Natural/Gentle Caesarean

- avoiding the obstacles and riding

the waves - where next?

Jenny Smith – Midwife

Photo credit: Joth Shakerley London 2019 Nat CS

Learning outcomes

• Contextualise background and the need for a ‘natural’ caesarean; a “family centred approach”

• Understand what is involved in a ‘natural’ caesarean section: the advantages & risks

• The natural caesarean critics

• Modifications of technique

• The natural caesarean in obstetric enhanced recovery programs

• Where next – natural caesarean heralds the way to change mainstream labour wards ?

London 2019 Nat CS

Fig 2. Global and regional trends in caesarean section, 1990–2014.

Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, et al. (2016) The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014. PLOS ONE 11(2): e0148343. https://doi.org/10.1371/journal.pone.0148343 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0148343

London 2019 Nat CS

Progress 1970s-2000s

• Consumer driven/woman centred

• Non-clinical environment

• Maternal involvement

• Early skin to skin

• Early breast feeding

• Paternal involvement

• Ritual driven/ staff centred

• Full surgical environment

• Shift GA to epidural

• Background music

• Minimal parental involvement

• Low breast feeding

• Poor maternal satisfaction

• Subfertility

Vaginal delivery Caesarean delivery

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• Improves rate breast feeding

• Improves duration breast feeding

• Reduces infant crying

• Increased maternal affection

2009

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Exclusive Skin‐to‐Skin Rate by Birth Method

Vaginal delivery

CS delivery

SCHORN, M. N., MOORE, E., SPETALNICK, B. M. AND MORAD, A.

Implementing Family-Centered Cesarean Birth

In-text: (Schorn et al., 2015)

:Schorn, M., Moore, E., Spetalnick, B. and Morad, A. (2015). Implementing Family-Centered Cesarean Birth. Journal of Midwifery & Women's Health, 60(6), pp.682-690. London 2019 Nat CS

2008

fMRI to own baby cry at 4-6 wks

Vaginal vs planned C section London 2019 Nat CS

• Parental participation

• Autoreuscitation

• Direct skin to skin & breast feeding

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Queen Charlottes and Chelsea Hospital

NATURAL Caesarean-parental participation

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Starts as normal

Photo credit: BBC News 2007

Father may stand

Photo credit: BBC News 2007

Drop the drape

Photo credit: Flutterby Films 2007

A B C

A

Face the mother

Parents call the sex

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Photo credit: BBC News 2007

Baby autoresuscitates

Photo credit: BJOG 2009

3. Gentle birth “Walking” the baby out

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Hands off

Photo credit: BJOG 2009

4. Immediate skin to skin Breastfeeding at CS

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Photo credit: BBC News 2007

“Walking the baby out”

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Photo credit: BBC News 2007

http://news.bbc.co.uk/1/hi/in_pictures/7154594.stm

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Reviewers’ comments

• “Unacceptable risks infection, transverse/oblique lie, extension of uterine angles, & tears extending into bladder, dislodged IV lines, increased maternofetal Tx”

• “A burden for junior registrars, too difficult for OBs”

• “Nothing natural about a caesarean, misleading & dangerous…should not be published”

• “Many OBs do something similar for the same reasons but have not thought it merited writing up”

• “Nothing new”

#1 #2

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https://www.youtube.com/watch?v=wdyzAuc3Ff8 London 2019 Nat CS

Photo credit: BJOG 2009

• Great danger in legitimising C section

• Women mislead to be believe that C section safest for them

• Sanctioning CS threatens the health of mothers and babies everywhere

• Term “natural CS” as misleading as “friendly fire”

• Challenge the ethics of making caesarean births “nicer”

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• #1 render a highly successful natural process dysfunctional

• #2 fix the created problem with technology

• #3 reframe the technology as a natural solution

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Natural Caesarean Section

2008 2012 2013

2014

2016

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NHS heads for ‘natural’ caesareans Katie Gibbons May 7 2016, 12:01am, The Times

Media

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Robert Armbrust, Larry Hinkson, Katharina von Weizsacker & Wolfgang Henrich (2016) The Charite cesarean birth: a family orientated approach of cesarean section, The Journal of Maternal Maternal-Fetal & Neonatal Medicine, 29:1, 163-168

London 2019 Nat CS

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“I had a natural labour followed by

a natural emergency caesarean”

Emergency Caesarean – failure to progress

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Twins – now 16 years old

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Enhanced Recovery – natural CS

ANTENATAL

Information

Breast feeding

education

Hb optimization

IN-PATIENT

Minimise fasting

Dedicated CS list

Neuraxial opioids

Antibiotics

LMWH

POSTPARTUM

Skin -Early feeding

Regular analgesia

Early removal urinary

catheter

Breastfeeding

Community

support

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“Photo used with permission from personal file of Dr.

William Camann, Director, Obstetric Anesthesiology,

Brigham & Women’s Hospital, Harvard Medical

School, Boston, MA, USA”

Clear drapes

• Use of hand mirror for mother to watch birth

• If cord long enough babe maybe given to mother by

scrub midwife and Dad can do first cutting of cord

• Baby born into clear operating theatre pouch

NUH MaternityAndy Simms Obstetrician

Discussion Points

https://www.nuh.nhs.uk/caesarean-birth-c-section/

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• If small scar may need to use forceps to assist head delivery ?

• After baby head out baby can sometimes wriggle out with very minimal assistance

• Syntocinon IV given once baby head out will increase uterine contraction?

• What is a maternal assisted caesarean?

• Maternal-assisted births, allow mothers who are unable to have a vaginal birth to play a more active role in their child's delivery.

• The procedure, more common in Australia than in the UK, allows the mother to pull their child from the womb themselves, before giving them skin-to-skin bonding.

https://www.abc.net.au/news/2016-08-23/maternal-assisted-caesarean-mother-helps-delivery-baby-boy/7776654

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Photo credit: BBC News 2007

Conclusions • The ‘natural/gentle CS’ is

• Possible

• Popular

• Fits well with enhanced recovery

• The ‘natural/gentle CS’ appears to

• Be safe

• Enhance breastfeeding rates

• Enhance “family- centred “birth experience

• The ‘natural/Gentle CS may reduce

stress and trauma for women, babies and partners?

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Could the natural caesarean herald the way forwards to normalizing all births

• All births family centred ?

• Birth pools for high risk births?

• Increase mobility with epidurals?

• Re-think episiotomy for all instrumental births?

• Reduce stress for all families in high risk births

Ante and post wards single rooms for all?

Double beds?

Environment adjustments “home from home” like that on birth centres

London 2019 Nat CS

The “natural caesarean” technique as inspiration for normalising practice for all types of birth- Jenny Smith.

Extract from: Donna, S. (2011). Promoting normal birth. 1st ed. Chester le Street: Fresh Heart Publishing, pp.210-218.