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Video to watch for discussion

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Baby-friendly caesarean birth | Maidstone and Tunbridge Wells NHS Trust

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About Caesarean Birth

Caesarean surgery is lifesaving for some mothers and babies, and avoids problems for others. But in many cases it is not clear that the benefits outweigh the risks, particularly if the risks to any future pregnancies and births are taken into consideration. Across the country more than 1 in 4 babies are born by caesarean, and is some hospitals it is more like 1 in 3 women who will have surgery for the birth of their baby.

Most women do not want a caesarean unless it is clear that their baby really needs to be born that way, but other women know that a caesarean birth is best for them. Our national guidelines make it very clear that women's preferences need to be taken into account when a caesarean is being recommended to, or requested by, a pregnant woman.

What is the difference between a planned, elective and emergency caesarean?

Caesareans may be planned before labour starts and these can be referred to as planned or elective caesareans. Elective does not mean that the women has chosen or wants the caesarean; just that it is planned surgery.

Other caesareans may be unplanned. Unplanned caesarean are often also called emergency caesareans, this is because they had not been planned and the reason for them 'emerged' before or during labour. Only a small number of emergency caesareans are urgent and the term 'crash section' may be used to describe this urgent surgery. Most emergency caesarean are not urgent and there is time to agree what you want for the birth of your baby.

Can you make a caesarean birth plan?

As very few caesarean need to be done in a rush and many are planned well before the birth, there is usually time to consider what you want to happen when your baby is born. Most obstetricians are happy to work with women to make a caesarean birth a positive experience. It is usual for the baby's father and/or a birth supporter to be in theatre for the birth and for the parents to be able to greet their baby and have skin to skin contact, providing the baby is well.

Other options for the birth might include:

lowering the screen so the mother can see her baby born

the baby to be passed straight to its mother for skin to skin and breastfeeding

delaying cord clamping (usually about a minute, so less than optimal cord clamping)

facilitating resuscitation of the baby, if required, at the side of the operating table without cutting the cord

lotus birth may be supported

If you are having a planned caesarean and are not being supported with your birth plan you have a right to be referred to someone else who will. For more idea of what you might like for the birth see http://caesarean.org.uk/caesareanBirthPlan.html

Can you choose a caesarean birth?

Some women feel strongly that their baby should be born by caesarean and usually have a very good reason for why they feel this is best for them. Reasons may be psychological or physical, and both should be recognised as medical reasons for requesting the surgery. The NICE guidelines provide recommendations on how women who want a caesarean should be supported, including being referred for psychological support where there is a fear of birth, but ultimately being booked for a caesarean or referred to someone else who will. If you are struggling to get your needs for a caesarean respected then please see the page on {your right to specific treatment}, but you may also find this Birthrights fact sheet useful http://www.birthrights.org.uk/library/factsheets/Right-to-C-Section.pdf

Why might a planned caesarean be suggested?

Some reasons for caesarean to be suggested before labour are (and there are many others):

baby is in the breech position (bottom down)

twins or other multiples

previous caesarean(s)

placenta previa (placenta is over, or partly covering, the cervix at the end of pregnancy)

With the exception of placenta previa, which usually (although not always) means that a caesarean is the safest way to give birth, none of the above situations means that a caesarean is inevitable, and you do have the option to decline. This is the case for many situations where a caesarean is suggested. If you would prefer to explore your options, you are free to do so. The decision to accept the offer of a caesarean is always yours, and yours alone.

When a planned caesarean is recommended there is time to consider whether this is the best decision for you and your baby. This will be a very personal decision. Most women need not only to think about why the caesarean is being recommended, but also about the risk of the surgery and about what their personal priorities are for the birth of their baby. For some women a caesarean birth will be something they can accept happily, but for other they will need to explore every other option before they can agree to surgery.

Why might an unplanned caesarean be suggested?

A caesarean may be recommended before or during labour if an issue arises such as:

a baby is thought to be distressed

placental bleeding

the site of a previous uterine surgery may not be holding together well

Although you may have less time to consider your options when an issue of this sort arises you still have the right to make an informed decision. In order to give or decline consent, you should still be provided with information about:

why it is being recommended?

what are the risk of surgery?

what the options are if you decline?

What are the risks of a caesarean?

When a caesarean is suggested or requested information about the risks must be provided in order that you can give consent for surgery, just as it would be for any other surgery. Signing a consent form without this information makes that consent invalid, and there could be legal case to answer from any surgeon who has not obtained valid consent to carry out surgery. People will consider different risks or benefit to be more or less important when making their decision.

Caesarean surgery has risks that would be expected of any surgery such as:

bleeding

infection

blood clots

problems with the anesthetic

accidental and sometimes unavoidable damage to tissues and organs

In addition, caesarean births have other risks specific to a baby being born this way. Common post surgical problems include wound infections and adhesions. Less common ones include permanent nerve damage, bladder damage and hysterectomy.

Do babies miss out on being born vaginally?

When babies are born by caesarean they miss out on the journey through the birth canal. Often it is suggested that this is an advantage, but we now know that important things happen for the baby during this part of birth, including helping to prepare the baby to breathe and seeding the baby's gut with beneficial bacteria. Research has confirmed that babies born by caesarean are at greater risk of:

All of these issues seem to be related to missing this part of the birth process.

Can a baby be injured at a caesarean?

Is is uncommon for babies to be injured, but about 1 in 100 babies will be cut during a caesarean birth. Most these cuts are minor, though rarely babies have been seriously injured.

Might future pregnancies be affected?

When a caesarean is carried out the uterus will be damaged. Usually a small incision is made which is extended by tearing as tissue that has been torn apart and is a bit ragged heals better than a straight cut when it is stitched back together.

The scar on the uterus does not cause a problem for the majority of women, but it does increase the chance of some problems. It has been shown that it takes women longer to conceive another baby than women who have had vaginal births, and that more women will fail to conceive another baby.

Pregnancies following a caesarean have higher rates of placental problems such as placenta previa and an abnormally adherent placenta (placenta accreta, percreta and increta). These are serious issue increasing the risk for the baby and the women, and if an abnormally adherent placenta occurs then a highly skilled medical team will be required in order to minimise risk of bleeding and to try to avoid the need for a hysterectomy.
Uterine rupture is extremely rare when a woman's uterus has not been damaged, but after a caesarean a rupture occurs in about 1 in 500 [VBAC] labours.
What sorts of anesthetic would be used?

It is very rare today for a caesarean to be carried out under general anaesthetic and most are done using an epidural or spinal, or a combination of the two. You should be provided with printed information by your hospital about these anesthetics and what to expect. The following page gives information from the Obstetric Anaesthetists' Association about anesthetics used for caesareans http://www.labourpains.com/UI/Content/Content.aspx?ID=44

What sort of stitches will be used?

There are several different sorts of stitches used to close skin wounds. Dissolving and removal stitches or staples may be used, but the most common way caesarean scars are closed is with a single running stitch with a bead at each end. This is easily removed, usually about 5 days after the operation, by cutting a bead off one and pulling the stitch out in one piece. A midwife should be checking your wound until the stitches are removed and for longer if it has not healed completely when the stitches are removed. You wound should gradually feel less painful, but if it should become more red, sore or oozing, then you may have an infection and need to contact a doctor, as infections after a caesarean can become serious quickly. The following page has a collection of caesarean scar pictures http://www.caesarean.org.uk/ScarPics.html

There will also be internal stitches that have been used to repair your uterus and the tissue around it, these will dissolve in time and rarely cause women a problem, although some women may find that a stitch comes out in the lochia.

How long will it take me to recover physically?

How quickly women recover from a caesarean varies enormously and you are going to be the best judge of what you are ready to do. This will include when you are ready to leave hospital. Many women are very keen to get home, but other feel that they are being rushed to free up a bed. If you do not feel ready to go home then make sure that the staff know this whether it is because you are still in pain, feel unwell or have no one to help you when you get home.

Over the weeks after a caesarean you should gradually find you have less pain and are able to do more. However, it is quite common to find that bleeding or pain may increase following a sudden increase in how much you are doing. If you do not feel you are recovering properly then you have a right to see the midwife or your obstetrician even if it is weeks or months after the birth.

What are the emotional effects of a caesarean birth?

Most women struggle a bit emotionally after a caesarean even if they are very happy to have had a caesarean birth, but many women are left struggling with trauma or grief about the birth which can be very hard to reconcile with the delight with their new baby. Understanding what happened, why it happened to them, and what they might or might not have been able to do differently are often key to recovering. Postnatal depression is more common after a caesarean, and some {women suffer with PTSD}. You have a right to help from your health professionals, but women often find the women's support group are helpful in their recovery.

Women who have had an unplanned caesarean or a problem during the surgery may want talk to someone about what happened. You can make an appointment to see your obstetrician or one of the senior midwives. You may want to get a copy of your notes and if you are unhappy with your care then it is probably a good idea to do this before arranging a meeting. Some women prefer to talk through their birth with someone from outside the Trust, perhaps an independent midwife. AIMS will help to support you if you wish.

Articles that may be of interest
Journal Vol. 22, No. 2 Caesarean Birth
Further Reading
AIMS Birth after Caesarean Caesarean Birth: Your Questions Answered
Written by: Debbie Chippington Derrick
Reviewed by: Emma Ashworth
Reviewed on: 19/08/2017
Next review needed: 19/08/2019

AIMS does not give medical advice. Our website provides evidence-based information to support informed decision-making. The AIMS Helpline volunteers will be happy to provide further information and support. Please email helpline@aims.org.uk or ring 0300 365 0663.

If you found this information page helpful please consider making a donation to support the work of AIMS. We are a small charity that accepts no commercial sponsorship, in order to preserve our reputation for providing impartial, evidence-based information. You can make donations at Peoples Fundraising. To become an AIMS member or join our mailing list see Join AIMS
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all.
Published on 26th July 2017

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Caesarean birth - AIMS looks at the pros and cons and your rights around this form of birth.

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Active Birth Centre - Jill Benjoya Miller’s ‘Natural Caesarean’ Birth Plan

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Active Birth Centre - Jill Benjoya Miller’s ‘Natural Caesarean’ Birth Plan

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Home " antenatal " Jill Benjoya Miller's 'Natural Caesarean' Birth Plan

In my last post I wrote about having a 'natural caesarean', inspired by the experience of Emily and Adam, who came to my Active Birth Weekend Course, which I teach with Jill Benjoya Miller. Emily and Adam wanted to have a natural birth, but they had a 'just-in-case' plan for a 'natural caesarean', which in the end made a huge difference to the birth of their daughter.

Every woman attending the course will have different needs and may be faced with different choices. So we always spend one session exploring how to combine Active Birth wisdom and techniques with medical interventions when they are necessary.

Here on the blog, we thought it could be really helpful to show everyone an example of a birth plan for a 'natural caesarean', which you can give to midwives and doctors. This isn't meant as an alternative to a natural birth - it is intended to make a necessary caesarean section the best it can be.

Here is Jill's birth plan. You can use it as it is, or as a guide to creating your own.

A 'Natural Caesarean' Birth Plan

Our first choice is for a natural birth. If, for good reason, a natural birth is not possible, we would still like to have a calm and happy experience and use the relaxation techniques we have been taught. Should our baby need to be born by caesarean, we would appreciate a slow and gentle birth, as close to a natural birth as possible, especially during the birth itself and immediately after. We appreciate that a caesarean birth requires different care and safety measures.

This plan describes what we would like, assuming there are no complications. It means so much to us that this birth feels special, and that we still get some of the important health benefits of a natural birth such as immediate skin-to-skin contact with our baby.

Thank you.
We would be grateful if you could do as much as possible from the following:
The atmosphere in the room and communication:

Easy communication with the team looking after us is important. We would like to be introduced to everyone in the team and for one person to continue to talk to us about what is happening.

Please talk to us and keep us informed of what is happening or if anything needs to change due to the health of mother or baby.

We would like to play our own music in theatre, for a calming and pleasant atmosphere.

Place the blood pressure cuff, SATS monitor and IV cannula all on one arm, leaving my other arm completely free to hold the baby.

Place the ECG tabs on my back, so that my chest and breasts are bare for skin-to-skin and breastfeeding.

I would like to wear my gown backward, or if not possible, to be without the gown so that my chest is easily accessible.

Lower the sheet/screen for us to see our baby as it is being born.

Dim or slightly deflect the bright overhead lamp from baby's eyes.

Bring the baby out of my body as slowly as you can, so that it benefits from the gentle squeeze and massage of birth to clear its lungs and stimulate its systems.

Be as quiet as possible for a few moments so that our baby hears our voices first.

The umbilical cord and placenta

Do not cut the umbilical cord.

Hold the baby beside my abdomen (level with its placenta) for the first minute(s) while the cord continues to pulsate.

We would like to wait at least one minute, or longer if possible, while baby receives the immediate natural transfusion of placental blood, reflecting the latest guidelines for newborns from UK and European Resuscitation Councils- a significant advantage for caesarean-born babies, and shown to often be possible.

We intend for our baby to remain attached to its placenta for the first hour or so after birth or until it naturally separates in a few days (lotus birth). Please deliver the placenta without cutting the cord. The placenta can be put in a bowl beside us or that we will hold.

We do not give permission for the cord to be cut unless emergency care is necessary, and we are informed and give consent.

First contact and skin-to-skin:

It is especially important to us to have skin-to-skin bonding with our baby as soon as possible after the birth, and for our baby to immediately share the mother's bacteriological environment (particularly as birth was not vaginal and was in theatre).

Place baby naked onto my chest and cover us with warm towels or blankets.

If possible leave fluids to drain naturally from baby's nose/mouth, but if suctioning is necessary, please do this while baby is on my chest and ideally still attached to its umbilical cord and placenta.

If you need to take baby to the paediatric table, bring him back as quickly as possible, unwrap him and place him naked, belly down on my chest with blankets over us.

If I am not feeling well enough to hold baby, help my partner to put baby skin-to-skin under (his/her) scrub top, or to remove the top and wrap them both in warm towels or blankets.

Initiating Breastfeeding

I may wish to begin breastfeeding while still in theatre. Ideally we would like the baby to self-attach, following the ideas of biological nurturing and optimal initiation of breastfeeding.

I might need your help at first to position the baby on its tummy on my body in any position to self-attach (across my chest, feet in any direction- down or toward my shoulder...).

I will appreciate your gentle and patient support and encouragement.

Thank you very much for looking after us during the birth of our baby.
'Natural Caesarean' was pioneered at the Chelsea and Westminster Hospital in West London by Professor Nicholas Fisk and professional guidance for obstetricians in the techniques used can be found online as can the recommendations of the UK Resuscitation Council regarding the placental transfusion.

Some other things to consider:

Partner, bring your phone to take pictures, and choose music to bring (probably on an iPod).

Bring a hat for the baby into theatre with you.

Would you like to listen to music with headphones to help you focus inward, or aloud on a speaker?

If your partner is not there, who will be with you for the birth?

In recovery and later in the postnatal ward, make sure mother and baby are not in a drafty area.

If you are planning an elective caesarean birth, or if a caesarean is more likely due to induction of labour, VBAC or other issue, then discuss this plan in advance with your midwives and doctors so that they have time to reflect and prepare and perhaps do some online research. If you are planning a natural birth, you could keep a copy of your caesarean birth plan in your bag or with your notes, in addition to your regular birth plan, and tell your partner or midwife it is there in case needed.

Before the birth, find out about 'Laid Back' Breastfeeding and Baby Calm. After the birth learn about attachment parenting and baby massage! If you are local to us we have wonderful classes to help you establish a great bond with your baby.

New research:
New frontiers in birth research indicate that the bacterial environment in the vagina during a natural birth, inhabit the baby's gut and provide important immune factors for the baby which may give both short and long term protection against disease. There are new ideas about ways to introduce vaginal secretions to babies born by caesarean with vaginal swabs currently in development. Its good to bear in mind that helpful bacteria in the gut are also nourished by breastfeeding and the mother's satellite bacteria also pass to the baby ongoingly through skin-to -skin contact. A baby born by caesarean cannot have all the benefits of a natural birth, but a 'natural' approach will go a long way to restore some of them.

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Jill Benjoya Miller's 'Natural Caesarean' Birth Plan

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In my last post I wrote about having a 'natural caesarean', inspired by the experience of Emily and Adam, who came to my Active Birth Weekend Course, which I teach with Jill Benjoya Miller. Emily and Adam wanted to have a natural birth, but they had a...

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The natural caesarean: a woman-centred technique

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The natural caesarean: a woman-centred technique

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Abstract

Although much effort has gone into promoting early skin-to-skin contact and parental involvement at vaginal birth, caesarean birth remains entrenched in surgical and resuscitative rituals, which delay parental contact, impair maternal satisfaction and reduce breastfeeding. We describe a 'natural' approach that mimics the situation at vaginal birth by allowing (i) the parents to watch the birth of their child as active participants (ii) slow delivery with physiological autoresuscitation and (iii) the baby to be transferred directly onto the mother's chest for early skin-to-skin. Studies are required into methods of reforming caesarean section, the most common operation worldwide.

Please cite this paper as: Smith J, Plaat F, Fisk N. The natural caesarean: a woman-centred technique. BJOG 2008;115:1037-1042.

Keywords: Bonding, caesarean section, natural childbirth, physiological resuscitation, skin-to-skin contact

Introduction

The management of vaginal birth has changed hugely in the 15 years since woman-centred maternity services were recommended in the Department of Health's Changing Childbirth report.1 Caesarean rates doubled during the same period; yet, abdominal delivery has changed little, apart from occasional background music and a safety-led shift from general to regional anaesthesia.

If promoting what is natural underpins the modern management of vaginal birth, the need for speed and resuscitation remain the principles governing techniques for caesarean birth today. Surgical rapidity, however, is unnecessary in the absence of fetal compromise, and a throwback to the days when general anaesthesia was the norm, with short induction-delivery intervals advocated to reduce fetal anaesthetic exposure and the subsequent need for resuscitation. Although paediatricians are no longer required at straightforward caesareans under regional block,2 the baby is usually taken to a Resuscitaire, examined, cleaned, tagged, weighed and swaddled before being introduced to the parents, often a good 10 minutes after birth. Early skin-to-skin contact and initiation of breastfeeding within 30 minutes as recommended by the WHO/UNICEF Baby Friendly Initiative3,4 is almost nonexistent.5

Increasing evidence shows that women undergoing caesareans have a less satisfactory childbirth experience than those delivering vaginally and are more prone to postnatal depression, bonding difficulties and unsuccessful breastfeeding.6,7 To improve the experience of women having uncomplicated caesareans, we have modified obstetric, midwifery and anaesthetic practice over the past 6 years to emulate as closely as practicable the woman-centred aspects of 'natural' vaginal birth.

Technique

We describe a technique for straightforward elective caesareans in healthy women with non-compromised singleton fetuses at term. It can be adapted for nonurgent emergency procedures but is not suitable for preterm or breech presentations.

Preparation

Antenatally, we use video clips to demonstrate what happens at a 'natural' caesarean. 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 couples are encouraged to bring their own music, and the woman can wear her own clothing if she wishes.

In theatre, the pulse oximeter is positioned on the mother's foot to keep her hands free, and the electrocardiogram (ECG) leads 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 as per usual practice. We use a combined spinal-epidural needle-through-needle technique with 7.5-10 mg bupivacaine intrathecally8 and a prophylactic infusion of the vasopressor phenylephrine. 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

Surgery starts with the screen up, and sterile routines observed as usual. After uterine incision, the drape is lowered and the head of the table 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. The principle for the surgeon is then hands-off, as the baby autoresuscitates: breathing air through the exteriorised 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 ( Figure 1 ), mimicking what happens at vaginal delivery. 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 ( Figure 1 ).

The baby is next left supported for up to a minute, allowing the mother to observe her child. The half-delivered fetus frequently cries but if not, the obstetrician observes its breathing, colour, tone and movement to indicate wellbeing. The rest of the delivery is achieved through a combination of passive expulsion by the contracting uterus and active assistance: the baby wriggles out while its head and torso are supported by the obstetrician. This enables the mother to watch the birth and ascertain the sex of her baby at the same time as the delivery team, replicating the situation at vaginal birth ( Figure 2 ).

Early skin-to-skin contact

Once the baby is finally 'born' and wellbeing again confirmed, the cord is clamped and cut in view of the parents. The anaesthetist/anaesthetic assistant clears the mother's clothing from her chest, and the midwife positions him/herself at the top of the bed beside the mother's head. Still scrubbed, the midwife receives the baby directly from the surgeon to prevent contamination ( Figure 3 ). The woman should be warned not to reach out for her baby, as this risks touching the obstetrician. The baby is laid prone between the mother's breasts, dried with a warmed towel and kept warm with fresh towels and bubble wrap.

After a plastic clamp is applied, the partner can cut the remaining cord if he wishes. Labelling and vitamin K administration are accomplished with the baby on the mother's chest. The baby is positioned so that he/she can begin to suckle. The midwife remains near the head end to monitor the baby and reassure the parents. The baby is only weighed when surgery is finished, and given to the partner while the mother is transferred to her bed. Skin-to-skin contact is then re-established with the baby in the same position.

Discussion

Caesarean section remains entrenched in hospital routines, seemingly immune to the tide of customer-focused changes that has swept maternity services and labour ward care. The 'natural' caesarean technique we describe has evolved as a series of measures to mimic the situation at vaginal birth, where birth attendants encourage early skin-to-skin contact, facilitate physiological resuscitation, but most of all, engage the parents as active participants in the birth of their child.

Randomised trials demonstrate that early skin-to-skin contact increases the rate and duration of breastfeeding, reduces infant crying and improves maternal affection. Although recommended by both the Royal College of Nursing and National Institute for Clinical Excellence,2,9 this has hitherto proved refractory to implement at caesarean section against a background of ritualised obstetric and midwifery routines.5 We describe how immediate skin-to-skin contact can be established at straightforward abdominal delivery without compromising operative sterility.

Respiratory complications like transient tachypnoea of the newborn are more common after elective caesarean than vaginal delivery,10⁻12 in which retained lung liquid is implicated, as is the lack of catecholamine and cortisol surge associated with vaginal birth.13 Pausing the delivery of the baby, as shown in Figure 3 , to allow physiological expulsion of lung liquid like at vaginal delivery may facilitate respiratory adaptation.

We report the technique at this stage in the absence of quantitative outcome data in response to frequent requests from obstetricians and women, and considerable media interest. In qualitative terms, the natural caesarean has been positively received by the couples involved (Supplementary material S1), with no adverse comment in more than 100 procedures. One fear that women expressed preoperatively was the possibility that they would see inside their own abdomen. We explain that the baby's head 'blocks the hole' and once baby is delivered, the screen goes back up. In reality, maternal position precludes this anyway. Formal audit of maternal and fetal outcomes is now indicated, with a view to eventual randomisation. We offer the following observations on introducing this package of measures.

Fetal safety is paramount, and we immediately resort to routine management if the baby is unexpectedly born in poor condition. The uterine incision-to-delivery interval is prolonged compared with routine practice, but usually still within the 3 minutes formerly recommended for optimal neonatal condition.14 However, during this period with the head out but the trunk still inside, not only is the crying baby establishing a resting lung volume but also the placental circulation remains intact. Experience with the partially exteriorised fetus during EXIT (Ex utero Intrapartum Treatment surgery to establish the neonatal airway) procedures suggests that fetal oxygenation can be maintained over much longer intervals, the largest series showing an average cord pH of 7.20 after a median of 17 minutes on 'placental bypass'.15 Because birth is timed when the baby is completely expelled from its mother's womb, natural caesarean babies often achieve a healthy Apgar score before they are actually born.

Thermal care warrants attention. Although neonates undergoing skin-to-skin contact after vaginal birth are no colder than those who do not,16 the theatre environment is different from that of a labour room. Air conditioning may increase heat loss through convection drafts, even when ambient temperature is maintained. Following conventional delivery, the baby is routinely placed under the radiant heat of the Resuscitaire before being swaddled. We warm and cover the baby on the mother's chest and maintain theatre temperature ≥25°C.

To establish that the mother's chest is a safe place for the baby while the woman is undergoing surgery, we ensure that the mother wishes to have the baby there and is in a fit state to do so. We request that the partner helps support the baby, and an important practice point is that the midwife remains at the head end after delivery, as the anaesthetist is busy at this juncture. The operating table should be levelled from the preoperative lateral tilt. An unanticipated problem was that the maternal ECG sometimes picks up the baby's heartbeat as he/she lies on the mother's chest, mimicking a potentially alarming maternal tachycardia.

Perhaps, the biggest obstacle to implementation is reluctance of staff to change roles and give up rituals. A multidisciplinary team approach is key. The surgeon cannot remain aloof behind the drape. The anaesthetic team must embrace the presence of the baby at the 'head-end', and midwives need to accept that what is good practice at a vaginal birth is also achievable in theatre. An initial midwifery concern that the technique would delay a busy operating list, with no opportunity to weigh, check and dress the baby or complete the paperwork until the end of the operation, was assuaged once the staff had witnessed the family friendly benefits of a 'natural' section.

Caesarean section rates are rising worldwide, and indeed, now exceed one-third of deliveries in many developed world centres such as our own. Given the negative effect that caesareans, whether indicated or discretionary, have on maternal satisfaction, bonding and breastfeeding, improving this experience while maintaining safety should be a priority. We describe an evolving approach, suitable for global export. Studies are now indicated on the effects of naturalising this most unnatural form of birth.

Editor's Commentary

Peripartum care of women and their babies has changed dramatically over the previous half century. While the evolution of prenatal diagnosis and fetal monitoring, safer anaesthesia, and improved surgical techniques have continued to improve and optimise perinatal outcomes, this progressive 'technicalisation' of the birth experience has also resulted in many ultimately unnecessary interventions as well as frequent dissatisfaction among women and their families with the institutionalised birth process. Many developed world medical centres have responded with various 'woman-friendly', 'family-friendly' and 'baby-friendly' initiatives, all with the intentions of optimising outcomes and satisfaction for mothers and babies, promoting bonding and breastfeeding, and minimising risks for all involved. These 'friendly' initiatives are predicated on healthy mothers and healthy babies, generally assuming the spontaneous onset and normal progression of labour at term and have been carefully monitored to ensure that outcomes are truly optimised (Waldenstrom and Nilsson, Birth 1997;24:17-26; Jackson et al., Am J Public Health 2003;93:999-1006).

While these initiatives have often been instituted by medical centres reactively rather than proactively, they have performed much to promote what is truly natural in human labour and delivery. Now, however, the worldwide caesarean epidemic is seen by many women as a further threat to their ability to safely and humanely deliver their babies. The group from Queen Charlotte's and Chelsea Hospital describe a surgical technique in this issue that has, by their report, evolved in their institution over the past few years in an attempt to improve the experience of women having 'uncomplicated' caesarean births.

The authors are to be commended for their caesarean birth preparation activities. While this can do much to enhance acceptance by women and their partners of caesarean birth, it should not be assumed that caesarean birth is 'natural'. There is impressive evidence that the risk of serious intraoperative complications increases with the number of previous caesarean births (Silver et al., Obstet Gynecol 2006;107:1226-32) and I hope that the option of a trial of labour would also be presented fairly in this setting.

Most importantly, however, no outcomes or safety data are presented to justify widespread utilisation of this technique. While this is acknowledged by the authors, it is critically important that readers understand this. We should demand that these techniques be adequately studied with appropriately powered clinical trials and meaningful outcomes. The history of clinical medicine is littered with examples wherein new approaches were adopted wholesale without adequate evaluation, only later to be found to be of no benefit or to have added increased risks. The reality is that protocols such as described here are evolving in many centres around the world, and it is imperative that they be adequately evaluated.

BJOG has a tradition of publishing controversial techniques (Chien, BJOG 2006;113:988). Constructive controversy, and the resultant dialogue, is good for everyone and generally accelerates improvement in techniques and outcomes. We look forward to clinical trials that evaluate the changing techniques of caesarean birth.

Acknowledgments

The authors acknowledge support from the National Institute of Health Research Biomedical Research Centre funding scheme.

Conflict of interests

N.M.F. undertook private obstetric practice (for institutional gain) until November 2007. N.M.F. is on the Obstetric Advisory Board of Ferring UK.

Contribution to authorship

N.M.F. conceived the initial idea, which was then developed, implemented and improved with J.S. and F.P. All three jointly wrote and approved the final manuscript. N.M.F. acts as guarantor.

Ethical approval

Approval was not required. This paper is a description of a technique that evolved over many years in response to patient demand and national guidelines. No end-points were recorded, and as with the many other 'soft' variations in routine surgical, obstetric and midwifery care, such practice does not come under the World Medical Association Declaration of Helsinki definition of human experimentation. Informed consent for caesarean section was personally obtained by the senior author and included showing video clips of the natural caesarean technique, discussion of the optional nature of the 'walking the baby out' component and the monitoring of fetal/neonatal wellbeing undertaken by N.M.F. as surgeon.

Supplementary material

The following supplementary materials are available for this article:

Appendix S1

Patient experiences of "natural caesarean".

These materials are available as part of the online article from: http://www.blackwell-synergy.com/doi/abs/10.1111/j.1471-0528.2008.01777.x.

(This link will take you to the article abstract).

Please note: Blackwell Publishing is not responsible for the content or functionality of any supplementary materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.

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# data[].attributes.attachment_link.title
The natural caesarean: a woman-centred technique

# data[].attributes.attachment_link.description
Although much effort has gone into promoting early skin-to-skin contact and parental involvement at vaginal birth, caesarean birth remains entrenched in surgical and resuscitative rituals, which delay parental contact, impair maternal satisfaction and reduce breastfeeding.