Wednesday, April 2, 2014

The Family-Centered Cesarean.

I am excited by a shift I am seeing (but very rarely, so far, in this country) in the way cesarean births may be supported. I am speaking of something often called the "family-centered cesarean" or "natural cesarean." Cesarean rates are high in many parts of the world (beginning to climb above 1 in 3 births here in the USA), and the family-centered cesarean is a response to problematic practices (dehumanization, non-individualized care, the all-too-routine separation of parent and child that makes for less-than optimal bonding and lactation, among other factors). It is still major abdominal surgery, of course, but with more thoughtful, evidence-based, and human-centered procedures woven into its medical protocols. These might include allowing a doula or midwife in the room with the surgical team, not strapping one or both the laboring parent's arms down, facilitating immediate skin-to-skin contact between birth parent and baby in the first minutes (and so-called "golden hour") after the birth, etc. 

The goal is not to make elective cesarean births more "desirable" than vaginal birth. It seems clear that work must be done to decrease the rate of unnecessary cesareans. The climbing cesarean rate is not making gestational parents and children healthier, ACOG just released a statement that cautions against many of the "traditional" non-emergency reasons for cesarean surgery, and the WHO suggests the rate should be well under 20% -- more like 10-15%. As this is a life-saving surgery, absolutely necessary in some situations, it will continue to be done, so it behooves us to improve the experience and its outcomes (both direct and related) if we can do so in ways that not only "do no harm," but may actually help families and babies. 

In one of my recent childbirth education training classes, there was a discussion about whether a particular video on this revolution in cesarean birth should be shown to local pregnant "consumers." (i. e. those taking a childbirth class we teach, or other prenatal clients).  

I've embedded the video here. It is not graphic, to my mind, but some of the surgery is shown. I understand if you would prefer not to watch for any reason. I also hope that anyone reading this who has had or supported a loved one in a previous cesarean birth will know I understand that, like any birth experience, feelings around it are very personal. I validate and value your thoughts and emotions, whatever they are. We do the best we can with the information and support we have. My thoughts continue below. 

Does this vision of a "kinder" surgery and explicitly compassionate caregivers set US (or other) pregnant people up for disappointment if/when their cesarean births are (likely) not done with this much care and respect? Or might it spur more people to reproductive rights activism -- on the world's behalf and/or on an individual level -- at the very least encouraging conversation with care providers (including surgeons and anesthesiologists) about how an all-too-often impersonal and medical cesarean experience can become more "family-centered" without compromising safety? Even if a caregiver says it can not, this may lead to an important discussion with that caregiver of why he/she disagrees.

I don't know if I would use this video in a class, but my gut says we should show this video to pregnant people -- and those who may become pregnant or who care about pregnant people (i. e. Just about everyone) -- because I think people should know it COULD be a different experience. I think it empowers "consumers" to know this kind of "customer service" (for it is a business, after all, at one level) is not fantasy. 

I was surprised by how many of my fellow teachers-in-training said they would absolutely not show this video to clients. I was surprised even though I know they made that decision out of compassionate consideration for people giving birth and the tender borders between hope/expectation/reality/disappointment. I can understand intellectually and emotionally that some (not all) pregnant people who watch this video and hope for a "natural cesarean" experience, if a cesarean becomes necessary -- but who go on to have an unwanted "traditional" medicalized cesarean birth experience -- could feel more traumatized by the birth because they know "there's another way." Once a person watches this video, that person is aware that there are practical choices (both a family's and a surgical team's) that can be made, and which are realistic and possible, but which a laboring person may still be denied. I can also imagine a pregnant person who feels empowered in a pregnancy after watching this video -- empowered to use this information to seek out a receptive caregiver, or even just to spread the word that these practices are possible, while choosing a support team and preparing for the birth experience.

I would love to know your thoughts. 

Disclaimer: of course, this video is a window (and a "produced" one, though not "faked") into an experience, not a complete picture. The risks that come with any c-section are real, and not discussed in this video. The nature of a surgery that may be done in a very immediate, emergency situation is that it will look different from birth to birth. As just one example, sometimes general anesthesia is necessary in an emergency cesarean, as opposed to an epidural/spinal, which would change the experience quite a bit. I still think the scenario of a family-centered cesarean -- whenever possible -- is one that is worth fighting for, especially when so many cesarean births in this country are planned and scheduled in advance. And even if we can't change it for every person who is pregnant now (though I am hearing encouraging stories of "natural" cesareans in the United States, as I seek them out), even if it takes a generation or two or three, it's still a worthy goal.

UPDATE! This story is an example of why I feel like pregnant people and partners SHOULD see this video. What an amazing birth -- and she advocated for herself! I'm so glad I came across her story.