1. Hi Jenna,

      The “natural” c-section certainly works best for elective, uncomlicated procedures. If you have a complete placenta previa you are going to have to be a little flexible. You are absolutely right that they are going to want to deliver the infant quickly. The clamp-down action of the uterus serves to choke off the spiral arteries that lead to the placenta after its removal. The lower segement of the uterus is not as good at clamping down as it is more fibrous and less muscular. This places you at risk for more blood loss. Not only are they going to want to get the baby out quickly, but everyone is going to have a semi-tense moment waiting to see what kind of bleeding they are about to get. Most of the time this part is non-eventful, but it still warrants the full attention of your OB and Anesthesiologist.

      That means that during those first moments after birth, your meeting with your little one can often take a back seat. And much like what they tell you in the airplane about the oxygen masks (ie put on yours first, then help your child), if you bleed a little bit more than normal after birth it’s important to get that sorted out first…because otherwise you won’t be in good shape for that meeting.

      However, I believe there is no right or wrong way to meet your baby and the meeting has the potential to be magical and wonderful even it it’s not the way you’ve been imagining it. You’ll bond, you’ll breastfeed if you want to and no one can tell you otherwise, okay? The hour or two in the OR is only going to be a blip in your overall parenting journey.

      That said, talk to your surgeon about having baby with you in the OR…and the anesthesiologist…and the OR nurses on the day of the procedure. Maybe the nurse you met before is mistaken. Maybe someone will make an exception for you. Maybe it was a misunderstanding.

      I also think it would be worthwhile thinking about what would make you more comfortable during the procedure. Many women bring in some music to listen to (I allow ipods and things like that – check with your anesthesiologist) and most ORs have a music player where we can plug your selection in to. A picture to focus on is often a great thing. I’ve seen sonogram photos which are really sweet, pictures of older children, wedding photos, whatever makes you happy. If the baby absolutely has to be separated from you during the stitching part, then get your support person to take about 20 pictures with an iphone or camera or other device so that you can look at them while you are waiting. It helps to pass the time and you get a head start figuring out if your baby has uncle Ernie’s ears or not.

      I personally find it useful to think through and visualize different scenarios. I do this for tricky cases all the time (visualizing plan A, B, C, D etc). You could, for example, visualize meeting your baby briefly in the OR and then seeing them again later in your recovery room and fill these imaginings with positive feelings…ie so happy so see the baby come out okay (cos sometimes with previa when they want to do the c/s a little early you can have concerns about that, right?) so happy to be reunited again, and some pragmitism (see, it is okay that I wasn’t the first and only person to hold her or him for their first hours of life). If you shift your expectations before the event, you may have a more positive experience.

      Anyway, that was sort of long winded. I wish you all the best and if you want, please come back and let me know how it went.

      TAM

  10. […] This is a conventional c-section, not the “natural” c-section I blogged about here. […]

  11. Thank you for this and for all of your replies to the above questions. During my pregnancy, I always told people that I wanted to watch my cesarean if it came to it. They thought I was bananas. Your blog is truly teaching me and I thank you so much for sharing your side of the field. ❤

  12. Emily · · Reply

    I had a c-section with my first child because she was breech (she was also 7 weeks early due to PPROM). They wisked her off without me even seeing her (my husband went along to the NICU) and while I was disappointed all I really wanted was for her to be okay.
    Two and a half years later I had a planned c-section for my second baby. It was a wonderful experience. Everything they did once she was born was within my sight. The have everything placed – the scale, etc. – so that I didn’t have to miss a moment and I got to hold her pretty much right away. One of the nurses took our camera and took lots of pictures so that my husband and I could both be in the pictures of me holding her for the first time.
    When I was taken to recovery they wheeled her down right next to me. I was nervous about nursing because it had not gone well with my first child. I had mentioned this in my phone interview (yes, our hospital actually talks to each mom personally beforehand if you are planning to give birth there to talk about needs and wants) and so they made sure to have lactation consultant there to help me start nursing in recovery.
    When I was cleared to go to my room they had one of the nursery nurses come down and ask if I wanted to have her first bath be in my room. That’s right – they went to the extra effort to bring in a tub and all the stuff so that I could watch and even reach over and touch her while she was getting a bath – and my husband could help too.
    Also, I just wanted to say that one of the things I really appreciated was that they allow new moms to order their meals off of a menu whenever they like AND they provide a meal for a partner as well! First of all it was just great to be able to choose what I wanted to eat by what sounded good and to choose when I got to eat it! When my baby needed to nurse or if I just wanted to hold her through the lunch hour I didn’t have to worry about missing a meal.
    This was also amazing because I was not allowed to hold the baby in the room by myself until I got off of the narcotics. I would end up having to send my baby to the nursery so my husband could go and get food for himself. They delivered both of our meals to my room within 10-20 minutes.

  13. I’ve had 3 c-sections. One emergency, one not urgent and one premeditated, in that order.
    My first one was ten years ago. I went to hospital at 2 in the afternoon at the week 40+2, because my water broke. I didn’t have any contractions and was given oxitocin IV. After couple of hours the labour was in full swing and by ten at night I asked for my first epidural. Funny sidenote: it was teaching hospital and the first one trying to put my epi was resident anesthesiologist. She tried and tried and coudln’t do it. She asked for help and soon in came an older man talking to a phone. He shook my hand, my husband’s hand, asked for a needle, stuck the epi in and walked out still talking to that phone. When I finally got to the OR, the surgeon asked me who put the epi in, because it was so well placed. I said I don’t know, I just saw a man talking to a phone. He laughed and said he should have guessed, it was Andrei and he always talks to his phone, but is still the best anesthesiologist there is. The labour went on and it wasn’t progressing. I had dilated 4 cm by morning and was given another epi. I got some sleep, my friend came to see me and everything seemed fine. The contractions were disappearing again, so I was given my second dose of oxitocin. By three in the afternoon, I was still dilated only 4 cm and my OB told me it might be better to do a c-section. I refused. I wanted to give birth to my baby vaginally. At five in the afternoon the baby’s heart rate crashed. I was rushed to the OR and prepared and so my son was born. After they showed him to me, they took him away for measurments and to wait for me with his dad at the labour room. I was stiched and wheeled to Recovery Room. I was in recovery for 4 hours, because I couldn’t stop shaking. After recovery, we were all taken to newborn unit, where we were staying. My son was and is healthy, can’t remember the measurments, but was given 10 apgar points. We stayed at the hospital for 5 days, as was a custom for a first time mom with cesarian.

    My second wasn’t an emergency, but wasn’t premeditated either. It happened little over a year after the first birth. I still had a dream of a vaginal birth and my OB said it was possible, maybe. Again the birth started with my water breaking at the week 39+5. It was three in the morning. I wasn’t given anything to eat at the previous time, so I woke up my hubby and told him to get me to McDonalds. I put my son’s diaper to my pants and hoped it would hold. It didn’t. So here I was, in the middle of Mickey D’s, with amniotic fluid running down my legs, ordering Big Mac in the middle of the night. Not one of my proudest moments. 😀 We were at the hospital by four and by then the cotractions had begun. I got to the labour room and was 2 cm dilated. The contractions were fading again and I got oxitocin IV. By morning I had dilated to 4 cm and got an epidural. By noon I was still at 4 cm. By four in the afternoon I was still at the 4 cm. My OB asked then if I was willing to give up and get a c-section. I was more than happy. The contractions were much stronger this second time and still I wasn’t dilating. I was prepped, wheeled to the OR with my hubby and operated and so my first daughter was born. She was a little smaller than her brother and got only 9 apgars, but still a very healthy baby. After the measuring, she and her father were escorted to the labour room to wait for me and then all of us went to the unit, where I was staying with my baby. She was a little yellow, so we had to stay in the hospital for 4 days. We would have been able to get home earlier if not for her yellowness.

    My third was premeditated and happened 5 months ago. It’s recommended here in Finland to have a premeditated c-section after two previous cesarians. This time I got to choose my birthing hospital and after hearing that one of them was baby friendly, that’s what I chose. My husband and I arrived to the hospital at the week 39+2 at 8 in the morning. We were guided to a room where I would be staying with the baby and were asked to change our clothes. After that I got some medication, the IV was set up and the waiting began. At 9.30 I was wheeled to the OR by my midwife, where all the staff introduced themselves and the operation began. The monitor pads were on my back, the IVs all in the left hand, so I could hold my baby after the birth. My hubby hold my hand through the operation. He could have looked and I was given a choice to have a monitor by my head so that I could look what they were doing. I didn’t want to. Soon my second daughter was born. She was given to me to hold for a minute and then they took her to take the measurements. It was nice that the midwife, who took the measurement talked to us through the measuring telling us how much she weighted and her hight. Not that I would have remembered them coming out of the OR, but it gave me a sense, that the baby is all right. When I was taken to recovery, the baby came with me and I got to try to breast feed her there. It was much nicer to have the baby with me. I talked to the nurse and she said that recovery times have dropped since the policy started. After the recovery, we were wheeled to our room. This time I stayed for 3 days.

    The best experience was the last. I didn’t feel so left out than in the previous surgeries.

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