natural/gentle caesarean - avoiding the obstacles and riding the … · 2019-11-07 ·...
TRANSCRIPT
Natural/Gentle Caesarean
- avoiding the obstacles and riding
the waves - where next?
Jenny Smith – Midwife
Photo credit: Joth Shakerley London 2019 Nat CS
Learning outcomes
• Contextualise background and the need for a ‘natural’ caesarean; a “family centred approach”
• Understand what is involved in a ‘natural’ caesarean section: the advantages & risks
• The natural caesarean critics
• Modifications of technique
• The natural caesarean in obstetric enhanced recovery programs
• Where next – natural caesarean heralds the way to change mainstream labour wards ?
London 2019 Nat CS
Fig 2. Global and regional trends in caesarean section, 1990–2014.
Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, et al. (2016) The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014. PLOS ONE 11(2): e0148343. https://doi.org/10.1371/journal.pone.0148343 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0148343
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Progress 1970s-2000s
• Consumer driven/woman centred
• Non-clinical environment
• Maternal involvement
• Early skin to skin
• Early breast feeding
• Paternal involvement
• Ritual driven/ staff centred
• Full surgical environment
• Shift GA to epidural
• Background music
• Minimal parental involvement
• Low breast feeding
• Poor maternal satisfaction
• Subfertility
Vaginal delivery Caesarean delivery
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• Improves rate breast feeding
• Improves duration breast feeding
• Reduces infant crying
• Increased maternal affection
2009
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Exclusive Skin‐to‐Skin Rate by Birth Method
Vaginal delivery
CS delivery
SCHORN, M. N., MOORE, E., SPETALNICK, B. M. AND MORAD, A.
Implementing Family-Centered Cesarean Birth
In-text: (Schorn et al., 2015)
:Schorn, M., Moore, E., Spetalnick, B. and Morad, A. (2015). Implementing Family-Centered Cesarean Birth. Journal of Midwifery & Women's Health, 60(6), pp.682-690. London 2019 Nat CS
2008
fMRI to own baby cry at 4-6 wks
Vaginal vs planned C section London 2019 Nat CS
• Parental participation
• Autoreuscitation
• Direct skin to skin & breast feeding
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Queen Charlottes and Chelsea Hospital
NATURAL Caesarean-parental participation
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Starts as normal
Photo credit: BBC News 2007
Father may stand
Photo credit: BBC News 2007
Drop the drape
Photo credit: Flutterby Films 2007
A B C
A
Face the mother
Parents call the sex
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Photo credit: BBC News 2007
Baby autoresuscitates
Photo credit: BJOG 2009
3. Gentle birth “Walking” the baby out
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Hands off
Photo credit: BJOG 2009
4. Immediate skin to skin Breastfeeding at CS
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Photo credit: BBC News 2007
“Walking the baby out”
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Photo credit: BBC News 2007
http://news.bbc.co.uk/1/hi/in_pictures/7154594.stm
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Reviewers’ comments
• “Unacceptable risks infection, transverse/oblique lie, extension of uterine angles, & tears extending into bladder, dislodged IV lines, increased maternofetal Tx”
• “A burden for junior registrars, too difficult for OBs”
• “Nothing natural about a caesarean, misleading & dangerous…should not be published”
• “Many OBs do something similar for the same reasons but have not thought it merited writing up”
• “Nothing new”
#1 #2
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https://www.youtube.com/watch?v=wdyzAuc3Ff8 London 2019 Nat CS
Photo credit: BJOG 2009
• Great danger in legitimising C section
• Women mislead to be believe that C section safest for them
• Sanctioning CS threatens the health of mothers and babies everywhere
• Term “natural CS” as misleading as “friendly fire”
• Challenge the ethics of making caesarean births “nicer”
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• #1 render a highly successful natural process dysfunctional
• #2 fix the created problem with technology
• #3 reframe the technology as a natural solution
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Natural Caesarean Section
2008 2012 2013
2014
2016
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NHS heads for ‘natural’ caesareans Katie Gibbons May 7 2016, 12:01am, The Times
Media
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Robert Armbrust, Larry Hinkson, Katharina von Weizsacker & Wolfgang Henrich (2016) The Charite cesarean birth: a family orientated approach of cesarean section, The Journal of Maternal Maternal-Fetal & Neonatal Medicine, 29:1, 163-168
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“I had a natural labour followed by
a natural emergency caesarean”
Emergency Caesarean – failure to progress
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Twins – now 16 years old
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Enhanced Recovery – natural CS
ANTENATAL
Information
Breast feeding
education
Hb optimization
IN-PATIENT
Minimise fasting
Dedicated CS list
Neuraxial opioids
Antibiotics
LMWH
POSTPARTUM
Skin -Early feeding
Regular analgesia
Early removal urinary
catheter
Breastfeeding
Community
support
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“Photo used with permission from personal file of Dr.
William Camann, Director, Obstetric Anesthesiology,
Brigham & Women’s Hospital, Harvard Medical
School, Boston, MA, USA”
Clear drapes
• Use of hand mirror for mother to watch birth
• If cord long enough babe maybe given to mother by
scrub midwife and Dad can do first cutting of cord
• Baby born into clear operating theatre pouch
NUH MaternityAndy Simms Obstetrician
Discussion Points
https://www.nuh.nhs.uk/caesarean-birth-c-section/
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• If small scar may need to use forceps to assist head delivery ?
• After baby head out baby can sometimes wriggle out with very minimal assistance
• Syntocinon IV given once baby head out will increase uterine contraction?
• What is a maternal assisted caesarean?
• Maternal-assisted births, allow mothers who are unable to have a vaginal birth to play a more active role in their child's delivery.
• The procedure, more common in Australia than in the UK, allows the mother to pull their child from the womb themselves, before giving them skin-to-skin bonding.
https://www.abc.net.au/news/2016-08-23/maternal-assisted-caesarean-mother-helps-delivery-baby-boy/7776654
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Photo credit: BBC News 2007
Conclusions • The ‘natural/gentle CS’ is
• Possible
• Popular
• Fits well with enhanced recovery
• The ‘natural/gentle CS’ appears to
• Be safe
• Enhance breastfeeding rates
• Enhance “family- centred “birth experience
• The ‘natural/Gentle CS may reduce
stress and trauma for women, babies and partners?
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Could the natural caesarean herald the way forwards to normalizing all births
• All births family centred ?
• Birth pools for high risk births?
• Increase mobility with epidurals?
• Re-think episiotomy for all instrumental births?
• Reduce stress for all families in high risk births
Ante and post wards single rooms for all?
Double beds?
Environment adjustments “home from home” like that on birth centres
London 2019 Nat CS
The “natural caesarean” technique as inspiration for normalising practice for all types of birth- Jenny Smith.
Extract from: Donna, S. (2011). Promoting normal birth. 1st ed. Chester le Street: Fresh Heart Publishing, pp.210-218.