Category: csections commentary

Like it or not, whatever your birth plan says, the fact is a third of UK births will be caesareans. As I have worked with practitioners and women preparing for birth over the years, it has become very apparent that fear and stigma can still be very much a part of caesarean experience for many. Unfortunately, in being unprepared for a caesarean outcome, when it happens some women in their sleep deprived, stressed and postnatal hormonal state, are unable to rationalise the experience describing it as “disappointing” or worse “highly traumatic”.

Understandably, many women take their adventure into motherhood very seriously, attending antenatal classes, buying book after book or, if neither of these, at least talking to family and friends about their options. Sadly in many cases despite the best of intentions many can remain quite in the dark about caesarean birth, inadvertently taking on board the negative opinions and media hype surrounding this mode of birth. And while some practitioners do try to talk about caesareans in a positive way, women often reflect they found it difficult to find the positive messages and that preparation advice was typically woefully insufficient.

One woman once wrote to me:

“I was actually on the table and surgery had started when it occurred to me to ask what the difference was between an epidural and a spinal anaesthetic,¦I should have known and it was too late to participate in any discussion.”

In the UK nearly 1 in 3 births are caesarean, and over 1 in 3 in the US with similar rates in many countries. Yet all too often the two phrases heard in connection are:

“major surgery” and

“it will affect your ability to bond with your baby”

While both can have an element of truth to them (for some women), the tone in which they are typically delivered and the total absence of any explanation, support or clarification makes them two of the most irresponsible phrases used in antenatal discussions.

That said it is becoming more acceptable to ask questions and a quick Google search will produce websites talking about how to improve your caesarean experience. But incredibly in 2021, the number of books which treat caesarean delivery as a valid and incredibly positive birth experience can still be counted on one hand.

I wrote the first edition of Caesarean Birth: A positive approach to preparation and recovery to redress this imbalance back in 2011 and it has since gone to a second edition (2018). As a complete caesarean ‘manual’ it covers:

• Why one might be suggested
• Why we should prepare
• How to make the most of a caesarean (preparation and recovery guidance)
• A detailed risk / benefit comparison with vaginal delivery
• Implications for future births
• A description of procedure itself and crucially how women can participate in and influence that process

The book blows apart the myths we hear about caesareans and women have reported feeling more confident and able to make informed decisions about their births as a result. Crucially it gives lots of ideas on how to prepare for and express preferences about the experience, radically improving the chances of perceiving it positively should a caesarean become necessary.

For example, knowing to ask to put your gown on backwards (opening at the front) prior to surgery means, assuming there is no emergency, you can easily hold your baby skin-to-skin and possibly even breastfeed while still in theatre. Such a seemingly simple thing is so incredibly important to so many and is actually totally achievable in many caesareans.

Asking questions and being better informed places us in a far stronger position to negotiate and actively manage the direction and experience of our birth whether it is a vaginal or a caesarean outcome, why leave out knowledge of a whole birth experience and risk being disappointed or traumatised unnecessarily.

“I am so glad I read this book before my birth. I didn’t intend having a caesarean but when it happened I wasn’t at all frightened and I fed ‘S’ in the recovery room. This book thoroughly demystified caesarean birth for me.” Vicki (35)

At 38 weeks our 2nd child decided she had had enough fun bouncing around in my belly and now wanted to bounce around outside. I had a caesarean scheduled for the following week (6 days before the due date) so I was a little surprised to feel my first labour pains. So surprised in fact I didn’t really believe it was labour. perhaps not surprising given I had been in hospital the previous week with a “false labour”, and this felt very similar. I dozed through the night and at 6am thought – Humm this no longer feels “false” to me.

By the time I went to hospital at 7:30am, contractions were every 3 minutes and excruciating, but only 1cm dilated!

After a very successful planned caesarean with our first daughter, we chose the same route for our second.  On my notes it said I was electing and so when the consultant checked on me at 9am, it was agreed I could go straight in. The most daunting thing I have found with both caesareans is actually the preparation. I have a horror of needles and the IV in the back of my hand is, for me, the most dreaded part of the whole experience. Our baby was born within 5-minutes of surgery beginning. They held her up to me before cutting the cord and then whisked her away for a quick check. Within what felt like seconds she was back and being placed on my chest for me to cuddle. It was a little difficult with the tubes and the screen but lovely to have her in my arms almost immediately. The whole experience was very relaxed and friendly. At one point after Celia had been lifted clear the pain management needed some adjusting and the drugs were bumped up a notch, but other than that it was a very stress-free birth.

We were back on the ward in an hour. It was rather uncomfortable getting in and out of bed that first day and when walking round I was bent slightly like an old lady, but within 2 days I was back on my feet and ready to go home. I highly recommend peppermint tea and prunes; I was taking both from the moment I got back onto the ward making toilet trips relatively stress free. All in all, a wonderful birth experience once again. I’m glad I had my husband around to help with lifting our eldest (2 years) once home. It has ensured that the scar wasn’t strained, and I had no trouble at all with healing, sailing through my 6-week check.

So why did I have a planned caesarean on both occasions?

Within my group of friends, I joined the baby club quite late. And while we were happy with the decision, it did mean we had a little too much time to listen to friends’ birth stories. It was only as I sat down one day and did the maths that I realised 7/13 friends had had caesareans and only one of these was planned.

Being newly pregnant, this seemed dauntingly bad odds to me. I couldn’t even blame it on my friends being in a specific health authority, they were dotted around the UK. I knew recent national statistics indicated that 1 in 4 women have caesareans. It was this information, coupled with my friends’ rather graphic narratives of emergency caesareans as well as ‘normal’ birth stories which made me start looking at my birth options in more detail.

I started on the web and at that time (2004), it was apparent there was a lot of information about caesareans, most of which quite negative and lots of positive hype about natural birth. Positive aspects of caesarean birth proved particularly hard to find but given the odds I thought I better keep digging.

At this point I thought talking to medical personnel might be more useful. It became obvious that, in terms of physical and mental recovery, elective and emergency caesareans were two very different things and actually 1/3 female obstetricians planned a caesarean over a vaginal delivery. On top of this, the mental approach to the birth itself could play a significant part in determining the speed of recovery.

To cut a long story short, after all the reading and talking, I opted for a caesarean in the absence of any medical need.

My husband and I were surprised and a little hurt by the negative reactions this decision provoked from a variety of people. But we were perfectly happy with our decision and able to justify it.

I am pleased to say both my birth experiences were every bit as rewarding as those described in typical ‘natural’ birth stories we’ve all heard.  Oh, and I was awake the whole time; I saw my babies born and turn pink; I started breastfeeding in the recovery room; I was walking within 20 hours; there was no sign of the baby blues and on both occasions I was behaving ‘normally’ within the week, well as normally as a sleep deprived new mother can.

Interestingly in my NCT group of 8 from my first birth, only 1 managed a totally natural birth. The remaining 6, who had all planned natural births, were all medically assisted in one way or another, 4 ending up with emergency caesareans.

The following is simply a list of all the things you can do before, during and after a caesarean birth to help improve both your experience and your recovery. This is worth thinking about even if you are planning a vaginal birth, as, in many countries, a quarter of births end in caesarean delivery (planned or otherwise).

Before:

• Maintain a healthy diet and exercise regime
• Accept the anti-nausea meds offered prior to surgery
• Be aware you do not need sedatives prior to surgery and have the right to refuse them (I am referring to sedatives, NOT anaesthetic)
• Remain hydrated, only stopping liquid intake 2 hours prior to surgery

During:

• A dedicated team member to keep you and your partner up to date and answer any questions
• A doula (as well as birth partner) permitted in theatre if you have been working with one in the lead up to birth
• Surgical gown on backwards (so it opens at the front) to enable skin-to-skin time in theatre if desired
• Delayed cord clamping unless in an emergency situation
• Baby passed straight to you unless medical attention is required. Weighing, cleaning etc. can be delayed
• Skin closure with stitches, not staples (unless staples are medically necessary)
• Appropriate pain relief regime begun immediately
• Pressure shoes or stockings applied

After:

• Encouraged to eat and drink within 2 hours, particularly peppermint to aid with gas (no fizzy drinks)
• Immediate breastfeeding support if breastfeeding is the intention
• Catheter removal as soon as possible, no later than 12 hours (unless specific medical reasons require it remain in place)
• Pressure stockings remain in place for duration of hospital stay
• Supported to walk the same day as surgery
• Keep on top of the pain medication regime – once you fall behind by an hour or more it can be difficult to build back up to an effective level
• Accept all the help you are offered; you can always say no thank you later

Once at home:

• Take it easy. Baby and you come first, not a guest’s cup of tea – let them make it and ask them to unload the washing machine while they are at it. Your on-going pain meds can mask signs that you might be over-doing it, so pay close attention
• Avoid touching the surgical site, but use clean hands if you really need to
• Keep an eye on the surgical site for early signs of infection
• Consider continuing to wear the pressure stockings for an extra few days
• Do not be tempted to resume exercise too soon, listen to your body – twinges reveal you may be over-doing it. With care you can begin very gentle exercise prior to 6-week wellness check (I am talking a gentle walk, I am definitely not suggesting situps, nor even a short jog etc.)

Some of these ideas are from an excellent article on ChildbirthU

And much more detail can be found in Caesarean Birth: A Positive Approach to Preparation and Recovery.

Caesareans are often given a bad rap. Women are led to believe a caesarean is a last resort for emergency situations when things have gone (or are predicted to go) wrong. They are scared off by being repeatedly told ‘it’s major stomach surgery’ don’t you know. Or judged for suggesting a selfish choice which will put the life of their baby at risk. The overall message still – caesareans are something to be avoided wherever possible.

In fact, a caesarean can be an incredibly positive choice for many women and battling against the stigma just makes us feel bad when we really shouldn’t.

Birth practitioners and natural birth campaign groups quite rightly talk about:

• A woman’s right to make an informed choice
• The importance of a woman’s perception of control before, during and after her birth
• The right to choose their mode of birth

So why am I complaining yet again?

Because for some practitioners and campaigners (and I want to make it clear this is definitely not all) this still excludes caesarean birth – by all means make an informed choice about your birth as long as it is in favour of a vaginal birth at home, in a birthing centre or at hospital.

An article by Tamara Parnay ‘Birth of Mutual Understanding and Respect‘ sums it up perfectly “Maternity care providers in all steps of the process, from pre-pregnancy though to postnatal care, need to move more in the direction of assisting people in personalised birth plans and helping them safely to realise these plans. In other words, they must consider the family to be an integral part of the decision-making process.”

She goes on to talk about the negative impact of competitive birth stories, the assumptions that are made about one’s own choices and outcomes compared with every other story we hear. The article is well worth a read!

It is of course wonderful to see such statements.

But the reality for many women is still that they will meet their clinicians and be told very little about one of the modes of birth – a caesarean. The balance of risk and benefit will still be skewed in favour of vaginal birth. And some women still find their informed request for a caesarean birth turned down flat.

In her book ‘Misconceptions’, Naomi Wolf says, ” Women deserve honest brokers and true advocates who will inform them about all risks and options available; who will explore what pain can be and what it might not have to be; who will make a concerted effort to eliminate unnecessary interventions; and who will stop romanticising either the control nature of high-tech mechanised labour or the culture of alternative birth.”

This is more like it – balance, reliable information and a non-judgemental approach to childbirth from absolutely everyone.

This is a fear many women experience following an emergency caesarean. No surprise really, an emergency caesarean is never planned, and some women find the experience highly traumatic, making it one they want to avoid ever going through again.

This is where being informed comes in.

In many cases a previous caesarean does not need to mean your next birth also has to be a caesarean.

Being informing about your rights is an important step in influencing such outcomes, but there are other factors to consider, namely:

• The reason for your last caesarean – occasionally there are medical conditions or previous birth complications which are likely to recur, and which mean a repeat caesarean is a safer delivery method
• How your current pregnancy is progressing – there may well be different circumstances this time round which indicate a repeat caesarean may still be a safer prospect
• When is a recommendation for a repeat caesarean just that – a recommendation? Knowing the difference between recommendation and necessity means you can negotiate more effectively. For example, contrary to popular belief, your baby presenting in a breech position does not have to mean caesarean delivery

All that said, you may well want to choose a caesarean next time round for a whole host of valid reasons. Assuming this choice is based on solid information and the progress of this next pregnancy doesn’t dictate otherwise, there should be no reason why you should not be able to plan a repeat caesarean. Easier said than done of course, multiple barriers may well be put in your way. Here again, knowledge is power. Make sure you have clear reasons for your request and fight your corner.