Preparing for Caesarean

The following is an excerpt from The Birth Map: boldly going where no birth plan has gone before

The medical terms used to describe pre-labour caesareans are ‘planned’, ‘elective’ or ‘scheduled’.  Any in-labour caesarean is deemed an ‘emergency caesarean’.  However in the interests of clarity, there are degrees of urgency.

From ‘Pregnancy, Birth and Baby:

There are four categories that describe the urgency for caesarean section:

• Category 1 – immediate threat to the life of the mother or baby
• Category 2 – there are problems affecting the health of the mother and/or baby but they are not immediately life threatening
• Category 3 – the baby needs to be born early but there is no immediate risk to mother or baby
• Category 4 – the operation will take place at a time that suits the woman and the caesarean section team.

Most emergency (that is – in labour) caesareans are Category 2 and mostly are done about an hour after the decision is made. Life threatening Category 1 caesareans aim to be done within 30 minutes.

In a Category 1 emergency, there might not be time to give you an epidural or spinal block. You may need a general anaesthetic, although this is rare. When you wake up you may feel dizzy, nauseous, and you may have a sore throat.

Your baby may need to spend some time in neonatal intensive care.

This terminology, however, is very limiting, and when determining our pathways, we need more detail.  For the purposes of birth mapping, there are four pathways for caesarean:

Before labour non-emergency

Before labour emergency

In labour non-emergency

In labour emergency

These are not the terms used by medical care providers.  I have based this terminology on Michel Odent, as it provides greater clarity and ability to determine the best pathway for your situation. 

In addition to the following general caesarean questions, each pathway requires different considerations.   Being aware of the differences and having an ‘if this, then that’ set of instructions can reassure you and your birth partner if these pathways present themselves unexpectedly.  At this point, your focus is to understand the options and the circumstances where these options are considered.

These questions can be applied to all caesarean preparations:

Who will be in attendance?

If a separation is required, who will be with you and who with the baby?

If circumstances permit, will you have skin-to-skin?

Will the cord be left attached to the placenta (for a time determined by you)?

Are you aware of any other options available?

Did you know a doula can support a caesarean?

You may find it helpful to source positive stories about caesarean to help minimise any trauma you may experience in the event of an emergency. It is also helpful to know that breastfeeding after a caesarean is possible.

For many women, the experience of a caesarean is less than positive. Part of this is because they feel they are no longer ‘needed’. This can negatively impact their ability to bond with and care for their baby. One way to help overcome this problem is to include the mother in the caesarean. Maternal Assisted Caesareans (MACs) are possible and appeal to many. When an image from a MAC is shared on social media, it is clear how universal the appeal of this approach to caesarean is.

Supporting women to be actively involved in their birth increases their power

The option of MAC will depend on the surgeon and policies within the facility. Even when MAC is impossible, a caesarean can be respectful and woman-centred.

MACs are planned with the surgeon, which means it is likely only possible for ‘elective’ caesareans. ‘Elective’ does not always mean wanted; it simply means that you have time to prepare and know the reason for it in advance. An ’emergency’ caesarean means it was performed after labour started. There may be some circumstances after labour has started where a MAC or mother involved is possible.

Before labour non-emergency

A ‘before labour non-emergency’ caesarean usually involves preparing for the surgery and recovery as your Expected Pathway. This will be termed ‘planned’, ‘elective’ or ‘scheduled Caesarean’. 

Depending on the circumstances surrounding this decision, you may have the option of a ‘maternal assisted’ or a more gentle approach.  

If you have known issues, your Birth Map will include your preparations for these.  For example, investigate what this will mean if your baby (or babies) will be in the NICU.  You may wish to look into prenatal expressing of colostrum, premature birth, kangaroo care, donor breast milk, expressing milk, and connect with other parents who can support and mentor you. 

Before labour emergency

If a medical urgency arises, there may be no, or very little, time to prepare properly. This scenario is not one we like to contemplate or dwell on, but taking a little time to understand this pathway as a Contingency and knowing where to seek support and information can ease the distress that will be felt at this time. 

You can do some things, including general contingency preparations, such as determining what you will do if mother and baby are separated and knowing your support network for the care of older children and general support.  Some women affirm the importance of skin-to-skin, breastfeeding or expressing colostrum as soon as possible.  Including a contact number for an additional support person can be reassuring if you need this contingency.

In labour non-emergency

Choosing to have a caesarean over an augmented birth will be a decision made in the moment.  Taking the time now to understand the risks and benefits of each option allows you to remain calm and make an informed decision at the time.

Michel Odent argues that in some cases, it is better to opt for an ‘in-labour non-emergency caesarean’ over augmenting a slow labour. If labour seems ‘stalled’ or progress is slow, Odent suggests that the birthing woman should be offered a quiet bath for two hours to determine the best option. If, after that time, she has made no progress, the chances that she will end up with an in labour emergency caesarean or an assisted birth is very high. At this point, the woman can opt for an ‘in-labour non-emergency caesarean’. In this case, the baby is fine, and there is no urgency. You may be able to opt for a ‘gentle approach’.  It is also possible that this scenario is a planned caesarean to be performed after spontaneous labour. 

In labour emergency

An in-labour emergency caesarean means an urgent problem with the mother and/or baby. Unlike the previously discussed in labour non-emergency caesarean, the need to act quickly will be apparent.  There are fewer options here, and separation from the baby is more likely. It is important to consider this ‘what if’, as this is one scenario where on-the-spot decisions are required. Considering them as a ‘what if’ will help avoid unnecessary stress.

In particular, you may wish to state in your Contingency Pathway whether or not permission is granted to express colostrum from you if you cannot do so yourself.  You may stipulate that your partner is to be guided in this, that your midwife is to do it, or that under no circumstances should this happen.  If the baby can, you may stipulate that skin-to-skin contact and assistance with direct breastfeeding be facilitated.

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