The Organic Cesarean: A protocol for a gentler surgical birth

In my doula work, I specialize in attending parents who have high-risk pregnancies and are anticipating surgical births. This is a niche unexplored by most of the doula field- and I felt called to step into this space and bring some of that famous doula juju to the OR.

Turns out, the OR can be a stressful place to give birth! Research shows us that having continual doula support reduces stress, and improves birth outcomes. In addition, early skin on skin contact facilitates better bonding, breastfeeding, and gut flora!

That can add up to a pretty hefty protective factor later in life, according to some.

After attending lots of surgical births, I've learned a few things:

1) Not every hospital does things the same way! In fact, not every OB team does things the same way. Every member of the team has their preferred protocol, informed by their own experiences.

2) The Anaesthesiologist runs the OR. What they say, goes. They stand by the birthing parent's head. I always treat the entire team with respect, but I find the birth goes smoother when I use extra nice words with the anaesthesiologist and ensure them I won't be interfering with anything. Doulas in the OR is an unusual thing, and can make some folks jumpy the first time around. It's important to remember that they're informed by their experiences, and everyone has the birthing parent's best interest and safety in mind. That being said, once in a while, I've had to roll my eyes (much later...and in a bathroom...by myself) and giggle at some things said when it's discovered I'm the doula.

"I'm a doctor. I'm not a nurse, don't ever call me a nurse, and we will be okay."

"So what does a doula do in the OR? You're not going to spray anything scented, right? Please don't sing a chant, ok?"

"Are you a parent too? Oh. A doula? Why would she need a doula now? She's not doing anything!"

I definitely didn't giggle at that last one- but it echoes the sentiments of plenty of folks I've met during my time of attending surgical births. I have since reduced my birth work to 4 or 5 a year (my lactation practice is burgeoning and I'm so happy doing my boob-genie thing- but birthwork has a siren song and I must answer), so I encounter this less- but I know the sentiment is out there.

Informed by all of that, I sat down and wrote a protocol. I shamelessly mined my nurse-friends for good things to include for an efficient use of time & space in the OR, and have added to and subtracted from it over the last few years.

I wanted to share it with you so that you can bring it to your birth team if you're expecting a surgical birth. There's no reason you shouldn't have some say in how your birth goes down! My favorite part (apart from the obvious urbane miracle) is listening to the songs families have chosen to be playing during their babies' births. It's a moving experience- and every family is so different!

Here you go! Feel free to bring this to your team & chat about it with them. I would love to hear your experiences and responses in the comments!

Organic Caesarean Protocol

written by Bryna Sampey, IBCLC, Doula

The benefits of a organic, biodynamic or “family centered” cesarean have been documented. The most important benefit is the skin on skin contact and thermoregulation that happens with this technique. The improved rates of both breastfeeding success and protection of the infant’s microflora colonization process are crucial to long term health of the dyad. The technique can delay the staff by as much as 10 minutes when compared to a typical caesarean delivery. Accommodations in OR scheduling should be made if this type of birth

is planned. The technique should never override other protocols in the event of life

threatening complications, but should be given priority in a normal planned surgical birth of a healthy newborn, for the beneficial reasons described above.

Preparation of Room: Lighting and Music

Family should be given the option of lowered lighting, with a spotlight for the surgeon, instead of full-bright lighting. This serves to ease the baby’s transition to the birthing parent’s chest, and allow them better viewing of the birth. This has an added benefit of reducing the partner or supporting person’s potential distraction with the surroundings and helps focus family on the birth.

Family should be given choices in music if a sound system is available. Instructions should be given regarding format of music to be provided (iPod, MP3, etc) with as much time as possible to select music.

Music has documented benefits of regulating breathing and heart rate, and the long term emotional benefit of giving the family this choice in birth is significant, as birth is a life altering event.

Preparation of Family: Consult and Transport

When the surgeon consults with family prior to delivery, attention should also be given to supporting partner- and time given for questions or concerns that may arise. This is also a time for surgeon to confirm the plan that has been made beforehand. This enhances family’s confidence and serves to lower cortisol level in birthing parent.

Lowered cortisol levels at the outset of delivery have been documented to aid in ease of transition of baby and in initiation of breastfeeding. Lowered cortisol levels also allows oxytocin levels to rise as normal and facilitate bonding, breastfeeding, and thermoregulation of newborn on birthing parent’s chest after delivery.

Partner should (if possible) be scrubbed in advance and remain with birthing parent during transport to OR. This serves to include partner in birthing parent’s birth team, provides continuity of environment, and serves to maintain low cortisol levels. While the partner dresses, the birthing parent should take some time to prepare their chest area with some vaginal mucous on a swab. This is applied in anticipation of skin on skin contact with the infant, and offering the innoculation of vaginal flora that is missed due to the surgical birth.

Preparation of Birthing Parent: Pre-surgical Checklist

Staff should walk family verbally through each stage of prep as it occurs. In the event of a scheduled cesarean, obtaining verbal assent before each step is completed is empowering for the birthing parent. It can be easy to do this. “I’m going to wash your belly now, is it all-right?”

This allows for some amount of control to be had by the family over a largely uncontrolled process, and lowers risks for postpartum stress and anxiety. In addition to standard protocols for caesarean delivery, these steps should be followed or used to modify existing steps to the best of the OR staff’s abilities.

• Using a removable or lowerable drape so that baby’s birth can be visualized by family if desired.

• Raising the head of the OR table a few inches or using a sterile pillow to raise birthing parent’s head to observe birth more comfortably.

• Use electric clippers instead of a disposable razor to prevent later discomfort and razor burn at incision site.

• Place ports on non-dominant arm for birthing parent

• Place ECG pads away from chest (on upper shoulders or back)

• Place a sterile towel around blood pressure cuff to maintain a comfortableexperience for newborn/protected environment on mom’s chest.

• Prepping site with chlorhexidine solution instead of providone-iodine solution.

Delivery

The infant should be “walked out” slowly through the smallest incision possible. This means delivering head first, slowly, then lowering drape to allow parents to visualize baby’s birth.

Parent or parents should be allowed to determine infant’s sex themselves, if desired.

The shoulders should slowly be delivered individually. Allowing the contractions of the uterus to assist with a slow, measured delivery of baby which approximates vaginal delivery. This facilitates better fluid removal from lungs as well.

If the birthing parent's chest was not prepped prior to surgery, a sterile pad should be immediately swiped across the vagina and anus and then swiped across newborn’s nose and mouth to initiate early gut microflora colonization of

infant.

Delayed cord clamping should be practiced, with the opportunity of a second cord clamping to allow partner to cut a shorter cord once infant has been placed skin on skin.

All initial checks should be performed on birthing parent’s chest, excluding any vaccines or medicines given to baby. Drying and bubble wrap or heated blankets may be placed over the top of the dyad.

Skin on skin contact should be maintained as long as possible.

Recovery

During transport of birthing parent to recovery, baby can go skin on skin with partner (if present)- who should come to OR prepared with a snap-style button-down shirt and no undershirt beneath the scrubs. After this time, Infant can then be weighed and assessed in detail while birthing parent is transported.

Infant can then return skin on skin to the birthing parent.

Breastfeeding should be assisted when baby gives cues. An IBCLC should be on-hand in recovery to assist with latching should the dyad need assistance. Permission must be granted by birthing parent before the IBCLC or nurse manually assists with initial latching. Routine postpartum care can commence at this time, with an emphasis on exclusive breastfeeding, and maximizing opportunity for skin on skin contact with newborn.

References:

Darouiche RO1, Wall MJ Jr: Chlorhexidine Alcohol

versus PovidoneIodine for SurgicalSite Antisepsis

Engl J Med. 2010 Jan 7;362(1):1826. doi: 10.1056/NEJMoa0810988.

Tumblin A.: A family-centered cesarean birth story J Perinat Educ. 2013 Summer;22(3):130-2. doi:10.1891/1058-1243.22.3.130.

Laopaiboon M., Lumbiganon P., Martis R., Vatanasapt P., Somjaivong B. (2009). Music during caesarean section under regional anaesthesia for improving maternal and infant outcome.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006914.pub2/abstract [ PubMed ]

Musa S. (2012). A doula facilitates skin-to-skin in the operating room. Washington, DC: Science and Sensibility; Retrieved from www.scienceandsensibility.org

Smith J. (2011). The natural cesarean: A woman-centered technique. London, United Kingdom: Jentle Childbirth

Foundation; Retrieved from www.JentleChildbirth.org.uk or www.youtube.com/watch?v=m5RIcaK98Yg

I hope you have found this useful- and I hope your birth is a beautiful one. Know that your entire team is rooting for you!