Friday, 8 November 2013

The positive caesarean

When I was training as a perinatal yoga teacher, the question was brought up: Should we discuss caesarean birth in a prenatal yoga class? Some teachers, predominantly those who come from a background of conventional yoga without being involved with birth otherwise, don't talk about birth at all in their classes. Their focus is solely on the yoga practice, for them this is no dilemma. Among those of us from a birth background, who do discuss the wider issues of pregnancy and birth in our classes, the response was mixed.

I've spoken to many mothers who have attended antenatal classes that had no coverage of what to expect if you have a caesarean. Apparently this isn't just a yoga teachers' problem.

Do I think caesarean preparation should be a part of birth preparation. Absolutely yes. Let me tell you why.

When the topic of caesarean birth is avoided, deliberately or not, it becomes a dirty word. A looming enemy that we don't talk about in the hope that it will go away.

Often, it is talked about it purely as something to be avoided. A ceasarean is a serious intervention, the side effects are far reaching and range from barely perceptible disadvantages, to serious and debilitating health problems. Avoiding an unnecessary caesarean is a worthy goal indeed, and certainly something we should be talking about more.

It is not uncommon currently, for a hospital to have a 25-35% caesarean rate. We need to work towards reducing this, without a doubt, as this figure reflects a large number of avoidable surgeries. Individual mothers can take measures to improve their chances of avoiding surgery, this should be encouraged too.

Regardless, the figures stand. As antenatal supporters and educators, we cannot assume that none of our students will birth surgically. The figures speak for themselves. So what happens to the women we support who do go on to have caesareans?

In short, they feel alienated. That thing that we are not supposed to talk about, it happened to them. They may feel disappointed or even guilty. All this on top of dealing with the extra challenges presented by recovering from major surgery whist caring for a newborn.

There is evidence that disappointment in birth outcome is a contributing factor to postnatal depression. Does this mean we should not be encouraging women to strive for good birth experiences? I don't think so, but as birth workers, with a duty of care to the women we support, we can help them to prepare for a positive birth experience, regardless of the method of delivery.

In fact, a major factor in the way a woman sees her birth experience, is not the level of intervention, or the difficulties she faced, but how much she felt in control of the situation. It should be said that in this case "control" does not mean strict control over the outcome, but to be a part of the decision making process within the boundaries of the available options. Women with "textbook" birth experiences can feel traumatised by the process, when their needs, preferences, decisions and consent are perceived to be disregarded.

If women approach birth fully informed about all of the available options, they can add contingencies to their birth plan. If the situation changes, they can make an informed decision quickly, whether it be a confident choice to accept an intervention, or an informed choice to refuse it.

As birth workers we can help by talking frankly about caesarean birth and the options that come with it. We can talk about avoiding unnecessary surgery by looking at alternatives (such as breech delivery, OFP and VBAC), by avoiding interventions that are known to increase caesarean rates (such as continuous monitoring, epidurals and induction) and birthing options to promote natural birth (such as active birth and natural pain management).

We can also find ways to improve the experience of caesarean birth, for mother and baby. This video shows some excellent ideas for small changes that can be made to improve the experience of caesarean birth for mothers and babies. It's important to remember that positive birth experiences aren't just an airy ideal for crunchy hippies, these measures are improving physical and psychological wellbeing of both mother and baby in numerous ways.

[there are graphic scenes of surgery in the video]

In my prenatal yoga classes, I use this handout, to break down some of the options parents may wish to add to their birth preferences in case of ceasarean birth.

Although the video above discusses elective sections, it is possible to implement some of these measures in an emergency situation too.

My second child was born by category 1/crash section. My notes report that the time from making the decision to operate to birth was 31 minutes, though to me, it felt much less. My husband spoke to the midwife while they were getting his scrubs, and highlighted the c-section part of my birth plan. My OB was brilliantly helpful. I had a spinal block (although a general had been discussed), he was shown to me as soon as he was born, then laid on my legs, skin to skin, for 2 minutes before his cord was clamped. After that he was placed straight on my chest where he nursed while they stitched me back up.  They even kept my placenta aside for encapsulation later.

Despite the frightening frame within which it happened, I came away feeling very positive about my son's birth.

If we allow caesarean birth to be "the elephant in the room". If we do not take opportunities to talk about it, then we are preventing women from having this kind of positive experience, and what does that leave them with?

It is really important to understand, in fact not just understand, but to believe, know even, that a good birth does not have to fit specific methodological criteria. A good birth can be a home birth, it can be a hospital birth, it can even be a surgical birth. A good birth does not have to fit the original birth plan. Most importantly of all, hope for a good birth is never lost, simply because it is necessary to make a decision we hoped we wouldn't have to.

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