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  • Writer's pictureBri Rice, RN, BSN

5 Ways a Doula Can Reduce the Risk of Cesarean

by Bri Rice, RN, Birth and Postpartum Doula based in West Hartford, Connecticut


As a former L&D nurse and Professional Doula for the past 13 years now, I have been in the Operating Room for many cesarean births and while many have been necessary, there have also been so many that were preventable. That is why I want to share with you ways to reduce the risk and also help you be ready in the case that that is how your birth is destined to go.


Rather than suppressing feelings of fear around cesarean, it does help to learn about when one would be indicated, what options you still have if that’s the way your birth goes, and what to expect.


We’ll start with how to optimize your chances of having a vaginal birth and then dive into what a cesarean entails, a cesarean birth plan, and plenty of recovery tips. Preparing for a storm doesn’t cause it to happen, but it can quell your worries, make you feel better, and help you have a safer experience.


1. First, as doulas, we normalize birth as a physiological event. Our bodies go into labor when they’re ready.


About half of births occur AFTER 40 weeks and 5 days. Providers are inducing for late-term (41-42 weeks) more often than true post-term pregnancies (after 42 weeks). Normal gestational age is 37-42 weeks. So we are often intervening for a normal gestational period. It’s also important to note that estimated due dates are just that, guesses. The risks and benefits of induction should always be discussed with your provider with special consideration for your unique situation.


Labor is physiological AND it is not linear. It does not always follow the outdated labor curve that is in old medical textbooks. The labor pathway can have twists and turns, ebbs and flows, be gradual, or sudden. Knowing that labor can take a very long time, it’s worth mentioning that doing a c-section for “arrest of dilation” is a man-made diagnosis.


A form of labor dystocia called arrest of dilation, can be diagnosed when dilation reaches 6 or more centimeters and it doesn’t change after 4 hours of adequate contractions or 6 hours of inadequate contractions with the use of pitocin. It can only be diagnosed when your water has already been broken. In my experience, this stall most often happens during inductions and not spontaneous labor. It is not a flaw with your body, it’s that medications don’t always work.


The diagnosis can only be made when the cervix doesn’t change AT ALL for 4-6 hours. Cervical change can mean opening up one more centimeter every few hours or longer. Just because it often takes LESS time than this doesn’t mean it’s not normal to take longer.


EvidenceBasedBirth.com has an article on cesareans being performed for “failure to progress,” or arrest of dilation, which many nurses and doulas translate to “failure to wait.”


A wrench can be thrown into the mix if you’re baby isn’t tolerating labor well or is showing signs of distress on the monitor. This can often be an indication for having a cesarean. Fetal heart monitoring is not black and white. The nurses and doctors review the baby’s heart rate constantly and watch for trends with interruptions in the oxygen pathway.


Decelerations in your baby’s heart rate can be normal or abnormal. Babies have extra oxygen reserved for the stress of labor and your provider will help determine when it is heading in an unsafe direction.


2. This brings me to the second way a doula can help prevent you from having a cesarean section: guiding you with positioning your pelvis in a way that optimizes your baby’s descent and also helps your baby get the most oxygen.


There are different positions that strategically help move labor along when used at different stages and there are also pain management and breathing techniques to help you take in the most amount of oxygen for you and your baby. When you feel more relaxed, you’re less likely to use or need interventions.


3. Besides getting into creative labor positions and using motion as lotion, emoting helps the process as well! Emotional release softens your body. Surrendering to your birthing body keeps your hormones flowing and brings you closer to your baby. It helps to have the calm presence of a doula. They can help keep an empowering atmosphere and keep the attention on you, the one giving birth.


4. Since we know monitoring the baby isn’t black and white, and just as cervical exams are subjective to the provider, it’s safe to say that each medical provider has a different threshold for when they would recommend intervention. Some providers and hospitals have higher rates of cesarean than others. You can ask your provider for their c-section rate and see how they respond. You can also ask your doula help research and check your findings.


5. Doulas can help prepare you prenatally for a cesarean that is out of your control. This mitigates fear and decreases stress hormones during labor which allows for the release of more oxytocin, the powerhouse hormone that contracts your uterus and slowly opens your cervix bringing your baby earthside.


Let’s talk cesarean birth!


Cesarean sections, a surgical way to birth your baby, can be planned or unplanned. In the United States in 2022, the rate of cesarean birth among low-risk, first-time birthers was 25.2%. The total percentage of cesarean births in the United States in 2022 was 32.1% which includes primary and repeat cesareans. (CDC) The World Health Organization recommends countries not exceed 10 to 15 percent for optimal maternal and neonatal outcomes. Yes, we have a long way to go. It is so important to advocate for yourself, do your research, and build your dream birth team!


How else to prepare for the possibility of a cesarean? Know your options. There are many ways to cultivate birth preferences for a cesarean birth if one is needed. Let’s discuss options and what one can expect. We’ll start with before the operation, then anesthesia, surgery and what comes after birth. A sample birth plan can also be found below.


PRE-OPERATIVE


Before surgery, a medication likely to be offered is an ounce of liquid sodium bicarbonate, or Bicitra, that helps neutralize the acid in your stomach because aspirating stomach acid can harm your lungs. Luckily this is rare, but a medication that is likely to be offered.


Labs will need to be drawn and an IV will be started, if not already in place. IV fluids will be administered prior to surgery to prevent issues with blood pressure. Your baby will be monitored and you will be asked to remove all clothing and jewelry.


The nurse or doctor may want to clip your pubic hair if there is hair that can get in the way of the incision. Know that they shouldn’t be clipping all your hair. Shaving the pubic hair can increase bacterial growth, so it’s important not to shave or wax your abdomen/bikini area near the end of your pregnancy.


ANESTHESIA


Having spinal anesthesia is the preferred option by most birthing people because the numbness lasts for 4-6 hours but allows you to stay awake and have freedom of movement in your upper body.


Your support person would come in after this procedure, the drapes are in place, your belly is prepped with solution, and it is confirmed that you are comfortable.


General anesthesia is generally used for emergencies and means being “put to sleep.” It requires you to have a breathing tube which can cause a sore throat and more pain when waking. If you need general, the staff would encourage the partner to wait in recovery and not be in the OR.


Understandably, being laid down on a thin table and not having control of your lower body can be anxiety-inducing, especially if this isn’t anticipated. It might help to know that the thin table is necessary for the doctors to be close to your side to work. The bright lights and cold air temperature all help your doctor perform their best work while decreasing chance of infection.


Sometimes it can feel like there’s heaviness on your chest or you can’t breathe. This is usually due to your chest being numb. The anesthesiologist is checking your vital signs and can help assess and ensure you are safe. Communicating with them is key.


There is the possibility of developing a severe headache from spinal (or epidural) placement. There is treatment for this in the 1% chance that it happens.


SURGERY


It is important to be aware that you may feel sensations of tugging and pulling during surgery. The surgery should NOT be painful but you will be able to feel touch. If you are in pain, communicate it to the team. You may notice bruising in the following days from the stretching.


You can request your doctor to give you a play-by-play as the surgery is happening or maybe you prefer conversation to be light about everyday topics. Or consider playing your own music. Knowing what is most important to you and communicating your birth preferences (not just on paper) throughout your care is essential.


AFTER BIRTH


After the birth of your baby and placenta, it’s common for the doctor to irrigate your abdomen with a solution of normal saline. This removes a lot of blood. Although you may not have a lot of bleeding from your vagina at first, it can increase later in postpartum.


SKIN TO SKIN IN THE OR


Consider having the monitor wires placed in a way for the baby to be positioned on your chest for easy skin to skin access throughout surgery and recovery.


Having skin to skin contact with your baby in the OR is your right and best communicated ahead of time. But, even if the plan is for skin to skin contact, the baby initially is handed to the NICU team for assessment. This also helps maintain a more sterile environment. The support person is then invited to the warmer to see the baby and then it’s time for skin to skin. You can choose to have your baby wiped and swaddled or have her come to your chest simply in her birthday suit. Although not common practice, it is possible for you to have a sterile gown and sterile gloves and for your baby to go to you immediately instead of heading to the warmer. Talk to your provider about this prenatally.


It takes strength and courage to birth your baby surgically. It can feel isolating and bring on a gamut of emotions. Allow yourself time to feel all the feels. Many people have a vision of what their birth will look like and this may not have been in the plan. Whether you’re feeling loss, sadness, or anger, it’s okay. And if you’re feeling relieved or happy, that’s okay too.


Sample Birth Preferences for Cesarean Birth


In case a cesarean birth is necessary, I respectfully request the following:


  • I prefer at least my partner to be present in the OR during birth. Ideally, my doula will also be present to help facilitate skin-to-skin.

  • I would like to play my own music of my choice (if non-emergent).

  • I request that conversation be primarily about the birth and not about sports, vacations, or traffic, etc. I will carry the memory of this birth for many years and would like to feel respected.

  • I do not want my arms strapped down.

  • I would like the monitors to be placed in a way to allow me to touch my baby or have skin-to-skin contact.

  • I would like the surgical drape to be placed in a way not to make me feel trapped.

  • I would like the drape lowered or have a clear surgical drape used so that I can see my baby be born.

  • I would love a warm blanket during surgery.

  • Please explain the surgery to me as it happens (or please don’t narrate).

  • I would like to have a slow delivery if safe to do so, with the intent to simulate the “vaginal squeeze.”

  • I would like for my partner or support person to be the one who announces the sex of the baby.

  • If possible, please keep the umbilical cord long so my partner can cut or trim the cord while the baby is in my arms.

  • I would like to see my placenta.

  • Delay cord clamping as long as possible.

  • I would like skin-to-skin with/without a swaddle as soon as possible and if I am not able, I would like my partner to have skin-to-skin as soon as possible.

  • I would like as many newborn procedures as possible to be done while my baby is on me or my partner.

  • Please do not give me medication after the birth that could make me drowsy.

  • Delay newborn bath.

  • I would like to be up and moving as soon as possible after surgery.

  • I would like my foley catheter to be removed as soon as possible.

  • I would like to eat and have the IV removed as soon as possible.


It is important to plan ahead if any of these are your wishes, and it is important to discuss these with your provider well in advance of your birth.


POSTPARTUM RECOVERY TIPS AFTER A SURGICAL BIRTH


  • Shaking after surgery is common. There are medications that can help with this or you can ride it out and request warm blankets.

  • Gas-x, Colace, Ibuprofen can all be very helpful to make having a bowel movement easier. (These are offered in the hospital and usually prescribed when going home.)

  • Splint incision with a pillow when coughing or sneezing.

  • If stairs cannot be avoided, walk backwards up the stairs.

  • High waisted undies, disposable underwear, or adult diapers can be extremely convenient.

  • Consider purchasing a trash picker to help you reach for items.

  • Use a step stool by your bed.

  • Cesarean scar mobilization can help release adhesions from healing tissues (after scar is healed and after consulting your physician).

  • Start with a clean new makeup brush or clean cotton ball to regain feeling around incision (after incision has healed).

  • Walk early and often, as tolerated.


It takes absolute strength to cross the threshold that is birth and parenthood. Give yourself time to heal and honor your experience and body with the utmost love and support, no matter what way you birth.

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