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Doulas and Cesarean Birth

I’m certainly no expert on etiquette in the operating room but I’ve learned a few helpful things for us non-medical folks over the years. 

100% of the time, when my client makes the cesarean decision, she is told that only her partner can go into surgery with her.  I’ve learned to question that policy.  Usually I’m still left alone in the L&D room staring forlornly at the remains of their labor scene.  But perhaps six times now (and three of those happened this year) I accompanied the couple past those double doors.  To the operating room. 

1)  How can a doula get an invitation?

Ask.  Ask quietly but with confidence.  Let them know it isn’t your first rodeo.  Ask everyone.  Ask the nurse.  Ask the OB.  Ask a passing nurse in the hallway.  The first answer will probably be “no.”  The nurse and OB usually defer to the anesthesiologist.  Why this god of the operating room gets to make the call, I have no idea.  But s/he does.  I’ve found that the nurse and OB often “forget” about my request.  So I ask again. 

I remember talking with an OB after a vaginal birth once.  I mentioned that I was never allowed into the OR at this particular hospital but XYZ hospital down the road usually let me.  She replied, “Huh!  I never thought about inviting the doula to come back.  I bet that would be good for the patient.  You be sure and ask me next time that happens.”  P.S. I remember a previous birth with her when I DID ask.  She said, “no.”  Sigh.  See, they “forget.”

“Would you ask the anesthesiologist to make an exception and let me go with my client?  I’ve been allowed to back before. ”  Repeat.  Repeat again. 

Before the cesarean, the client may want to make her special requests to the OB (delayed cord clamping, dad to announce gender, keep the placenta, etc).  Of course, you might also remind staff of these choices in the moment.  Just in case they forget.

2) What will you wear to the party?

Usually I’m given the same paper scrubs as the dad.  They may be huge.  I’ve had to tie knots in the back of the shirt 1980’s style.  Once a kind nurse brought me cloth scrubs in my size.  It was wonderful!  Mainly because I was wearing the same color and fashion of all the other masked nurses and had more freedom to move about the OR.  Doula undercover. 

You’ll also get a fancy shower cap, mask, and covers for your shoes.  Strangely, no gloves.  But there is usually a hand sanitizer pump just inside the operating room.  I use it just to be on the safe and clean side. 

3) Confessions of a wallflower

You will be ushered to a stool beside the mom’s head.  Maybe once or twice, I was directed to stand.  This is the time for grace.  No tripping over your feet or craning your neck for a view.  Prove to the anesthesiologist and/or nurse anesthetist that you’re one of the cool kids.  Sit.  Meekly.  Hands folded.  No snapping pictures yet.  Perhaps a nod to the medical staff. 

Mom will be lying flat on her back with her arms outstretched.  Often her arms will be strapped down.  There will be a curtain between mom’s chest and her belly.  When I’m standing, I have to stand on my tiptoes to see anything on the other side.  I do not recommend standing on tiptoes.  See earlier mention of grace. 

 

4) The popular kids in the room

Sitting/standing behind mom is the nurse anesthetist and/or anesthesiologist.  This person is monitoring mom’s vitals.  You want this person to like you.  This is the aforementioned god of the OR. 

The OB is below the curtain with his/her surgical assistant(s).  Sometimes a student and an attending are chatting in the background as in the picture below.  Classy.

Mom’s labor and delivery nurse is there.  Often with an L&D nurse who is on cesarean duty. 

Near a baby warmer is a pediatrician and a baby nurse.  See them in the background?  Try to look beyond the bloody gauze in a hanging shoe organizer bag.  No, it isn’t really a shoe organizer bag.  But it surely looks like one hanging there.

5) When the party is in full swing

Once the surgery is underway, I sort of inch my way out of the stool and move away from mom’s head.  I want to get some pictures of something other than a blue curtain.  This part is when I’m in ask-forgiveness-rather-than-permission mode.  This part is also how I’ve managed to watch and photograph from below the curtain.  Just call me Sneaky McSneakerson. 

During this time, partner stays right by the mom.  There isn’t any physical support that can be offered during this time.  Mom can’t have ice chips or a cool cloth.  Her partner’s presence is THE essential support.

Of course the big moment is when the baby is lifted up over the curtain for mom to see.  Often the partner is instructed to stand up to see this moment.  The curtain is usually lowered a bit. 

The OB passes the baby to a nurse.  Baby goes to the warmer for the pediatrician to check.  This is standard for cesarean.  I switch places with the Dad so he can follow baby while I stay near to mom.  I pass the camera to Dad. 

And I giggle/cry/oooh/aaaah with the mom about the amazing baby.  I describe what I see happening over at the warmer.  “Aww, baby just got her first rectal temp. check.”  Good stuff.  If it is taking a long time, I will grab the camera back and show mom pictures of her baby. 

Post-birth, I’ve also noticed that many moms experience pressure in their abdomen.  Sometimes they are shaky or feel dizzy/nauseous.  Blood pressure might drop.  There isn’t much I can do except encourage and normalize her physical feelings.  Or speak to the nurse anesthetist about what she is feeling. 

6)  Making your moves

Dear super doula, you can be a game-changer if you play the cards right and all the stars are aligned.  You can sometimes get almost-immediate skin-to-skin contact for your client.  If the pediatrician and the nurse anesthetist/anesthesiologist agree, your humble request may be granted.  You may have to pinky swear you’ll hold the baby in place especially if they are unwilling to unstrap mom’s arms.  And swear on your great-grandmother’s tomb that you will not let the baby get cold. 

When your wish is granted, unsnap mom’s gown at the shoulders, expose some skin.  There may be monitors stuck to her chest.  Ignore them.  Place baby skin-to-skin on mom’s chest, cover baby with a blanket, and then you or partner hold the baby there.  Sometimes, against the hopes and dreams of the medical team, the precocious baby will even latch on to a breast while the OB sutures away below the curtain.  Babies don’t know hospital policy. 

It is tough to see since I pinky swore baby would stay covered by the blanket, but the picture below is a baby skin-to-skin.

However, please be attuned to mama during this time.  She may have been vocal about skin-to-skin before the surgery.  But a cesarean is a pretty big deal.  And if she doesn’t feel able to hold her baby just then, encourage dad to hold on to baby (and not to let go!). 

7)  Last dance and farewells

Cesarean births can be a tad bloody.  Expect to see bloody guaze, perhaps some blood on the floor.  Sounds of suction.  The smells can be strong especially if the OB uses a cautery.  And it is a little unnerving when the OB and nurse count the instruments and gauze to double-check that nothing was left inside.  I have plenty of pictures to illustrate my point but I think I’ll spare you. 

Sometimes birth partner and doula are asked to return to the L&D room or recovery with the baby.  If the nurse says to put the baby in the warmer in the room, I suggest dad strip his shirt off and do his own skin-to-skin with his offspring.  Makes a nice picture for mom to see later.  

Dad should be clear about mom’s wishes for possible baby procedures.  If he isn’t sure and it is not an emergency, he would be wise to delay until mom is there.

At some point soon after, everyone is reunited.  If I’m told the policy is only one person in recovery, I pretend I didn’t hear.  Yep, I develop strange and sudden hearing loss.  I melt into the background (those nurse scrubs sure could help!) or become indispensable to someone.  I have not yet been kicked out of a room after the one-person-policy has been stated.  The same technique works for epidural placements.  Just pretend the rule doesn’t apply to you.  “Hmmm?  Who are they talking about?  Not me, surely.”  Or write intently in your client folder and don’t make eye contact.  Be invisible.  

Your job is now breastfeeding initiation.  The L&D nurse or recovery room nurse will focus on mom’s blood pressure and other vitals.  Sometimes mom needs to lie almost flat until her bp stabilizes.  But babies can still nurse.  You may need to hold a breast and hold a baby because mom might be weak or shaky.  One client tells me she remembers very little of this time but she is thankful that someone was there to (literally) support her and baby.

I hope that helps some!  Does anyone else have insights into the world of cesarean birth?  Was your doula able to accompany you?  What could have made your cesarean birth better?  What can you add?

*And a big special thanks to the families who let me share these pictures!

ETA:  By request, I’m adding a better picture of the shoe organizer.  🙂

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And speaking of cesareans

Time Magazine has released a timely article on VBACs.  A quote from the article:  “When the problems with multiple C-sections start to mount, we’re going to look back and say, ‘Oh, does anyone still know how to do VBAC?'”

Curious about which hospitals ban VBACs in your state?  Check out ICAN’s new database.  The closest hospital to my house makes the list.  Ahem, Palmetto Baptist Easley.  I was surprised to see AnMed on the list of “de facto” bans.  I know of at least one VBAC at AnMed in the past year.  I hope this listing is a mistake.

Cesarean Practices

I’m going to try to write this post without sounding like I’m on a rant.  Deep breath and…

I want to talk about the immediate postpartum of a cesarean birth.  First, let me mention, that I’ve only attended cesareans at Greenville Memorial.  My experience is limited and what I’ve heard of other local hospitals is just that–hearsay. 

What bothers me the most about preparing my clients for cesarean birth is the inconsistency of practices.  I honestly don’t know what to tell them to expect anymore.  Examples: 

1)  Sometimes I’m permitted in the operating room.  If the doctor says I can attend, then the anesthesiologist must ok it.  I receive that answer second-hand from a nurse.  Sometimes after I’m already dressed in scrubs, I’m told “the anesthesiologist said ‘no’.”

2)  In that case, I’m taken to the mom’s recovery room to await her arrival.  Since Greenville Memorial doesn’t permit recovery room “rooming-in,” I stay with mom while dad goes with baby.  Recently, however, I was not allowed in recovery at all.  Like the anesthesiologist decision, it was at the say-so of one person–the recovery room nurse.  In that situation, the mom was left alone in recovery while dad stayed with baby.  I learned that if I was her immediate family, the nurse would let me in.  I’ve never heard that one before.  I wonder if it is written down anywhere?  

3)  If baby is healthy, he is taken to the nursery where inane people smile at the babies lying alone in isolettes behind the glass.  I have so much trouble with this scene.  The babies are alone.  These newborns are not skin-to-skin with a parent, are lying on their back under bright lights, and are surrounded by unfamiliar open space and smells. Why are people smiling at this?  But I digress.  The inconsistency is how quickly and easily the dad is able to bust his newborn out of the nursery.  Sometimes, it is no big deal.  Dad walks over to the nursery door and requests his baby.  Sometimes, he is told that the baby must be observed for an hour.  Sometimes 2 hours.  Sometimes he is told the baby must have a bath first.  I’ve actually started suggesting my clients flirt or fib to get their baby.  I watched one dad do both!  Tip:  go to the Mom/Baby info desk, ask for the room number of your wife, then go tell the nursery that you have been assigned a room and need to take your baby to his room. 

What logic suggests it is best practice to keep baby alone in an isolette immediately after birth?  When every medical journal is promoting immediate skin-to-skin and early initiation of breastfeeding, why this practice?  Babies do best in arms.  Why do newborn nurseries still exist?  Now I’m sure Greenville Memorial has a logistical reason for this practice but I doubt it is based on logic.

What my issue boils down to is this:  how your baby is handled after a cesarean birth is often determined by one person’s whim or mood. 

Another example:  one of my clients wanted the baby to be placed skin-to-skin on her chest following her cesarean.  She and her doctor discussed how that would work.  Everyone agreed.  Doctor exited.  OR nurse entered.  She said “absolutely not.  the OR is too cold for skin-to-skin.”  And so ensued a tense discussion that ended with a sour OR nurse influencing much of what subsequently occurred in the OR and in recovery. 

In some hospitals (even St. Francis), families remain in recovery together.  In some hospitals, babies are routinely placed skin-to-skin on mom immediately and in a few hospitals, permitted to nurse in the operating room.  I’ve heard of one Australian doctor who encourages the mother to “birth” her own baby during cesareans.  He delivers the head and then guides the mom to pull the baby to her chest, cord still uncut.  I’m not sure how the whole sterile field issue is handled in that situation.  The point is that there are ways to make a cesarean birth feel more like, well, birth.

Step 4 of the Mother-Baby Friendly Hospital Initiative is to initiate breastfeeding within one hour of birth.  And while I’ve had one client who nursed her baby immediately after leaving the OR (before baby was removed to the nursery), this is not the norm.  On average, for the cesareans I’ve attended, the delay has been more like 2-4 hours.     

And in case you’re wondering why breastfeeding within the first hour of birth is so important, here are a few reasons:

1)  Mom’s body regulates the baby’s body temperature. 

2)  Baby is less stressed, calmer, and has steadier breathing and heart rates.

3)  Baby is exposed to bacteria from the mother which are mostly harmless, or against which the mother’s milk contains protective factors.  Mom’s bacteria colonizes the baby’s gut and skin.  These compete with more harmful bacteria from health providers and the environment, and so prevent them from causing infection.

4)  Baby receives colostrum which, among many other protective factors, stimulates the baby to have bowel movements so that meconium is cleared quick.  This helps get rid of the substances in the baby’s body that produce jaundice and may help reduce it.

5)  Touching, mouthing, and sucking at the breast stimulates oxytocin to release in the mom.  Oxytocin causes the uterus to contract which may reduce maternal bleeding.  It stimulates other hormones which cause a mom to feel calm, relaxed, and “in love” with her baby.  And finally, it stimulates the flow of milk from the breast.

6)  Mom experiences joy.  The process of bonding is strengthened.

If you had a cesarean birth or attend cesareans, what has been your experience?  What are the practices like at other hospitals? 

 

 

 

 

 

 

Beware Those Trendy Homebirthers!

Homebirths are trendy?  Fashionable?  The latest cause celebre?  Huh?  Did I miss the memo?  

These are the adjectives used in the American College of Obstetricians and Gynecologist’s (ACOG) newest statement against homebirth.  Wanna hear more? 

Why are there so many C-sections in America?  Oh, blame it on the women, according to ACOG, who attribute the US numbers to “maternal choice and the rising tide of high-risk pregnancies due to maternal age, overweight, obesity and diabetes.”  Hmmm…how do they explain the incredibly low rate of homebirths that end in c-sections?  Or the fact that other developed countries don’t have such high cesarean rates?  Do they really believe that more American women are unable to give birth vaginally? 

This is my favorite part:  “Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby.”  Wow.  Those stupid homebirthers.  They only care about the latest trends and causes celebre.  I’,m sure they haven’t looked at the links between common hospital interventions and cesarean birth or difficulty breastfeeding.  They haven’t considered that the US ranks 2nd to last in infant mortality rates among developed countries or that the National Center for Health Statistics reports that an estimated 40% of maternal deaths were due to “quality of care.”  And I’m certain none of these homebirthers read the British Journal of Medicine’s study which concluded planned North American homebirths were safer than hospital births.  I wonder if ACOG read that study?  Obviously, these homebirthers aren’t thinking about the well-being of their baby.  They care most about “the (trendy) process of giving birth.”

Homebirthers are some of the most well-researched people I know.  They don’t choose homebirth just for the fun of it.  They do it because they believe it is the safest choice for their baby and for the mother.  And the research that ACOG says is not “rigorous” enough supports their choice.  If ACOG really wants to speak against homebirth and direct entry midwives, then ACOG should fund a study, track the outcomes, and maybe, GASP, actually attend a homebirth! 

I wonder if this latest ACOG statement is a reaction to “The Business of Being Born” release on DVD this month?  Could Rikki Lake have stirred up this venerable establishment so much?  I surely hope so.