Podcast: Caesarean Birth with Consultant Obstetrician, Florence Wilcock
Caesarean Birth with Consultant Obstetrician, Florence Wilcock
Season 2, Episode 6
Around 1/3 births in the UK happen by caesarean, so it's certainly something you might like to learn about during pregnancy.
The prospect of major abdominal surgery whilst awake can be quite daunting for many of us, so in this episode we talk through exactly what you can expect from a caesarean birth.
Not just that, but thinking about- what are your options and what considerations might you make to support yourself and your baby and mark this as a positive, transformative, special way of giving birth.
I am joined by Consultant Obstetrician Florence Wilcock to shine a light on caesarean birth and hopefully leave you feeling more prepared, more confident and more empowered if you birth your baby by caesarean.
TRANSCRIPT
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Hi, everyone.
Welcome back to The birth-ed podcast.
This week, we are going to be talking about the topic of Caesarean birth.
I am joined by the wonderful Florence Wilcock, who is a consultant obstetrician in the NHS, where she is a lead consultant for perinatal mental health and works closely with her Trust's Home Birth Team, Birth Options Team, and the team that look after women having a birth after a Caesarean.
Alongside her clinical work in the NHS, Florence has a special interest in improving women's experience of maternity care and is closely involved with her Trust's MVP, which is the Maternity Voices Partnership.
She is co-founder of Maternity Experience and hosts her own brilliant podcast, The OBS Pod.
Florence, welcome.
Thank you so much for joining me.
Thank you very much for inviting me.
It's lovely to be here.
So to start with, I thought it might actually be a kind of helpful place to begin.
Just kind of touching on the language that we are going to use in this episode, talking about Caesarean birth and the language that women might hear or choose to use themselves in different capacities.
Both you and I have supported women who have given birth by Caesarean.
And one of the things that I think is really often overlooked is simply what we are calling this experience.
And have you noticed clinicians and women tend to use different language or prefer specific choices of language?
I think that we do use different language, very much so.
I do think there's a bit of a shift going on in the language, though.
Professionals will often refer to a Caesarean as a section, because classically it's known as a Caesarean section.
And I definitely think in the last few years, probably because of my work with women, I've started to refer to it as Caesarean birth rather than Caesarean section.
And certainly when I'm doing a consent form with a woman, I now write Caesarean birth.
So for me, the word section has kind of slightly gone out the window.
Yeah, I know a lot of women do write C section because Caesarean is really difficult to spell.
So I think that does form part of it.
But I think certainly that's the language that I use is Caesarean birth or giving birth by Caesarean.
And I think it just flips sometimes the kind of narrative in the sort of political landscape, I suppose, of what it is to give birth by Caesarean.
And historically, there's sometimes a narrative around being too posh to push or the easy way out.
And as we go through this podcast, you'll definitely see that those things certainly are not true.
And so I thought that was just a good place to start, that that's the kind of language that hopefully we'll be able to use during this podcast.
The other thing we do is we use abbreviations.
So we might write CS in the notes, or we might write LSCS.
And that stands for lower segment Caesarean section.
And although that might not seem very relevant, it's very relevant to us as clinicians, because that tells us where the incision on the womb is, and therefore that has implications for birth in the future.
So LSCS might be something you see written in your notes as well.
Great.
And so this is a thread that will probably continue to run through our conversation.
It's that emotional journey and the kind of emotional impact of giving birth in this way.
And the feelings that women have around that can be very mixed.
They can be completely delighted and feel supported, and that's everything that they've ever wanted.
Or some women can feel the kind of total opposite.
And language certainly plays a kind of a big part in that, and the kind of emotional reflection, I suppose, after the birth itself.
So taking it right, right, right back to basics then.
I thought a helpful place to start would be considering Caesarean birth from the perspective of pregnancy.
So it's probably simple enough to break Caesareans down into planned, i.e.
the decision is made before labour begins, and unplanned, so the decision is made during labour itself.
And we can break that down a little bit further later on.
But I wondered if you could share some of the kind of most common reasons that you would be seeing women anti-natally, so during pregnancy, that may either be choosing or be recommended to plan a Caesarean birth.
So there are some conditions for which we absolutely recommend Caesarean birth.
I guess the most obvious one would be placenta previa.
So where the placenta has implanted low down in the womb, possibly even across the cervix, across the neck of the womb, and therefore giving birth vaginally just isn't possible without the woman bleeding very significantly.
So that's an absolute indication for Caesarean birth.
Another one might be if the baby is in an awkward position.
So, for example, transverse lie.
So if the baby is lying horizontally across the womb, in some situations, we can correct that and turn it.
But in many situations, if the baby is transverse, absolutely again, that's an absolute indication for Caesarean birth.
The baby cannot come out vaginally.
Twins might also be an indication depending on the type of twin pregnancy.
So identical twins, monochorionic twins, will often advise a Caesarean birth.
Or we might advise a Caesarean birth if a baby is very growth-restricted, so it's having problems growing in the womb, it's very small, we're wondering how it will cope during labor, or if the baby needs to be born pre-term for the mother's health.
So there are some absolute indications.
Because I specialize in birth options, I see a lot of the women that are asking for a Caesarean birth or choosing a Caesarean birth, and that would be what we would call maternal request, although I'm not even sure that that's great terminology either.
And in my experience, it's almost never what the woman thinks is an easy way out.
There is always a multifactorial complex set of reasons and a lot of thinking behind those requests.
And it's interesting because I think my view on that has changed quite a lot over the years in terms of, because I spend a lot of time listening to women, I probably think I understand better now why a woman might come to the conclusion that that's the right choice of birth for her.
And we don't discourage that at all.
If that's what the woman feels will give her a positive birth experience.
But we do want her to understand that whilst it is, and it is a birth and it is a valid choice, it is also a surgical operation.
And she needs to understand the choice she's making and the pros and cons and the possible complications of each type of birth, so that she's making a really well-informed decision.
Yeah, fantastic.
Thank you.
And so, well, some Caesarean births are planned or at least sort of scheduled.
Again, going back to that kind of use of language, I've been chatting to a lot of people recently and one phrase that often doesn't sit well with people is the term elective.
For instance, any of the women in those situations that you just talked about where it's a kind of absolute, for the absolute safety of mother and baby, that is absolutely the kind of best or only way to give birth.
I think sometimes people feeling like they've been told that they have elected it makes it sound like they had a kind of a choice or an option when sometimes there really isn't a choice or an option.
So certainly, let's say, scheduled before kind of going into labour.
Of course, some caesareans happen unexpectedly during labour itself.
Now, these are often referred to within kind of clinical settings, but also by women themselves as emergency caesareans, which again, going back to the use of language, when you're having one or when you're hearing about them, can make them sound like pretty terrifying.
And so are you able to explain a little bit further the kind of the types of emergency or unplanned caesareans?
Yeah, absolutely.
And it's something I talk to women a lot about in my clinic, because emergency is a very emotive word, and it sounds like it's going to be everything crashing around, alarms going off and absolutely terrifying.
The reality is, there are a very small number of reasons for which we might need to do what's called a category one section or category one caesarean.
That is classified as there's an immediate threat to the life of the mother or the baby.
And with that sort of caesarean, we're aiming to get from decision time to the birth of the baby within 30 minutes, if we possibly can.
So that's a life-threatening situation.
And that's a very small percentage of caesarean births, you know, maybe a couple of percent.
It's very small.
More commonly, what people are referring to with an emergency caesarean is category two, which is actually this labor's not going to plan.
The baby's in a difficult position, or we have some concerns about the baby's well-being, or we have some concerns about the mother's well-being, and we need this baby to be born in the next 75 minutes, so an hour or so.
So we've got plenty of time to calmly talk a woman through what's going to happen.
Top up an epidural if she's got an epidural, or give a spinal anesthetic if she hasn't got anything already prepared.
And go to theatre in a calm way and have her baby.
There's a third type, category 3, which is either we were scheduling and planning a cesarean, but you have now come in with a problem that means we need to move it forward.
So perhaps you were planning a cesarean for placenta previa, but you've been admitted with some bleeding, and we now think the baby needs to come out.
Or maybe you were planning a cesarean, but you've gone into labour early.
That's what we call an expedited or category 3 cesarean.
So we need to get this baby out in the next 12 hours or 24 hours, depending on what the indication is.
But it's not a big rush.
And then category 4 is the completely scheduled, we booked you a date, you came in and had your baby on that date.
Yeah, thank you.
I think that's really helpful because again, just that use of even thinking of it from an unplanned perspective, I think most people's minds kind of jump to, oh my God, the baby has to be out in 10 minutes or something.
And it's very, very rare for that to be the reality of it.
Now, this might be an entire topic of its own and need an entire podcast of its own, but we might be able to kind of scratch the surface at least.
So, should we just chat a little bit about some of the things that can make an unplanned cesarean birth more likely and some of the decisions that women might make during pregnancy or birth that they can do to kind of reduce the chances of that happening.
Presumably, if they haven't elected for a cesarean birth or chosen or needed a cesarean birth before going into labour, they've gone in with the intention of having a vaginal birth.
So, what sort of considerations might somebody make to reduce that risk?
Well, the first thing would be place of birth.
So, we know that women who choose home birth or midwifery-led birth on a birth centre, assuming they haven't got other factors medically that mean that that's not the safest option for them, they have a much lower chance of intervention.
Even if they are planning a home birth perhaps and need transferring labour, their chance of a cesarean is still significantly lower than if they hadn't started at home.
So, there's something about a choice of place of birth that is very important.
The other thing that is important is spontaneous labour.
So, if your labour starts naturally, your body is ready, your baby is ready, then you definitely reduce your chances of cesarean birth, in my opinion.
Now, there is some controversy about this, and there have been some research papers that suggest, oh, we could induce everybody, and it wouldn't make a difference to the intervention rate.
But in practical terms, on the ground, looking at data in my own hospital and in other hospitals, we know that the women that are induced do have a higher emergency cesarean rate, which makes sense, because we're trying to get the body to do something that it's not quite ready to do.
Yeah, and we've got actually a really good episode on induction and making decisions around that as well.
And in terms of what kind of cesarean that is, I think that the outcome that often isn't described or often explained properly to women is that you can opt for an induction, and it just doesn't ever put you into labour.
Like, that is a situation that can arise, that then the final option of that process is a cesarean birth.
And sometimes I think we sort of miss that part off when explaining what induction might look like to women.
Yeah, that's true.
And we used to, going back to language, we used to call that failed induction.
I prefer to call it unsuccessful induction.
But yes, there are some women that, whatever prostagandine pesteries or things we've given or hormone drip, however much we've done, we just haven't managed to start the labour.
And then, you know, if we really feel that that baby needs to be born and we can't wait, then absolutely, cesarean is the only option.
And this is why the decisions around, particularly around induction, it's there as a potentially life-saving intervention and very helpful if there is a very good reason why either mum or baby needs that pregnancy to end at this moment.
But it is a decision that a woman is certainly in charge of making and one that hopefully they will have the opportunity to really take their time over deciding and gathering the information that they need to make that informed decision.
The final thing, a really helpful bit of research that I always share with women that I'm working with is to do with epidurals and particularly birth position.
So I don't know if you've seen it, there's a great bit of research about the use of peanut balls reducing the rate of cesarean birth.
And so using a peanut ball to sort of support, so what a peanut ball is, I should explain to anybody listening who doesn't know, it's a bit like one of those giant inflatable exercise balls, but in the shape of a peanut that can be used to kind of support the legs and the pelvis.
And there's some research to show that actually using that can reduce, I think it reduces the rate in the bit of research from about 20 to about 10% of unplanned cesarean.
So quite a significant difference potentially.
So I haven't seen the research, I will admit, but I have seen the peanut balls because we're absolutely obsessed with biomechanics where I work.
We've got some great midwives, and we have masses of peanut balls.
And when we do the wardrobe, we had some demos.
So I did have a bit of a Robozo session myself to see what that was like.
That's using the scarf.
But yes, the peanut ball is very much so in terms of opening up, first the inlet and then the outlet to allow the baby to come through the pelvis.
And when we do the wardrobe, for babies back to back, so occipital posterior, which we know can cause a slow and problematic labor and increase the chance of caesarean birth or assistive vaginal birth, we will literally on the wardrobe and go, okay, you're going to do biomechanics, you're going to do sideline release, which is another exercise that can be done, and you're going to use the peanut ball, and then we're going to check in four hours whether that's worked.
So yeah, I'm used to that in my day-to-day practice.
Yeah.
I don't know if it will be out when this episode comes out, but we've got an episode with Molly O'Brien, who you might be familiar with.
Who is all about the biomechanics.
So if you want to know more about that, then tune in to that one.
Okay, so let's take it back then to Caesarean birth.
Now, I think the one thing that makes Caesarean most daunting is the unknown, like the prospect of being awake during a birth, yes, but during like major abdominal surgery is probably quite scary for most women.
So for women that are having, let's start with women that are having a Caesarean that is scheduled in advance.
Can we talk through on a kind of like, from the moment they wake up that morning, what can they expect from this journey step by step, or even I suppose before that?
Yeah, I'd go back a couple of days.
So we see people a couple of days beforehand.
We do some blood tests, and we, at the moment we take a COVID swab, and we will give them some instructions about when not to eat and drink.
And that will depend on what time they're coming into hospital.
And we also give them some anti-acid tablets to take, just get rid of the acid in their stomach.
So they'll normally be told to take one tablet at 10 o'clock at night.
If they're coming first thing in the morning, we'll tell them not to have anything to eat after midnight.
But they can drink water.
And then they'll take a second tablet when they get up in the morning of the anti-acid.
And then we'll be asking them to come into the hospital pretty early in the morning, which is easy if it's your first baby.
It's not quite so easy if you've got other children to think about, because normally we're asking people to turn up at 7.30 or 8 o'clock in the morning.
So they will then come into the maternity unit, and they'll be usually greeted by a midwife who will be the midwife that's going to be in theatre with them.
We'll give them a hospital gown to get into, and we're going to put some lovely anti-clot stockings on, which are really unattractive.
They prevent blood clots in the legs.
And we're going to give the birth partner a set of scrubs to get into.
So people usually enjoy that.
It feels a bit like dressing up fancy dress or something.
Like they're on Grey's Anatomy.
Exactly.
And we will ask for the important things, which are a hat and a nappy for the baby, because that's all we're going to put on the baby because we want to do skin to skin.
And the midwife will go through a checklist.
So she'll check the blood test results from the couple of days before.
She'll check when you last...
What were those blood tests for?
So blood count to look at iron levels, so we know what sort of starting iron level we're at.
And something called a group and save, which means we've got blood in the lab so that if for some reason there's excessive bleeding and we need to think about a blood transfusion, we've got a sample already in the lab that they can match it to.
So we'll check those blood test results, make sure that group and save is in the lab.
And she'll do a checklist that, you know, checks, did you follow our instructions about eating and drinking?
We'll make sure you haven't got any nail varnish on because we'll want to put a little monitor on your finger that looks at your oxygen levels when you're in theatre.
And we will listen in to the baby's heartbeat and check the baby's doing OK.
And then you'll be seen by an obstetrician who will come and chat you through a consent form, look at your scar if you've had a caesarean before, talk through any other operations you've had, anything that we need to know that might be relevant to that surgery.
And you'll be seen by an anaesthetic doctor who will talk to you all about the spinal anaesthetic and exactly what to expect.
And they'll also check your mouth and your neck because they'll be preparing just in case we need to give a general anaesthetic for some reason.
So they might ask you some funny questions, like open your mouth, which may seem totally irrelevant, but what they're doing is they're checking if I needed to put this lady to sleep, would it be problematic?
What's her throat like?
Is that going to be okay?
And then we almost never use it.
So some of the things we ask might seem a bit strange, and some of the things we ask will seem totally obviously sensible.
So bear with us.
And then you'll be probably waiting in an area, maybe with one or two other women.
And we will go into theatre, and we'll have our little team brief.
So we'll discuss all the caesarean births that are happening that morning, and we'll decide what order we need to do them in.
And it won't be as straightforward as when you arrived in the hospital, because there might be some clinical considerations.
So if you've got diabetes, for example, it's very likely you're going to go first, because women with diabetes can't fast for as long as a woman who hasn't got diabetes.
We don't want her blood sugar to drop.
So it might be that we've got that to think about, or it might be that we need to think about the particular difficulties.
So if we know someone might have a difficult spinal because they've had spinal surgery before, we may choose to do that first, if we've got a consultant anaesthetist at that point, or we might decide we're going to do that later on in the morning when we've got someone more expert arriving.
So we'll decide clinically the order.
If you're very, very anxious, we often will try and do your cesarean earlier so that you're not hanging around waiting.
And then we'll come out and tell you roughly what we're expecting.
Either you're going into theatre first, or actually we think it might be mid-morning, what it's likely to be.
And depending on which hospital you are at, and specifically how many theatres they have, that can sometimes be further delayed by, certainly the hospital that I trained at, there was only one theatre.
So anybody who was waiting for a planned cesarean, if somebody else needed to use the theatre in the meantime, that could potentially push them back.
Yes, that's absolutely true.
It varies a bit, hospital to hospital, and if the workload on the labour ward is very, very busy.
So we have two theatres in my hospital, and we usually use one for planned cesareans and one for the unplanned cesareans.
But sometimes if things become very busy, yes, a planned cesarean could end up being delayed.
But we'll try and keep you informed, but we know it's quite a nervous time waiting.
So bring plenty to distract your friends.
Yes, I usually say to people, bring music.
Some women have done hypnobirthing, which is brilliant at keeping them calm, relaxation.
Or some people these days obviously stream some television on an iPad maybe, or a book to read, anything like that.
So then we'll walk you into theatre.
This is another bit that always surprises people.
I think people are always surprised that they walk there.
I don't know why.
I think you're not unwell, you're not poorly.
You've walked around for the past nine months, most people.
But I think it's just this idea about...
The first time I've had an operation before, again, was like, oh, I mean, well, obviously I'm fine.
Of course I can walk there.
But I think you just have these visions, again, through what you see on kind of telly and stuff.
It's like you should expect to go there on a bed or in a wheelchair or something.
But you do.
You literally stroll in.
Yeah, you walk into theatre.
And I'm lucky.
Our theatres are quite nice.
We tried to make them a bit more cheerful.
So we've got multi-coloured drawers, and we've got pictures on the ceiling of cherry blossom and butterflies.
And you'll sit on the theatre operating table, which is quite narrow.
And often you'll either sit or lie on your side for the anaesthetist to put in the spinal anaesthetic.
So you'll have a little injection of local anaesthetic in your back, and then you'll have the spinal anaesthetic, which makes your legs tingle and feel a bit weird.
And then immediately it's gone in, they'll lie you down.
They'll also put on some monitoring, so they'll put a blood pressure cuff on one of your arms.
You'll have a drip in one of your arms, and you'll have some ECG dots, which we normally put around your shoulders or back, if you're going to be doing skin-to-skin, so they're not in the way on your chest.
And that's to monitor your heart.
So because we'll need to watch your blood pressure, your pulse, your oxygen levels, all those things very closely while we're doing the surgery.
Once that's happened, the anesthetist will test the block to make sure it's working.
And it's a bit weird because you'll feel people touching you.
And what they're testing for is, can you feel cold or can you feel a pinprick?
Because pain and cold are the same nerves detected in the same way, whereas pulling and pushing actually is not the same.
So they'll check that and make sure it's working.
And when they're happy it's working, the midwife will then insert a catheter tube.
So that's a little rubber tube into your bladder.
And that's because the bladder needs to be empty because it's just in front of the womb where we're needing to make our cut.
So we'll put in the catheter tubing and check that the urine is draining into a bag.
At that point, we then do what's called the WHO checklist.
So we'll just confirm with everybody that we've got the right woman.
We know her date of birth and hospital number.
We all know what we're doing.
We haven't got any equipment problems.
Everything's all good.
And then we'll clean your tummy with some antiseptic on a drape.
About that WHO checklist, the bit again that I think often people find surprising is that everybody goes around and introduces themselves, don't they?
And it can sometimes feel like they've never met each other before.
But that's not what it is.
It's for the notes, isn't it?
It's a safety thing.
And it's very well known that in an emergency situation, it's better to give instructions to somebody as an individual.
So if I say, if I'm operating and I go, can you ring the lab and cross-match some blood, then who in the room, because there's quite a lot of people in the room, is going to go and do that.
Well, we don't know who's going to take responsibility.
If I go, Carol, can you ring the lab and cross-match some blood, then Carol knows that's her job.
So knowing each other's names and knowing who's in theatre on that day with you is actually really important for that clear communication.
So I just mentioned there's quite a lot of people.
Do you want me to talk a little bit about that?
Who's in this room?
Because again, that can be frightening and it can make you go, God is something really wrong.
Why are there so many people here?
Yeah, there's a lot of people because they've all got different roles.
So you'll have with you and your birth partner at your sort of head end, as it were, you'll have an anaesthetic doctor and you'll have an ODP, an operating department practitioner.
They're like the anaesthetist's assistant.
They'll be looking after you.
They'll be sorting out any drugs you need, drawing those up ready.
They're responsible for the who the checklist, safety checklist that I just mentioned.
Then you'll have a midwife who's looking after you and will be looking after your baby.
Then you'll have two obstetricians, one who's operating and the other who is assisting, holding things back, making it easier for the surgeon to do their job.
You'll have a scrub nurse or midwife who's handing the surgeon the instruments they need.
And there'll be someone called a runner who's getting additional pieces of equipment.
So we might ask for an extra stitch or some more swabs, and they'll go and get those and open them.
Because those of us that are scrubbed, we can't go and touch anything else because that will desterilise us.
And then there may be a paediatrician present as well for the baby if we're expecting that the baby might need some help or support or assessment immediately at birth.
And so that's eight people plus the person giving birth plus birth partner.
So you're looking at like ten people in a room.
So next time you're in a room with ten people, just clock how many people that looks like.
So in our kind of in-person antenatal courses, we often have about 12 people in a room.
And, you know, when you look around the room, you're like, oh, wow, it does feel like a lot of people.
But I think understanding that they're all doing completely different jobs in that space can be reassuring.
Exactly.
So I think we had got to the point of, after the WHO checklist, getting actually kind of ready for the birth.
Yes.
So we're going to clean with antiseptic and then we're going to put on a drape.
So you won't see any of the operating you don't want to see.
And then we start the actual surgery.
Another bit that often, again, comes as a surprise, is you shave the top part of the pubic hair most of the time, do you?
Sometimes we do.
I mean, quite often women have already done that at home.
But if you didn't know.
If you didn't know, we might, you might suddenly hear a razor.
We will ask your permission, don't worry.
But we might say to you, actually, we just need to give you a little bit of a shave.
And that's because we want to go about two centimetres above your pubic bone.
And that may be in your hairline, quite often is.
You're absolutely right.
And so I think sometimes, again, people sometimes feel more comfortable doing that themselves, that in the morning.
So if it's something that you're planning and you know is happening, you may want to consider that.
We know that if you're planning a vaginal birth, there is literally no need to do any shaving.
And actually, hair is there to protect our bodies from infection.
So it wouldn't be something that you absolutely have to do for giving birth in any other way.
Oh yeah, absolutely not.
People sometimes apologize to me for their hair, and I'm like, literally, I don't care.
You know, it's absolutely fine.
And yes, please do not, you do not need to prepare for us at all.
So you've sterilized the area, the drip is up.
Now comes the birth, I suppose.
Yes.
So what we're going to do is make a cut.
Obviously, it's got to be big enough to get a baby out.
So people are sometimes worried about the size of the cut.
I would say it's usually somewhere sort of 15 to 20 centimeters long, realistically.
And as I mentioned, it's a couple of centimeters above the pubic bone.
So we go through the skin first.
Most women have a little bit of fat below the skin.
And then what we're looking for is a sort of silvery layer that is called the rectus sheath.
So that's the kind of fibrous tissue that goes over your tummy muscles.
So we will cut that.
And once we've cut that, we then separate that off the muscles that are below it.
So you've got your, what would be your six pack, if you're very athletic, you've got two strapped muscles coming down the front of your tummy vertically.
And we don't cut those, but we just lift that fibrous tissue off those muscles.
And then we go in between.
So often in pregnancy, there's already a bit of separation there between the rectus muscles.
And we just go in between and put our finger through what's quite a filmy layer called the peritoneum to enter the abdomen.
So we're then inside the abdominal cavity.
And usually the womb is right there as a very big pink organ, particularly if you haven't had any surgery before.
And then we pick up, there's another layer of filmy peritoneum just on the front of the womb.
So we pick that up and cut that.
And that's so we can push the bladder down out of the way and get to that lower segment I mentioned, that lower bit of the womb.
Then we make a horizontal incision in that.
And then you'll hear usually a bit of a splash because the waters are going.
And you'll hear we have a little suction thing.
So you'll hear that sucking.
And then we just stretch that opening and put our hands in to reach and get the baby's usually head, but it could be bottom to reach the baby and start to bring the baby out of that opening.
So usually at this point, you'll feel a lot of pressure, a lot of pushing on your tummy, because the assistant is pressing on the top of the womb, what's called fundal pressure, to try and help squeeze the baby out of the womb and to be born.
And usually what I do is I will just lift up the baby's head and we will drop the drape and hopefully ask the shoulders and the torso of the baby's being born.
The woman can look down and see the birth of her baby and so can her birth partner and meet their baby.
Can I just, just on that, again, this is another thing that's often surprising.
How long does that take?
The beginning of the operation is very quick.
Yeah, it's like surprisingly quick.
It's much quicker to cut things open than to put them back together.
I usually tell women that it will be five or ten minutes from the beginning of the surgery to having their baby.
And that's true unless there's a lot of scar tissue from a previous operation.
So it's usually very quick.
Yeah.
Yeah, and this next part, that's the longer part.
Yeah.
So I will give the baby to the midwife who's standing at the top end.
And she will put the baby straight down skin to skin with the cord still intact.
If I can.
I can't if the umbilical cord is very short or if the baby doesn't start crying.
I know that that isn't normal practice for a lot of obstetricians.
So a lot of obstetricians will show you your baby and then the baby will be put down on your tummy between your legs for a minute or so while we're waiting for the blood from the umbilical cord.
And then the cord will be clamped and cut.
And the midwife will take the baby and either then give it to the mum or sometimes take it to the machinery, the resuscitator to just dry the baby, check the baby over before the baby comes for skin to skin.
So there's a little bit of variation here.
And you can ask staff for skin to skin in theatre and make sure that the midwife knows that's important to you, if it is.
Some women are a bit squeamish, and they don't want that immediately.
They want the baby wiped and dried a bit first, and that's absolutely fine as well.
And this is, yeah, your preferences are important here.
And we'll try and do what you want, but it will depend a little bit on the condition of the baby.
And so when we're talking about skin-to-skin, the benefits of that are that you've got kind of bacteria on your body that your baby's going to kind of pick up, get into their mouth and their nose, and start to form something called their microbiome.
It's really good for creating oxytocin in mum, which is important for bonding, establishing feeding, and eventually contracting the uterus back down again.
It's also good for regulating a baby's body temperature, so keeping them hopefully warm.
Exactly.
So we'll chat a little bit more about the kind of options and things that people can ask for at the end, I suppose.
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Now back to the podcast.
So where have we got to?
Baby has been born, hopefully now, with mum, or sometimes when you're having a cesarean, sometimes you can feel a bit sick or you can feel a bit woozy, and actually that might be a reason why you don't actually feel happy having baby on you, and then potentially could go skin-to-skin with partner or just kind of held very, very close to you instead.
Yes, completely.
Then we're delivering the placenta.
So the placenta will separate because the anaesthetist will have given a dose of centosanone to help the placenta separate.
And then we just clean out with a swab inside the womb to make sure we've got all the bits of the placenta and membranes, because sometimes little bits can be left behind.
So we'll swab out to check that it's empty, and then we start to stitch the womb.
And the womb is stitched in two layers.
So we want to do it as quickly as possible because the quicker we stitch the womb, the less amount of blood loss, because most of the blood loss is coming from the womb, which has been having an amazing blood supply to grow your baby.
So we're stitching up the womb two layers, and then checking that we've got all the bleeding points and that everything looks like it's dry.
Before I go on, sometimes you might hear us talk about taking the womb out or exteriorizing the womb.
So sometimes it's difficult to see what we're doing.
We might lift the womb out of your tummy.
So it's still attached.
It's all perfectly safe.
But I think sometimes when I hear some of the doctors say, can I take the womb out, I'm thinking, yeah, yeah, yeah.
Oh my god.
So we don't do that as a routine practice, but sometimes we do that.
If it's a bit difficult to see what we're doing, it makes it a bit easier.
You're not removing it?
No, you're not removing it.
It goes back in absolutely fine.
But we'll normally ask the anaesthetist, because we'll just warn the anaesthetist, because sometimes that causes a bit of a different sensation for the woman.
So if you hear us say that, don't panic.
And then what we will be doing is we'll be cleaning what we call the gutters.
So this is another bit where I think sometimes women must wonder what on earth we're talking about.
At this point, we want to clean down the sides of the womb.
And this anatomical term is the paracolic gutters.
So sometimes you will hear us tell the anaesthetist, I'm just going to clean the gutters.
And what that actually means, because it must sound totally mad, is we're going to take a swab on an instrument and just pass it down the side of the womb to check are there any blood clots there.
And that's important for two reasons.
One is it tells us how much blood we've lost, because if there's a big blood clot hiding down there, we might not have realised how much blood we've lost.
And the other important reason is because it allows us to check the tubes and ovaries.
So we're inside your tummy, it makes sense to check that everything else looks healthy.
So we'll normally routinely have a quick look at your tubes and ovaries to make sure there's nothing, no ovarian cyst or something that we should be dealing with at the same time.
So we'll clean the gutters, we'll check everything looks dry, that there's no bleeding from the womb.
Then we will stitch up, we don't stitch that filmy layer, the peritoneum, we leave that, and that's because research has shown that you get more scar tissue if you shut that.
So we don't stitch that, we go straight to that silvery white layer, the rectus sheath, and close that with a stitch, and that's very important because that's the layer that keeps your tummy contents in and prevents you from getting a hernia or a weakness in the tummy wall.
So we stitch that up, and then we stitch the fat layer, and there's normally not much fat, so it may sound horrid to say we're stitching your fat, but actually what we're doing is trying to bring the skin edges closer together so that the skin layer is going to be well supported.
So we do as, usually I do with the same stitch, a fat layer, and then the skin.
And we do what's called subcuticular, which is under the surface of the skin, so it looks like you haven't got any exterior stitches.
It's all buried under the skin, and the stitch we use at my hospital is dissolvable, but sometimes you'll have a stitch which is blue, bright blue, and it's sort of plasticky, and that sort of stitch called proline needs removing, usually about five days later.
So you might have it to sew...
With the little bead.
With the little bead, exactly.
And then your midwife will just cut that and pull it out in one long line.
It's like one long stitch, but you may have a dissolvable stitch that just goes away on its own and you don't need anything doing.
So you might have no visible stitches, having had quite a big operation.
Then when we've finished doing that, we will clean and dry your tummy and put a dressing on where we've made the incision to cover it.
And then we will take down that big drape we put on at the beginning.
And normally we'll bend your knees up to just clean the vagina, make sure there's again not a lot of hidden blood there.
And often we will offer you a suppository, a painkiller that goes in your bottom that is really good painkiller for when the spinal anesthetic wears off.
And then we'll give you a little clean up and theatre staff will move you onto a bed because remember at this point, you're still on the operating table, which is quite narrow.
We'll get you into bed.
How long has that part taken?
Depends a bit how complicated things have been, maybe half an hour or so.
Yeah, so much, much longer in comparison to baby label.
But normally that's okay because you're focusing on cuddling or looking at your baby, maybe listening to some music, taking some photos.
The anaesthetic doctors and the ODP, they love nothing more than to take family portraits.
And so you're hopefully enjoying that bit of the surgery a bit more.
Great.
Let's just touch on, then, the kind of very, very immediate sort of hour after the birth, what you can expect from that.
And then I might take you back and ask a few more questions.
So moved on to a bed, hopefully with baby, and moved to recovery.
Yes.
Then we're going to be checking your pulse, your blood pressure.
Quite frequently, the midwife or nurse will be checking your tummy to make sure the womb's well contracted and your pad to make sure you're not bleeding excessively.
And they'll be looking at your urine in the catheter tube.
So you're having a lot of regular checks, usually for the next two to four hours, depending on how complicated the surgery's been.
And during that time, they'll usually be helping you also start that first feed with your baby, helping you get that baby onto the breast if you're breastfeeding.
A lot of skin to skin.
Yeah.
And at what point can people expect to start feeling things again?
Sensation, being able to move their legs, feeling the fact that they've had surgery?
Probably about four hours or so afterwards.
So you'll start to gradually feel your legs again, and you may start to feel some pain in the wound.
But as I mentioned, we already preempted that with some painkillers, and the nurses or midwives will offer you more painkillers, such as oral morphine, so that's liquid morphine, or paracetamol, neurofen.
That's usually what people need, and if you're planning a caesarean, definitely have some packs of paracetamol and neurofen or ibuprofen ready at home.
Yeah, I mean, I say that for everybody sometimes.
Either after pain or stitches or anything.
Yeah, and people sometimes say, what do you mean?
Is that all I'm going to need?
Well, actually, most of the time, yes.
You might need something a bit stronger for the first few days, but actually not for very long.
But you do need to take them regularly.
That's usually what I would advise.
So don't kind of struggle till you're in pain.
Take them, you know, four times a day, three times a day at the maximum dose because you're going to need it.
Yeah, OK, fantastic.
Now, I think that's probably a good place to kind of pause because if we start talking about caesarean recovery and everything after that, I think this episode will end up being about three weeks long.
But what I would like to kind of take it back to, and now some of these things you have talked about as kind of the way that you practice, but obviously the reason I wanted to do this episode with you is because I know you're very women-centered and sort of these things are part of your kind of general standard practice anyway, but they aren't standard for everybody.
And so women can't always necessarily expect skin-to-skin immediately or, you know, delayed cord-clamping and things.
So when I am working with families that, you know, I actually get everybody to consider what a Caesarean birth would be like for them.
So regardless of whether it's something that they initially want to think about or not, you know, I would think if you've got your best-case plan for every situation, then at least you know what it is you might want to be asking for if the situation arose.
And so I always, it sounds a bit strange.
I actually got it from, I don't know if you're in, midwife Sheena Byrom, who does kind of a lot of work with midwives and women's choice in supporting physiology and things.
And she always says taking Caesarean birth back to physiology as your kind of starting point, which sounds a little bit strange when you're thinking about, but ultimately it's a surgery as well as a birth.
But when you can kind of understand what the benefits are of physiological birth, then you can start to consider how some of those things could potentially be replicated or transferred to a birth by Caesarean, if that's something that is either the right way for you to give birth or the way that you're choosing to give birth.
And so there are kind of lots of things that you could ask for, lots of things that you could do, slightly differently maybe than the kind of certainly historical way of a Caesarean birth taking place.
So a good place to start, I suppose, is with the environment.
So we know that the environment that we're in, not just for birth, but at any time, can alter our emotions, and that alters the hormonal state that our body is in.
So when we're feeling calm, we're feeling safe, we're feeling relaxed, we produce oxytocin.
And we know that in terms of birth, in terms of labor, oxytocin is crucial, but it's actually for the kind of the longer, the kind of the journey of birth itself, it's crucial for bonding, breastfeeding, generally kind of feeling happy and good.
So what can we do to protect our environment in Caesarean birth?
What's possible in the realms of an operating theater?
So I normally suggest to people that they think about what music they would like.
So people often bring a playlist.
We've got a Bluetooth speaker that people can use.
And that often kind of just puts people at ease, makes them feel a bit more relaxed.
It's quite a good distraction.
So definitely music.
I've had people bring a cuddly toy that had a particular importance to them.
I've had people, I've suggested people might bring a photo if there are other children or particular family they want to think about.
I have done a small number of caesarians with the theatre lights off.
I have to say it's not something I'm doing as a routine yet, and that's putting the main room lights off.
Obviously, you have to have an operating light.
You have to see what you're doing.
But you can.
Sometimes women ask for dim lights, and it depends a little bit more for me on the anaesthetist than it does on myself, actually.
Because I'm OK, I'm standing under a very, very bright spotlight, whereas they've got to give drugs and things perhaps with a bit less light.
But potentially turning the main theatre lights off and just having the operating lights on can be feasible on condition that if there's a problem, we'll have to turn everything on.
So there are some options.
I noticed when you sent me something in preparation for today, you put something about smell, which is something I haven't actually thought about.
So I thought that was a great idea.
It's something that actually we do kind of, it goes nicely hand in hand.
I do a lot of preparation, hypnobirthing preparation with clients.
And something that, one of the tools that we use is something called an anchor.
And what an anchor is, is basically we all have them day to day anyway.
You know, if you smell, I don't know, a particular smell of bacon cooking in the morning, and it reminds you of, I don't know, being at uni and feeling hungover.
It takes you like back to a really, really specific moment in your life.
What that smell is, is basically a sensory anchor or a trigger for a memory or a sensation or a feeling.
And we can create these for ourselves in pregnancy.
And so using a smell, it might be like a deodorant or it might be like an essential oil or something or a kind of pillow spray.
It can literally be anything that you want.
You can start, if you do, if you use that every time you have a bath in pregnancy, every time you listen to a guided relaxation in pregnancy, every time you have a massage from your partner in pregnancy, you start to create an association between that smell and that feeling of feeling relaxed or feeling positive about the birth of your baby or whatever it is.
And so smell is certainly something that's transferable, just like a drop on a hanky or a drop on the kind of top of your hospital gown, just to make that you can smell that's not going to kind of overwhelm the room as a kind of trigger for relaxation.
Is it just a really nice way of transferring it?
I think that's an amazing idea, do you know?
I'm listening to you thinking, oh my god, you know, I had, listeners of my podcast will know I've had two emergency caesareans myself.
And I'm immediately thinking, oh my god, if I'd had a smell of my husband's, it's the stuff he uses to shave, his shaving oil.
Anytime I smell it, I'm like, oh, that's my husband, it just feels lovely.
That would have been so nice.
Yeah, and it is, you know, people often say it's the smell of their partners.
I have a really, really vivid association with a specific deodorant that my husband used to wear when we lived somewhere that we don't live now.
And anytime he buys it, I'm like, oh, you smell of Enmore Road.
That's what he smells of.
And it's like a fond pre-kids, footloose, fancy free time of our lives.
It's amazing how you can use anything to be your anchor.
Some people use the stroking of a hand or the stroking of a hairline.
So you can create this association with basically anything sensory.
We have it with songs, we have it with tastes, but it just seems to be a much more poignant or effective one.
And people that are kind of particularly interested in things like aromatherapy or essential oils, then you can look into it in more depth, but sometimes people feel that specific oils have specific properties.
And again, partly an association, but things like lavender tend to make you feel more chilled out and relaxed.
If you think about like any bubble bath that says relaxing on the front of it, it's normally got lavender in it.
Like the citrus oils are generally quite energizing.
If you think about any shower gel that's like a morning shower gel, it's always got citrus in it.
And so thinking about it, again, transferring how you think about a physiological birth, thinking about how all of my senses kept happy, and transferring back to giving birth by Caesareans.
We've talked about music, talked about what you're looking at, what you're seeing, what you're touching, what you're feeling, and what you're smelling.
Obviously, you're not going to taste much in a Caesarean birth.
Probably, no snacks for that one, but maybe something nice for afterwards.
So that's kind of the environment.
The other thing I would just touch on in terms of the environment would be, and this, again, you'll probably confirm that this is very different from person to person.
Some people like real quiet, real kind of undisturbed environment where they can really kind of focus and focus on their baby and feel quite relaxed.
And so asking for sort of minimal conversation can be helpful.
Other people find, actually, that it calms their nerves much more to be distracted and chatted to and kind of pulled away from the kind of focus of what is going on.
And so just considering that before you're in that situation, what do you think would help you most?
I had one client, she was like, Anissa just talked to me about coffee the entire way through, and it was great because I just needed to be completely distracted because I was feeling so nervous.
And other clients who have said, And then everybody started talking about their own, what they were doing that weekend, and that suddenly I was like, Oh, no, this is my birth, please stop.
So these are all considerations that you just don't think about.
Yeah, and I think we are not great sometimes in forgetting we've got a paper screen here, and we will be, Oh, yeah, did you have a nice weekend?
Or particularly when we get into the stitching up bit, and things have gone well, and we may just make some conversation.
But I think you're right, the distraction, the anaesthes are phenomenal at chatting and distracting people.
And with my second daughter, I was very nervous, and it sounds nuts given that I'm an obstetrician, but it's very different having it done to yourself.
And she was born in May, and it was the night before the FA Cup Final, and I'm quite into football, and it wasn't my team playing, but he literally was yacking on about the Cup Final, and who did I think was going to win, and blah, blah.
And I was so absorbed in that, next thing I knew, she was out.
And that was brilliant for me, that complete distraction.
So I wasn't thinking about what they were doing.
And some people like to be talked through what is happening.
Yes, some people are like, don't tell me what you're doing.
Other people are, please tell me what you're doing.
There's two moments when I do tell people what I'm doing.
One is the pressure I mentioned, because that really can feel like someone's almost standing on you.
Very, very intense pressure.
The other one is when we're just going through that peritoneum, in that first filmy layer, sometimes you can feel a kind of stretching feeling.
So I normally warn people about those two things, because they often do say, oh, what's that?
But yes, some women want to know, some don't.
So yeah, just another thing to consider.
So that's helpful things to consider in terms of the environment.
So how about the birth itself?
So we know when a baby is born vaginally, there are processes that happen in the baby and in the mum giving birth.
So when they pass through the vagina, they are squeezed very, very tightly, which sort of squeezes mucus out of their lungs, their sinuses, their noses.
We know that they pick up bacteria in the vagina, and as they pass the anus on the way out, which starts to form their microbiome, and when supported to, they can receive their kind of full blood complement, the kind of the amount of blood that's sitting in the placenta.
If that is left to it until the cord turns white, then baby's kind of receiving all of that blood.
So we mentioned some of these things kind of as we went in terms of kind of potentially delaying cord clamping skin to skin, but what other options that women can kind of potentially ask for or explore a little further in terms of replicating or supporting some of those things?
Yeah, sometimes women talk to me about they want a gentle caesarean or a natural caesarean.
It is a surgical operation, but certainly the way you bring the baby out, you can try and do it a little bit more slowly so that the baby's chest is squeezed as it's coming out, and hopefully helps to start getting rid of some of that liquid in the baby's lungs.
And it's very normal for a baby that's born by caesarean to be quite coffee, spluttery, mucousy after the birth.
They will cough up, and you'll see liquid dribbling out of their mouths.
They're often, we call it a bit mucousy, but it's just amniotic fluid that they're getting rid of, and that's a good thing.
So trying to bring the chest of the baby out a little bit more slowly, and then trying to give the baby that benefit of the, I'm not even going to say umbilical cord blood, because I know you've had Rachel Reid on your podcast, and it's the baby's blood.
Yeah, it's the baby's blood.
It's the baby's blood.
So if you clamp and cut the cord too early, you're taking the baby's blood away from it.
So leaving the baby to get its blood from the cord, we try and do that.
And some obstetricians are worried about that in terms of blood loss for the woman, because remember I've said when the womb is open, that's when the woman is bleeding.
And we have some clamps that we can clamp on any big bleeding blood vessels on the womb.
So if I'm not giving the baby to the mum, I will put the baby down, and then I will immediately look, well, the baby's still attached to the placenta.
Are there any big blood vessels I need to clamp to try and minimise blood loss while I'm waiting for the baby to get its blood from the cord?
So definitely delayed cord clamping of some kind, definitely is feasible.
And we sort of touched on skin-to-skin already, which is another thing that's generally doable.
The other thing people ask me about is vaginal seeding.
So this is the idea of taking a swab from the vagina and using that to inoculate the baby because the baby hasn't been exposed to the normal bacteria coming down the vagina.
Certainly, babies born by cesarean do not have the same microbiome as babies born vaginally, but there isn't any evidence that vaginal seeding corrects that.
And there is some potential for risk if the woman is a carrier of Group B strep bacteria, which is quite commonly held bacteria.
Maybe 30 or 40% of women will have it in pregnancy and can cause a neonatal infection.
So if a woman wants to do vaginal seeding, I will, yeah, I'm perfectly happy for her to do that, but I won't recommend it.
Yeah, so at the moment, we do actually have an episode on the microbiome, and we talked to somebody kind of a little bit more depth about that.
There just isn't really any...
The research that there is is on like 12 babies or something, so there just kind of isn't...
There just isn't any research.
In theory, you know, a baby would have been passing through that bacteria had it been born vaginally.
And so it's...
It's at the moment, it's a kind of in theory practice rather than something that is...
You know, as doctors, as midwives, you have to be practicing from a kind of place of evidence.
And at the moment, there isn't evidence to either kind of support or condone it.
But it's something that some women kind of choose to explore.
If you were supporting it, and again, this would definitely be kind of different from hospital to hospital, obstetrician to obstetrician, but is it something that you would then encourage women and their partners to take responsibility for and to do?
Or is it something that the hospital team can...?
No, it would be something we'd suggest that the couple do or the woman does.
So I have done it once for a woman.
The first time I did it for a woman, I asked the lovely Jenny the M, who's my kind of go-to for slightly different things, had she ever done it and how?
How do you do it?
Or how do you suggest people do it?
And she told me to just give them a small swable piece of gauze with a bit of saline on it for them to put in the vagina while they were waiting for their cesarean for an hour or so.
And then when the midwife put the catheter tube in, she removed the swab and put it in a little sterile pot.
And then that was given to the parents after the cesarean for them to do whatever it is they want to do with the baby.
Okay, amazing.
Thank you.
And so finally, and the decisions that we've kind of talked about up to this point will play into this, but something that is often overlooked with cesarean birth is just how do we keep ourselves kind of emotionally safe and how do you still mark a cesarean birth as this kind of transformative, wonderful, sacred moment in a family's life rather than just like an operation and then there's a baby at the end of it.
Have you seen anything either culturally or spiritually that people have kind of done or reached for or anything?
I mean, we tend to say congratulations or I will often say happy birthday as the baby is born.
And there's definitely a very sort of celebratory atmosphere in the operating theater.
We're very conscious that this is a birth and this is a parent meeting their baby for that very first time.
And that it needs to be a very special atmosphere.
And that's why I mentioned about Aneesthys taking photos or video, the birth partner trimming down the cord if they're unable to cut the cord.
We'll bring the weighing scales close so the woman can see the baby being weighed.
And it's very much a celebration.
If there's a particular song or piece of music they want the baby to be born to, we'll tell them, you know, the baby's going to be born in the next minute or so, so you need to put your special song on or whatever it's going to be.
I've had one or two cultures where they've either sung something special as the baby's born or said a particular prayer as the baby is born.
But it's very personal.
I think we're reasonably good at letting the fact that it's routine day-to-day work for us take a little bit of a backseat, but I do appreciate sometimes that may come through.
And if there is anything that is important to you when you're preparing or having a cesarean birth, I can't remember where I was listening to it.
I'm sure it was on a podcast, but similar to what you mentioned, there was a family, and I can't remember which religion they were, but something that was tradition was that the father speaking, this father's voice should be the first voice that the baby hears, and it should be a specific prayer.
And that was kind of facilitated that after the baby had been born, nobody spoke until this kind of moment had finished.
And just little things like that, which even if you're not religious or you're not spiritual, just thinking about actually what is important to me and what can I do?
Things like, can I see the placenta?
Can I, some of us will want to take the placenta away, but even just being kind of talked through it and kind of looking at it, like all of these little moments, I just think are so important.
And you can build them into pregnancy, you can build them into birth, however you birth your baby, and into the kind of postnatal period.
Sometimes people do like a rebirthing or a kind of receiving ceremony when they're at home where they kind of bathe with their baby or whatever it is.
And so you, there's so much that you can do that make this similarly kind of a beautiful way to birth a baby.
Yes, totally.
And I think that is one of the joys.
So, you know, I'm very lucky in obstetrics.
I, almost all the operations I do, the person is awake.
And, you know, I think women are sometimes frightened about being awake.
Yes, they don't want to miss out on the birth, but the idea of having an operation while you're awake is quite frightening.
But actually, it means we can talk to you, you know?
I can hear sometimes the women asking the anaesthetist, how's it going, or is everything OK?
And I can go, everything is going beautifully, you know?
It's all very straightforward, you know, relax and enjoy your baby.
Or, you know, they can say, was the scar tissue very bad that you were expecting?
And I can reassure them.
So, you know, we can have a conversation during the cesarean.
And as soon as the cesarean is over, I will go and say to the woman, you know, many congratulations.
And this is what I'm expecting for your recovery, and this is how the surgery went, and this is what we're planning, you know, for your recovery.
So I think don't be daunted.
The fact you're awakened there and very much present is very, very important.
Yeah, amazing.
And I'm aware that we've kind of focused on kind of planned or kind of scheduled Caesarean birth here.
And some of these things will still be doable in those kind of category two, category three situations.
There may obviously be situations where actually kind of mum or baby's immediate health takes the priority over some of those things, which hopefully we've kind of touched on.
We could literally, I mean, I still have about a billion questions, so we could talk about this absolutely kind of all day.
But this is probably a kind of help, a good point to kind of pause and sort of wrap up.
So the final question, I don't know if you saw this before, if I'm going to spring it upon you, that I ask at the end of every episode is if you could give a pregnant mum, a birthing person one thing, what would it be?
I did see this and then I completely forgot about it.
I think it would be to be empowered.
So we didn't talk about statistics, but the caesarean section rate in this country, so we're recording this in England, is upwards of 26%.
So the latest data is around 26%, but that's from 2017 to 2018.
And I know we're probably somewhere in the 30% now, of which planned were 11.5 and unplanned 14.7.
So statistically, you've got a chance you're going to have a caesarean.
So be empowered.
Use this episode and other preparation to think through what would your choices be in those different categories?
What would be the things that would be really important, even if it's only one thing, and be empowered to ask for it?
And the midwife that's with you, either in labour will go into a theatre situation with you, or a midwife, if you're having a planned caesarean, will be going into theatre with you.
And that midwife is there to help support you through that birth, just in the same way as if it was a vaginal birth.
So be empowered, understand that not everything may be possible in an actual category one, very urgent situation.
But in most other situations, something will be possible.
And think about it in advance, and then use your birth partner and your midwife to advocate for that thing.
Because in my mind, the most important thing is preparation, so that you end, like we've said, not just physically safe, you and your baby, but psychologically safe.
And I think being empowered in that way will help you feel psychologically happy with whatever birth outcome you have.
Amazing.
Wow, so much covered, but still so much to say.
Thank you so much for joining me, Florence.
It's been an absolute pleasure.
Like you say, we could talk all day.
Maybe we have to do part two at some point.
Yeah, what happens next, I think.
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