"Natural" caesarians and the quest for the perfect vagina.

"Natural caesarian section" is a term coined around a decade ago in an article called The natural caesarian: a woman-centred technique written by Smith, Plaat & Fisk (midwife, director of women's and children's services, anaesthetist and surgeon respectively) and published in the British journal of gynaecology. 

This paper created chatter, which continues till today, where more and more often we see pictures and film, hear words of encouragement and praise, all so excited to see positive change in how women and their babies are cared for during cesarian births.

 
 

The original article/ designers marked an acknowledgement in obstetric circles that c/section, for many women, is not an experience they find "satisfactory" (this is possibly the most beige way I have heard women's negative experiences of surgical birth described). Although there is no mention of the increased risk of death, haemorrhage, infection or any other complications this article does focus on women post-caesarian being more likely to experience postnatal depression, bonding with their baby and breastfeeding. 

And behold they found the answer:


With about a third of babies in Australia being born by cesarian section it has been a long time coming and we are finally listening to women who are deserving of so much more.


"To improve the experience of women having uncomplicated caesareans, we have modified obstetric, midwifery and anaesthetic practice over the past 6 years to emulate as closely as practicable the woman-centred aspects of ‘natural’ vaginal birth."

This needs to be unpacked.

What is an uncomplicated caesarian? I assume it is a planned caesarian, one where the baby is expected to be born in a reasonable condition.

How have the practices been modified? There is a bit of variance depending on where this is practised however you can find a good description here.

Having a baby born this way, slowly, with delayed cord clamping, skin to skin and free to breastfeed if wanting to. Where possible there is the woman's choice of music, (somewhat) dimmed lights, midwifery support and partner in attendance. It is about time. With about a third of babies in Australia being born by cesarian section it has been a long time coming that we are finally listening to women who are deserving of so much more.

I have been present in theatres where women, stripped naked, alone and terrified are paralysed and ignored in the centre of a brightly lit room, where a room full of staff carrying out their preparations take the time to talk, laugh and joke, in a way that would not be out of place at any office. But this is not an office. This is a child's birth. And this mother is an incidental element to the morning's procedure.

So I am genuinely relieved to see this positive shift towards respectful births for women undergoing a caesarian section.

But there is nothing natural about it. 

Can we call it respectful caesarian? I feel like calling it natural, in 2017, the era of kale chips and green smoothies connotes a sense of wholesomeness and implies an organic ideal. We really need to be clear, this (caesarian birth) is a completely contrived situation, albeit one that is completely necessary, acceptable and even desirable when it is used to save the lives of women and babies.

I also question how women-centred it is. I accept women want their babies close, and being supported to have a skin-to-skin contact at birth is a step in the right direction. I would argue that many of the other 'steps' in this style caesarian are baby focused more than women-focused.


Can we call it respectful caesarian? I feel like calling it natural, in 2017, the era of kale chips and green smoothies connotes a sense of wholesomeness and implies an organic ideal.


I understand the development of this technique took 6 years, however, it is unclear how they came to choose these particular interventions? Were consumers being consulted in any formal way? Anecdotally there HAVE been stories of women describing an intense desire to be the first to touch their baby. This certainly can't be discounted.

There are other areas that could be looked at. Allowing doulas in the room, no separation between mother and baby in recovery, continuity of midwifery support, one to one midwifery care postnatally, antenatal expressing of colostrum to reduce delay in milk production. Are women given these options? Or are they offered only the interventions acceptable to the institutions performing caesarian sections?

We are also still lacking data that confirms these changes are making any difference to breastfeeding, maternal satisfaction, bonding and postnatal depression.

I am not the first person to recognise that most of the time when we discuss "risks" associated with birth it is the baby who is central to the discussion. Although the background risk for any woman, even a healthy, young one, to be seriously injured from birth is much much higher for women birthing via cesarian section (compared to vaginal birth) we tend to hear almost exclusively about the benefits and risks for infants. 

I am concerned that as this kind of caesarian birth is glorified some advocates might forget to mention that this is actually a risky procedure. For women, they are 3x more likely to die from caesarian section than vaginal birth. This statistic is the same regardless of the lighting*.

For those who might benefit from more women birthing via caesarian here is a now a way to package and promote caesarian as the new and improved vaginal births. Just with better vaginas. 

Dr Gerry Burke, Consultant Obstetrician/Gynaecologist and Clinical Director, Maternal and Child Health Directorate, UL Hospitals Group,  stated that the gentle Caesarean represented “another small step in the evolution of this most ‘normal’ of all the surgical procedures”.

Unpack that. And tell me all the ways a cut in the belly is normal.

And then answer me, where does this evolution end?

*Actually I have no idea if the lighting affects the stats of maternal mortality. This is hyperbole gentle readers. 

Autoresuscitation. After delivery of the head, the baby establishes respiration while still attached to the placental circulation. Pausing with the head in this position allows external compression from the uterus and maternal soft tissues to expel lung liquid (arrows A and B—time lapse) as happens at vaginal delivery. Note that neither the surgeon nor the assistant is touching the baby. The baby's trunk is then eased out by a combination of uterine contractions and gentle assistance from the accoucheur to ensure it facies the watching parents (C). The baby often unleashes his/her own arms from the uterus with a vigorous extension reflex (D), and his/her wellbeing is monitored by observing crying and facial reactions (E). Representative photographs from different deliveries (with permission).

Autoresuscitation. After delivery of the head, the baby establishes respiration while still attached to the placental circulation. Pausing with the head in this position allows external compression from the uterus and maternal soft tissues to expel lung liquid (arrows A and B—time lapse) as happens at vaginal delivery. Note that neither the surgeon nor the assistant is touching the baby. The baby's trunk is then eased out by a combination of uterine contractions and gentle assistance from the accoucheur to ensure it facies the watching parents (C). The baby often unleashes his/her own arms from the uterus with a vigorous extension reflex (D), and his/her wellbeing is monitored by observing crying and facial reactions (E). Representative photographs from different deliveries (with permission).

Parental participation. Dropping the drape and tilting the head of the bed upwards allows the parents to establish eye contact and learn of the baby's sex as he/she emerges. The father may stand if he wishes. (A) and (B) show representative photographs from different deliveries (with permission).

Parental participation. Dropping the drape and tilting the head of the bed upwards allows the parents to establish eye contact and learn of the baby's sex as he/she emerges. The father may stand if he wishes. (A) and (B) show representative photographs from different deliveries (with permission).

Early skin-to-skin contact. The baby is handed by the surgeon (left) first to the midwife (right) waiting alongside the mother's head (A), then directly to mother. Skin-to-skin contact is established within a minute of delivery. The screen is then restored while surgical closure is completed, and the baby kept warm with towels and bubble wrap (B). Representative photographs from different deliveries (with permission).

Early skin-to-skin contact. The baby is handed by the surgeon (left) first to the midwife (right) waiting alongside the mother's head (A), then directly to mother. Skin-to-skin contact is established within a minute of delivery. The screen is then restored while surgical closure is completed, and the baby kept warm with towels and bubble wrap (B). Representative photographs from different deliveries (with permission).