A Family Centered Cesarean Birth Plan

A Family Centered Cesarean Birth Plan can help you to achieve your desired Cesarean birth. A plan is helpful for families who need to plan for a Cesarean as well as those who wish to be prepared should the need for Cesarean arise despite other plans. You can link to my Family Centered Cesarean Birth Plan here: fccbirthplanpdf

Please use this list of preferences as a way to identify what is most important to you in the case of a Cesarean birth. Choose those items that resonate with you to include in your own plan. Or use this plan just as it is! If you do, please give credit and know this plan is copyrighted by Family Centered Cesarean. Share it with your friends and family and spread the word about what is possible.

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What is Family Centered Cesarean?

Family Centered Cesarean is a term that is beginning to appear in many places on the Internet (you’ve seen the photos of Australian women pulling their own babies from their wombs during surgery, right?) and is just starting to cross the lips of many care providers. The name is somewhat self explanatory. We all know, on some level, what we mean by “family centered”. It means that the family is the focus. It holds a similar connotation to “student centered” when we are speaking of education. In a student centered classroom, the teacher focuses on what the students are excited by, uses teachable moments to create understanding, and keeps the learner in the spotlight. The opposing model, the “teacher centered” model, involves the teacher imparting information that they deem important, typically through lecture, while students sit quietly and take in the instructor’s great wealth of knowledge. This draws an easy comparison to “client centered” or “patient centered” health care. When care is client centered, the individual is treated as a unique person, their concerns are heard, they are treated holistically, and every effort is made to create a model of care that fits well with their preferences. When we talk about maternity care, instead of saying “client centered” we say “family centered” because in our realm, the entire family is a part of the plan of care. Not involving all members of the family and also including the newest member to be would be erroneous and contribute to an unsatisfying experience.

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So then, what does it really mean to have a family centered Cesarean birth? While there are very specific ingredients that contribute to the family centered Cesarean, such as the lowering of the drape or lack of routine family separation in the immediate postpartum, the core of this practice remains the same as that of all client centered healthcare. The family is the focus. The family’s needs and desires are heard by the medical staff who then makes every effort to ensure that these preferences are met. The staff that provides family centered Cesarean understands that every birth is a momentous occasion, and that the need for a baby to be born surgically does not negate the need for the family to celebrate this wondrous time. I propose that the true definition of family centered Cesarean is essentially doing whatever it takes to ensure that the family has a fulfilling and satisfying Cesarean birth experience. While I have my own opinions on what is most important (skin-to-skin in the operating room, for example), my job is to understand what is most important to each family and provide it whenever possible. Only they know what is most meaningful to them and will bring them the most joy.

So, don’t feel like being able to reach down and pull your own baby out into the world is the definition of family centered Cesarean (even though that is really awesome). Families making their Cesarean birth their own and care providers supporting them is what defines a family centered experience.

Real, Raw, Beautiful Cesarean Birth

A post came across my Facebook recently with a trigger warning. The link was to photos of babies taken within the first twenty seconds of life. What was atypical about these photos compared to other newborn pictures we see every day in our news feeds is that these photos were of babies born by Cesarean.

It is so much more common to see beautiful images of babies born vaginally, drawn to their mother’s chests, with a room full of weeping onlookers. We often see images of babies born in the water, coming for the first time to the surface. Those beautiful pictures tug at our ovaries, bring a tear to our eye, and receive comment after comment about how lovely they are. These photos of Cesarean birth, however, received a great deal of criticism. Commenters stated the photos made them feel uncomfortable, that they appeared violent, that they were offensive. I disagree. This is what birth looks like. Are they violent or offensive simply because the births were surgical?

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Photo credit Christian Berthelot.

To me, these images speak to the fact that Cesarean birth is real, raw, amazing birth, just like vaginal birth. Blood and fluid are a part of the visceral experience of birth. All babies come out of their mother’s wombs covered in amniotic fluid, blood, and vernix. The shock that babies emulate when they are born is universal, it is not just an experience of Cesarean. They all get squished and many wear surprised expressions. Their bodies emerge in all kinds of wild positions. The babies in these photos are wonderfully messy, new and amazing and miraculous. It is glorious to see this evidence of the womb covering these Cesarean babies. It is just a reminder that Cesarean birth is indeed birth. 

In my three Cesarean births, I never saw these images of my own children. My babies had been moved, cleaned, wrapped up, and presented to me in a way that mimicked the pristine, sterile environment of the operating room. And there was something missing there. The primal feeling of giving birth was lacking in my experiences. And I mourned that loss. I wish I had pictures like these of my babies. It might have saved me some of the strange feelings of having not given birth that I experienced after my own Cesareans.

I recently received this quote from a woman who had a traditional Cesarean birth followed by a Family Centered Cesarean. “I had never seen my other babies freshly born. I did not get to see them until they were bathed, wrapped, all evidence that my womb had supported them for the last 10 months washed away. Covered in blood and amniotic fluid, my baby was a beautiful sight.”

Christian Berthelot, the photographer of these awesome images, explained his project this way, “Far from all the clichés and platitudes, I wanted to show us as we are when we are born. And regardless, whether a cesarean delivery or natural…everyone is born naked, in tears, in blood and other body fluids”. That is beautiful, and so are the babies in the photos.

To see more photos from this project , click here.

 

 

John Luke’s Family Centered Cesarean Story

I was on track for a home water birth, but baby was postdates so I had to go in for a visit with a nurse midwife/OB team to have a biophysical profile done. My homebirth midwife had a good relationship with them, and if a hospital was needed, we would be established with them. When they checked my blood pressure it was very high. Even when they double checked it with the manual blood pressure cuff and stethoscope it was high. They admitted me for observation of my BP and to run blood work, also to monitor the baby and make sure it wasn’t having any adverse reactions to my condition. My liver enzymes and uric acid were elevated officially making my case one of preeclampsia. Since we were now in the care of the most mother friendly nurse midwife/OB team anywhere around us we needed to move forward with an induction, something that we definitely hadn’t planned on. I had to send my husband home with a long list of things he needed to bring back. Even still, I would be able to have my medication free water birth, just with a location change.

They inserted a balloon to encourage my cervix to dilate past the 2-3 cm it had been at for the past few weeks. Hopefully that would start my labor without needing to use any drugs. After a little while of having the balloon placed my BP climbed higher so it was decided that some Pitocin needed to be started to try to get labor going. The Pitocin was set on the lowest dose, and the nurses very slowly upped it overnight, letting the balloon and the medicine work together to dilate my cervix. By the next morning I was beginning to swell drastically, my hands, feet, and face were very puffy. Magnesium was suggested again, we had denied starting it the day before because if it was started I’d be bedridden and lose my water birth and have to have much bigger doses of Pitocin. Being stuck in bed took away my biggest pain relief method of standing during contractions and resting on the birth ball between, and I knew if I was stuck in bed with a catheter and unable to get up I’d need an epidural to manage my pain, which I was set against. My husband and I talked some more about our situation and decided we would see how far dilated I was since the balloon had fallen out and if I was close to fully dilated we’d continue to deny the Magnesium. I was 5 cm dilated with a bulgy bag, which wasn’t as far as hoped. We decided the best thing to do would be to break my water and try to encourage labor to really take off and hopefully I would progress enough that we wouldn’t need the Magnesium. We would try this for at least an hour. The nurse midwife agreed, but not without letting us know that she really felt that I should have started the medication the day before, so we were really pushing the envelope waiting longer. She also said she didn’t feel comfortable with us moving to the water birth part of the hospital farther from the OR and the rooms, so they would be bringing in the inflatable pool for my birth.

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Not long after this was decided my blood work came back and for the second time in a row the numbers were getting worse. I was now risked out of the water birth in total, which I was upset about, but around the same time I began to feel pressure like I needed to push, so on the other hand I was excited that I was nearing the end. After what I was hoping was my final check I was actually still only 5 cm and it was found my pelvic muscles, like the rest of my body, were beginning to be very swollen from the preeclampsia. My baby wasn’t going to come naturally; my body wasn’t going to be able to dilate any further. We were going to have our baby via Cesarean and I needed the Magnesium quickly to make sure I didn’t start seizing or have a stroke. I was sobbing after hearing this news, but we were given time, just my husband and I, to be together and mourn the loss of our ideal delivery and to boost each other up for what was to come. I was started on a bolster of Magnesium, a concentrated dose that made my skin red and my whole body feel hot. Prep for the surgery was handled very caringly, besides a gruff anesthesiologist, who wasn’t happy with my slouch for the spinal. It took 4 attempts to get the numbing medication in correctly.

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I couldn’t believe I was in an operating room, getting the dreaded spinal that I had spent more than the length of my pregnancy not wanting. I was in such good hands though, the nurse midwife and OB worked as a team during the C-section to do what they call a gentle C-section. I was not strapped down and I was able to have my whole support team there, my original midwife, my doula, as well as my husband. Since we had all of our helpers in the OR with us one was able to film the birth and the other was able to take pictures for us, so my husband was able to focus solely on me. Everyone in the OR was reminded that we didn’t know the sex of the baby and that my husband was the one that wanted to say what it was. The surgery started and I was able to just be with my husband, not worrying about anything else that was going on. When it was time for the baby to be born they dropped the drape and my husband and the anesthesiologist helped prop me up so I could watch our baby being born! My husband told everyone that he was a boy and he was placed directly on my chest by the nurse midwife. They left his cord attached to completely drain to him. He was checked for temp and suctioned etc. right on my chest. The surgeon let me know that the cord was empty so they were going to cut it long, leaving plenty for my husband to cut later when baby got weighed and measured. I only let the baby go away from me during the surgery when I felt the pushing and movement of them closing me up, because it made me nervous that I might drop him, probably something that could not have happened, but my IV was in the crook of my elbow, I felt numb pretty high up, and the bed was tilted so that I felt like I was laying downhill. When I handed him off to daddy he was taken to the side where he was weighed and measured. We opted out of any eye ointment or shots, so he had no real reason to cry, he was content, getting wiped down and bundled up.

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They gave him back to me as we were taken back to our room. We nursed instantly after reaching our room, there was no stay in a separate recovery area. We stayed in the hospital a total of 5 days, from arrival and start of the induction on Monday, birth on Tuesday, and going home after breakfast Friday morning. During our whole stay no one pushed us to do anything we didn’t want to do. Our little boy was not poked or hurt in any way, no vaccinations, no circumcision, no leaving for weigh-ins or baths. He wore nothing but a diaper and I stayed topless for 24 hours after his birth and besides some family holding him we stayed skin to skin the whole time, establishing our nursing relationship. None of the nurses or other staff said anything about me or my husband sleeping with our baby. We even got to see a lactation consultant, not because we were having trouble, but because that is protocol for the hospital to make sure nursing mothers have all the support the need. I was sore, and it was hard to get up and around for the hospital stay, but seeing that baby, smelling him, feeling his skin against mine, and feeling his breath was the best thing that has ever happened to me, and it was worth it all. I’d do the whole crazy experience again without a second thought. Did I want a C-section, no, but what we got was the best care that we could ever expect after a long time of us getting to explore our options and try our best to have a natural delivery until it was truly urgent. We are so happy with the care that we received that we already plan on using the same nurse midwife/OB team for our next baby, trying for our VBAC in the water.

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Thanks to Megan Ray for sharing this amazing story. Notice how the drape was lowered and Megan’s head was raised at the time of birth so she could see her baby being born. Her arms were left unrestrained and she was able to immediately hold her baby, whose cord was left intact until it had stopped pulsating. The baby was skin to skin from the time of birth and throughout recovery.

Top 5 Ways to Improve the Cesarean Experience

With Cesarean rates in the upper 20th to low 30th percentile in recent years, many families have found themselves facing an unexpected Cesarean birth. With numbers like these, it is vital that every expecting family understand how to navigate the topic of Cesarean as well as the possible scenario of an unexpected surgical birth.

The first step for families is to educate themselves on ways to avoid unnecessary Cesarean surgery. Understand the risks of major abdominal surgery and access resources that explain how multiple interventions increase the risk of Cesarean birth. A wonderful resource is ICAN’s “Things You Can Do to Avoid an Unnecessary Cesarean” available at http://www.ican-online.org/pregnancy/things-you-can-do-avoid-unnecessary-cesarean. ICAN also has a webinar available titled “Cesarean Prevention” at http://ican-online.org/webinars.

A family’s education should also include an understanding of the processes and procedures involved so that the family understands what to expect if they are facing a surgical birth. Families who write a birth plan need to include a page of preferences for a Cesarean birth and postpartum. Make sure that all caretakers receive a copy of the Cesarean birth plan and postpartum plan.

Education should also include an understanding of methods a family can use to make a Cesarean more family centered. There are some good sources out there already that can help with this. In my personal experience, here are the things that help the most:

1. Consistent support for mom throughout the birth process. This means someone by mom’s side in the OR at all times. If there is only one support person, most moms will encourage that person to leave with the baby if the baby is taken out of the OR to the nursery or recovery. But the baby is born in the first 10 minutes of surgery, and there is a good 30-45 minutes of stitching afterward, during which the mother’s uterus is removed from the abdominal cavity for stitching and then returned. No matter how good the anesthesiologist is, this feels strange and can be scary, especially if no one is talking the mom through it. It is an extremely vulnerable time. If the anesthesiologist will not allow more than one support person in the OR, then suggest another family member or support person take the partner’s place at the mother’s bedside if the partner needs to exit with the baby before surgery is over. Most hospitals will allow this even if they prefer to limit mom’s support people to one in the OR at a time. Ask that support people and baby be able to remain in the OR and go with the mother to recovery. Evidence shows there is no need for mother and baby to be separated immediately after birth. A support person should make sure the mother is comfortable. Encourage her to leave at least one arm free during surgery. Ask if she is breathing comfortably; since epidural and spinal anesthesia work by gravity, a mother lying flat may get the sensation of numbness up to her neck, causing a fear of not breathing. This is easily remedied with a pillow under the head. Warm blankets can help with the cold environment of the OR.

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2. A record of the birth. This can be done in a variety of ways. Some doctors allow video taping, and even those who do not wish to have the surgery taped will often allow taping to begin as the baby exits the womb. Still photos are typically allowed in the OR. A mirror held at the correct angle allows mom to see the birth of the baby. Have the drape lowered at the time of birth and ask the surgeon to hold the baby above the drape before moving the baby to the warmer. Ask if your birthing location has the option of a clear drape. All of these can help mom embrace the birth experience and fully understand her importance, which can sometimes be difficult when a baby is born surgically. One of the most difficult aspects of a Cesarean birth for many mothers is the aftershock of feeling as though they did not birth their own baby, which can lead to difficulty bonding and postpartum mood disorders. A chronological record of the birth helps parents reminisce about their baby’s birth, especially if the surgery was emergent or hurried.

3. Keeping the focus on the birth. Let’s face it, Cesareans are routine for RN’s, OB’s and CNM’s in the hospital setting. Staff can sometimes lose sight of the importance of each individual birth. You can help by encouraging your birth team to direct the focus onto the birth experience. Parents can request that conversation in the OR be limited to the birth, and can help steer discussion back to them and their baby if it veers off course during the surgery by asking questions, etc. No one wants to listen to a story about their scrub tech’s crazy Friday night during the birth of their baby. This is the family’s moment. The environment in the OR can also be enhanced by the use of calming music (most anesthesiologists have a radio in the OR) and aromatherapy (even if you can’t bring in bottles of essential oils, the mother’s favorite on a napkin or cotton ball can be sniffed throughout the surgery).

4. Maximizing contact between the parents and the baby. Request the baby remain with you as long as possible in the OR so that you can touch and hold your baby and begin bonding. Some hospitals now keep the family together throughout the process or bring the baby into recovery rather than to the newborn nursery so that parents can be with the baby during the mother’s recovery process. Request skin to skin in the OR. A small number of hospitals nationwide are now promoting this evidence based practice. Some other ways to encourage bonding and promote breastfeeding include leaving the baby’s first bath until later when the family is in their postpartum room, or delaying the administration of eye ointment, Vitamin K or any immunizations the family has requested for a minimum of the first hour in recovery. This allows bonding and breastfeeding time during the “golden hour” after birth. Baby and mother can be skin to skin and begin breastfeeding during recovery if they can’t do this in the OR. This helps both of them recover more quickly, creates a more fulfilling experience, and supports breastfeeding success.

5. Have support in the postpartum period. Cesarean birth is major abdominal surgery. Make sure you understand the recovery process and access resources early on. Take it easy and spend waking time bonding as a family. Rest when your baby sleeps. Accept help from family and friends in the way of prepared meals, assistance with chores, etc. and limit visitors in your early days at home to those who are willing to pitch in and lend a helping hand.

Preparing for the possibility of a surgical birth is not “negative” thinking, nor is it a self fulfilling prophecy. It is simply addressing the reality of birthing in the United States today. There are many ways to decrease the risk of a Cesarean birth, including choosing your birthing location wisely and hiring a doula. If you do have to have a surgical birth, however, know that a Cesarean birth can be a beautiful birth, and understanding how to navigate the waters of Cesarean will take you a long way to achieving the birth experience you desire.

 

Does Your Care Provider Support FCC?

A friend messaged me recently to ask if I was aware of any practitioners invested in Family Centered Cesarean where she lives, on the east coast, far away from where I am currently located. I wished in that moment I had a list I could hand to her to make her life and journey easier. But I don’t. Truth is, I don’t even have a list of more than one hospital and a handful of practitioners in my home town of Denver. Family Centered Cesarean practices are in flux right now, really catching on in some locales, and never even heard of in others. In addition, the factors that influence them are complicated. So instead of handing over a list, I am writing this to help my dear friend and all the moms out there wondering how they can access Family Centered Cesarean. How do you know if your hospital, practice, midwife, or obstetrician incorporate family centered practices into Cesarean birth?

First, ask your care provider if they are familiar with the concept of Family Centered Cesarean. Sit back, watch, and listen. Does your care provider seem excited, accepting, or put off by your question? Do they seem to have a good grasp of what you expect from a Family Centered Cesarean experience? Can they list out family centered practices specifically that they have and do support in the surgical births that they attend?

Second, ask your care provider specifically about skin to skin in the operating room if they don’t address it in their answer to your first question. Skin to skin contact for mothers and babies is an evidence based practice. We have multitudes of research that shows the amazing benefits of skin to skin. If your care provider balks at this or doesn’t have a grasp of this evidence, this is a red flag.

Third, contact your birthing location and ask to speak with the Clinical Nurse Specialist or Nurse Manager for Labor and Delivery. Let them know you are a potential client and you have some questions as you are working on choosing a birthing location. Ask them the same two questions you asked of your care provider. Many hospitals don’t yet have true policies for Family Centered Cesarean and skin to skin in the operating room. If you hear phrases like, “we can try” or “it’s up to the anesthesiologist” push for more direct answers and if you can’t get a clear picture, consider that a red flag.

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I have heard of situations where a care provider told a client they could have a Family Centered Cesarean and then once the client was in the hospital they heard that several of the things their care provider had approved in their birth plan were actually against hospital policy. I’ve also heard of skin to skin being completely dependent on who the anesthesiologist on call is, because the hospital doesn’t have a policy on skin to skin. This is why you need to make sure that you get the same answers from your care provider and your hospital to be sure what you want is really available.

Once you have the information you need, develop your Birth Preferences (I prefer the term “preferences” to “plan” when talking about birth). There are several good samples of Family Centered Cesarean birth plans out there, and they can be found on our Facebook page at www.facebook.com/familycenteredcesarean. Take your written preferences to your care provider and have them sign. Then make multiple copies for your care provider, birthing location, and to keep in your birth bag. When you go for a hospital tour (which I recommend every family do, even if they are not planning to birth there) carry a copy and have the tour guide take a look. Sometimes family educators in the hospital can offer additional tips based on their experiences there.

Family Centered Cesarean is a consumer driven initiative, and you will have the most success being proactive and asking for what you desire. And always feel free to send a message to us on our Facebook page if you have specific questions! Love and luck to you in your journey. Remember, all birth is sacred, and the way we experience birth matters.