Introducing...the concept of the 'natural' cesarean...
I have struggled with whether or not to post on this YouTube video for some time. The title, in and of itself, is aggravating. And I don't mean from a judgmental standpoint, but simply from a realistic standpoint: cesarean birth - whether positively, clinically indicated or not'is not - natural.' It is an alternative method to birth compared to how nature originally designed it.

I have heard many others refer to the practices described in the video as 'gentle cesarean.' This, at least, seems to be a bit more accurate - except for the cutting, pushing, tugging, pulling, suctioning, cauterizing, and externalizing of the uterus that goes on. (In a former career life, I used to surgically assist on cesareans, so I'm pretty familiar with what the procedure looks like.)

A list serve I'm a member of has recently spent a lot of time debating practices that surround cesarean births: should hospital policy allow for placement of baby skin-to-skin with mother directly following birth? Should breastfeeding be allowed in the OR while mom is still being sewn up? Should separation of mom and baby in the minutes and hours be avoided following a C-section in the same way this practice has taken hold in the vaginal birth setting?

Other questions about cesarean birth discussed frequently in my own local birth network include: Should birth plan elements such as low lighting, quiet music and delayed cord clamping be integrated into the C-section setting? Should doulas be allowed into the operating room to provide the emotional support the mother/parents hired her for? (An aside here: the most common argument against allowing doulas into the OR at my local hospital is that, 'the OR is too small to have an extra person in there.' Every time I hear this I nearly explode: the OR seems to be large enough to admit medical and nursing students at-will, along with the various OR staff coming and going from the room throughout the procedure. And yet the presence of a doula sitting quietly and still beside the birthing woman/couple seems to take up WAY too much space!)

The 'Natural C-Section' video encourages many of the issues discussed above. It follows a second-time-mama into the OR for her second cesarean birth and features obstetrician, anesthesiologist and midwife talking heads who all describe this version of a cesarean birth in a universally positive light. In fact, mood lighting does seem to be implemented. The sterile drape separating mom's head and the rest of her body is dropped in time for her to see her baby being pulled from the incision in her belly. The doctor holds the baby up, legs spread, so mom and partner can 'discover' the baby's sex on their own, as the OB narrates, '...it's one of them.'Baby is placed right away, vernix, fluid, blood and all, on mom's chest. Dad cuts the cord following a delayed cord clamping. In this video, the midwife's job following the baby's birth is explained as being focused on facilitating bonding measures like skin-to-skin contact and early breastfeeding, while also assessing baby's well-being.

Interestingly, the anesthesiologist included in the video describes the birthing woman as 'awake and participating in her baby's birth.' I have a hard time agreeing with his sentiment. While it is certainly preferable for the mother to be awake and aware the moment her baby exits the womb, I'm not sure how much 'participating' she is doing when strapped down with 2/3 of her body numb and immobile.

For women who must deliver via cesarean - I can definitely see the appeal in this version of a surgical delivery. It attempts to come up to speed in so many ways. There is no hour-long separation between mom and baby. When mom goes to the PACU (Post Anesthesia Care Unit), so does baby. The midwife in the video even acknowledges the associations between postpartum depression and cesarean rates as well as decreased breastfeeding initiation rates amongst women who have undergone a cesarean birth. She then goes on to imply that this gentler approach to the C-section might just ameliorate some of this association.

Criticism Against the 'Natural Cesarean'
Here is the cause of my hesitation: does this promotional video of the 'Natural C-Section' run the risk of making surgical birth look so enticing that the risks of C-section get pushed under the table?

Dr. Andrew Kotaska, an obstetrician in Yellowknife, NT, Canada describes his concern over the 'Gentle Cesarean' this way:

'It is admirable to minimize the necessary disruption of normal early maternal- neonatal contact associated with NECESSARY cesarean section. The gentle measures employed will not, however, reduce the maternal risk of amniotic fluid embolism, pulmonary embolism, operative injury, infection, severe hemorrhage, and death - all several times higher with C/S than vaginal birth. They also will not help achieve the neonate's normal immune system activation during labour, perhaps leaving it more vulnerable to autoimmune disease later in life.

'In no way can the 'gentle cesarean' be construed as making C/S safer. In the best quality prospective data set on elective C/S, 1/2300 women died. Soft, family-centered window dressing does not change the cold, hard risks; it is important practitioners and women keep this in mind.' (Landon; NEJM 2004)

In the United States, we are struggling against an ever-increasing cesarean rate. Readers of this blog are well-aware of the ~ 33% C-section rate that doesn't seem to be decreasing any time soon. In an age when we should be working to reduce the C-section rate to somewhere at least close to that which the WHO recommends, the promise of a gentler, naturalish surgical birth could threaten the work many maternity care professionals and normal birth advocates, alike, are doing to properly inform women (and some providers) of the true risks associated with cesarean birth.

On the same list serve I mentioned above, another related thread developed: should we 'allow' post-cesarean moms to initiate breastfeeding while still in recovery? The meat of the debate was whether or not women with anesthesia levels up to the nipple line will suffer nipple damage from incorrect infant latches, if they cannot feel the latch. Hospitals apparently have policies on this: when a mother is and is not allowed to nurse her baby, depending on the type of birth they have experienced (and the resultant side effects - such as prolonged numbness). Since when did it become reasonable for maternity care facilities to dictate when a woman is and is not'allowed' to feed her own child?

This is exactly the type of down-stream effect of surgical birth that 1) likely does not get discussed prior to consenting for a cesarean and 2) is not erased by a gentler approach to the procedure and 3) involves the institution of policies that certainly are not evidence-based.

A Wolf in Sheep's Clothing
I will never become the person who denies the importance of C-section as an option in a few, particular cases: umbilical cord prolapse, placenta previa, abruptia or accreta to name a few. The cesarean method of birth was, after all, developed to be a life-saving measure and, to this day, continues to be just that in a handful of circumstances. And when a C-section is truly indicated (but not emergent) then, YES, incorporating gentle, respectful, best-practices elements into the cesarean experience should be done. To me, this should quickly cease to be a point of debate at all.But for the remainder of women who find themselves in the position of contemplating the type of birth they'd like to experience - those who might be considering an elective C-section; those who have had a previous cesarean and are toying with whether or not to go for a VBAC - the promise of a 'Natural C-Section' may turn out to be a wolf in sheep's clothing.

As one participant on the list serve summarized:

'Can we work to make cesareans less common and also kinder - at the same time?'

Click on image above to watch the entire video on YouTube

Posted by: Kimmelin Hull, PA, LCCE

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