International Cesarean Awareness Network

When Surgery Becomes Necessary: Planning a Family-Centered Cesarean

The International Cesarean Awareness Network, Inc. (ICAN) opposes the use of cesarean surgery where there is no medical need. Vaginal birth is a normal, physiological process, and cesarean is major abdominal surgery. Cesarean exposes the mother to all the risks of major surgery, including a higher maternal mortality rate, infection, hemorrhage, complications of anesthesia, damage to internal organs, scar tissue, increase incidence of secondary infertility, longer recovery periods, increase in clinical postpartum depression, and complications in maternal-infant bonding and breastfeeding as well as risks to the infant of respiratory distress, prematurity and injuries from the surgery. It has been suggested that cesarean section is the safer method of birth for infants. However, scientific evidence proves that infant outcome does not improve once the cesarean rate climbs above 10 percent. All physicians take an oath to "Do no harm." This means choosing the path of least risk to patients. Medically unnecessary elective cesareans increase risk to birthing women. It is unethical and inappropriate for obstetricians to perform unnecessary surgery on a healthy woman with a normal pregnancy.

 

Common methods to avoid cesareans include choosing a caregiver expert in natural birth with low cesarean rates (below 15 percent is recommended), and preparing to birth naturally without induction or anesthesia medication. Medications tend to disrupt the normal process of labor and birth, and can negatively affect the mother and the baby, inviting other interventions including a cesarean. ICAN supports women’s rights to accurate, complete, evidence-based medical information; women’s right to the best and safest medical care in childbirth in situations where medical care is actually needed in childbirth. ICAN will continue to work to protect women’s rights to ethical and appropriate care in childbirth.

 

Planning a Family-Centered Cesarean

By: Michelle Smilowitz, CD(DONA)

The birth of a child is one of the most significant events in the lives of families. It is considered a rite of passage by many women, and involves the first interaction between parents and their baby. There is much buzz today about the necessity of making birth a "family-centered" experience, where the focus is often on creating a special environment for bonding between parents and child in the first moments and days of life. But what if you are one of the one in three women who experiences your baby’s birth as a cesarean section? Is it possible to make your surgical experience into a family-centered birth?

 

The answer is a resounding yes. While planning a family-centered cesarean is easiest for the woman who must, for whatever reason, schedule her baby’s birth, there are a number of ways that a woman who encounters an unplanned or even emergent cesarean surgery can make her experience into a celebration of her baby’s birth.

 

Become Familiar with the Procedure

It is first important that every pregnant woman and her partner become aware of the procedures that surround a cesarean surgery. Many women who experience unplanned cesarean deliveries lament that, "I skipped the section of the book on cesareans, I assumed it couldn’t happen to me!" Having some familiarity with the procedure and all that it involves can help reduce much of the surprise and fear that can surround the unknown. (For an excellent explanation of cesarean section go to http://www.ican-online.org/resources/white_papers/wp_cssurgery.htm)

 

If your cesarean is planned, it is important that you have the opportunity to fully discuss with your care provider the reasons for your surgery. Knowing that this surgery is the best choice for your or your baby can create a less tense environment for the delivery. If you desire a vaginal birth and feel that a cesarean surgery may be unwarranted for you, consider getting a second medical opinion that all medical consumers are entitled to.

 

Write a Birth Plan

Next, plan this birth just as you would a vaginal birth. Write up a birth plan including your preferences for the surgery as well as for yours and the baby’s postpartum care (See second article attached below, written by Connie Banack). In the case of a pre-planned cesarean, it is usually possible to schedule an appointment ahead of time with your anesthesiologist. He/she is the person who actually controls the environment of the operating room. For example, generally, women’s arms are strapped down for their surgeries, so that they do not dislodge IV wires or sully the sterile surgical field. Ask if you can have at least one of your arms free – or have your support people hold your arms in place.

 

Discuss the pros and cons of both epidural and spinal anesthesia as well as the effects of various other medications you may receive both during and after the surgery. Some of the medications that treat specific symptoms such as trembling and nausea may cause extreme drowsiness or amnesia. You may decide that you would rather tolerate these symptoms than be asleep for the first few hours of your baby’s life.

 

When you write your birth plan and discuss it with your care providers, there are a number of things you may want to consider. Many women negotiate to have two support people with them in the operating room, generally their partner and a doula or friend and family member. Doulas are a great addition to a cesarean birth team. They are familiar with the process and can reassure you and your partner. Additionally, if you and your baby need to be separated at any point, your partner can accompany the baby while your doula stays with you. Doulas also often have some expertise in post-cesarean breastfeeding and can help with this.

 

Many women ask for (and are given) the right to play music of their choosing for the birth – this can soothe you and serve as a pleasant way to welcome your baby into the world. Feel free to ask those at your birth to refrain from extraneous conversation, and request that if possible someone (generally a member of the medical team) narrate for you exactly what is going on throughout the birth. Ask if you can take photographs or videotape the birth – many women enjoy the opportunity to “see" the birth later on. Sometimes black-and-white pictures are preferable for this – they preserve the drama of the birth while eliminating a direct view of blood.

 

Many women feel a disconnection from their cesarean baby because they did not actually see or feel the baby born. If you are interested in actually seeing your baby as it emerges from your body, you can ask to view this by having the drape across your abdomen (that blocks your view) lifted for the actual delivery or by using a mirror.

 

Before the cesarean, ask that the medical personnel not announce the sex of your baby, instead allowing you or your partner to discover this. Request that all necessary newborn exams be done in your line of vision (or even on your chest), and to make physical or verbal contact with your baby as soon as possible. Your baby has been accustomed to hearing yours and your partner’s voice for the past nine months – even if you cannot touch your baby, you or your partner can soothe your baby with your voice. With the help of an excellent nurse or doula, some women are able to nurse on the operating table, while others wait until the recovery room. Regardless, ask to touch your baby as soon as possible, and to keep the baby with you in recovery if all is well.

 

Get Help after the Cesarean

During the immediate postpartum period you are going to need a lot of help! After a cesarean surgery, women are often confined to bed for as much as a day or two. Once you have been given permission to get up, even such simple movements as rolling over in bed can be quite painful. Clearly, trying to take care of yourself as well as a new baby is generally too much. Having a partner, friend or relative stay with you in the hospital can help ensure that your baby will room in with you. This person can help with changing diapers, bringing the baby to you to nurse (and positioning the baby at the breast), as well as assisting you with your needs.

 

Once you are home, extra help will enable you to have a more rapid recovery, as well as giving you the opportunity to nurture yourself and bond with your new baby. Many women find that they need extra help with breastfeeding after a cesarean, and there are a number of resources for this.

 

Not all of these suggestions will work for every situation, and of course, in the case of the emergencies that can occur during surgery, plans may need to be changed or abandoned. Nonetheless, using some (or all) of these suggestions can help your surgery feel more like your baby’s birth!

 

Michelle Smilowitz is the former leader of ICAN of Seattle, founding editor of “Birth Journeys", and a certified doula. She currently lives in Beit Shemesh, Israel, with her husband and three children. Her oldest was born via unplanned cesarean surgery and her second two children were born vaginally at home. Michelle can be contacted at msmilo2@msn.com.

 

Article originally published in “Birth Journeys" a newsletter of ICAN of Seattle, Summer 2004.

 

Family-Centered Cesarean Birth Plan

By: Connie Banack, CCCE CPD CLD

 

Family-centered birth is used to describe a birth that is more family oriented, allowing the new family to experience their birth more fully. Many believe that this cannot apply to a surgical procedure. This is not true. Even with a cesarean surgery you can have a family-centered birth, if you know your options and choose to apply them. Some of the options will be the same as for a vaginal birth. You may have to work harder to have a family-centered birth in the event of surgery, but planning ahead (even if you don’t foresee a cesarean) can go a long way. Make a birth plan! They won’t know what is important to you unless you let them know and a birth plan is actually a legal contract as it is providing your wishes in a document provided to your birth team.

 

Very few women would choose a cesarean for their birth experience; however, about 25% of the women in North America will have a cesarean. Therefore, it is important that every pregnant woman is aware of the procedures that surround a cesarean section. This will give those who do birth by this process more choices, and hopefully, less fear. If you are not familiar with how a cesarean section is done, please learn more about the procedures (and there are many) involved. Silent Knife by Wainer-Cohen & Estner and ICAN’s white paper at www.icanonline.org/resources/wp_cssurgery.htm both give excellent explanations of what happens when a cesarean is preformed.

 

A Word About Doulas

The continuous support of a doula has been found in numerous scientific trials to positively affect obstetric outcomes and the women’s satisfaction with their birth experiences. Many women and couples choose to have a doula because they want and need this extra assistance. During labor, an intense bond develops between the doula and the couple, and if a cesarean becomes necessary, it is very distressing for the woman to have to choose only one person to be with her. Mothers will hire doulas even during a scheduled cesarean birth to provide the consistent professional support a doula provides. Check with your doctor to see if your doula is allowed into the operating room and recovery to support you.

 

Benefits of a doula during a cesarean*:

 

• Doulas are familiar with cesareans and do not find them upsetting.
• The doula’s familiar presence can calm and reassure the mother who is likely to be very frightened and worried.
• The doula can reassure the partner, who is also likely to be worried and frightened.
• The doula can explain what is happening.
• Once the baby is born, the partner usually goes to see the baby, leaving the mother’s side. The doula remains with the mother, tells her what the baby is doing, and helping the mother feel less alone.
• The doula goes to recovery with the mother. If the partner has gone to the nursery with the baby, the mother still has a support person with her.
• The doula does not get in the way or behave inappropriately.

*Doulas at Cesarean Birth by Penny Simkin; SOAP, Summer 2001

 

Birth Plan Preparation

In preparing a birth plan, each point needs to be discussed with your caregiver, even if s/he may not be at your birth. They will be able to tell you if what you would like is an option with this caregiver or at the hospital you have chosen. Start early and discuss a few points each prenatal visit rather than trying to cover every point in one or two visits. This will help you in providing more time for questions about each point and reduce confusion for both you and your caregiver.

Communication is vital in learning about philosophy, options and rapport. A good way to communicate with your caregiver in putting together a birth plan that will be read and followed is through the “Who’s the Boss?" Method.

1. Acknowledge provider’s expertise
2. Add personal information
3. Listen and consider
4. Summarize
5. Respond in appreciative and authoritative mode

Example:
You: One of my friends was telling me about avoiding post-operative pain medications just after her baby was born which made her fall asleep, and I wanted to get your professional opinion on the subject.
Dr.: Routinely, a pain medication is given to you after the baby is born to help you relax during the long suturing process which can take up to an hour. It can make you sleepy or even relax you enough to put you to sleep. You can then wake up refreshed when you meet your new baby.
You: Is it possible to ask not to have this given?
Dr.: Absolutely.
You: OK. Thank you for discussing that with me. Now I understand, and I’ll think about what you said before I decide.

 

When writing your plan, start by introducing yourself through a prologue. This provides a familiar base on which to build a rapport with your nurses and attending caregiver. This is followed by your wishes, which have been discussed with your doctor prior to your birth. Point form is the most efficient way to list these, as you don’t want your birth team to become mired in your plan looking for a lost point. Wording is crucial in a birth plan. It can make all the difference between a supportive or hostile atmosphere during your birth. Yet it is also a legal document. Gretchen Humphries emphasizes, “The language ‘I do not consent’ may sound harsh but in fact, is the only statement that has clear legal power so I encourage you to use it for things that you feel strongly about. If someone does something to you after you state that you do not consent to it, legally they have committed assault and battery on you. Hospitals are well aware of this, but they assume you are not."

 

Make your birth plan short, preferably one page long. Include only those points most important to you. Providing two plans, one for birth and one for your new baby is an excellent way to ensure that both you and your baby are cared for as you wish. The birth plan stays with you and the newborn plan goes with your baby if s/he not able to stay with you. Have several copies with you and give it to everyone involved in your cesarean. And finally, after you have finished discussing the points with your caregiver, consider having him/her sign it. This helps ensure that it will be read and followed during your birth.

 

Prologue

Most nurses and doctors appreciate a “prologue" to a birth plan. A prologue introduces you to your birth team and can give insight into the choices you have made in the plan itself. For instance, parents who have had a former general anesthesia cesarean experience could include this in the birth plan as an explanation as to why they are choosing an epidural for this birth.

 

Example:
We understand that there are times when a cesarean delivery is in the best interests of the mother and infant. We also understand that cesarean delivery, as a surgical procedure, is common and even routine in most maternity centers. However, we would ask that the staff respect that this individual surgery is a unique and never to be repeated event in the life of our family. For us, it is neither common nor routine, but rather is an event that will have effects lasting a lifetime. We have already experienced the cesarean delivery of our sons and because of that, have certain requests and requirements to be taken into account.

Pre-operative Preparation

If an elective cesarean is necessary, then you should request that you be able to begin labor naturally before the cesarean is done. That is, you do not want a date and time preset, you wish for your baby to decide the day on which it is ready to be born to avoid any problems with prematurity and for both of you to reap the benefits of your hormones. It is also important for your benefit in both recovery and in establishing your breast milk. Labor signals your body to start producing breast milk about 2-3 days after your baby is born and this is thwarted when baby is removed surgically without labor, often prolonging the production of milk by several days.

 

If a scheduled cesarean must be performed, then you should request preoperative blood work and tests to be done on an outpatient basis, and hospital admission on the day of the birth (not the night before).

 

There are several preparation procedures that are done before you enter the operating room such as establishing an IV and giving a bolus of IV fluid, placing the epidural catheter and ensuring adequate anesthesia, inserting a urinary catheter, checking of vitals (blood pressure, heart rate, temperature), and checking fetal heart tones. There is no reason why you cannot have your partner and others there to comfort and support you during any of them.

 

One procedure specifically, inserting the urinary catheter, can be quite uncomfortable and many mothers recommend delaying the insertion until after the epidural or intrathecal is in place.

 

Example:
I do not consent to placement of a urinary catheter until after regional anesthesia is in place, unless it has been discussed with me in advance.

 

Anesthesia

Women have three options for anesthetic during a cesarean section, general anesthesia (mom is unconscious), epidural anesthesia and intrathecal anesthesia (with both of the latter, mom is awake for the delivery). Please research each option both for availability and benefits & risks of each to find which is right for you. What many women do not realize if they are awake is that medications are often given before, during, or just after the baby is born which to relax the mother, but the postoperative medication especially often puts the mother to sleep. You will need to decide if you want this or not and include it in your birth plan if you want to avoid further pain medications during or after the surgery.

 

Example:
I do not consent to any pre, peri, or postoperative medication without prior verbal consent from myself, or my spouse if I am incapacitated. I wish to discuss the complete anesthesia protocol with the anesthesiologist prior to any medication administration. I desire post-operative analgesia to be administered via epidural, before any use of systemic analgesics, sedatives or tranquilizers. I have used this protocol in the past and was pleased with the results.

 

During Surgery

It is the anesthesiologist who makes the decisions in the operating room. It is important that s/he reviews a copy of your birth plan and discusses it with you prior to your birth.

 

Ensure you include in your birth plan who you would like to attend during and after your birth in the operating room. Some anesthesiologists allow only one person with you in OR, others allow two or more. Find out what your options are and prepare accordingly. If only one is allowed, one alternative may be having your partner be with you until the baby checks are completed and then have your doula or another support person come in when your partner leaves with baby, assuming baby is moving to the nursery.

 

Routinely, your hands are strapped down to prevent tangling of the various cords to the medical equipment that is monitoring you and to prevent your arms from falling off the narrow boards they are placed on. You can ask to not have your hands strapped down so as to better receive your baby when s/he is brought to you.

 

Would you, and your partner, like to view the actual birth? Then make sure your Obstetrician realizes this. Explain you would like the option of viewing the birth, either by lowering the screen or by positioning a mirror. Maybe your previous cesarean is still a bit unreal, as you never have actually seen a baby leave your body - they tend to just appear from behind the green screen and be held up for a quick look before they disappear to be wrapped up and tested. Make sure that the operating room staff realizes that you would appreciate a verbal description of the birth as it occurs. You may have previously felt left out of your past cesarean(s) as your body and labor might have been discussed as though you weren’t there.

 

I bet you would love to meet your new baby in his/her unclothed, naked newborn state - a wet, slippery baby? Request that the baby please be placed on your chest with a warm blanket over you both. It would do a lot to make this surgical delivery a bit more natural for mother, father and baby. And it may even resolve a few inner conflicts that are faced after the birth. In addition, ask that no screen be placed in the way as you will be able to see the baby as s/he emerges from your body immediately and even be placed on your chest for the baby checks and to cut the cord.

 

Other options include taking pictures or videotaping the birth, having or even choosing background music to be played during the surgery, and your partner cutting the cord.

 

What about that placenta? Most women who birth vaginally get to see it, at least, and maybe you would like to too. If you would to, make sure operating room staff knows you want to view the placenta. Make sure they realize the importance of this and let them know not to just discard a part of you that you have carried for nine months as insignificant. You may like to take the placenta home, to plant under a tree, or even to eat (it reduces the incidence of postpartum depression) so please tell them to be sure to make suitable arrangements with you to see that this happens.

 

If an emergency cesarean is necessary, under general anesthetic, then you can have your baby given to your partner as soon as possible after birth and held by him (hopefully next to his naked chest - skin to skin contact) until you are awake and can be told of the baby’s sex and well-being (by your partner).

 

As with any surgery, there are risks and sometimes those risks can have drastic consequences. Some obstetricians remove the uterus to solve a problem like hemorrhage. Is this a concern for you? Many times a hysterectomy can be avoided using other treatments. Have you considered the option of tubal ligation during the surgery? Many women have been asked on the operating table this question and have answered hastily only to regret it later. Make the decision before your surgery. Also, with any surgery, administration of blood products may be an option when there is excessive bleeding. Many have fears or religious considerations surrounding the dispensation of blood and blood products. Options may include banking your own blood or refusing blood products and building your own supply back to normal in the days following your birth.

 

Finally, closure of the incision. There are two methods to closing the uterus. Highly recommended is the double suturing method (suturing of both the inner wall and outer layer of the uterus) to further ensure scar integrity for subsequent pregnancies and labors. Closure of the skin layer can be done either with staples or with sutures. If either of these is preferable, note it on your birth plan as well.

 

Example:
I do not consent to having my arms strapped down unless I am physically unable to control them. I am familiar with surgical fields and understand the necessity of maintaining a sterile surgical field.

 

Infant Care

How about breastfeeding your baby straight away, rather than hours later? Let them know that you would like to feed your baby while you are being sutured, if you feel up to it, and you would like your baby to stay with you throughout the surgery and even during the recovery.

 

Your baby should remain with you at all times, no disappearing off to the nursery with your partner. This simple routine can seriously affect your bonding with your child. If your baby must go to the nursery, then DO send your partner and encourage the "skin-to-skin" contact mentioned before. Your baby will be much less stressed when with someone s/her recognizes, as baby will respond to your partner’s voice.

 

Let them know that your partner would be delighted to hold his/her child within your view throughout these procedures, if you feel unable to participate in the bonding (at least you would be able to witness it this time).

 

Newborns are also subjected to various interventions too. Routine health checks using the APGAR assessment, vitamin K injection, eye ointment application, PKU test, weight and height measurements, a bath, and possibly Hepatitis B or other vaccinations. It is highly recommended you research each of these and make an informed decision on allowing, delaying, or not allowing these procedures. You can also ask that the procedures which are done right after baby’s birth be done while in your presence rather than in the nursery.

 

If you are planning to breastfeed your baby, you may want to include in your birth plan that you would like your baby to avoid artificial nipples or supplements (including water, sugar water, or formula). If there is a glucose or nutritional concern, ask that it be discussed with you before an action is taken.

 

Example:
We do not consent to the PKU test until after my milk is in. We believe that this will reduce the likelihood of an inadequate sample, making it less likely a retest will be needed.

 

Special thank you to Gretchen Humphries, Penny Simkin, Nicette Jukelevics, ICAN (International Cesarean Awareness Network) Inc., Birthrites: Healing After Cesarean Inc. founder Jackie Mawson, my three cesarean born sons, and the many clients I have supported through cesarean birth experiences.

 

Connie Banack is a practicing doula as well as a doula & childbirth educator trainer residing in Alberta with her husband and four children. Her volunteer time is devoted to the International Caesarean Awareness Network (ICAN) Inc as International Director and as President of the Canadian Doula Association. Connie specializes in VBAC in her practice and just recently gave birth to her fourth child vaginally after three cesareans. You can contact her at connie@mothercare.ca.

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