Surgical birth

Pulling into the driveway of Catrina Girotti’s Toronto home I am struck by an unusual sight. In the back corner of the yard, among the overgrowth, lies a green birth ball. It’s deflated and dirty. I picture a woman in a fit of despair or rage flinging it from her bedroom window. She is trying to purge the intense feelings of loss that can come when the vaginal birth she so badly wants eludes her.

I am here to meet a small group of women who gather regularly, each of whom hoped for a vaginal birth, yet all gave birth by Caesarean. The abandoned birth ball, a popular tool for coping with labour, seems an apt symbol for their lost hopes.

Caesarean birth is probably the most difficult birth there is. Most likely the woman has already spent many hours in labour. Now she is facing major surgery, a birth done for her, rather than by her. She is usually the last person in the room to see her baby. She must wait for her abdomen to be stitched before she can hold or breastfeed her baby. And then she faces the challenge of recovering from surgery. Is it possible to have a positive birth experience when your baby is born by Caesarean section?

Acknowledge that it could happen
Girotti, Gisele Gallie and Wendi Gardiner know that the first step to having a positive Caesarean birth experience is to admit it as a possibility during pregnancy. Gardiner, who had a C-section because her baby was in the breech position (head up, bum down), acknowledges, “A Caesarean never occurred to me. If it was on TV I turned it off. There was lots I missed out on in my birth because I was so overwhelmed by the experience.”

Gardiner adds, “When the natural delivery went out the door everything went out the door. Had I considered the possibility of a Caesarean I would have been prepared to apply the pain-coping techniques I had learned to the situation I did have.”

Says Gardiner: “It would have been helpful to learn the statistics on how many women have Caesareans (20 to 25 percent in Canada) and what circumstances lead to it. Prenatal classes should acknowledge that it’s pretty likely you could have one.” Her advice? “Have the frame of mind: I’m delivering vaginally or having a Caesarean birth.”

Karen Weinthal, a childbirth educator at Toronto’s Sunnybrook and Women’s College Health Science Centre, includes information on Caesareans in every series she teaches. Her challenge is getting women to face the possibility of a Caesarean. “Women often have the impression that most Caesarean sections are planned and that it is unusual to have one in a low-risk pregnancy. That’s not true. And they generally avoid entertaining negative thoughts.”

Girotti acknowledged the possibility of a Caesarean birth when her friend’s fourth baby was born this way. Girotti wrote an extensive birth plan including a section on Caesarean birth. She advises, “If you think about the possibility of a Caesarean ahead of time then you can have a positive experience. Talk to people who have had a Caesarean and find out what did and didn’t work for them.” Girotti accepted a Caesarean after she developed a fever in labour and was advised that an infection in her uterus could spread to her baby.

What will the birth be like?
Sometimes women know in advance that a Caesarean may be necessary. There may a medical reason - a placenta lying over the cervix, active herpes lesions, a mother ill with eclampsia, a single baby or twins in a poor position for birth (breech or transverse). Much more often the reasons for a surgical birth develop during labour.

How, then, is the need for a Caesarean determined? Usually a couple is aware that labour is not progressing as expected. Their caregiver may have suggested augmenting it by rupturing the membranes or giving the hormone pitocin through an IV. If there is concern for the baby continuous monitoring of the baby’s heart rate will have been suggested, possibly with an internal monitor attached to the baby’s head. If the mother develops a fever, suggesting an infection in her uterus that could spread to the baby, she may be given antibiotics through the IV. All these actions will alert the couple that, while these interventions may be all that’s necessary, there is a possibility further assistance may be needed. In this situation, ask your nurse to explain procedures and the reasons for them.

If there is slow response or no response to these remedies then a conversation about a Caesarean may be initiated. Keep in mind that a slow labour with no sign of distress in the baby or mother may only require patience. Usually there is lots of time for questions. Women are always entitled to ask for more time before a decision is made or to refuse consent for recommended procedures. Alternatively, when the women themselves feel great anxiety about their labours or babies, they may be the ones to initiate discussion about a Caesarean. Sometimes a woman exhausted or discouraged by a long labour will ask for options.

Gisele Gallie laboured for 36 hours at home before going to the hospital. There the doctor recommended a Caesarean, but also offered the option of first monitoring her contractions and the baby’s heart rate, then augmenting her labour with pitocin. While her support people encouraged her to continue labouring she and her partner put their trust in the doctor and agreed to the surgical option. Gallie feels she made the right decision.

Even while a woman grasps the rational argument for a Caesarean she may need time and support to come to terms with it emotionally. Her partner can hold her while she cries and listen to her while she expresses her fears and disappointments. Ask the nurse to explain what pain control will be provided, what procedures are necessary and what to expect physically. While still in the labour room, couples should bring out their birth plans (See, “Your Caesarean Birth Plan”). Their nurse can help communicate their requests to other medical staff.

Gardiner was surprised and disappointed when she was moved into the operating room and her husband was told to stay behind. “He was in the hall for 45 minutes before he was invited into the operating room.”

Gallie, on the other hand, looked at this period positively, relieved to be away from the conflicting advice of her support people. “I needed to be by myself and get peace with myself and my decision.” During this time her belly was shaved and a catheter inserted into her bladder.

She appreciated her anaesthetist who performed the epidural procedure, monitored her pulse and blood pressure, and explained what was happening during the surgery. “He reassured me.”

What else helps a woman find comfort during the procedure? Of course the reassuring presence of her partner. Gardiner also remembers, “They put a warm towel on my head to reduce a reaction of shock.”

Once the surgery begins it’s just 15 minutes before the baby is born. None of the three women saw their babies emerging from their bodies and all regret that the screen between their upper bodies and their bellies was not dropped. Gallie explains, “I would have liked to have seen her immediately. I wanted to see that she was healthy.”

Both Gardiner and Girotti planned to take photos of their birth but Girotti was not permitted to. Gardiner’s husband kept to their plans. She explains, “My husband peeked the video camera over the curtain. It’s nice to go back and look at the video.”

Gardiner describes what happened next. “They brought Ethan over to the warming unit and swaddled him and then brought him over to us. I think it was really wonderful that he didn’t leave the room.”

Your hospital stay
Parents can remain together in the surgery room, usually with the baby in the father’s arms, while the mother’s abdomen is stitched back together, a procedure that takes about 40 minutes. During this time the father can unwrap the baby to allow mom to give skin-to-skin contact. Some parents will save this moment to discover the sex of their baby. Then the new family is moved to a recovery room, unless the baby has already been taken to a special care nursery.

Gallie remembers the challenges of caring for herself and her baby after surgery. “You can’t get out of bed by yourself afterwards. Next time I would plan in advance to have someone spend the night with me, a fresh, well-rested person who was not part of the birth. Someone to help me to the washroom, bring me the baby and change the diaper. That first night was my biggest problem.”

Girotti adds, “Make it clear if you don’t want your baby supplemented. If your baby is in the nursery ask the nurse to bring your baby to you for feedings.”

By the next day women are usually able to care for their babies more independently. Caring for themselves is also important. Those who’ve been there advise women not to be afraid to get out of bed (with help at first). Your body heals better with lots of oxygen so breathe deeply all the way down to your abdomen. And consider Gardiner’s experience: “I think walking speeded my recovery.”

Three or four days after the birth most women head home. Before you leave the hospital find out how to take care of your incision, when to take the tape off and how to recognize an infection in your incision. Know whom to call to answer your questions.

Remember that surgery compounds the fatigue of having a new baby. Ensure that you have help at home to prepare meals, do laundry and assist you in caring for the baby.

Coming to terms with a surgical delivery
Some women accept their Caesareans easily. Brenda Cohen* is one of them, “The Caesarean was a very positive experience for me.” She learned that her baby was in a transverse position (lying across her body rather than head down). “I had 24 hours to deal with the fact that I was probably going to have a Caesarean. That time made all the difference in the world. I talked to my doula and family a lot that day. I read all the chapters in my books about Caesarean that I had always skipped before.” Cohen’s water broke late in the evening. She kept her birthing team together. “My doula was just as important as in my previous vaginal birth. She interpreted for me and my husband.” Her family doctor, who would have delivered the baby if born vaginally, agreed to be there in the middle of the night. Cohen and her doula discussed her experience later. “My doula wrote up my birth story just as she did in my previous birth. The written birth story validated that my Caesarean was still a birth.”

Cohen adds: “I didn’t feel cheated in any way because I had a wonderful vaginal birth the first time with no medication. This birth was over in a short time and I could sit down afterwards - no stitches, swelling or hemorrhoids.”

Cohen even enjoyed postpartum more. “The good thing about the Caesarean was that I got maternity care and post-operative care. I got to stay in hospital for four days. The first week was easier because I got the attention I needed.” Cohen, as a second time-mother, this time recovering from surgery, found her attitude was different as well: “I would never have let my first son go to the nursery for a few hours when I was exhausted.”

Not every woman processes her Caesarean birth so easily. Bonnie Annis had two Caesareans and now, as facilitator of The Birthing Circle in Oshawa, Ontario, helps women learn to reduce their chances of having a Caesarean as well as deal emotionally with the experience of one. She says, “It’s okay to rejoice in the birth of your baby while mourning the loss of your birth. Don’t let anyone take your right to mourn away from you. There’s no schedule for healing. People cry years later.”

Sadness is not the only emotion women experience. “I felt like I didn’t do a job and I wasn’t part of the vaginal birth club. I felt ripped off. I’m jealous of other women who had labour,” explains Wendi Gardiner.

Annis says anger is a common emotion even when one believes, as she does, that her Caesareans were necessary. “I am angry with the universe. At the same time my births made me who I am.” She advises, “Every pregnant woman should read Silent Knife, a revealing book about women’s experiences of Caesareans. It tells it like it is. Men whose wives have had Caesarean births should read it to understand the full emotional and physical impact of Caesareans. Bookmark some of the pages for your partner. For men the Caesarean is the end of the pain. They get the baby.” For women the emotional aftermath remains.

Talking with other mums who had Caesareans helps. Girotti, Gallie and Gardiner got everyone’s phone number in their prenatal class and called one another afterwards. Says Gallie, “I feel fortunate that Catrina, Wendi and I have become a support for one another.”

Girotti insists, “You’ve got to talk about it. And joke about it.” At their first meeting after their births they bared their scars and compared them, then named their group, The Cut Above.

Beyond the importance of the birth experience, everybody acknowledges the bottom line, as expressed by Girotti: “The most important thing is a healthy baby. The second most important thing is that you are as unscathed as possible, physically and emotionally.”

As I leave Girotti’s home, I muse on the mystery of birth. Looking back across the yard at the birth ball I am reminded of the path they expected to take and of how very different their journey was.

I want to share with them a passage from Silent Knife:“Cesarean mothers ... are courageous women who are willing to be cut apart for the lives of their infants. Perhaps it is time to congratulate yourself for your strength and courage.”

*Name changed by request

Resources

Ended Beginnings: Healing Childbearing Losses by Claudia Panuthos & Catherine Romeo, Bergin & Garvey Publishers, 1984.

Silent Knife: Cesarean Prevention and Vaginal Birth After Cesarean (VBAC) by Nancy Wainer Cohen & Lois J. Estner, Bergin & Garvey Publishers, 1983.

The International Cesarean Awareness Network (ICAN) has a newsletter and annual conference. Visit the Web site at www.ican-online.org or write ICAN, 5990 Beaman Old Creek Rd, Walstonburg, NC, 27888, USA

The Birthing Circle (a chapter of ICAN) is a support group for pregnancy, childbirth and new parenthood. To contact them, email bcircle@home.com or call (905) 576-1833. They will provide phone support for anyone who calls.

Your Caesarean Birth Plan
Bonnie Annis is a facilitator of the Oshawa, Ontario support group, the Birthing Circle and mother of three, the first two born by Caesarean. She recommends that women have a separate section for Caesarean birth in their birth plans. “Remember that it is still your birth. It’s your baby and your body. Stand up for the type of environment you want just as you would with a vaginal birth.”

Below are some topics you may wish to include in your Caesarean birth plan.

Scheduling If you know in advance of labour that your baby will be born by Caesarean, discuss the timing with your doctor. There are several advantages to waiting for labour to begin. It is more likely that your baby will be born full term, you will experience at least some labour, and labour benefits the baby by preparing the lungs for life outside the uterus. However, there may be more pressing health reasons that would make waiting for labour inadvisable.

Time to adjust If the reason for the Caesarean develops in labour, Annis advises that you take time to ask questions. Caesareans are rarely emergencies. “There’s time to think about it and cry about it. Then talk about ways to make it better.”

Anaesthesia Find out what pain relief is available in the hospital. Regional anaesthesia (spinal or epidural) is safer than a general anaesthetic for pregnant women and allows the mother to be awake for the birth of her baby.

Incisions Ask your doctor about the type of incisions in both the skin and in the uterus. Both can be vertical or transverse. For aesthetic reasons women often prefer a skin incision to be transverse (called a bikini cut as it runs just at the top of your pubic hair and won’t show if you wear a bikini). A low transverse incision in the uterus usually heals well so that the uterus is strong enough for a future vaginal birth.

Other procedures Often pubic hair is shaved where the incision is to be made. Shaving may increase the risk of infection and hair growing in makes the area around the incision itchy. The incision may be closed with stitches or staples. Ask your doctor about the advantages of each.

Presence of support team Usually women are separated from their support people while they are being prepared for surgery. Ask about remaining together. Often only one support person is allowed to attend the Caesarean birth and only if you are awake. Decide in advance who that person would be. You may state in your birth plan that you’d like your doula or another family member to attend.

Explanations Ask someone who can see to describe what is happening. Usually the anaesthetist who is standing by your head will do this for you.

Seeing the birth You may want to ask the obstetrician to lower the drape between your upper body and your belly so that you can see the birth of your baby. Adjusting mirrors in the room may also be a possibility.

Contact with the baby Ask that you be allowed to see your baby as soon as possible after the birth. Your partner can hold the baby against your cheek so that you can feel her. While some babies need special care after the birth and are taken to the nursery, you can insist on seeing your baby first, even for a few seconds. It may be hours before you are mobile enough to get to the special care nursery yourself.

Personal touches If you wish to take photos or make a video of the birth, ask hospital staff for permission. Decide who you want to announce the sex of your baby: the doctor, your partner or you when you are able to see for yourself. Play music of your choice. After you are stitched up, you can ask to see the umbilical cord and attached placenta that accompanied your baby in the womb.

Breastfeeding Your birth plan should include information about breastfeeding your baby in the event of a C-section. A few women have been helped to breastfeed their babies while being stitched. Most babies go with their mothers to the recovery room after the surgery is complete and feed there. Ask for help in breastfeeding your baby. If your baby needs to go to the nursery make it clear whether or not you want your baby to be supplemented.

Hospital postpartum Who will help you breastfeed, change and soothe the baby, as well as help you to the bathroom as you are recovering from surgery? Ask a friend or family member to plan to stay the first night with you in hospital if your baby is born by Caesarean. (Your partner may be too exhausted after a long labour.) Alternatively, you may ask the staff to take your baby to the nursery for the night and bring her to you for feedings.

Annis, while acknowledging that many of your plans may have to be surrendered in a Caesarean birth advises, “Have a bottom line. Know what is most important in your Caesarean birth plan.”

Emotional Recovery:
What helps?

Women who give birth by Caesarean need both physical assistance and acceptance of their emotional responses. “People only want to pay attention to the baby, but you’ve just had major abdominal surgery. If I’d had appendicitis more people would have helped me to the bathroom. What would help is if people would bring meals to your door and ask, “What do you need to help you get better now?” says Catrina Girotti.

Women feel excluded because they did not have a vaginal birth. Brenda Cohen explains, “When you say you’ve had a Caesarean section, no one asks you any of the details. I ask now.”

Bonnie Annis finds it particularly annoying when people say, “Look, it’s a Caesarean baby. What a beautiful round head.” She asks, “Who cares? It doesn’t make up for anything.”

Girotti suggests people respond this way when they learn a women has had a Caesarean, “I’m really sorry you had a Caesarean. It must have been tough. I’m glad your baby is okay and I’m glad you’re okay.” Like other women, Girotti feels angry when she says she’s upset by the way her birth went and people tell her she should just be glad she has a healthy baby. “Don’t invalidate my feelings,” she responds.

Wendi Gardiner’s partner is sympathetic but she admits, “I don’t think that he sees the magnitude of the disappointment that it was. To this day I think he looks at me like I’m daft because I still cry very easily about it.” Partners may be surprised by how often women want to review their experience. The partner’s role is to listen, and accept that for many women processing a complicated birth can take a long time.

It’s not easy to accept the physical scar left by the incision but others can help. Girotti says, “You need your partner to acknowledge that it hurts and will leave a scar. My husband said, ‘I’m going to see that scar and remember for the rest of my life that that is where the baby came from.’ I really liked that.”