Editor’s note: This article first appeared in Midwifery Today, Issue 107, Autumn 2013.
Subscribe to Midwifery Today Magazine
Cesarean section is the most commonly performed surgical procedure among women in the US (Trimble 2009). The World Health Organization (WHO) recommended an optimal rate of cesareans between 10 and 15% while the US cesarean rate as of 2010 is 32.8% (Gibbons 2010). This number has varied minimally over recent years regardless of the increased awareness concerning cesarean statistics. Women served by certified professional midwives are attempting to avoid the high cesarean figure by electively choosing an out-of-hospital natural birth. Their chances of undergoing a cesarean are dramatically reduced, although not eliminated.
Opinions differ on the benefits of achieving an empowering birth experience. For many women, giving birth is a transforming life event, one that is anticipated for months or even years. Unexpected events can cause postpartum depression or posttraumatic stress disorder (Alcorn et al. 2010; Allen 1998; Griebenow 2006; Smith et al. 2000). Evidence shows that the majority of women who have a cesarean have a less-than-satisfactory childbirth experience (Smith, Plaat and Fisk 2008).
A new cesarean method has been designed by an anesthesiologist and a midwife in the UK and acclaimed by participants. Anesthesiologist Felicia Plaat and Jenny Smith, CNM, co-created a “natural” cesarean in which women can have greater participation in the birth of their child regardless of the surgical route of delivery (Jentle Childbirth Foundation 2011). Overall, research has shown that mothers are more satisfied with their cesarean deliveries when the surgery is family-centered (Plaat and Smith 2010). Providers can implement techniques to help achieve this satisfaction when a cesarean is anticipated. There are also tactics to help women recover postoperatively, especially in circumstances where a cesarean could be considered traumatic.
One technique being highlighted by the natural cesarean approach is early skin-to-skin (STS) contact offered in the operating room. Studies have proven that immediate STS after birth leads to less breast engorgement and pain and fewer maternal anxiety disorders. For the newborn, STS offers more effective suckling, less crying, more stable vitals and regulated blood sugars. Researchers found no risk to implementing STS for nearly all babies and WHO recommends that all newborns receive STS care, regardless of weight, gestational age, birth setting or clinical condition (Dekker 2012).
Another report found that STS after cesarean can restore the healthy bacterial colonization that normally occurs with vaginal births. Babies who are born via cesarean do not experience this bacterial colonization to the extent that babies who are born vaginally do. In fact, due to the lack of bacterial colonization during cesareans, there is an increased prevalence of staphylococcus aureus and sometimes MRSA (Methicillin-resistant Staphylococcus Aureus), which can be detrimental to newborns. Early STS and breastfeeding as soon as possible helps to restore some of the lost beneficial bacteria, through exposure to mother’s breast and chest flora (Muza 2012).
“Walking the baby out” is a technique being used during a cesarean to reduce the need for infant suctioning and resuscitation. This is accomplished by birthing the infant’s head but leaving the trunk in utero for a few minutes while the baby’s chest is squeezed, reproducing on a small level the same effect that a vaginal delivery offers. While waiting for the infant to spontaneously cry, he is still attached to placental circulation. Once the infant is crying, the shoulders are eased out slowly and at this point he will usually deliver his own arms (Plaat 2010). Leaving the baby’s body in utero for a slighter longer period of time also minimizes maternal bleeding and risk of infection and delays the clamping of the cord (Smith, Plaat and Fisk 2008). Delayed cord clamping is associated with a lesser need for prolonged medical resuscitation and a lesser risk of anemia throughout infancy (Emerson 2011).
Doula support helps to shorten labors and decreases the use of epidurals and Pitocin as well as decreasing the risk of instrumental deliveries and cesareans. Should a cesarean be necessary, a doula can help facilitate the methods of a natural cesarean. Lastly, although cesareans most often are not anticipated by the client, it might be beneficial to create a brief and concise cesarean birth plan in order to achieve some of the goals should a cesarean become a reality.
Plaat admits that when she proposed the natural cesarean to the hospital she is affiliated with, it was a “slowly evolving” process to get the staff to agree, and the process needed to be audited at each stage. Despite the beneficial outcomes that have been noted, Plaat still struggles to persuade midwives to implement some of the methods due to a “lack of interest” (Plaat, personal communication).
With the statistics indicating that the majority of women are dissatisfied with their cesarean birth, it is important to provide follow-up care for these women. Asking critical questions can help the mother to process her birth experience and professionals can provide guidance.
The Essential C-Section Guide recommends that clients seek support from family and friends who have also experienced cesareans, connect with local or online support groups, use alternative healing methods (spiritual, physical, artistic expression, etc.), exercise, journal about the experience and write letters to involved providers without necessarily mailing them (Connolly 2004). Other recommendations include role-playing, reading through medical records to help process the experience, one-on-one counseling and joining organizations such as ICAN and Scars of Love.
In many situations, the emotional response to an unexpected situation and how a person chooses to deal with it depend on how disappointment is handled, how traumatic the experience was and how much support was received (Connolly 2004).
With the high prevalence of cesareans, it is important to remember that each woman’s experience should be treated uniquely. Facilitating an empowering birth experience can help to avoid depression and PTSD.
- Alcorn, K, et al. 2010. “A Prospective Longitudinal Study of Posttraumatic Stress Disorder Resulting from Childbirth Events.” Psychol Med 40 (11): 1849–59.
- Allen, S. 1998. “A Qualitative Analysis of the Process, Mediating Variables and Impact of Traumatic Childbirth.” J Reprod Infant Psychol 16 (2): 107–31.
- Connolly, M, and D Sullivan. 2004. The Essential C-section Guide. New York: Broadway Books.
- Dekker, R. 2012. “The Evidence for Skin-to-skin Care after a Cesarean.” Evidence Based Birth. Accessed July 24, 2013. http://evidencebasedbirth.com/the-evidence-for-skin-to-skin-care-after-a-cesarean.
- Emerson, K. 2011. “Cesarean Section and Delayed Cord Clamping.” Delayed Cord Clamping: Cord Clamping Information & Research. Accessed July 24, 2013. http://cord-clamping.com/2011/09/08/cesarean-delayed-clamping/.
- Gibbons, L, et al. 2010. “The Global Numbers and Costs of Additionally Needed and Unnecessary Cesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage.” World Health Report (2010), Background Paper, 30. World Health Organization. Accessed July 24, 2013. http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf.
- Griebenow, J. 2006. “Healing the Trauma: Entering Motherhood with Posttraumatic Stress Disorder (PTSD).” Midwifery Today 80:28.
- Jentle Childbirth Foundation. 2011. “The Natural Family-centred Ceasarean.” Video file. Accessed July 24, 2013. http://www.jentlechildbirth.org.uk/portfolios/the-natural-caesarean/.
- Muza, S. 2012. “Unintended Consequences: Cesarean Section, the Gut Microbiota, and Child Health.” Science and Sensibility. Accessed July 24, 2013. http://www.scienceandsensibility.org/?p=4995.
- Plaat, F, and J Smith. 2010. “The ‘Natural’ Caesarean.” Midwives. April/May:36–37.
- Smith J, F Plaat and N Fisk. 2008. “The Natural Caesarean: A Woman-centred Technique.” BJOG 115 (8): 1037–42.
- Smith, R, et al. 2000. “Randomised Controlled Trial of Midwife-led Debriefing to Reduce Maternal Depression after Operative Childbirth.” BMJ 321 (7268): 1043–47.
- Trimble, E. 2009. “Hysterectomy Fact Sheet.” Office on Women’s Health, US Department of Health and Human Services. Accessed July 24, 2013. http://womenshealth.gov/publications/our-publications/fact-sheet/hysterectomy.cfm.