Planning your caesarean

There is a lot to do when planning any birth and this includes a caesarean. The procedure will not be booked until you reach approximately 30 weeks and at this point there are still lots of questions to ask, a birth plan to prepare and preferences to agree.

Questions to ask

These will be personal to you and you should create as full a list as you think necessary. Try not to feel intimidated once in front of the health professionals. They do this every day, you do not, so it is reasonable for you to ask lots and lots of questions. If you are not satisfied with the answers that you are given, keep asking the questions until you are. Subjects you may want to ask about are:

• Hospital policies on caesareans, including the scheduling of the procedure
• Anaesthetic options available
• The hospitals specific approach to the whole procedure, including pre-incision antibiotics
• How you will first meet your baby
• The fine details relating to your birth plan

What is a birth plan?

A birth plan is a document that is created by the mother and birth partner and is an important consideration for any type of birth. It is not mandatory but it is a useful tool for ensuring that you have discussed all your hopes and requirements with the health professionals who are going to be looking after you. This is particularly important if you have any requirements which are not general practice i.e. determining the sex of your baby yourself, lowering the screen to see the moment of birth, viewing the placenta etc.

Women should be encouraged to define a birth plan as an essential part of preparing for birth. However, in doing so you should not assume that somehow preparing such a plan will ensure that you will get the exact birth that you want. Every birth progresses differently and the best laid plans may need to change as events change during labour. Unplanned caesareans do happen for a wide variety of reasons. Indeed all forms of medical intervention occur far more often than not. The Association for Improvements in Maternity Services (AIMS) has found that by its definition of a normal birth (no medical intervention of any sort), only 1 in 6 first time mothers achieved a spontaneous vaginal birth. Medical intervention (including one or more of the following: induction, artificial rupture of membranes, a caesarean section, general anaesthesia, forceps and/or ventouse, epidural anaesthesia or an episiotomy) occurred in the other 5 34.

Preferences to consider for inclusion in a caesarean birth plan

• State you wish to have a caesarean. Simply asking for a caesarean is not necessarily going to guarantee one unless there are clear medical indications. Where there is no medical indication, you will need to have good reasons and be prepared to fight your corner. In the UK caesareans are usually schedulled in week 39 or later. There is quite a lot of evidence to suggest that delaying as late as possible reduces the risk of respiratory problems for the baby. 106 The principle being that the necessary hormones and process are in place and the baby is expressing it's readiness to be born and therefore the mother's body is also prepared for delivery. If you wish to delay the caesarean until your labour has started you really must agree this in advance
• Specify that you wish to have your birth partner with you at all times. This is standard practise in the UK (with the exception of a general anaesthetic caesarean procedure), but it is worth checking to be sure
• If you do not wish to have a catheter, you should state this in the plan, but make sure you understand the advantages of having one over not having one. Alternatively if you are planning to have a catheter it is worth specifying that you want to have it inserted after the epidural has taken effect. This is because the procedure can be mildly uncomfortable and it is not necessary to have the catheter inserted prior to the epidural
• Specify the type of pain relief, but only following detailed discussions with your anaesthetist. In particular specify if you do not want a general anaesthetic. There are instances where it might not be possible to avoid one, but in general your wishes will be respected and it is not common practise in the UK. It is better (for monitoring both you and your baby during the surgery and recovery afterwards) to remain conscious during the caesarean. A combined anaesthetic can achieve this and allow for the anaesthetic to be topped up should that prove necessary
• Specify that you do not want to have your arms strapped down or restricted during surgery. This is not common practise in the UK but does occur in some hosptials. It is an unnecessary practise and worth mentioning that you do not want this to happen to you
• Specify whether you or your partner wish to cut the cord. Make sure the surgeon is aware of this in advance so that they leave the cord long enough
• Discuss when the cord will be cut. You may need to specify that there is a delay in cutting the cord. The policy on when to cut the cord varies from one hospital to the next. So this is something that really must be agreed with the team before the procedure commences. Research has not been able to say definitely whether there are any significant benefits to early or late clamping. "One recent review showed that delayed clamping resulted in a decreased need for blood transfusion and lower risk of haemorrhage. Other studies didn't find either approach to be vastly superior. Some studies have found that a slight delay in cord clamping is beneficial for preterm infants. Late clamping improved the blood count and iron status of the babies and reduced the risk of anaemia." 108
• Discuss the possibility of wrapping the abdominal organs prior to closure. It is possible to use materials such as Seprafilm (traditionally used in USA in hysterectomies etc.) to wrap the organs during the procedure. The purpose of these materials (which gradually disintegrate) is to prevent scar tissue attaching itself to other organs in the vicinity. This material is not in common use in the UK, but you may wish to discuss it's potential with your consultant. It is being used increasingly in abdominal surgery in the US.
• The screen, which is there to obscure your view of the surgery, can be lowered slightly at the point of delivery so that you can see your baby being lifted out
• To have the screen and your gown positioned such that you can have skin to skin contact at the first opportunity. Once your baby has been checked and all is well there should be no reason why your baby cannot be placed on your chest for the remainder of the surgery.
• To be allowed to breastfeed in the recovery room should you feel well enough to do so. Some women have even breastfed during the final stages of surgery, though sometimes the screen is too far up your chest to make this possible. Breastfeeding is actively encouraged in the UK so it is reasonable to assume that any pain relief that you are given is compatible, but if you are worried about this ask about it
• Whether your birth partner is to be present at a caesarean birth. Only under a general anaesthetic will the hospital discourage this. In all other instances it is your right. Your birth partner is there to hold your baby (preferably skin to skin) and talk to you during the remainder of the procedure. In some hospitals a second person is allowed to be present with you if that person is a doula
• If you want to see the placenta make sure staff are aware of this, it is not standard practise to offer you this choice
• Specify whether you would you like to wear your own birthing clothes and use your own pillow
• UK guidelines 27 state that the placenta should be removed using controlled cord traction and not manual removal (as this reduces the risk of endometriosis) you may want to check that this is going to be the case for you
• At the moment of birth, you may wish to ask for a quiet and intimate environment, dimmed lights with no unnecessary noises
• Whether you wish to have your baby passed to you before he / she is taken away to be checked. This is more possible with a straightforward elective caesarean. Some medical indications may not make this possible on the day, it may be more important that they baby is checked out first. In most cases your baby will remain in the same room while he / she is being checked but you may want to confirm this in advance
• Whether or not you wish to discover the sex of your baby yourself. This is increasingly common. Your baby will be passed to you or your birth partner and you can check for yourself
• Anyone you do not wish to have present, i.e. students
• Whether or not you wish to have photographs taken at the moment of delivery and while your baby is being weighed etc. You might want to consider having a black and white film
• If you want specific music to be played during your time in theatre
• Specify that your baby stays with you at all times once back on the ward. This is normal practise in most UK hospitals, assuming that there are no medical issues for you both, but it is worth confirming
• If you do not want your baby to be given any formula (even if you are sleeping) you need to specify this. Repeat this when shifts change if necessary. Staff may think they are helping your recovery by not disturbing you. This instruction can extend to if your baby is in a special care unit. In this case you can express milk for your baby
• You may want to request a private room for most of your stay in hospital. Most hospitals will not allow you to do this in the first 24 hours, as they need to keep a very close eye on you and prefer to do this on the ward. However it is worth requesting one after that. Bear in mind that these rooms are limited and there is often a fee associated

Flexible Birth Plans

Birth plans are excellent for helping you to think through many of the issues surrounding the birth of your baby. The plan is there to show your preference. However "preference" is the important word here. Circumstances may arise which mean that at the last minute it might not be possible for your preference to be accommodated.

The more flexible your approach to your birth plan, the less likely you are to have an extreme, negative reaction to your overall birth, in the event that it deviates from your original plan. For example, incidents arising during a vaginal birth may mean that medical intervention (forceps or ventouse) is required. If you have prepared for this your birth plan can make statements about how you would like staff to proceed in the event of such intervention i.e. ventouse without an episiotomy and no forceps. It is possible that, in the event of an emergency, you will not have time or feel able to work through the issues before deciding on a course of action. The same is true for a caesarean.

"If women are well prepared during pregnancy, then they are more likely to have realistic expectations of the levels of pain, less likely to feel a failure and have increased confidence, which in turn can lead to more a positive experience. Women may have ideal hopes of what they would like to happen, but they need to be educated or informed to ensure that they are prepared for what might actually happen and give them the tools to deal with this." 109

Research suggests that regardless of mode of delivery, 2% of women may have such negative reactions to their delivery that their symptoms register on the Post Traumatic Stress Disorder scale 91. And in the case of emergency caesarean delivery as much as a third of women may experience "intrusive stress reactions" 92. Such studies serve to reinforcing the importance of understanding the caesarean procedure and developing an open-minded and flexible birth plan when preparing for birth. There are so many things that can be specified that will help make an unplanned caesarean a more positive experience.

Nowadays UK guidelines 27 are quite strict about the practises in theatre and your rights in particular. Being aware of these will help you, both in preparing your birth plan and on the day, should circumstances change.

Preparing yourself mentally

Robert Oliver writes in The Ideal Caesarean Birth: "When it is known in advance that the birth will be a caesarean, the ideal caesarean birth will include emotional as well as physical preparation of the mother before she 'goes under the knife'. She must fully explore her feelings about and fears of the operation and recovery. She must identify with the operation and 'own' the procedure and see it as the means for her transformation to motherhood, not as a failure of herself or of her womanliness." 125

Discussing the issues described in the section on birth plans will help you cover most of issues surrounding caesarean birth. If you still feel apprehensive you may wish to try hypnosis or meditation techniques to help copy with any worries before hand. These techniques can also be used to help you on the day.

"Removal of fear by combining education with experience of progressive alternative states of consciousness prepares the woman, her intended child and the support family to create an ideal caesarean birth regardless of the medical model or hospital environmental conditions they may encounter." 125

Preparing your home

• There are a number of things you can do to make your time easier in the first days at home. Think about putting everything that you and your baby might need on the same level in your house so you don't have to go up and down stairs continuously.
• It is worth having the cot or moses basket prepared in advance if your baby is not going to sleep in bed with you.
• Make up the changing station and consider having more than one, particularly if you house is on more than one level.
• The pram and car seat are essential if you want to start taking any form of mild exercise. A papoose might cause a bit more strain on your abdomen in the first week or so but is generally a comfortable way to carry your baby around even after a caesarean.

Things to take to hospital

In addition to all the nappies, baby clothes, blanket, muslins, wipes etc. that your new baby will need, take things for yourself:

• It is usual to be "Nil by Mouth" prior to an elective caesarean, (though an emergency caesarean can still be performed if you have eaten). Once back on the ward you can snack so take in drinks (in particular peppermint tea bags to help with trapped wind) and any homeopathic remedies that are compatible with breastfeeding. Meal times do not necessarily follow your usual pattern, breakfast is often early, so healthy snacks of fruit and high energy sweets might prove essential
• Disposable pants or large "belly warming" pants are essential following a caesarean as their elastic line is well above the incision site. The incision site may feel rather sensitive for a while and elastic will irritate it
• Maternity sanitary towels, extra long to accommodate the fact that you will be lying down for longer periods of time
• You wont get to a shower for at least the first day so wipes for your face are a good idea because you start to feel a bit dishevelled after a while
• Breast pads and the all important nipple cream. Using a cream such as Lansinoh from the first day is a good idea if you hope to avoid cracked nipples
• Comfortable clothing, slippers, nightwear and dressing gown all of which are loose round the waist and hips and of course your new feeding bra. Avoid dresses unless they are specifically for breastfeeding. You will still feel about 6-7months pregnant in the first few days after your birth and so you should not expect to fit into anything fancy (unless you buy it in larger sizes)
• Don't forget your maternity notes