The Natural Caesarean

***If you already know about natural or gentle caesarean births and want to jump straight to writing birth preferences for a caesarean birth, see here.***

The term “Natural Caesarean” sounds like an oxymoron…how can a caesarean birth be “natural”? But this increasingly popular technique tries to make a caesarean birth more like a natural birth.

I researched the topic for my own information this year and have since written a document on the natural caesarean for Doula UK doulas. I’ve become quite passionate about promoting the technique as options for caesarean birth. Whilst, I definitely agree that caesarean birth rates are too high in the UK and I’m all for promoting natural vaginal birth as well, caesarean births will always be a part of the birth spectrum. Given that, it would be good if more women and families facing a caesarean birth had more options and that, wherever possible, the possible negative impacts of caesarean birth on babies, mothers and families could be minimised.

So, what is a natural caesarean?

The natural caesarean – also called the gentle, woman-centred or family-centred caesarean – method seeks to maximize parental connection with the birth, limit the negative effects of caesarean section on the baby and provide a less potentially traumatic and more family-centred way of performing caesarean section.

This way of performing caesarean sections was pioneered by the Division of Maternity at Queen Charlotte’s and Chelsea Hospital, London. Since the publication of a paper explaining the technique in 2008 (Smith, Plat and Fisk, 2008) and the subsequent online distribution of a video showing the technique (Reelflowtv, 2011), the natural caesarean method has been adopted by obstetricians and hospitals worldwide.

Key points of the natural caesarean method include:

• the parents watching the birth of their child as active participants
• slow delivery with physiological autoresuscitation
• delayed cord-clamping, either between delivery of the head and complete delivery of the baby or in addition to this
• the baby to be transferred directly onto the mother’s chest for early skin-to-skin contact in theatre.

The technique lends itself to caesarean births where there is no immediate rush, either elective (planned) caesarean births, or emergency caesarean births where there isn’t a life-threatening emergency where minutes matter – for example, if there is a medical complication that means a caesarean birth is required, but where mother and baby’s health is stabilised for now. However, many of its elements can be used even in emergency situations and natural caesareans have been performed in real emergencies (read Elise’s story of her son’s birth by natural caesarean despite a Category 1 emergency with suspected placental abruption).

Also see this news article and video about a 2016 gentle caesarean:http://www.coventrytelegraph.net/news/health/watch-baby-deliver-itself-during-11675631 .

How does the Natural caesarean technique actually work?

Preparation

Antenatally:

• The parents are educated about the technique, using videos of ‘natural’ caesareans.
• When possible, the woman (and her partner) meet the midwife and obstetrician preoperatively and are shown the operating theatre to render the environment less intimidating.
• The parents are encouraged to bring their own music.

In theatre:

• The pulse oximeter is positioned on the mother’s foot to keep her hands free.
• The electrocardiogram (ECG) leads are positioned away from her anterior chest wall where the baby will be placed.
• The anaesthetic block aims to permit pain-free surgery without requiring supplementation (which may obtund the woman’s responses). It should not affect the upper limbs needed to hold her baby nor cause haemodynamic instability with its potential for light-headedness, nausea or vomiting.
• The intravenous line is placed in the nondominant arm.
• Once the block is sited, one of the woman’s arms is freed from her clothing to facilitate skin-to-skin contact.
• Cardiotocography is continued until skin preparation to confirm fetal wellbeing.

Delivery: walking the baby out

• The protocol for natural caesarean used by Queen Charlotte’s Hospital (Smith et al, 2008) suggests that surgery starts with the screen up, and sterile routines observed as usual. After uterine incision, the drape is then lowered. Alternatively the drape could be dispensed with.
• After uterine incision, the head of the table is also raised to enable the mother to watch the birth.
• As the fetal head enters the abdominal incision, the operative field is cleaned of blood and the partner is invited to stand to observe the birth. A member of the surgical team or the mother’s birth partner can provide a commentary of what is happening for the mother if/when she is unable to see clearly.
• The principle for the surgeon is then hands-off, as the baby autoresuscitates: breathing air through its mouth and nose, while its trunk still in utero remains attached to the placental circulation. This delay of a few minutes allows pressure from the uterus and maternal soft tissues to expel lung liquid, mimicking what happens at vaginal delivery.
• The half-delivered fetus frequently cries but if not, the obstetrician observes its breathing, colour, tone and movement to indicate wellbeing.
• Once crying, the baby’s shoulders are eased out, and the baby then frequently delivers his/her own arms with an expansive gesture. Concurrently, the baby’s torso tamponades the uterine incision, minimising bleeding.

Delayed cord clamping

The use of the natural caesarean method automatically enables a delay of up to around 3 minutes between delivery of the head and the baby starting to breathe independently, and delivery of the body and then clamping & cutting of the umbilical cord. This delay wouldn’t be considered delayed cord clamping in a vaginal birth, and it is a natural part of a normal (not instrumental) vaginal birth, but even just this is still an improvement over the more typical (fast) caesarean birth.

• Once the baby is finally ‘born’ and wellbeing again confirmed, the anaesthetist/anaesthetic assistant clears the mother’s clothing from her chest, and the midwife positions him/herself at the top of the table beside the mother’s head.
• The operating table should be levelled from the preoperative lateral tilt.
• The protocol for natural caesarean used by Queen Charlotte’s Hospital (Smith et al, 2008) suggests clamping the cord immediately after the complete delivery of the baby, before the (still scrubbed) midwife receives the baby directly from the surgeon to prevent contamination.
• Further delay in cord clamping can be achieved without contamination by either:
  • the baby being passed from the surgeon to the (still scrubbed) midwife after delivery – without clamping and cutting of the umbilical cord – and the midwife holding the baby within the parents view while the cord remains attached to the placenta. The cord is then clamped, after a delay, within view of the parents.
  • The baby being delivered onto the woman’s stomach, thigh or between her legs, wrapped in a warmed towel and kept there for a delay (of at least 2 minutes for a term baby that appears well) before cord clamping (Southern West Midlands NHS Newborn Network 2011, Hutchon and Ononeze 2006).
  • NB. With either technique, the woman should be warned not to reach out for her baby, as this risks touching the obstetrician.
  • While the cord is intact the baby should not be lifted more than 10 cm above the uterus (RCOG, 2009) and should ideally be kept below the level of the placenta (Southern West Midlands NHS Newborn Network 2011).

Early skin-to-skin contact

• After the cord is clamped and cut, the baby is immediately laid prone between the mother’s breasts by the midwife, positioned so that he/she can begin to suckle.
• After a plastic clamp is applied, the partner can cut the remaining cord if he wishes.
• The baby can then be dried with a warmed towel (patted dry if parents request that the vernix is not removed) and kept warm with fresh towels and bubble wrap.
• The screen can then be restored.
• The midwife remains near the head end to monitor the baby and reassure the parents.
• Most midwifery tasks (AGPAR scores, labelling, etc) can be accomplished with the baby on the mother’s chest.
• When the surgery is finished and the mother is being transferred to a bed, the baby can be weighed before being given to the partner for skin-to-skin and then returned to the mother for further skin-to-skin contact.

Discussion of evidence

There is no real quantitative evidence about the efficacy and safety of the natural caesarean protocol as compared to more usual caesarean protocols. However, there is evidence and evidence-based guidance relating to specific aspects of the natural caesarean technique.

The NICE Guidance on Caesarean section (NICE 2011) states that “women’s preferences for the birth, such as music playing in theatre, lowering the screen to see the baby born, or silence so that the mother’s voice is the first the baby hears, should be accommodated where possible.”

Delivery: walking the baby out

• The NICE Guidance on Caesarean section (NICE 2011) recommends that medical staff take into account the condition of the woman and the unborn baby when making decisions about rapid delivery and that they should remember that rapid delivery may be harmful in certain circumstances.
• There is significant evidence that neonatal respiratory complications are more common after elective caesarean than vaginal delivery, in which retained lung liquid is implicated, as is the lack of catecholamine and cortisol surge associated with vaginal birth (Smith, Plaat and Fisk 2008). Whilst there is no yet quantitative evidence of this, pausing the delivery of the baby, after the delivery of the head, to allow physiological expulsion of lung liquid like at vaginal delivery may facilitate respiratory adaptation.

Delayed cord clamping

Much of the evidence surrounding the effects of delaying cord clamping is from trials and reviews considering vaginal births. However, the potential benefits of delayed cord clamping for the infant in any birth can be extrapolated from this.

• A Cochrane review (Rabe et al 2012) of the evidence on the timing of umbilical cord clamping with preterm birth found that delaying cord clamping for at least 30 seconds was associated with fewer infants requiring transfusions for anaemia, less intraventricular haemorrhage and lower risk for necrotising enterocolitis compared with immediate clamping.
• Another Cochrane review (McDonald and Middleton 2008) of the evidence surrounding the effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes concluded that delayed cord clamping does not affect maternal outcomes and it is important to weigh the growing evidence that delayed cord clamping confers improved iron status in infants up to six months after birth, with a possible additional risk of jaundice that requires phototherapy.
• A randomised controlled trial (Andersson et al 2011) looking at the effect of delayed (at least 180 seconds after birth) versus immediate (less than 10 seconds after birth) umbilical cord clamping in 400 full-term infants found that delayed cord clamping, compared with early clamping, resulted in improved iron status and reduced prevalence of iron deficiency at 4 months of age, and reduced prevalence of neonatal anaemia, without demonstrable adverse effects.
• The Royal College of Midwives (RCM) has updated its third stage of labour guidelines (RCM 2012) to be clearly supportive of a delay in umbilical cord clamping.

One complication of caesarean section over vaginal delivery when considering delayed cord clamping is that a physiological third stage is not possible with a caesarean section. Use of uterotonic drugs to facilitate the removal of the placenta is routine and it used to be accepted that the use of uterotonic drugs meant that immediate cord clamping was required, in order to prevent excessive placental transfusion. However, this is no longer clear:

• Mercer and Eriskson-Owens (2012) stated that uterotonics are not contraindicated with delayed cord clamping.
• The Royal College of Obstetricians and Gynaecologists (RCOG) Scientific Impact Paper ‘Clamping of the umbilical cord and placental transfusion’ (RCOG, 2009) states that the use of a prophylactic uterotonic drug does not significantly alter the volume of placental transfusion and that neither intramuscular oxytocin nor intramuscular Syntometrine, given with delivery of the anterior shoulder, is likely to have a substantive effect on placental transfusion.
• The Royal College of Midwives guidelines for the Third Stage of Labour (RCM 2012) now state that “delayed cord clamping is currently the recommended practice”. Although the guidelines do not specifically state a delay suitable when using oxytocic drugs, discussion prior to the publication of the guideline (Midwives 2012) emphasized that the change in guidance (from not recommending delayed cord clamping) would have an effect, not on physiological birth (when no oxytocic drugs are used), but if active management (including oxytocic drugs) is used in the third stage.
• The Southern West Midlands NHS Newborn Network Guideline on Delayed Umbilical Cord Clamping (Southern West Midlands NHS Newborn Network 2011) states that “delayed cord clamping does not interfere with the management of the third stage of labour, nor operative delivery.”

Early skin-to-skin contact

• Randomised trials demonstrate that early skin-to-skin contact increases the rate and duration of breastfeeding, reduces infant crying and improves maternal affection (Smith, Plaat and Fisk 2008).
• The NICE Guidance on Caesarean section (NICE 2011) states that “early skin-to-skin contact between the woman and her baby should be encouraged and facilitated because it improves maternal perceptions of the infant, mothering skills, maternal behaviour, and breastfeeding outcomes, and reduces infant crying.”

References:

Andersson O, Hellström-Westas L, Andersson D, Domellöf M. 2011. Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BMJ. 2011 Nov 15;343:d7157. doi: 10.1136/bmj.d7157.

Hutchon DJR and Ononeze B. 2006. Available from: <http://www.hutchon.net/NFMMSIG/cordclamp.htm&gt; [Accessed on 9 May 2013]

McDonald SJ, Middleton P. 2008. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004074. DOI: 10.1002/14651858.CD004074.pub2

Mercer JS, Erickson-Owens DA. 2012. Rethinking placental transfusion and cord clamping issues. J Perinat Neonatal Nurs. 2012 Jul-Sep;26(3):202-17; quiz 218-9. doi: 10.1097/JPN.0b013e31825d2d9a.

Midwives magazine. 2012. Available from: < http://www.rcm.org.uk/midwives/news/in-focus-clamping-update-to-be-delivered/ > [Accessed on 9 May 2013]

NICE. 2011. NICE Guideline CG132 Caesarean section. Available from: <http://publications.nice.org.uk/caesarean-section-cg132/introduction > [Accessed on 9 May 2013]

Rabe H, Diaz-Rossello JL, Duley L, Dowswell T. 2012. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD003248. DOI: 10.1002/14651858.CD003248.pub3

RCM 2012. Evidence Based Guidelines for Midwifery-Led Care in Labour: Third Stage of Labour. Available from: < http://www.rcm.org.uk/college/policy-practice/evidence-based-guidelines/> [Accessed on 9 May 2013]

RCOG, 2009. Clamping of the umbilical cord and placental transfusion (Scientific Impact Paper 14). Available at: <http://www.rcog.org.uk/clamping-umbilical-cord-and-placental-transfusion> [Accessed on 9 May 2013]

Reelflowtv, 2011. The natural caesarean: a woman-centred technique. Available at http://www.youtube.com/watch?v=m5RIcaK98Yg&feature=player_embedded [Accessed 9 May 2013]

Smith J, Plaat F, Fisk NM. 2008. The natural caesarean: a woman-centred technique. Br J Obste Gynaecol 115(8):1037-42

Southern West Midlands NHS Newborn Network. 2011. Delayed Umbilical Cord Clamping. Available from: < http://www.networks.nhs.uk/nhs-networks/southern-west-midlands-newborn-network/documents/SWMNN%20-%20Delayed%20Cord%20Cutting.pdf > [Accessed on 9 May 2013]