Friday, January 29, 2010

C-section Birth Plan: An Oxymoron? (Not even.)


Birth Plans. Normally, they're a collection of things to do or not do in order to give birth the way you prefer, and a major component of that for most women is avoiding a c-section. Same goes for a doula, right? In addition to helping create a birth that is as close to your ideals as possible, moms choosing to birth in hospital settings hire doulas to get their best chance at avoiding a cesarean.

So why would you even want to think about cesareans during your pregnancy, when you're focusing on visualizing your birth as positively as you can? And why would you bother with a birth plan if you know you're having one? Once the plan changes to surgery, whether it's in the heat of labor or in advance, isn't the whole raison d'etre for birth plans and informed choices out the window? Isn't it basically all the same?

Not at all. There are absolutely choices you can still make, choices that can make a huge difference in the experience for both your baby and yourself.
Hypothetical Reader: But I don't have any indication for a scheduled c-section, and no reason to think that I will be more likely to have an emergency arise during labor than any other low-risk mom. I want a natural birth if possible, or at least a low-intervention one. Are you saying I should write a backup cesarean plan? And doesn't thinking about this stuff risk manifesting it?
I remember all too well when I was facing the very real possibility of a cesarean, and a scheduled one at that - the very antithesis of the home birth that I had been planning and yearning for. Over the course of my pregnancy, my placenta moved from complete to partial to marginal, to finally, finally just over 2 centimeters (the minimum required to be in the clear for a vaginal exit) away from the os, at my 34 week ultrasound.

That whole story is a post unto itself, again, but I want to talk today about how I dealt with the possibility. Or rather, how I DIDN'T deal with it. Because I was intensely focused on doing visualization to help my placenta move upwards, I deliberately avoided reading anything at all about cesareans. I'm a pretty voracious reader, especially when it comes to this subject, and I read quite a few pregnancy books. But I confess to you all now, right here in virtual public, that I skipped right over everything that had to to with cesareans. I covered my ears and sang "Mary had a little lamb . . . (at home in her birth pooooool)".

Yes, it's true that I was able to dodge this bullet by the skin of my teeth, but in hindsight, I think this kind of willful denial was really not the best thing to do. Now, I'm not talking about turning it into a fixation that becomes a self-fulfilling prophecy, investing your energy into fear and anxiety. And as I said, I can relate. I understand not wanting to think about it too much. But I have read enough birth stories now where the mothers, in their admirable preparation for a natural or low-intervention birth, wind up heading into surgery for one reason or another, having absolutely no idea what was in store for them.

So to go back to our Hypothetical Reader, on the first question, "Are you saying I should write a formal backup cesarean plan?" No, not quite going this far (unless you have reason to schedule one, in which case, definitely yes; keep reading below), necessarily, but it is worth taking a deep breath, looking over some information on cesareans, and thinking about what your preferences would be if this were to arise. Perhaps write them down based on the examples to follow, if writing works for you. Take a few minutes to talk to your partner, doula, and anyone else on your birth team about these wishes. Confront it calmly, and then put it away. On the second question, "Doesn't thinking about this stuff risk manifesting it?" Again, this isn't about fixating on it and creating a self-fulfilling prophecy, this is acknowledging it and letting it go. Again, confronting it calmly, and then putting it away.

I want to share with you some really eye-opening and helpful information I've culled so far on the matter, most notably from Morgan of Adventures in Diapering and Beyond. (By the way, in case it's not already clear, let's assume for the purpose of this post that we're talking about necessary cesareans, both scheduled and unscheduled. You all know how I feel about unnecessary ones, and there's much to be said on them. But not today. Today we're talking about the ones that really do save lives.) First, Morgan herself gives a great explanation for using a birth plan for a cesarean here. An excerpt:

Why bother with a birth plan if you're having a c-section because you don't really have any say in what happens, right? Wrong. Even when you are expecting a c-section, there are still choices that you can make during and/or after the birth. Knowing what your options are can help you feel more a part of the birth experience rather than just an observer. While researching your choices, you will become better informed on what your doctor and hospital's expectations are and what you can/cannot do in a hospital setting.

Morgan provides a comprehensive collection of posts on c-section information, from questions to ask, what to pack, recovering from surgery, and a good visual guide for what to expect. She even shares a video of one of her own births. If yours needs to be scheduled, I would pore over every single link she provides. For those who aren't planning a cesarean but want to take my advice re: confronting it briefly but thoughtfully, her example of a c-section birth plan is a must. I'm going to quote extensively here, to illustrate just how many choices there really are, but all credit goes to her:
During Surgery:

*Catheter put in AFTER spinal (this is standard procedure at many hospitals)
*Volume down on heart monitor beeping
*Husband will photograph c-section
*One of the staff members from my dr.'s office will video tape Baby's birth
*I'm allergic to (x drug). Please make sure I am not given this drug.
*Warm blankets during surgery
*No sedatives after birth. I want to remember my Baby's first day of life.
*Please reinforce my uterus and use dissolvable stitches for closing me up [Note from Dou-la-la: I would recommend making sure that your doctor uses a double suture, as this increases likelihood of a safe VBAC. There is also evidence supporting sutures over staples - this is important to discuss with your doctor as well.]

Baby:

*Please hold baby up for me to see as soon as Baby's born
*Husband to announce Baby's gender (or maybe not announce gender at all and allow me to see for myself)
*Keep cord long for Hubby to cut
*No Eye Gel, No Hep. B vaccine. I will sign the waiver ahead of time.
*Please bring Baby close to me during measuring & weighing.
*If Baby is doing well medically, please bring Baby to me as soon as she is suctioned, weighed, and measured. Please do not worry about cleaning her up much before bringing her to me.
*I would like to hold Baby while Baby is being foot printed, getting bracelets on, and while the paperwork is being filled out.

Recovery:

*Once back in our room to recover and been checked as stable, we would like to be alone with Baby to nurse.
*We would like to keep Baby with us at all times. If Baby must go to NICU due to medical reasons, my Husband will follow.
*If someone arrives to visit, please check with my husband or I as to whether we are up for company before allowing them in our room.
*Delay Baby's bath until the evening after Baby is born rather than bathing Baby right after birth.
*I am willing to be up and walking as soon as possible so I can get leg compressors off sooner
*I would like my Catheter out early the morning after surgery
*Baby will sleep with me in the hospital bed. While I am sleeping, there will be another adult in the room with Baby and I.
*I will be nursing on demand and whenever Baby is fussy to help stimulate my milk to come in and to soothe Baby.
Excellent, right? I think she has done a wonderful thing in providing all this information. make sure to also check out her post on Things I Wish I Had Known Before My 1st C-Section. It has lots of firsthand information about possible side effects, descriptions of some of the strange sensations and hospital protocols you MUST be aware of if you want to avoid them (like taking baby to the nursery while you recover). Morgan, my hat is off to you.

I also want to address some possibilities that may be outside the realm of most OB's experience, but if you have a really good one, they might very well be willing to try something new. If you poke around in the birth spheres on the internet as much as I do, you may have run across the term "gentle cesarean". Dr. Nick Fisk in the UK has been a proponent of this approach, pointing out that "while couples having normal deliveries have been given more and more opportunities to be fully involved in childbirth, very little has been done to see how we could make the experience more meaningful for those having caesareans."

The scent of lavender fills the air and classical music is playing quietly. On the bed, Jax Martin-Betts, 42, is calm, focused and in control. With the birth of her second child just minutes away, the midwife, Jenny Smith, is giving her a massage. Her husband, Teady McErlean, is whispering words of encouragement: just a tiny bit longer, and our baby will be in our arms!

It could be a natural birth at any maternity unit in Britain, but we are in an operating theatre at Queen Charlotte's and Chelsea hospital in west London, and the birth we are about to witness sounds a contradiction in terms: a "natural" caesarean section.

Jax has been on the theatre table for half an hour, and the obstetrician, Professor Nick Fisk, has almost completed the incisions through her abdominal wall and into her uterus. "OK, the baby is about to be born," he says. "Let's prop you up so you can see him coming out."

Smith removes the blue drape between Jax's head and her belly, and the head of the bed is lifted to give Jax a clear view. Fisk cuts into the amniotic sac and a fountain of fluid rises into the air before he rummages around to locate the baby's head. In a few seconds it comes into view, covered with the milky-white vernix that has protected it in the womb. For the next few moments, the atmosphere in the theatre is electric: Jax and Teady gasp in wonder at their new son, who is now looking around, although his lower body and legs are still inside his mother's uterus.

The "gentle cesarean" tried to make the environment more soothing and slows the pace of the entire process down, making the baby's entrance more gradual and thus, hopefully, more peaceful. It may even help in squeezing the lungs out, the way vaginal birth normally functions, and one of the distinct disadvantages of surgical birth for the newborn's respiratory function. The parents can see the birth if they wish, rather than being walled off by drapes, and the baby is given immediately to the mother, instead of whisking him or her away just because of protocols/habits.

This may or may be your cup of English Breakfast, so the specifics are up to you and your doctor, but if a necessary elective cesarean is required, you could think about incorporating some or all of this into your birth. I encourage you read the whole article - you might want to consider printing it and bringing it in to your doctor to discuss it.

In a similar spirit, Radical Doula featured a story on what was termed an "assisted cesarean", where the mother was able to catch her own baby! Check out this image:


A far cry from the usual image we see of someone holding the baby next to the face of the mom, who is strapped motionless to the table, unable to touch her baby. Radical Doula raises a very important point here, commenting, "But is this just an attempt to make an entirely medicalized process seem more mother-friendly? Luckily both the mother and doctor in this situation don’t want this procedure to encourage c-sections:"

But women should not consider assisted caesareans ahead of vaginal birth. “I still think a vaginal birth is the best way to birth your baby,” Ms Chapman says. “I don’t want women to choose to have a caesarean because of this,” [Dr. Gunnell] says. “We need to be very clear that this is not a good alternative to a vaginal birth; the caesarean section rate is very high . . . "But for those of us who don't necessarily have that opportunity [for a vaginal birth], this is a way of making an intervention experience a better experience.”

The original article also acknowledges that this certainly isn't going to appeal to everyone. Many women would shudder at the thought of seeing their own incision, for one thing. But if you look at the picture above and think this is a pretty amazing thing under the circumstances, why not at least ask your doctor? It's worth a shot. Even if he doesn't go for it, hey, maybe your other preferences won't seem like such a big deal anymore, by comparison. A nice bargaining chip, at the very least.

One final thought from Dr. Michel Odent. He was asked for his thoughts on how to make the best of the situation if a cesarean is inevitable, and he makes a case for allowing labor to begin on its own (hey, one of the Healthy Birth Practices, even if the context is a bit different) even if the end result is known.
Q: We now find ourselves preparing for a cesarean birth. We are wondering what things would be helpful to keep in mind/plan for/request in order to have the gentlest birth possible considering the circumstances.

A:
The best way to deviate as little as possible from the physiological model of birth would be that the medical team is comfortable with the principle of an elective in-labor cesarean. In other words, the medical team would accept to wait until the day when you are in labor to perform an "in-labor non-emergency cesarean." This way it is a guarantee that the baby will have given a signal indicating that his or her lungs are mature. We know today that the baby participates in the initiation of labor. Furthermore, during labor contractions, the baby is exposed to hormones that make more complete the maturation of his or her lungs. This is why, as all pediatricians know, there is an increased risk of respiratory problems during the days following a cesarean performed before labor starts.
I think that's a pretty strong case, whenever the situation allows for it. Logistics would have to be managed, especially in terms of making sure your own doctor is available, or that his or her partners are also on board with whatever your plans are, but the effort is likely to be well worth it.

All efforts to reduce cesarean rates aside (and you know I'm all about that), a cesarean birth is still a birth, and is worth all the TLC you can possibly give to it, for both mom and babe. It IS possible to make it a healthier, less traumatic, and gentler experience. They both deserve it.

*****

Hypothetical Reader: Wait, isn't one character glaringly absent from this whole picture? What about having . . . a doula?

Indeed, what ABOUT having a doula? This is addressed in a future post.

Top photo by Arif Tanju Korkmaz.


9 comments:

  1. Thanks for this post. I am really hoping to avoid a c-section, but I do have a small part of my birth plan that lists my preferences if I have to have one [lower drape at birth, husband present, minimal medications, skin-to-skin contact and breastfeeding as soon as possible, & low-transverse incision repaired with double sutures in case of a future VBAC].

    One thing I have to give kudos to the local hospital childbirth class for is that the teacher pointed out some of these things, especially the importance of making your wishes for breastfeeding & newborn care known before the surgery.

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  2. This is a great post! Very comprehensive and interesting. I think having a c-section plan is very important -just in case- of an emergency! especially with points like the double suturing, as you mentioned.

    It had never occurred to me that they might let you watch or even catch your own baby during a c-section! Or that women would even want to! fascinating!

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  3. I think the idea of "catching" the baby during a c-section is incredible. With my next birth, I would really like to have the baby put on my chest as soon as safely possible. I plan to ask them to do the foot printing, paper work, wrist bands, ect. while I hold baby. I understand that a certain amount of vitals and suctioning done after birth to make sure baby is okay (as I've had one baby who was very sick at birth), but some of the time wasted waiting to hold Baby is simply because the nurses are filling out paperwork. Couldn't moms hold their babies while all that paperwork is being done?

    I also believe that giving options to women facing a c-section will not further the "elective" c-section movement. I've had 4 (going on 5) and I can honestly say I just don't get why someone would voluntarily put themselves through a medically unnecessary surgery. That's crazy. But for those of us that are reluctantly anticipating a c-section, it's nice to know it does not have to be a completely out of control horrible experience.

    Thanks for linking to me Ann. I was nervous about putting my baby's birth video on the web as I wasn't sure the reaction (plus it's not high-quality video footage), but I'm glad it's there for someone that needs to see it. I may put another one on there someday.

    I'll be looking forward to your C-Section Doula post! I'm curious on whether most hospitals allow a doula (or 2nd. person) to be present in the O.R.

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  4. Wow, Dou-la-la. If, for my next baby, I have to have a c-section for some reason, you BET I'll be thinking of this post. THANK YOU.

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  5. You're so welcome!

    I would want to catch the baby, too, Morgan, and in general implement a lot of the things I learned from your birth plan, and incorporate some of the components of the "gentle cesarean", should I ever face a scheduled one. And if I get pregnant again, I will take a day (and then let it go) to write out my preferences, whenever possible, should the need for a cesarean arise in labor.

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  6. I know of someone who had an elective cesarean with two doulas. Overlooking the obvious privilege issues with being able to afford two doulas and other issues with elective cesarean, she felt very supported and in control. She had nothing but wonderful things to say about her experience.

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  7. So glad to hear it! My post specifically on doulas and c-sections is almost done . . .

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  8. I had three low risk pregnancies. I had three birth plans. I also had three sections for if I had a c-section. I think being prepared for any situation is key and I actually recommend that all my clients write an "if I have a c-section" part in their birth plan.

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  9. Apparently, Morgan's blog is now only available to read by invitation only?

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