Caesarean birth & how to support women pre- and post surgery

Caesarean birth & how to support women pre- and post
surgery
Beverly Pearson (December 2007)
Wellmother Course July 2007 – London

Contents:
1. Introduction
i) placenta praevia
ii) breech presentation

2. Reasons to be offered a caesarean
i) Absolute indications for caesarean birth
ii) Debatable indications for a caesarean birth
iii) VBAC (Vaginal Birth After Caesarean)

3. Risks associated with caesarean births

4. The Massage therapist’s role in supporting women before and after a caesarean birth

5. Caesarean Birth (pre- /aftercare advice)
a. Physical
i) Before the planned caesarean
ii) During the caesarean operation
iii) Post caesarean
iv) Mother – 6-12 hours after surgery
v) Weeks 1+ post surgery
vi) Natural medications to consider with professional advice
b. Mental / Emotional
i) Terminology
ii) Bonding

6. Medical Model vs Midwifery model
i. Fear / stress
7. Conclusion
8. Bibliography

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Caesarean birth & how to support women pre- and post-
surgery


1. Introduction:
After episiotomy, caesarean section is the most common operation performed on women – over
20% of babies are born in this way in the UK, and in some countries over 40% (e.g. Brazil – up to
80% in private hospitals, a large part of Latin America, a great part of the Asian continent,
Southern Italy – (Odent; 5)) (Gordon; 419). If the need becomes apparent during pregnancy (e.g.
placenta praevia), a caesarean may be ‘planned’; if it occurs in labour, it is known as an
‘emergency caesarean’ (e.g. foetal distress, abnormal bleeding, high blood pressure, prolapsed
umbilical cord and lack of oxygen to the baby), usually performed as it is considered essential to
the baby’s safety; and if it is through personal choice it is termed ‘elective.’ Choosing to have a
caesarean (elective) with no medical necessity is a topic of heated debate – some women may
choose this option due to fear of the pain of vaginal birth (perhaps after a previous traumatic
experience), fear of harming their baby or due to doubts over their physical ability, others due to
scars from physical abuse. In most cases, the preference is to avoid the operation unless it is
necessary to deliver a baby safely – this is due to higher maternal risks, higher costs and a longer
recovery period. (Gordon; 420)

Most midwives and antenatal classes encourage active engagement in maintaining good
antenatal health through balanced diet and a modified exercise programme (walking, swimming,
yoga) to increase the mother’s chances of a vaginal birth, which is what most desire as it is what
they feel is natural and right. However, many caesareans are necessary and should not always
be avoided – they can be life-saving to mother and baby in some cases. “Caesareans, and more
rarely chemical inductions of labour are sometimes necessary to the safety of mother or baby. At
the same time we need to recognise that caesarean surgery significantly increases the risk of
death of a woman.” (Gaskin; 290)


My interest in how to support women pre- and post- caesarean birth began during the course of
my case studies when one of my clients, Mrs H, presented with placenta praevia – it was her first
pregnancy, and another, Mrs T, with a breech presentation and a complicated history of labour -
her third pregnancy.

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i. Placenta Praevia:
If a placenta is found to be low-lying in the uterus at the 18-20-week scan, it is not appropriate to
talk of a planned caesarean at that stage since as the uterus enlarges with the growth of the
baby, it is often the case that the placenta moves with it into the upper part of the uterus away
from the cervix. “Only six percent of low-lying placentas which were detected at by ultrasound in
early pregnancy turn out to be lying over the cervix.” (Kitzinger; p139) When I met Mrs H for the
first session, I used this information as positive encouragement that she may well not have to
have a caesarean. She really wanted to have a natural birth more than anything and said she
would feel cheated if she had to go down the caesarean route. However, if Placenta Praevia is
present in the last weeks of pregnancy, as it was in the case of Mrs H, the risks of depriving the
baby of nourishment and oxygen during a vaginal birth due to the placenta likely being torn away
from its roots as the uterus thinned are so great that it almost certainly means delivery by
Caesarean. This occurs in about 1 in every 200 births and Antepartum Haemorrhage (APH) or
bright red bleeding from week 27 onwards is a typical symptom of this condition (Kitzinger;
p139)., although my client did not present with this. “A real placenta praevia is a diagnosis of late
pregnancy. It is an absolute indication for caesarean.” (Odent; p74)

ii. Breech presentation:
This was Mrs T’s 3rd pregnancy – her first two were characterised by early onset of labour at 32-
33 weeks, with two traumatic birth experiences, not involving caesarean. Her first baby – a boy-
was healthy in utero but was diagnosed with cerebral palsy after the birth and her second child –
a girl – also experienced incompetent care which caused her to need several operations to her
scalp after she was born. Mrs T’s consultant would only have her in his care if she agreed to a
planned caesarean at week 38 due to her being high risk; as it was she went into spontaneous
labour at week 37, early as she expected. Since the baby was also breech it was clear that she
would only be offered a caesarean, which is what happened. Mrs T was more than happy to go
along with this advice as she did not want to repeat painful birth experiences, although she would,
in an ideal world, have loved to have had a spontaneous natural birth with no need for
intervention of any kind – to see if her body really could do it.

Types of breech presentations:
1. Frank Breech – buttocks first with hips flexed and knees extended so the legs are like splints
along the baby’s trunk.
2. Complete Breech – hips and knees are flexed but not below the buttocks
3. Footling presentations – one or both feet are below the buttocks

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Odent lists breech presentation under ‘debatable indications for caesarean.’ (see the rest of these
below) (2004; 76). Having attended 300 breech births by the vaginal route, he suggests that the
optimal conditions for this are a place with no one else present except an experienced, motherly
and low-profile midwife who is not scared by a breech birth. If it is clear that the first stage of
labour is long and difficult, then a caesarean should be the course of action. If not, he
recommends total privacy to allow the birth to progress as easily and as fast as possible.
However, it is not easy to find an obstetrician today who would accept responsibility of a breech
birth by the vaginal route. (Odent; 78). Most routinely schedule caesarean births; there are, on
the other hand, independent midwives who advertise this as their forte or at least offer women
and their partners the choice. The main reason breech babies are delivered surgically is,
according to Connolly and Sullivan (2004; 15), that the baby’s head might become stuck during
the birth if the legs or buttocks descend first , thus perhaps compressing the umbilical cord stuck
in the birth canal, depriving the baby of oxygen and thus possibly causing brain damage. A recent
study has shown that “ babies born vaginally from the frank breech position were three times
more likely to suffer serious injury or death than frank breech babies delivered by planned
caesarean. For that reason alone, many physicians won’t attempt a vaginal birth if the baby is
breech when labour begins.”(2004; 15)

If a baby is presenting buttocks first (breech) after 36 weeks, it is possible to turn it by a
procedure called external version. If done before this time, the baby may move back again. It is
successful in 70% of cases done between weeks 37 and 39. (Kitzinger; 243). In China, the use of
moxibustion, (a herbal stick of Motherwort which is heated) to turn breech babies is centuries old.
The moxa is lit and held over a point on the edge of the nail of the little toe, the theory behind
which is that the heat travels up the bladder meridian, which is linked to the uterus. (West; 88).
Other suggested complementary practices include inverted yoga poses (head level or lower than
the rest of the body), positive visualisation of the baby being in the cephalic presentation (head
down), walking for 20 minutes a day, as well as adopting forward-leaning positions from week 34.
Homeopaths may prescribe Pulsatilla. (West; 89). Kitzinger, in the same way as Odent,
reassures women that their bodies are designed to expand during labour, particularly the bones
and tissues of the pelvis, therefore making delivery of a breech baby a distinct possibility, as long
as the first stage of labour is not inefficient, painful and protracted and as long as the mother is in
a supported squatting position and not dorsal or semi-seated. (Kitzinger; 275).

As the following information demonstrates, both my clients fell into categories where caesarean
was really unavoidable in that it was to make birth safe for them and their babies. Although
breech presentation is a debatable indication, according to Odent, in the case of Mrs T, planned

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caesarean was her only option due also to her two previous traumatic and early onset labours, in
the opinion of her consultant and medical team.

2. Reasons to be offered a Caesarean:
Caesarean rates have risen almost everywhere in the world; one of the main reasons why is that
the operation has become safer and more acceptable. Before the Second World War, the
Classical Section (vertical incision through skin, fascia and uterine muscle an inch above the
navel to an inch above the pubic bone) was performed as a last resort as the risks of bleeding
from the thick uterine wall and of infection were too high, as were those of bowel adhesions to the
uterine scarring causing abdominal obstruction. However, the development of the Transverse
incision (side to side) in a thin zone called the low segment reduced all kinds of complications and
was cosmetically acceptable in the time of the bikini revolution. This happened at the same time
as the introduction of safer methods of anaesthesia, the first antibiotics, blood transfusions and
intravenous drips. (Odent, pp9-10); and the technique continues to evolve.

i. Absolute Indications for caesarean birth:
• Cord prolapse – if the bag of waters ruptures and the cord slips through the cervix to the
vagina, becoming vulnerable to compression and therefore could cut off the baby’s blood
supply.
• Placenta Praevia (see above)
• Placenta Abruption – the placenta separates from the uterine wall before or during labour;
typically experienced as a sudden, terrible and continuous abdominal pain. This is one of
the main causes of intrauterine death.
• Brow Presentation – the head of the baby is midway between full flexion and complete
extension.
• Transverse lie or Shoulder presentation – baby lying horizontally. It also involves a
modification to the incision in this type of caesarean.
• Cardiac Arrest – occurring once in every 30,000 late pregnancies. Speed and timing of
caesarean are critical.

ii. Debatable indications for a caesarean birth:
• Previous caesarean (uterine scarring) – see information below on VBACs (iii)
• Failure to progress in labour – perhaps related to fear (see below)
• Foetal distress – related to failure to progress

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• Cephalopelvic disproportion (CPD) – baby’s head is too large to fit through the mother’s
pelvis – this can only really be known once labour has begun and often women give birth
vaginally to bigger babies in subsequent pregnancies.
• Fibroids & ovarian cysts – if large and low they can block the baby’s passage
• Previous anal sphincter rupture
• Breech presentation – see above for information on vaginal breech birth
• Twin births – as one baby is usually breech or in 8% of cases, both are. Kitzinger (348)
cites a study where birth outcomes in two areas of Denmark were compared – one
where caesarean rates were twice as high as the other, but there was no difference in
rates of mortality or morbidity perinatally.
• Triplets
• HIV-infected women – to reduce transmission of the virus from mother to baby
• Herpes virus – if a woman has developed it for the first time in pregnancy and hasn’t built
up antibodies so could transfer it to baby in a vaginal delivery.

iii. Vaginal Birth After Caesarean (VBAC):

There is a lot of confusing and often contradictory information surrounding VBACs. Ina May
Gaskin and her team at the Farm Midwifery Centre in Tennessee, USA have attended out of
hospital VBACs for over twenty years with a 98% success rate – two women they referred to
hospital during labour due to suspected dehiscence (thinning or separation of the previous scar).
She puts their success down to the fact that none of the women in their care had induced labours
with use of prostaglandins or oxytocin (Gaskin; 302). She suggests that VBAC is safe when other
risk factors such as Cytotec or other prostaglandin induction aren’t added (Gaskin; 295). They
would also always send women to hospital for care by a highly skilled obstetrician in cases where
there is a case of placenta accreta (placenta overlying previous scar), if a woman in their care
has had more than three previous caesareans and no vaginal births or those with previous
classical incisions if they have also never given birth vaginally. (Gaskin; 302). She suggests that
the confusion arises due to media-driven obstetric policy – the fear of malpractice lawsuits is a
huge factor.(p300) “The risk of rupture of a uterine scar in a woman with a previous transverse
lower uterine incision (the safest location on the uterus for incision) has always been and remains
0.5%.” (p295)

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3. ‘Risks’ associated with caesarean births:

“Caesarean surgery is just as risky as any other major abdominal surgery for the mother – a
considerably higher risk for her than vaginal birth. With repeat caesarean she has three times the
chance of dying and roughly five to ten times the risk of complications such as infection,
dangerous blood loss, transfusions, complications from anaesthesia, injuries to the bladder,
intestines or urethra; future bowel obstructions, hysterectomy, ectopic pregnancies, infertility and
dangerous placental complications. …most of the above complications involve weeks of recovery,
inconvenience, emotional trauma and expense, at the least. (Gaskin; 295)

The rate of C-section in the USA is 24% or up to 50% in certain hospitals. “But there has not been
a corresponding rise in foetal survival rate.” (Kitzinger; 348) In fact, it has been shown that
caesarean birth can pose risks to the baby’s postnatal health too. Montagu (61) posits that it is
the cutaneous stimulation of the foetus during labour “which activates the autonomic nervous
system, with (this) in turn acting upon the respiratory centres and viscera.” So, these short,
intermittent stimulations of the skin produced over a prolonged period of time by contractions
upon the body of the foetus “appear to be perfectly designed to prepare it for postnatal
functioning.” However, when there is inadequate cutaneous stimulation, as in the case of
Caesarean-born babies, “we should expect to find disturbances in the gastrointestinal,
genitourinary and respiratory functions” (1986; 61). Gordon (421) also points out that babies born
by c-section are more likely to have breathing difficulties as they have not been exposed to the
same hormones as a baby delivered vaginally.

Breastfeeding problemsThe flow of hormones during the birthing process are the same as those
of lactation. “It is debatable whether women who have had no labour can release oxytocin as
effectively as those who gave birth in physiological conditions.” (Odent; 66-7). Before 1980 most
women who had a caesarean did not breastfeed, quite different from today’s picture; however,
“the initiation of lactation cannot be the same as after a birth in physiological conditions. After a
caesarean, for obvious reasons, mother and baby need help.” (Odent, 70) Odent also points out
that non-labour caesareans seem to be associated with more breastfeeding problems as there
has been no opportunity for the release of hormones involved in childbirth and lactation. He,
therefore highly recommends that these mothers seek support groups to share their experiences
and receive reassurance and assistance.

4. The Massage Therapist’s role in supporting women before and after a
caesarean birth:

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My client, Mrs H had been monitored for low-lying placenta from her week 20 scan. The first time
that I saw her (at week 36) she was still uncertain as to the outcome. After this session, we talked
at length about positive visualisation and imagining the placenta moving up away from the cervix
as the uterus was growing. I also lent her a CD with visualisations and a book, which she took
away excitedly! She left with a very positive spring in her step. As it was only the second time that
I had met Mrs H when she informed me she was, after all, going to have to have a caesarean
birth due to placenta praevia, I really felt such sympathy for her as she seemed so utterly
disappointed, as though something had been taken from her. “Both yesterday and today she has
felt quite flat and detached from everything; anxious and not feeling excited – just knows to
expect the unexpected – this she knows is due to the fact that she has been told she must have a
caesarean due to the still low-lying placenta. However, she is starting to feel a bit more positive
and prepped for the birth in this way, having chosen some music to be played while she is having
the baby – Mrs H and her husband compiled it yesterday evening – so they are doing what they
can to be positive about the birth.” (Mrs H case history notes). The third massage session with
Mrs H was the last before her scheduled caesarean (3 days’ later) so I focused on encouraging
relaxation and the desire to ‘go within’ for inner strength and confidence for the birth; this included
a great deal of energy work – “to the spine – with a hold to the occiput and coccyx and palming up
the spine where I finally gave an energy hold on GV20 and the third eye.” (case notes, Mrs H)
“After the (final) session, I also put together a list of ideas for holistic aftercare for after the
operation and birth and dropped it in to her and her husband over the weekend so that they felt
supported – she was grateful for that.” (case notes, Mrs H).

“I feel that it would have been of greater benefit had I been able to see her perhaps earlier on in
her pregnancy and continue with her care over a longer period, likewise, after the birth of her
daughter, it would have been ideal to have worked earlier after the caesarean to support her both
physically and emotionally, as it is clear she had a difficult time with her general health and
healing postoperatively. I would like to have been able to introduce lymphatic drainage massage
soon after the operation, which could have helped with the scar healing and also general
decongestion of tissues and therefore improved immune function sooner.” (case history
evaluation, Mrs H)

This led me to become very interested in how I could better support and treat women who were
about to have caesarean births, either through choice or planned, due to medical say-so. I felt
there must be so much more that can be offered on a physical, mental and emotional level pre-

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and postnatally. These are some of the ideas and advice that I have since tried to incorporate into
my practice – either in the massage practice itself or passing on information.

5. Caesarean Birth (Pre-/ Aftercare) Advice:
a. Physical:

i) Before the planned caesarean:
• Lymphatic drainage techniques carried out pre-surgery can facilitate postoperative
recovery – preparing the abdominal area for the operation/ decongesting tissues


ii) During the caesarean operation: (teach birth partner)

• Help the mother to breathe as deeply as possible
• Make eye contact and gentle, yet firm hand-holding and stroking to communicate
soothing, caring attention

iii) Post Caesarean:
Physically, the major concerns for a mother post-caesarean are: pain from incision, involution
(uterus shrinking), abdominal and intestinal gas; extreme fatigue and low energy; need for
movement, gentle exercise and other comfort measures; increased risk of thrombophlebitis (2-3
times higher risk than those who birthed vaginally) & pneumonia (Osborne-Sheets; 130).

iv) Mother – 6-12 hours after surgery:

• Gentle, frequent movement to produce pain relief and improve circulation – wiggling feet /
sliding legs (bending and straightening) / bracing legs in bed. Then, brief walks, within 6-
12 hours of surgery help with peristalsis and therefore ease of elimination, hasten incision
healing, improve bladder tone and reduce the risk of postsurgical complications such as
thrombophlebitis and pneumonia (Osborne-Sheets; 130);
• Other recommended exercises post-surgery are (Noble; 199-201):
o
Diaphragmatic deep breathing (upper, mid chest & abdomen – with wall
tightening as exhale) – this helps to dissipate trapped air under diaphragm from
surgery which may be causing pain under shoulder blade.

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o
Huffing (forced exhalation by pulling in the abdominal wall rather than pushing it
out – therefore less painful than coughing) - important to rid the lungs of excess
mucous after shallow breathing during the (epidural /general) anaesthetic.
o
Bridge and twist – good for prevention of gas pain done twice a day for first three
days
o
Pelvic rocking (lie on back and gently rock pelvis front to back, using abdominal
and buttock muscles – can support incision with hands) – to help sluggish
intestines
o
Relief from gas can be obtained by lying on left side with knees curled up while
gently kneading abdomen in clockwise direction
o
Check midline (recti muscles) on third day – then progress to abdominal toning
exercises as for any postpartum mother
• Take as many naps as possible and ask for extensive assistance with daily tasks; Expect
nurturing and attentive care!
• Work on pressure/ reflex points on the feet can address pain from gas, the incision and
constipation initially while the abdomen is still out of bounds
• Breastfeeding – perhaps side-lying initially will be more comfortable until pain from gas
has dissipated. If the baby is reluctant to suck (common after medical analgesia) milk
production may be low, so working on shiatsu points ST18 and L1 can help with lactation.
If engorgement occurs, try working points GB21, ST36 and SP6 to help milk flow.(Yates;
137).


v) Weeks 1+ Post-surgery:

Postpartum goals are: to nurture and provide emotional support; facilitate restoration of pre-
pregnancy physiology; promote pelvic floor healing and comfort (after increased weight of
enlarging uterus during pregnancy); rebalance spinal and pelvic realignment; restore and
normalise abdominal structures; restore normal walking patterns; prevent and reduce back and
neck pain from newborn care (Osborne-Sheets;148)

• It is normal after a caesarean to experience pain from incision, involution (uterus
shrinking) and abdominal and intestinal gas. Start to introduce gentle abdominal
kneading to reestablish peristalsis, ease gas pain and foster lymphatic flow. Start to focus
on the ileocaecal valve for elimination / constipation
• Delay abdominal techniques until medical clearance is given and the incision has healed
– 2-3 weeks before doing any massage work which mobilises the scar tissue.

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