Positive Caesareans

Breastfeeding can be difficult to establish however you give birth. Even women who have had a straightforward vaginal birth can experience challenges. The stress of an unexpected caesarean birth can undoubtedly make things feel more challenging for some, but the proceedure itself does not prevent breastfeeding.

When breastfeeding following a caesarean, the main thing to think about is protecting the incision area as bruising around this area can leave you feeling tender for a week or more. Learning alternative breastfeeding positions to the well known cradle position we typically see in antenatal class and in the media, can make feeding feel that bit easier.

There are two other positions you might like to consider:

– Side-lying puts you and your baby on your sides next to each other, this way your incision is less easily kicked. And a folded handtowel over the incision area can help protect you from wriggling feet

– The football hold is a seated position and involves you holding your baby to one side of your body, rather than across your body, again protecting your incision. A few pillows can raise your baby to the correct height, making this position very comfortable – it is also easier for managing your baby’s latch in the early days of learning to feed as you have both arms free.

The more traditional cradle position actually works perfectly well for many women following a caesarean, particularly after incision site bruising has reduced. But it is worth learning the alternatives to help you in the early days.

If you are experiencing challenges with feeding, talk to your health visitor, find out about local breastfeeding support groups and talk to other mums. Just one new idea from any one of these might be the thing that makes all the difference for you and your baby. Remember too, if breastfeeding is not working for you don’t beating yourself up, acknowledge you have tried and switch to a bottle. It is far better your baby has a confident, happy mum than one who is stressed out from pain or negative feelings.

Caesareans are blamed for all sorts of things: childhood obesity, autism and food allergies to name just three. Time and again research finds against such claims, but this doesn’t make for good headlines. So we are left with the myths spinning around in conversation and for many of us, it is on the back of these that we attempt to make our birth choices.

Last year an Australian study concerned about the rise in infant food allergies decided to evaluate whether there was any truth in the idea that caesareans increase the risk of an infant developing food allergies. They considered whether the caesarean was an emergency or elective, and whether it was prior to labour commencing or not. Regardless, of the 2045 births assessed, they found the incidence of food allergies to be almost identical across mode of birth:

• Caesarean delivery – 12.7% infants with food allergies
• Vaginal delivery – 13.2% infants with food allergies

If anything there is a fractionally higher incidence in food allergies with vaginal deliveries.

While caesarean babies do not have the same level of exposure to the mother’s gut and vaginal bacteria, this “doesn’t appear to play a major role in the development of food allergy.” Associate Professor Peters

What does this mean for Mums?

One of the things we frequently worry about as we try to make choices about our birth options is all the science telling us one way is better than the other. There are of course pros and cons to both modes, and what we really need is accurate information, not myths.

And for those mums facing an unwanted or unplanned caesarean intervention this new knowledge may help to allay at least one fear, making for one less thing to worry about.

Of course, everyone’s recovery experience is different and it depends on a lot of factors:

• The amount of help at home
• How much you listen to your body and take recovery at your body’s pace rather than any other arbitrary schedule
• How active your other children are
• How your birth went on the day
• How you are managing with breastfeeding, or not
• How baby (and you) are sleeping

Any one of these can, at times, throw a bit of a spanner in the works. Something that felt manageable yesterday, can, after a sleepless night, feel insurmountable.

For example: carrying your baby upstairs may feel daunting today simply because you went up and down stairs too many times yesterday, when (after a day of taking it a bit easier) tomorrow you will be fine again.

The good news is, there are lots of things you can do to assist your recovery but perhaps the most significant is to listen to your body!

A slight twinge should be viewed as an indicator to change how you are doing something or indeed refrain from doing it (or do it more slowly). And remember  the regime of pain medication may well be masking some of the warning signs, so treat any twinge as a signal to slow down.

However, before you go into hospital, there are a few things you can do which can radically improve your recovery chances:

• Get everything on one level e.g. the changing area (with all relevant supplies) on the same floor as the one you are going to spend most of the day on (at least for the first few weeks). Perhaps ask your partner to replenish the stash before they head off for the day, in the early days it is important you limit the number of times you go up and down stairs
• Enlist the help of others, perhaps have a rota for family and friends who can pop in to lend a hand. It is worth spelling out ahead of time that if they visit, they are coming to help, (and that is not mean just cuddling the baby), they are not there to be waited on by you. It is even ok to go and have a nap while they watch baby for you
• Organise car sharing for the activities older children may be still participating in. You should not drive for 6 weeks (insurance can be invalidated by abdominal surgery), so you are going to need someone else to take your other children to swimming lessons or football practise. Planning this ahead of time when you can still do your share of carpooling takes away any pressure or guilt you might feel
• Manage the expectations of your older children before your birth – with toddlers, start them climbing onto your lap rather than picking them up, give them simple jobs to ‘help mummy’ before the baby arrives to reduce the chances of any resentment being associated with baby
• If you have pre-schoolers at home after the birth, plan more sedentary activities ahead of time. For example investing in play dough, puzzles, colouring books and sedentary games, and start visiting your local charity shops weekly prior to birth to stock up and don’t bring it all out at once, stagger the new things)
• Above all, ask for help

Personally speaking, I found recovery after my second baby easier than the first time round. Second time round, I didn’t fret about getting off the pain medication as fast as possible, I knew how to get out of bed without hurting myself. I had my ‘baby station’ set up and my toddler loved ‘helping’ (though I didn’t sell it to her as helping – she thought she was playing games seeing how many things she could fit in her trolley – the muslin, the remote, the telephone, the baby wipes, when all I actually might need was the baby wipes).

A bit of planning ahead can make things so much easier.

From the contact I have had with mums-to-be over the years, it is safe to say there are many different reasons why women fear caesarean birth. For many it stems from an overall fear of the unknown – both the surgery itself and the possible outcome. But then there are those women whose fear is based on previous experiences – experiences which may be birth related, but which could also derive from other surgical and hospital experiences. While still others experience fear because of the stories they have heard friends tell or clips they have seen in the media.

Researchers have often documented birth dissatisfaction as higher in women who have given birth by caesarean than those who deliver vaginally. ‘Loss of control’ being long established as a significant factor in the poor satisfaction ratings associated with unplanned caesareans in particular. A study in 2016 attempted to quantify this a bit more.

The top 4 reasons given by the women in the study were:

• Poor communication – not so much in terms of what they were told, but rather the extent to which they felt listened to by those caring for them
• Fear of the operating room
• Distrust of the medical team – again relating to not being listened to and feeling something was being ‘done to them’ without due consideration
• Loss of control

In this study, many women expressed the wish that they had been given more information about caesarean birth, both its likelihood and the procedure, prior to giving birth.

The study recommended for any birth, proceeding towards a caesarean delivery, a ‘collaborative plan’ should be negotiated and that such a plan must involve discussion beyond the relaying of the medical facts. Failure to do so would increase the likelihood of all the fears highlighted above.

‘Informed consent’ is a formal procedure, one which is carried out in all caesareans, unless the mother is unconscious and a caesarean deemed time critical. However, this study revealed that the process of ‘informed consent’ was all too often a formality where the mother was simply expected to agree, without time allocated for a more ‘robust exchange’.

What this all points towards is the importance of antenatal education in providing a rounded and balanced approach to modes of birth, where caesarean birth are given as much time and respect as vaginal birth, where myths and fears can be openly addressed. Being informed well before the event that a caesarean might be a possibility, what will happen and how means women can participate in their birth and this could go a long way to reducing the feeling of loss of control and fear so often unnecessarily tied up with caesarean birth.

Sit any group of women down to talk about caesareans and you will hear all sorts of alarming ‘facts’. Common ones are:

• You will have to have a caesarean if your baby is breech
• You cannot pick up your baby or drive for 6 weeks
• Bonding with your baby will be severely affected
• Once you have had a caesarean, your next birth will have to be a caesarean too
• the list goes on and on

What is really alarming about these facts’ is not one of them need be true.

Hard as it may be to hear, antenatal education often does little to disabuse women of these misconceptions. Rather, it can perpetuate the idea that this important procedure is a last resort best avoided.

In reality, in addition to being lifesaving in an emergency context, caesareans have significant benefits in certain pre-labour situations where attempting a vaginal delivery carries greater risk for mother or baby. Add to these, those women who view a caesarean as preferable because of the unbearable fear and uncertainty they associate with vaginal birth (tokophobia) and there are a lot of women who can benefit from planning a caesarean delivery.

Unfortunately, many women still understand so little about caesareans it will perhaps be no surprise to hear some find their caesarean experience so traumatic they go on to develop post-traumatic stress disorder (PTSD). And those who do want (or need) to plan a caesarean are left totally unaware of the opportunities for making their birth feel special and personal.

Nearly one in three women in the UK will have a caesarean, with unplanned caesareans accounting for two thirds of these.[ii] They are a possible outcome of even the most straightforward pregnancy yet are barely touched on in many antenatal classes.

This reluctance to talk positively about caesareans has forced them to the periphery of antenatal education. Books and classes can be biased in favour of vaginal delivery making it impossible for women to have open, rational discussions with those responsible for their care. Most remain unaware of the huge benefits of preparing for the possibility of caesarean birth, either planned or emergency.

Helen Walsh, author of Go to Sleep,[iii] said of her antenatal classes:

“They did not prepare me for a caesarean outcome and perhaps more importantly, the implications of such an outcome. Had I known more I would have opted for an elective caesarean and I would not have endured such a traumatic birth experience [breech baby] which I firmly believe contributed if not triggered my descent into postnatal depression.”

It is well known that a woman’s preconceptions can affect her labour[iv] and realistic expectations are significant in determining both how she ultimately perceives her birth[v] [vi] [vii] and how she approaches her recovery.[viii] Yet women are still unable to get access to the information they need in order to develop a flexible approach to birth. All too often the risks of vaginal birth are downplayed while caesareans are portrayed as an intervention to avoid wherever possible, with those planning a caesarean labelled selfish or ‘too posh to push’. This systematic bias (intentional or otherwise) leaves women in the dark about what they face.

The likelihood of needing intervention (epidural, instruments, induction or caesarean) during vaginal birth is made light of, but actually effects a significant number of women – over half of UK women will experience some form of intervention[ix] yet many remain poorly equipped to negotiate their way through the experience.

The feelings of distress and loss of control that can become associated with such a birth can have a significant impact both physically and emotionally on mum and baby.[x] [xi] Women need to know more about their options so they can assess the risks for themselves. While some would prefer to leave things in the hands of their carers, many more would prefer to play an active role in decision-making. [xii] To achieve this they need realistic information about the experience they face. Women need to know the implications of the decisions they might be tempted to make, and they need to know their rights in this regard. In the case of caesareans: knowing how to prepare for the procedure; being aware of the opportunities open to them during surgery; learning alternative positions for breastfeeding and ways to improve recovery can all radically improve the experience for many women, even if the caesarean was not their original preference.

Fortunately, in the UK at least, the National Institute of Clinical Excellence (NICE) are addressing the issue of antenatal education, in relation to caesarean birth.[xiii] They agree:

“It is important that women are presented with evidence based information in order that they are able to make an informed decision…For all women requesting a caesarean, if after discussion and offer of support a vaginal birth is still not an acceptable option, offer a planned caesarean.”

This was a huge step forward back in 2011. Unfortunately, the reality is that the extent to which this guidance is followed is still very much in the hands of the individuals providing the care – their personal opinions (as well as hospital policy), consequently perspectives can vary widely.

The toxic combination of out of date or inadequate information and biased advice means women will continue to face their birth with huge gaps in their knowledge. Failing to inform women properly contributes significantly to the mismatch between their birth expectations and birth experience exposing many to unnecessary levels of trauma.

[ii] J. Thomas, S. Paranjothy and Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National sentinel caesarean section audit report. (London: RCOG Press, 2001)

[iii] H Walsh ‘Go to sleep’ (Canongate Books Ltd, 2011 ISBN:978-0857860057)

[iv] K. Hofberg, M. R. Ward, ‘Fear Of Pregnancy And Childbirth’ Postgraduate Medical Journal, 79 (2003) 505-510

[v] J. Lally, M. Murtagh, S. Macphail et al, ‘More in Hope Than Expectation: A Systematic Review of Women’s Expectations and Experience of Pain Relief in Labour’ BMC Medicine, (2008) 6:7doi:10.1186/1741-7015-6-7

[vi] C. Oblasser, The Faceless Caesarean (BoD, 2009)

[vii] C. Francome, W. Savage, H. Churchill et al, Caesarean Birth in Britain: A Book for Health Professionals and Parents (London, Middlesex University Press, 1993)

[viii] L East, Caesarean Birth: A positive approach to preparation and recovery, (Tiskimo 2011  ISBN: 978-0-9568480-0-0)

[ix] NHS, Latest Maternity Statistics Show How the Pattern of Giving Birth in England is Changing, (NHS Information Centre, 2008)

[x] J. Lally, M. Murtagh, S. Macphail et al, ‘More in Hope Than Expectation: A Systematic Review of Women’s Expectations and Experience of Pain Relief in Labour’ BMC Medicine, (2008) 6:7doi:10.1186/1741-7015-6-7

[xi] L East, Caesarean Birth: A positive approach to preparation and recovery, (Tiskimo 2011 –  ISBN: 978-0-9568480-0-0)

[xii] K.L. Ingold, author of ‘A phenomenological exploration of women’s experiences of giving birth in Leeds and discussion within the context of NHS maternity policy’ (Masters dissertation in Public Health, University of Leeds Academic Unit of Public Health, 2011)

[xiii] National Collaborating Centre for Women’s and Children’s Health, Caesarean Section Guideline, Draft (Commissioned by National Institute of Clinical Excellence, RCOG, 2011)