‘I never thought I’d have a caesarean. I thought it was something that happened to other women, the sort who had “complications”. It was profoundly shocking to me and I still don’t understand why it happened.’
CLARA, 36, MOTHER OF TAMSIN (7) AND GRADY (2).
‘My caesarean was a blessing. I thought my baby was going to die. The operation saved him and I will always be thankful for that.’
DANA, 29, MOTHER OF RAOUL (6 MONTHS).
SIX REASONS TO READ THIS CHAPTER
SIX COMMON CAESAREAN MYTHS
If you are considering skipping this chapter, don’t. You may feel perfectly healthy. Your pregnancy may have been utterly straightforward. You may see no reason why anything should go amiss in the birth. But you still have, statistically, almost a one in four chance of greeting your baby for the first time on the operating table.
I am a classic first-time caesarean mother. After a healthy pregnancy, I went into labour on my due date. I spent a long day in pain on hands and knees in a soulless, brightly lit hospital room and by the end of it I was exhausted. My cervix had not dilated any further than 4 cm. I’d had nothing to eat or drink for 16 hours and no sleep the previous night (I was too excited when I realized I was going into labour, to lie down and even rest). So I had an epidural and the midwife broke my waters to try and ‘speed things up’. I was then given a syntocinon drip to strengthen my contractions. Eventually, after several more internal examinations by a series of complete strangers, I was advised to have a caesarean. I was wheeled into surgery and, bulldozed by medication, my shell-shocked husband next to me in a mask and gown, I had my operation. I remember thinking, clearly, when I held Izzie the next day: ‘I have a baby, but I don’t know what it’s like to give birth.’ Of course I did know what it’s like to give birth: after all, this is how 22 per cent of British women do it these days.
The emotional fall out was what surprised me most. Like around half of first-time caesarean mothers, the three-word reason I was given for my operation was ‘failure to progress’. In the months after the surgery the word ‘failure’ stuck. I began to feel I’d somehow chickened out of giving birth properly, that I’d missed some important ‘rite of passage’ by not pushing out my baby and even – weirdly – that I’d disappointed my husband (who in reality didn’t give a damn how our daughter got out as long as we were both safe). Nobody was more surprised than me about all this. Before having Izzie, I’d thought caesareans sounded like a good idea – pain-free, private parts intact, all nice and safe and time-limited and under control. My post-caesarean emotions seemed to me, at times, hysterical and silly not least because I didn’t believe any of these things rationally. But I couldn’t stop feeling this way.
In the months afterwards, in an attempt to pull myself together, I began to do some reading. Despite my antenatal yoga, childbirth classes, and diligent reading of What to Expect When You’re Expecting, I’d managed not to really understand that walking around, resting or eating and drinking in early labour can help your contractions get going. I didn’t know that my fears about labour (and they were big) might possibly get in the way of how my labour progressed. I didn’t know the basics about any of the things I agreed to: and above all I didn’t have any idea that a caesarean was a realistic possibility whatever I did right in my birth preparations, and in the labour itself. Consequently, I was totally unprepared for surgery: my childbirth teacher never discussed caesareans in any detail (even though, in the end, half of our group ended up with one) and it genuinely never occurred to me that I’d give birth that way.
I’m actually very lucky. My caesarean wasn’t traumatic. I was never seriously worried for my baby, I didn’t have to have any other major interventions first, like ventouse or forceps; the doctors were kind, I had pain relief early on and my recovery was OK. But to say the experience was ‘easy’ would be a lie. It was disempowering, scary and undermining – largely (I think) because I was totally unprepared for it.
A caesarean can be a perfectly manageable experience and, as obstetrician Michel Odent writes in his book The Caesarean1, it really can be a ‘magnificent rescue operation’. Women who feel fully informed and in control while this is going on generally don’t have a problem afterwards. ‘I’d planned a home water birth,’ says Dea, 38, mother of Scarlett (4), ‘but she became distressed and I was transferred to hospital. There was no doubt for me that this was the right thing. Every step was explained to me, and I was consulted the whole way. I was just relieved, in the end, that she was safe. I stayed calm during the whole thing and I never felt bad about what had happened afterwards.’
A caesarean can also be a blessing if you have been genuinely traumatised by a bad experience of a previous birth. Jennifer, mother of Miles (5) and Louise (2) says ‘Miles’ birth was a nightmare. He ended up in intensive care and I was traumatised by the whole thing. This time I just wanted them to extract a healthy child from me in a safe, medical environment whatever that took.’ She got an epidural early on, felt in control throughout the labour, and the caesarean she ended up with was, she says ‘empowering’.
Giving ‘birth from above’ is, then, neither inherently bad nor good. But it should certainly be something that every pregnant woman thinks and learns about – before she goes into labour. Caesareans carry certain risks and you should understand these before you are offered one. There are also many ways to minimise your chances of giving birth by caesarean. Should you have one – and you might well - you should know that there are ways for you to make your operation feel more like a birth; there are ways to make it calmer, more joyful, less scary and clinical. This should help not only your own recovery, but your ability to bond with your baby and move on into motherhood totally reconciled to what happened.
Caesareans are becoming increasingly common. These days most major health bodies, including the World Health Organization (WHO), are trying to reverse this trend. The WHO recommends that no more than 15 per cent of births should be by caesarean because of the unnecessary risks it can pose to both mother and baby. But the numbers keep rising. In the UK you are now five times more likely to have your baby surgically than you were in 1970 (around 24 per cent of first births are now by caesarean).
Your chances of giving birth surgically depend on tons of factors, not all of which will be obstetric. One is where you live. According to NHS statistics2 some maternity units have a caesarean rate lower than 5 per cent, while others perform the operation on over 30 per cent of mothers. Some of this may be down to what kind of hospital yours is (a large regional unit that takes special cases may have a high surgical birth rate because it sees more mothers with complications). But equally some of this may be down to a more ‘interventionist’ ethos. There is certainly an increasing fear, among medical professionals, of litigation: if something goes wrong with a vaginal birth you don’t want to get sued, so you’ll operate ‘just in case’. In other words, the reasons why a caesarean might be performed are not always straightforward or obvious.
WHAT ARE THE RISKS OF CAESAREANS ?
A caesarean is major abdominal surgery, whether it’s planned or not: in fact, it’s actually more risky – for you – than giving birth vaginally.
Clearly, virtually every woman would be prepared to risk all of these things if it meant saving her baby.
A WORD ABOUT EXTREME RISKS | Whether or not you are more likely actually to die during a caesarean is debatable. The International Cesarean Awareness Network (ICAN) says that you are two to four times more likely to die during a caesarean than a vaginal birth. However, the Confidential Enquiry into Maternal and Child Health, which looks at the reasons for maternal death in this country does not list caesarean section as a risk factor. Basically, it’s a complicated issue because it’s hard to disentangle the effect of the operations from the reasons for it. Perhaps all you need to know is that the risk of you dying – whatever way you give birth – is absolutely minute in Britain today.
The emotional after effects are rarely talked about, in childbirth classes, with other caesarean mothers, or really at any point after the event. Friends or family can be reluctant to engage in your emotions, feeling understandably that the only thing that matters is that ‘you and the baby [or babies] are OK’. Your partner may genuinely not understand what you are going on about, for the same reason. Of course having a healthy baby is the most important thing of all. No birth ‘experience’ could possibly matter more than this. But this doesn’t mean you’re not feeling some other stuff. It can be distinctly isolating to be told that what’s upsetting you is selfish, irrelevant nonsense.
This gets worse if you are genuinely traumatised by your caesarean. Caesarean birth (like traumatic vaginal birth) has been linked to post traumatic stress disorder and postnatal depression: some women report feeling ‘violated’ by their operation, others – many of whom encountered frightening, emergency situations – will have flashbacks, panic attacks and nightmares long after the event. Women who have had a caesarean (particularly an emergency one) can be very frightened of giving birth again and this is something that many medical professionals don’t fully acknowledge.
Where to go for help:
If you feel traumatised or panicky because of a past caesarean you need to get help and support from professionals. Start by talking to your midwife or GP and asking for help. You can also try these support groups:
International Cesarean Awareness Network: www.ican-online.org
Birth Crisis: an organisation set up by childbirth educator Sheila Kitzinger which offers support to women who have had traumatic or difficult birth experiences. Helplines: 01865 300 266/ 0207 485 4725/ 01380 720746/ 01454 299449
Yes, this section IS for you: don’t skip the description below out of squeamishness or fear. It is far better to have an idea, in advance, of what could happen, than to be shocked and upset by it if it does. (Even if you don’t have a caesarean, someone you know might.)
What happens during a caesarean will depend on why you are having one. Some caesareans are planned – you are usually asked to go into the hospital in the morning, and are not allowed to eat and drink for 12 hours before the operation. Unplanned caesareans, on the other hand, may feel more panicky. Some – if you do not have an epidural already in place and need to get the baby out immediately – will involve a general anaesthetic (this is relatively rare). Others, though they happen in labour, are not really an emergency, and there’ll be time for you to have a spinal anaesthesia (this is like an epidural) before you go in. In most caesareans, there’s a bit of a run up as interventions begin and the baby begins to look distressed. Most women, by the time they get to the caesarean stage, have already been given an epidural, which then just needs ‘topping up’.
Whatever the circumstances, when it becomes clear that you are going to give birth surgically, you’ll be asked to sign a consent form. The top part of your pubic hair will be shaved. An intravenous drip and a catheter will be inserted (your bladder needs to stay empty). Your blood pressure will be monitored with a cuff on your arm. Your jewellery (except your wedding ring, which will be taped down) will be removed. Your nail varnish will be taken off. If you already have an epidural in, the dose will be increased so you are completely numbed from the waist down. If not, you’ll be given spinal anaesthesia and when the anaesthetic is fully working, the surgeon will paint your abdomen with antiseptic. You’ll be shielded from seeing anything by a kind of screen that starts at your chest.
Your partner will usually be allowed in with you, wearing scrubs. Some surgeons might allow a doula, or another female birth partner, to come in too (the only issue, really, is space). If you know in advance that you’re having a caesarean, this is something you may want to request and negotiate about. You can also put in your birth plan that you strongly want both the baby’s father and a female birth partner in surgery with you (see Chapter 9 page for why you might want a female birth partner too). They won’t have to see anything gory (they’ll be standing at your head).
The surgeon will make an incision – which you definitely should not feel – and the birth begins. Mostly, you’ll feel tugging and pulling and pressure. This doesn’t hurt. But it can be surprisingly weird and uncomfortable. Some people describe it as ‘someone doing the washing up in your abdomen’. Not a nice idea, but you get the picture: there’s lots of disturbing rummaging. This is when you need your relaxation/visualisation techniques for distraction and calmness.
Your baby will be lifted out – and, in most cases, you can see and touch her right then (the surgeon can drop the screen so you actually see her being born if you want). If she is in good shape you should ask for her to be placed on your chest – skin to skin – as soon as she is out. There is usually no reason why this can’t happen (though the staff may not be used to this request). A paediatrician will only be in the room if the doctors know there may be a problem with the baby. When you are ready (unless it’s an emergency), your baby will be taken to a corner of the room to be checked over. If she needs more help – oxygen or resuscitation, you won’t be able to hold or touch her first. Her APGAR scores will be taken (see Chapter 2, page). Then she’ll usually be wrapped up, and given to your husband to hold as you’ll still be on the operating table, and at least one of your arms may be immobilised by your drip. (See below for better ways to have contact with your new baby.)
Repairing your womb and abdomen (these are both stitched up, one then the other) takes about 30 minutes. After this, you and your baby will be wheeled into the ‘recovery room’.
A WORD ABOUT ANAESTHETISTS | The anaesthetist can be your greatest source of comfort and reassurance in a surgical birth and will talk you through the process when it’s happening. Mine talked calmly to me throughout my caesarean, and made a vast difference to what was, for a hospital-phobe like me, an essentially terrifying experience. Of course, you can’t choose your anaesthetist but if he or she is reticent, ASK for reassurance and information. Most will be glad to give it to you.
When the surgeon was rummaging about, I was freaked out to see sweat on her forehead, assuming (in some horror) that it was because of the physical effort of opening my womb and pulling out my baby. This is not the case. Your surgeon may perspire but not because of the physical strain: the operating theatre is hot, the plastic aprons they wear under gowns are hotter, and the longer they are in the room the more they will sweat.
Clearly all of this messy stuff – physical and emotional – is worth it if your baby’s life (or your own) is at stake. Absolute indications for having a caesarean are really quite rare, but they certainly do exist.
Usually pre-labour:
Usually in labour:
Here are some reasons that are often given for caesareans, which may not be straightforward.
LABOUR NOT PROGRESSING/BABY IN WRONG POSITION | About half of all first caesareans are performed because of ‘dystocia’ – this means either labour stops progressing, or the baby seems to be ‘stuck’ in some way. The most common reason for this is that the baby – though he is lying head down – is still in the wrong position for birth (see Chapter 5, Your Baby’s Position, page). If the wider part of the baby’s head enters your pelvis first, this part of the baby’s head does not press down efficiently on your cervix to dilate it with each contraction of your womb. The upshot is that although you are getting strong, painful contractions your cervix dilates unevenly and very slowly.
When this happens, and the baby does not shift into the right position (a baby can turn at any time in labour), it’s common for a ‘cascade’ of medical interventions to ensue. The baby can then become ‘distressed’ and – ultimately – you end up with a caesarean. Many childbirth experts believe that if our births were managed in a more ‘woman-centred way’ (where we feel safe and confident rather than scared or panicky, and where we keep moving, upright, hydrated and supported during the course of labour) the incidences of caesarean for ‘dystocia’ would decline.
Here are some things you can do to minimise (though by no means eliminate) your chances of having a caesarean for dystocia:
It is much more common for the head of your first baby to be in a difficult position for birth, than it is for subsequent ones. If you had a caesarean for ‘dystocia’ first time around, you are very likely to give birth vaginally next time.
Where to go for help:
The Labor Progress Handbook by Penny Simkin ed. (Blackwell Science, UK, 2000) While a bit technical, this book will tell you all you need to know about dystocia.
BABY’S HEAD TOO BIG | Although a fairly common reason given for a caesarean, ‘cephalopelvic disproportion’ is actually an extremely rare condition in the UK and is usually associated with a pelvic deformity or an incorrectly healed pelvic break.
BABY TOO BIG ALL OVER (MACROSOMIA) | It is actually unusual for a woman to grow a baby that is genuinely too big for her body to push out. And the way that doctors can estimate a baby’s weight is very inaccurate (see Chapter 1, Fear of having a big baby). ‘I have seen several cases in which women choose to have a caesarean with no trial of labour because they are told the baby is big,’ says Deanna, a doula. ‘I’ve heard things such as “My baby was over 9lbs so there was NO WAY I could have had her naturally if I had tried”. But I have seen many babies, way over 9lb, born with no complications.’
PROLONGED SECOND STAGE | Sometimes women are hurried through labour because of hospital protocols that dictate that you should dilate at 1 cm per hour and not push for more than one hour. The main reason for limiting your active pushing stage is that your baby’s condition can deteriorate if pushing is not going well. For ways to help your pushing stage, see Chapter 5: Your Options, page. Many doctors and midwives say it is actually less traumatic to have a caesarean if the baby genuinely is ‘stuck’, than to have a difficult instrumental birth.
A PREVIOUS CAESAREAN | We talk about vaginal birth after caesarean (VBAC) below; see page.
The labour room is NOT the place to start debating these issues with doctors and midwives. Once you are in labour, have chosen your hospital, your midwives and your birth partner(s); once you’ve made out your birth plan and understood the basic risks and benefits of various procedures you should never find yourself arguing between contractions over whether or not you are experiencing true dystocia, or whether your baby’s head is, really, disproportionate to your pelvis. Ultimately, you have to do all you can to minimise your chances of having an unnecessary caesarean, then trust your health care team to keep you fully informed and consulted. You can certainly ask questions, or negotiate on certain points. But if you are being told categorically by an obstetrician that your baby will be damaged if you don’t have surgery – and you are given good solid medical reasons why this is the case – then you really do have to take their word for it. Caesareans are not necessarily ‘traumatic’. And doctors are not evil monsters lurking with scalpels to get you when you’re vulnerable. Indeed, obstetricians don’t want to see you in surgery unless you really need to be there.
A WORD ABOUT TWINS | Having twins certainly increases your chances of having a caesarean, but in itself it is not a reason to schedule one. ‘Multiple pregnancy’ is the primary reason behind 1 per cent of caesarean sections and, overall, 59 per cent of twin pregnancies are delivered by caesarean (37 per cent elective and 63 per cent emergency). Having a caesarean to deliver the second twin after giving birth to the first baby vaginally happens in 3.5 per cent of twin births.3 However, a normal twin pregnancy – that is, one where the babies are healthy and the first twin is head down (cephalic) – is not in itself a reason to schedule the operation. The National Institute of Clinical Excellence (NICE) Guideline on caesarean section (CS) says that in otherwise uncomplicated twin pregnancies there is always a slightly increased risk to the second twin at birth. But ‘the effect of planned CS in improving outcome for the second twin remains uncertain and therefore CS should not routinely be offered’.4 If you are having identical twins, however, the obstetrician might advise you to have a caesarean because your twins share a blood supply through the one placenta. Discuss the risks and benefits with your obstetrician before you make any decisions, and don’t be bullied into something you are not comfortable with. Keep asking questions until you feel happy with any decisions you have to make.
TEN WAYS TO AVOID AN UNNECESSARY CAESAREAN
Many caesareans are unavoidable, for many different reasons. But there is much you can do to maximise your chances of having an uncomplicated vaginal birth.
More of us are asking for caesareans than ever before. Doctors put the rise in ‘elective caesareans’ down to anything from an increased fear of birth to our modern obsession with celebrities: ‘It has become a sexy operation,’ obstetrician Yehudi Gordon, known for his natural approach to childbirth, once told me in an interview. ‘People see celebrities like Liz Hurley or Victoria Beckham having planned caesareans and think it must be the best option.’ ‘Too posh to push’ makes great copy, but it’s not the reality for most women who elect to have a surgical birth. Most do so because of medical reasons, after discussions with midwives and obstetricians and usually after quite a bit of soul-searching.
There is no complete consensus among obstetricians about absolute indications for having a planned caesarean. This means that if a planned caesarean is mentioned to you, it’s important to discuss the subject fully with your doctor and midwife. Before you agree to the surgery, make sure that you have fully understood:
If you don’t feel happy after these discussions, it is fine to ask for a second opinion, and, if you are tactful about doing this, your doctor should not be offended.
In theory, ‘informed consent’ means you have surveyed all the available information, talked to people in the know, explored your options and made up your mind to have the caesarean (without pressure). Many doctors are very careful about this. But some are more fixed in their views. In practice, informed consent may mean you are informed by one doctor who has given you the information they want you to have but it may not be the full picture. You then consent, thinking you know all sides, but with a gnawing sense of doubt (or regret) in your gut about what you have agreed to do.
True informed consent involves:
If you don’t get the resolution you need, ask for a second opinion. Bear this in mind when discussing whether to schedule a caesarean.
There’s a lot of talk these days about the modern woman wanting to schedule the baby’s arrival around her board meetings, or hair appointments or something. This is largely a media fantasy. Currently only 7 per cent of caesareans in England and Wales are carried out because of maternal request alone5. As one midwifery text book6 puts it: ‘There is much evidence to support the fact that very few women actually request caesarean section in the absence of medical indications.’
Most women who request caesareans, when they are not medically indicated, do so for powerful emotional reasons (often fear-related) that might stem from things like past sexual abuse or a previously traumatic vaginal birth. Studies have shown that if women requesting caesareans because they are afraid of vaginal birth are given proper counselling, they are likely to withdraw their request.
Some women feel they might prefer a caesarean because they are reluctant to subject their vaginas to the stretching necessary to get a baby out. The truth is that every woman is different. But normal vaginal birth is unlikely to leave you permanently damaged, particularly if you do your pelvic floor exercises afterwards (see Chapter One, page). Vaginas are made to stretch and contract again and most of us do not feel we’ve permanently stretched out of all proportion after giving birth. Women also say things like ‘a caesarean will stop me being an incontinent old lady’. This isn’t strictly true either. Studies have shown that caesarean birth will not necessarily protect you from incontinence pants later in life because pregnancy alone can weaken your pelvic floor. Pelvic floor exercises, done regularly for the rest of your life, are the best way to reduce your chances of incontinence.
If you are considering a caesarean for non-medical reasons, don’t beat yourself up about it. But do talk it over fully with your midwife or obstetrician and if your fears are driving you towards that scalpel, consider asking for a referral to a counsellor. You may end up feeling that you still want the caesarean, and this may indeed be best for you. But you do want to be informed, reconciled and ready for it.
Try and make it feel like a birth. If your caesarean is planned, you may be in an even better position to make it feel more like a ‘birth’ than a scary operation (see below).
Beware waiting times: ‘Be prepared for a long wait!’ says Astrid, 38, mother of three caesarean-born children. ‘I was told to come in at 7 a.m. on the day of my caesarean, having consumed nothing for 12 hours beforehand. I didn’t get into the operating theatre until 5 p.m. that day (still with no food or drink). It was nerve-wracking. Because you’re not the emergency, if it’s a busy day you’re going to be bumped down the list repeatedly. Bring plenty of distractions: magazines, books, games to play with your husband – anything that’ll take your mind off your situation. And be mentally prepared for a long wait. The worst thing is the expectation.’
Prepare your partner. Don’t make the mistake of thinking that because it’s a planned ‘operation’ you won’t need support. There are quite specific things your partner can do during a caesarean, and he needs to know about them, and to understand caesareans so he’s not freaked out. Get him to read this chapter.
If you were considering having a female birth partner too, she can still be a huge help (see Chapter 9: The Love of a Good Woman) but you may have to negotiate with your obstetrician about whether she’ll be allowed in. Do this in advance (see Julia’s story below).
If possible, make sure that you are more than 39 weeks pregnant: the likelihood of your baby having breathing problems after a caesarean is higher if you are less than 39 weeks pregnant.
Talk to an anaesthetist: you might get the chance to meet an anaesthetist at your pre-booking appointment so use this to build up a picture of what the operation will be like: ask lots of questions, no matter how silly they may be.
On the wall of the maternity unit at Queen Charlotte’s hospital in London are black and white pictures of a caesarean birth. In one, the mother, baby and partner are snuggled together in a blissful moment: the baby is lying on the mother, skin on skin, their heads are all close together, marvelling at each other. Behind this beautiful image you can just see the surgeons, finishing up the operation. This is how caesarean birth can be – if it is handled well.
One of the most disturbing things about a surgical birth is how clinical the whole thing can feel. Lying immobilised on a trolley, awake, while surgeons operated on me certainly put me way beyond my comfort zone – and I’m sure these feelings contributed to my sense that I’d undergone an operation, rather than a birth. Of course, if you are being rushed in during a dire emergency, you’re not going to be caring about aromatherapy but there are many simple things you can do to make your caesarean feel like a birth. You can also ensure that you don’t feel like an inanimate object, being unzipped, and having the baby ‘extracted’. This is your body and your baby’s birth. You can ‘normalise’ it, even in the most ‘abnormal’ circumstances.
Julia was once hired for a planned caesarean:
‘Melinda’s baby was breech so she planned a caesarean. She then hired me. We used my 2–3 pregnancy visits to talk about caesareans and she did a lot of on-line research into surgical birth. We all met early in the morning at the hospital. She was very nervous. It can be very unsettling to get into a hospital bed, have physical exams, an epidural and an IV put in when you are a healthy person. I spoke reassuringly to her while this was going on. Many women are also terrified that the epidural won’t work and they’ll feel something. Throughout the operation my head was near hers, reassuring her, until she asked me to take photos. My role in making it a birth was simple: I called it a BIRTH about a million times and I told Melinda again and again how well she was doing (she used her relaxation techniques to calm herself). Together we normalised that birth. Melinda asked to have the baby put on her chest, and then kept him with her constantly – he was totally healthy so this wasn’t a problem. After a caesarean, many women feel upset by things that are, in fact, normal parts of surgical birth. If those women had known about caesareans, they wouldn’t have been so shocked at the procedure. This – the physical reality of being operated on – is a big part of post-caesarean distress for many women. If a pregnant woman educates herself on all forms of birth then she’ll know what to expect from, and hopefully how to get, a fantastic caesarean birth.’
WHY BOTHER? | The main reason is that a negative caesarean experience can affect mother-baby bonding. Most people would say that just getting the baby out is all that matters when it comes to surgical birth, and sometimes there just isn’t the time, or opportunity to make the experience more positive for the mother. Clearly safe baby, safe mother is the number one priority. But a caesarean is not always, by any means, an ‘emergency’, even when it is done during labour. As midwife Jenny Smith says, ‘Part of the problem is that when things do go amiss, the birth quickly becomes a medical procedure. Many women say to me that in those first few days after the surgery they felt somewhat unconnected to their baby. This can be very damaging.’
This emotional fallout can also affect your confidence in your body. Many women feel it hasn’t worked properly. And there is a link between caesareans and postnatal depression and post traumatic stress disorder where women have panic attacks, flashbacks or nightmares about the birth (this can happen with a traumatic vaginal birth too).
Though some women will, unavoidably, end up with a difficult or scary emergency caesarean, surgical birth for the rest of us simply does not have to be this way. The psychology of caesarean birth is often overlooked by health professionals who are, understandably, focusing on delivering a healthy baby. There is huge scope for improving our experience of caesarean birth. ‘Even surgical birth can be magical,’ says midwife Jenny Smith. ‘While all medical precautions need to be taken, it’s important that, for instance, you should be able to hold and touch your baby straight away – skin to skin – if possible in the operating theatre. You should also stay with the baby afterwards, in the recovery room. The moment when you first meet your baby is really the miracle of birth. You can never get that back and as professionals we should do all we can to help women have these profound first few moments of being together.’
HOW TO MAKE YOUR CAESAREAN A BIRTH
Before the operation:
During the operation:
Ask if your partner can take pictures during the surgery, if you (and he) want. ‘Instead of sitting near my head, my partner was next to the surgeon, with his camera,’ says Patty, mother of twins. ‘I love those photos – they make me feel really connected to the birth.’ (If you have a digital camera, this can be really useful if the baby has to be taken off for special medical attention: you can look at the picture straight away.) Michelle, chair of International Cesarean Awareness Network (ICAN), Seattle says, ‘Black and white photos can be better than colour ones – they show the beauty of the baby born with less of the graphic elements of the surgery.’ Matt finish tends to be better than gloss for the same reason.
Smell nice smells not surgical ones. This sounds bonkers, but if your caesarean is not a dire emergency (i.e. you have time to think about this sort of thing) you might want to use a drop or two of essential oil (like lavender) on a handkerchief next to your face or dabbed onto your neck, to counter the surgical smell, particularly if you’re scared of hospitals. Aromatherapy is unlikely to be at the forefront of your mind if the operation is an emergency, but your birth partner might be able to do this for you.
It is common to get the shakes after surgery, so don’t panic if this happens (though do call the midwife if she is not there). Warm blankets will help.
For some women, recovering from a caesarean is straightforward, but for others it can be arduous. Much will depend on the kind of caesarean you had: if you have an emergency caesarean after 24 hours of labour and are exhausted, you may take longer to recover than if you have a calm, planned surgery. Perhaps the most important thing about recovery is to remember that you have had major surgery. It’s hard to think of another major operation where people would expect you to leap up and start caring for others just days after the surgery. Caesarean recovery can be unexpectedly painful and long-lived. Up to 10 per cent of caesarean mothers end up with an infection (usually of the wound, uterus or bladder). It is, then, worth being cautious, taking medical advice and making sure your partner understands that you need time to recover.
HOSPITAL STAY | Most women stay in the hospital for about three to five days after a caesarean, though many of us leave earlier (sometimes you just want to go home – wards can be noisy, hospital food is rarely nourishing, and then there’s the fear of hospital borne infections…). It’s worth thinking about your home situation before you discharge yourself though, and setting up extra help if you have other children. You also need to be totally sure that you are healthy and that going home will pose no risks. The community midwife team should know you are going home, and should visit you each day for about a week. After this, your health visitor will see you regularly.
YOUR BODY | Post-op weakness: Many women feel weak for a while after a caesarean. This may be because you have lost a lot of blood (blood loss can be higher than with a vaginal birth). What to do: rest, eat plenty of leafy green vegetables and take iron supplements (watch out for constipation though: drink plenty of water and eat fruit and vegetables). Moving around: you’ll be encouraged by midwives to get up and move around very early on. This is not because they’re fascist maniacs: it’s to lower your risk of thrombosis (blood clots), the leading cause of maternal death in the UK.
YOUR SCAR | I’ve always been surprised at how unobtrusive my scar is. Most of it is below the pubic hairline and it has now faded to white. In the days after the operation you may find the scar shocking but by day two or three the incision should look all sealed up (though still very red). The midwives should remove your stitches after about five days: this is quick, but can be sore (see tip below). Don’t leap on your treadmill just yet though: you do not want to strain or – God forbid – reopen the scar. When I got home from hospital after my caesarean, I was – I have no idea why – on a mission to prove to myself that I’d ‘recovered’. I was out walking with Izzie in a sling within a week, bustling around, not resting, trying to squeeze into inappropriate clothing. I began to feel a very painful burning patch on my scar. I ignored it for as long as possible. Then, after a day or two, I reluctantly went to the GP. I had an infected stitch. Antibiotics are the usual treatment but if you leave it, you may need to have the infection surgically drained. So don’t linger.
Your scar might seem, initially, to have a life of its own. It might itch or ache. It might be numb. It might feel as if it’s permanently tugging your skin, or ‘pinning you in’. You may have a complicated relationship with this scar for quite a while, particularly if you really wish it wasn’t there. Some women describe feeling ‘branded’ by theirs. Others, meanwhile, see it as a badge of honour. How you feel about your scar will depend, of course, on how you feel about the birth. Your scar will enjoy a certain limelight at first: it will look quite dramatic; will be red, raised, possibly semi-obscured beneath an attractive fold of your post-baby flesh, initially exposed because the top of your pubic hair has been shaved. Most scars fade to a pale pink or white with time, and the uncomfortable feelings should disappear. But that scar is not going to go away (though when your hair grows back it may be harder to find). The best possible approach is to try and make friends with it: ultimately, it’s a sign that you’re a mother.
SCAR WARNING SIGNS
Call the doctor if you feel any of the following in your scar:
Take a couple of paracetamol half an hour to an hour before the midwife comes to remove your stitches.
Follow the instructions you are given and take them seriously.
Lift nothing heavier than your baby for a minimum of three weeks and preferably longer.
Support your scar with your hand or a pillow before coughing, sneezing, or laughing.
You might want to pad your scar with a super-size sanitary pad: wear snug knickers and stick the sticky side of the pad to them, so that the pad runs the length of your scar, supporting it and keeping it comfortable.
Some women say that wearing a surgical support wrap around your belly also helps you feel comfortable. You can get one that has Velcro so as your belly shrinks, it shrinks with you. At a pinch, high support pants will work as well.
Don’t scrub your scar in the weeks after surgery.
Some women find it hard to get breastfeeding going after surgery. Some say it took their milk a long time to ‘come in’. Others say it was very uncomfortable at first, trying to manoeuvre the baby to avoid the scar. Medications that make you feel very tired and sleepy for a few hours after the birth can also make immediate breastfeeding harder. Your midwives should give you help and encouragement from the very beginning on this. But if they are not forthcoming, ask for help.
A skin-to-skin connection between you and the baby starts the suckling/milk cycle, so taking your shirt off and putting baby onto your skin as much as possible in the early days can help.
Different positions work for different women: many women find they breastfeed best lying down on one side, or holding the baby under one arm, in a ‘rugby ball’ hold. Ask your midwife to show these positions to you.
Use tons of pillows to prop yourself and the baby up, and to protect your scar. A semi-circular pillow that fits round your middle can really help.
There’s an old adage ‘once a caesarean, always a caesarean’ which, though wildly out of date, seems to hold some unofficial sway even now in many hospitals. There is a small risk your scar might rupture if you experience labour when you have already had one caesarean. But this risk is really tiny, if you labour in the right – safe – conditions. Part of the reason for this outdated attitude to VBAC (pronounced ‘veeback’) is that caesarean incisions used to be vertical or (‘classical’) – running up your womb. This kind of incision can sometimes open (‘rupture’) – during labour, and this can be life threatening for you and your baby. Nowadays, however, most incisions are horizontal (‘low transverse’) – running along your bikini line. A bikini line incision in the womb is massively less likely to come apart under the pressure of labour. Doctors also now understand more about what can cause a scar to break open than they did in the past. All of this means that nowadays, if you labour in the right conditions with care from experienced staff, the risk of ‘rupture’ is minute. VBAC is now much safer than it ever was. This is why the official NHS guidelines given to doctors and midwives say: ‘Pregnant women who have a previous caesarean section and who want to have a vaginal birth should be supported in this decision.’8
The slight complicating factor is that the scar you can see on your tummy does not tell you what kind of scar is on your womb. Doctors make two incisions to get the baby out: one to get to your womb and one in the womb itself. In British hospitals these days virtually all incisions in the womb are the ‘bikini’ kind. But in rare cases (for instance if your baby is extremely premature) the scar in the womb may be classical. This will be in your notes. If you are considering VBAC and are in any doubt about the nature of the scar on your womb, it is worth checking that it is a low transverse (‘bikini’) one.
It’s quite simple. Studies have shown that VBAC is, in the majority of cases, a very safe option. And a repeat caesarean has its own risks.
The Royal College of Obstetricians and Gynaecologists, and the American College of Obstetricians and Gynaceologists, support VBAC under safe conditions. In general, obstetricians are not concerned about whether you have the holistic birthing experience you’ve always dreamed of: they support VBAC because, under the right circumstances, it is not a dangerous thing to do. Indeed, according to the American College of Obstetricians and Gynaecologists, if you give VBAC a go, you have up to an 80 per cent chance of success.
The important thing is to get balanced information about the pros and cons, not emotive and off-putting comments. When I got pregnant with Sam, my obstetrician said I could have a ‘trial of labour’. But there were ‘conditions’ under which I’d have to pop that baby out:
This is a common list for VBAC mothers, and there are some good reasons for many of the criteria. You may be happy to know that there are limits that will stop you from suffering unduly during this birth. But then again, you may feel that restrictions like these are off-putting. It might help to understand why such safety ‘criteria’ are given.
My obstetrician’s explanations sounded terrifying: she talked about uterine rupture, scar ‘dehiscence’ (where the scar comes apart slightly), haemorrhage, brain damage to the baby, hysterectomy. Soon afterwards, I hired Julia. She was committed to getting me through this birth intact – both emotionally and physically – whether I had a caesarean or not. To do this, she knew I had to give VBAC my best shot in the safest possible conditions. Over the next six months, she helped me to better understand the reasons behind any safety measures (see below), work out how I would work with, not against, the ones that seemed restrictive or off-putting, and helped to build my confidence and knowledge about what to expect in a normal birth. She also encouraged me to plan what would happen should I end up in surgery again.
TRIAL OF LABOUR | You’ll hear the term ‘trial of labour’ or ‘trial of scar’ applied to your VBAC. Don’t be put off by this terminology. The idea is that doctors want to know that your labour is moving along well, so that there is little strain on your scar. The way they do this is to say that once you’re in established labour your cervix should dilate by about 1 cm per hour. You usually wouldn’t want to be in an active pushing stage for more than about an hour (as this may also put too much strain on your scar). If your labour does not seem to be progressing along these lines, doctors will then ask themselves why this could be happening, so you and your baby are not put at risk. They won’t be hanging over you with a stop-watch, but they’ll be aware of whether your cervix is, or is not, dilating. If the notion of being a watched pot concerns you, you should know that none of these limits are set in stone. If you are coping well in labour and there is no sign that your baby is in any distress, your doctor should not force you to stick to any rigid time limits against your will. As always, you can negotiate (talk to your obstetrician before you are in labour if the time limits worry you).
RUPTURE: THE FACTS | Uterine ‘rupture’ is a terrifying image for any pregnant woman to have in her head. But it is vital to understand the known risks. If your scar ruptures completely and you don’t get to an operating theatre on time, you or your baby can indeed die, or be damaged. But no birth is risk free (indeed, even a uterus that has never been cut can rupture). The chances of you experiencing a life-threatening rupture in a VBAC are extremely low:
One in 200 VBAC mothers experience uterine rupture of some kind. Not all ruptures, by any means, are life-threatening.
This one in 200 statistic does not distinguish:
You do, then, need to get that one in 200 figure into perspective. VBAC is something you should not dismiss until you really understand these risks and benefits. If you are giving birth with proper medical support, in – or close to – a decent hospital, your scar and baby will be monitored throughout labour and if a rupture happens, or looks like it might happen, you’ll be whisked into surgery.
GIVING VBAC YOUR BEST SHOT
VBAC success is most likely:
THE TOP FIVE VITAL COMPONENTS OF A GOOD VBAC EXPERIENCE ARE:
TALK TO YOUR MIDWIFE | She is absolutely KEY to your VBAC success. You should talk to her about it early in pregnancy and ask for any VBAC resources she has. After 20 weeks you should also see your obstetrician and talk it over with her. You want to understand all the risks and benefits of your VBAC.
HAVE A FEMALE BIRTH PARTNER (IN ADDITION TO THE BABY’S FATHER) AT THE BIRTH | Studies have shown that having a trusted female companion lowers your chances of caesarean (and other intervention). If hiring a doula is a possibility this is a good idea: they can be invaluable in a VBAC.
WORK AROUND FETAL MONITORING | One of the best signs of rupture is the baby’s heart rate speeding up and staying fast. (In about 70 per cent of scar ruptures, the first sign is a change to the baby’s heart beat.) This is why most hospitals will insist that you are hooked up to an electronic fetal monitor (EFM) throughout your VBAC. But the last thing you want is to be immobilised on your back like last time, unable to change position, walk around or use a tub for pain relief. You are more likely to need an epidural if this happens, and studies associate epidurals with slower labours and more medical intervention.
Ask if you can have EFM only once you are in established labour (so you can get labour going by moving around freely etc.).
You do not have to be on your back throughout the labour even if hooked up to a monitor. You can still move, sit upright, use beanbags, birth stools or birth balls, stand or rock.
Some hospitals may have monitors that use ‘telemetry’ and can let you roam free. Ask if yours has one.
NEGOTIATE ABOUT TIME RESTRICTIONS | Setting an artificial time limit on how long you labour for might lead to unnecessary interventions like ventouse or forceps. It is vital that you understand why any time restrictions may be imposed (see above). Talk it over with your obstetrician and come to an agreement with her that leaves you feeling confident and not under pressure to produce a textbook birth.
BUILD YOUR CONFIDENCE | Midwife Jenny Smith believes that ‘30 per cent of VBAC is confidence’. Many of us are told that the reason for our first caesarean might stop us having a VBAC. This isn’t always true. Failure to progress or ‘dystocia’ do not preclude VBAC. Many women who were told first time that their pelvis was too small to let the baby’s head through have gone on to give birth vaginally, often to even bigger babies. What to do: understand your previous birth fully and research any medical condition you had. If you had a caesarean during labour last time (even if your cervix did not dilate far) your womb is very likely to be much more efficient this time, even though you never got to push the baby out (my VBAC took 5 hours from start to finish).
AVOID AN EPIDURAL IF YOU CAN | Epidurals can also slow labour down – which may not be helpful in a VBAC, particularly if your hospital is twitchy about time limits. They can also limit how mobile you are, which is what you want to avoid as much as you can: movement and using positions that let gravity work can really help a birth progress. Lower abdominal pain between contractions can sometimes be an early sign that your scar may be having problems. An epidural can mask this. It is not a disaster if you have an epidural (particularly a mobile one, where you can stay upright), but do try and avoid it if possible.
FINALLY…. . | ‘Remember that you haven’t failed if you have a second caesarean,’ advises obstetrician Lucy Chappell. ‘Go into VBAC doing all you can to maximise your chances, whilst accepting that it’s OK if it does not work out that way. You have done the best you possibly could, for you and for your baby.’
OVERCOMING PRESSURE | When I was thinking about VBAC with Sam a few people said ‘Why not just have another caesarean?’ The implication was that it’s somehow making things difficult for yourself by avoiding the ‘easy option’. People can make you feel selfish, masochistic, or hippyish when you say you want a VBAC. Often this is simply because they have no understanding of the issues. Remind yourself (and anyone who insists on questioning or criticising you) that a caesarean – even a repeat planned caesarean – is far from easy, is not safer for you, and that VBAC, in the right conditions, with no contraindications, is considered by major medical organisations to be a safe option.
VBAC AT HOME? | Many women, having had what they see as one ‘negative’ hospital experience, are desperate to avoid replaying the same scene, so start to consider homebirth. If you are at low risk of uterine rupture (i.e. your scar is transverse and you have no medical complications) home VBACS are certainly possible (depending on why you had the first caesarean). But if you are thinking about homebirth consider what your home has that the hospital is not supplying, and find out if you can work around this with the hospital. It is crucial, if you choose to give birth at home this time, that you really have balanced the additional risks and benefits of this decision, that you live near a hospital (so can get to an operating theatre should a problem arise) and that you are attended by a supportive and senior midwife with a lot of experience of both homebirth and VBAC. This is vital.
MORE THAN ONE PREVIOUS CAESAREAN | It is still possible to have a VBAC, but most obstetricians will recommend that you have a repeat caesarean if you have more than one scar as your chances of rupture increase with each caesarean you have. Again, it’s up to you to weigh up your risks.
UNSUPPORTIVE HOSPITAL | ‘Your best shot at VBAC,’ says midwife Jenny Smith, ‘is to find a hospital that will give you good informed choice and will be supportive of you.’ The NHS is certainly a lottery in this respect. According to the National Sentinel Caesarean Section Report (2001), in some hospitals as few as 8 per cent of caesarean mothers are even offered a ‘trial of labour’. In this country the VBAC rate is currently only 33 per cent, but it ranges from 6 per cent in some hospitals to 64 per cent in others. What you can do: Ask your hospital what their VBAC approach is. If their answers are less than encouraging try to negotiate on individual points (see above). Ask if there are any pro-VBAC midwives who might take you on as a ‘special case’. Swap to a different hospital or, if you can afford one, consider hiring an independent midwife who will fully support your VBAC.
Online:
We have more information on VBAC on www.bloomingbirth.net
Vaginal Birth After Caesarean website: www.vbac.org.uk
National Childbirth Trust: www.nctpregnancyandbabycare.com
Active Birth Centre: www.activebirthcentre.com
International Cesarean Awareness Network: www.ican-online.org
It can be tough, if you have set your heart on a VBAC, to end up having a caesarean again. However, if you have done your research, sorted out supportive medical care and made conscious choices, and still you end up in surgery, you will – hopefully – be far more reconciled to it than you were first time around. You will also, if you follow our tips on making the surgery feel more like a ‘birth’ (see page), hopefully have a much more positive birth experience this time.
Julia knew one woman who planned meticulously for a VBAC. ‘Carmen informed herself and understood all her options. The same complications happened with her second baby that had happened before, but with one difference: she was informed and involved at every step. By the time she chose to have the caesarean, she had walked the hospital halls, used water for pain relief, been given a nice amount of undisturbed labour time and space (she knew to ask for that this time), been massaged, tried every position in this book and kept herself calmly informed about her progress. The caesarean happened for reasons she understood and agreed with, and because she had worked hard on her fear of another caesarean, she wasn’t panicked by the operation like she had been before. The birth was wonderful: Carmen didn’t miss a thing, breastfed immediately and had all the postpartum help she didn’t know to insist on before. She decided to call it an “EBAC” (Empowered Birth After Caesarean).’
If you have read the rest of this chapter, you will be able to weigh things up and make the decision that’s right for you and your family instead of just taking the path of least resistance. If you are still uncertain, try this:
INFORMING YOURSELF
Questions to ask your doctor:
Questions to ask yourself:
The risks associated with caesareans rise with each one you have, and increase more steeply after you have had about three. This is why most obstetricians advise women to stop having babies after three caesarean births. (Of course, in some countries women have seven or eight caesareans: it’s all about balancing the increased risks of the operation against your fervent desire to procreate.)
If your first birth was vaginal, and extremely difficult, you may be considering a caesarean because you see it as the ‘easier’ option. If there were problems with your first baby’s health after the birth, you may also want a caesarean this time. Your reasons might be perfectly valid. But the decision does require serious thought. So, before you decide for definite, make sure you have really examined the risks and drawbacks of surgery against vaginal birth this time. And make sure you have got all the information about what to expect with a second vaginal birth (see Chapter 3: Second Time Around).
NHS Direct is a good place to get some really basic information. Phone NHS Direct on 0845 46 47 or go to www.nhsdirect.nhs.uk.
NICE Caesarean Section Information for Pregnant Women A clear booklet from the NHS laying out basic issues, risks, benefits etc. of caesareans. You can get it from the NHS Response Line: 0870 1555 455, quote reference number N0479. Or you can download it from: www.nice.org.uk.
Caesarean Birth: Your Questions Answered by Debbie Chippington Derrick, Gina Lowdon and Fiona Barlow (National Childbirth Trust, UK, 2004). Answers questions that mothers frequently ask when they are told they may need a caesarean, and gives the information you need to make an informed choice.
The Caesarean Experience by Sarah Clement (Pandora, UK, 1995) Written by a psychologist, this book deals with caesarean emotions as well as the main issues.
The Caesarean by Michel Odent (Free Association Books, UK, 2004). Obstetrician Odent is credited, among other things, with ‘popularising’ water birth. This is an interesting look at caesarean issues today, including why so many of us have them.
Misconceptions by Naomi Wolf (Chatto & Windus, UK, 2001) American feminist writer Wolf, who had two caesareans, unpicks some of the politics and emotions of this way of giving birth.
The Thinking Woman’s Guide to a Better Birth (Perigee, US, 1999) and Obstetric Myths versus Research Realities: A Guide to the Medical Literature (Greenwood, US, 1995), both by Henci Goer. We’ve already recommended these books in Chapter 5, but they are useful resources when considering caesareans too.
The VBAC Ccompanion: The Expectant Mother’s Guide to Vaginal Birth After Caesarean by Diana Korte (Harvard Common Press, US, 1997) An American book, explaining risks and benefits of both repeat caesareans and VBAC. Also good on overcoming your fears.
Ina May’s Guide to Childbirth by Ina May Gaskin (Random House, US, 2003)
Birthing From Within: The Extraordinary Guide to Childbirth Preparation by Pam England and Rob Horowitz (Partera, UK, 1998)
Birth Reborn: What Childbirth Should Be by Dr Michel Odent (Souvernir, France, 1994) OK, it’s a bit dated, but this classic book really gave me a huge sense of hope, when facing my VBAC, that my body could do its job brilliantly under the right conditions.
Caesarean birth and VBAC information: www.caesarean.org.uk
International Caeesarean Support Network www.ican-online.org