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We all know caesarean birth is not rare – it seems as though many of our friends have had Caesarean sections, our neighbour, maybe our sisters too BUT most of pre-birth information spends very little time on teaching us about Caesarean sections.
For some women, a Caesarean section is a mystery right up until it becomes their reality. This is where we hear, “if only someone had told me”. Well here is the good news, we’ve put some gold into this podcast to help you be the full bottle.
In this podcast you will learn:
Brigid [00:00:36] Well, welcome, everyone, to Episode 18 and actually what we’re going to do today, Pat, is a two part podcast and this is Part 1. That’s right. How common is caesarean section? And firstly, we just actually want to start off with saying thank you to a few people that are giving us feedback on the podcast. We love the feedback. Yes. And so this one is from Lenny. And Lenny has written “fantastic podcast. Thanks for creating such a reliable source of information. We recently had a preconception carrier screening completed and listening to your episode on this made us feel much more informed. Thank you”. So thanks, Lenny, for that. So I think what Lenny is talking about is Episode 3, what I wish everyone every woman knew before becoming pregnant.
Patrick [00:01:20] Yeah, it’s great to see lots of people have had listen to that episode because it’s dear to our heart.
Brigid [00:01:25] Yeah. And we’ve got some more feedback Pat haven’t we.
Patrick [00:01:28] Yes. This one’s from my brother Mick who said actually you guys sound pretty good. So thank you, Mick.
Brigid [00:01:34] Yeah. Thank you. So Paddy have you got any little titbits for us.
Patrick [00:01:40] Yes we are talking about caesarean section today and I was I was super pleased during the week. Some new patients of mine came back there probably about halfway through the pregnancy. Couple in their early 20s, super informed and super into all of the podcasts and socials and everything. And they had been watching our Instagram on the maternal assisted caesarean section. Yeah. Which was really great. And they they brought it up and they said how how terrific it was to see it and that that’s part of their education, that they’re learning a little bit about caesarean section. Healthy 21 year olds, probably low risk for caesarean section, but you never know. And I think it’s brilliant that they’re factoring the possibility of caesarean section into their education plan for the pregnancy because you never know.
Brigid [00:02:33] You never know. And maternal assisted caesarean. We’re gonna talk a little bit about that today. But if anyone’s curious, it is on our Instagram. Just scroll through our magnificent feed and you’ll see Pat actually performing a maternal assisted caesarean with one of his lovely patients.
Patrick [00:02:47] Not for everyone, not for everyone, but for that patient with her particular circumstances, it was really sort of a life changing experience for all of us. The patient loved it. The theatre staff it, I loved it. It was amazing.
Brigid [00:02:59] Yeah. Yeah. She’s actually coming back again for another maternal assistant. Caesarean, perhaps. Yeah. How exciting. So, Pat, I’m gonna put my hand up here and say that actually I didn’t learn anything about caesarean birth in my first pregnancy because I really thought that if I ended up with a caesarean birth, that I was a failure. And in fact, for a long time, I did think that I was a failure after I ended up with a caesarean birth. And I don’t think I’m alone. I think that a woman is often disappointed with her caesarean birth. And, you know, it’s not what she expected. And some I’m sure other women I’m sure it’s not just me feel like they are a failure, but do you see this with your patients?
Patrick [00:03:41] Well, the answer is yes. Sometimes people do feel very disappointed. I think that it really depends on the circumstances of that woman’s particular pregnancy and labour. For example, if somebody is known to have a placenta previa, for example, and we’ve known for most of the pregnancy that a vaginal birth was not going to be recommended, then she’s had plenty of time to get her head around that and to understand the possibility, learn a bit about caesarean section and so forth. But when we’re coming into a woman’s first baby, most of the time it’s not a planned situation. We don’t know in advance that a caesarean section is going to be recommended. And in fact, it’s something that arises during the labour, the labour isn’t progressing very well or the baby’s showing signs of compromise. So that’s not the time to suddenly learn all about caesarean section and try and incorporate that into our plan, which is why we think with our with our podcasts and our insta and our programme, that learning a lot about this stuff during the pregnancy is a great idea. It can help you work out how you feel about things, try and get the best, make a plan to get the best out of the experience and then say, well, I hope that doesn’t happen to me. But if it does, then I’m then I’m as prepared as I can be. And I suspect that’s part of the key to managing the sense of disappointment and perhaps coming out coming out of a of a labour where caesarean section wound up being necessary, feeling rather than disappointed or I’ve failed. Feeling more like, well, that didn’t go how I planned, but I knew that was a possibility. And it went that way. And at least I’m confident that that I’ve done the safest thing for me and my baby.
Brigid [00:05:33] Yeah, it’s about having a true plan B. Yes, fully fleshed out. You know, the twists and turns that it could take. Yes.
Patrick [00:05:40] And part of that is learning about things that we don’t want to happen. Yeah. Yeah.
Brigid [00:05:44] I don’t know why I just avoided it, but maybe that’s my personality.
Brigid [00:05:48] But one thing that I did have in my thought processes way back then we’re talking 16 years ago and folks better way back then, I had it quoted to me that the World Health Organization sort of has an ideal cesarean rate of about 10 to 15 per cent. And I know that it’s a little bit higher than that. So but what do you think about that?
Patrick [00:06:10] Well, that’s a low figure by Australian standards, for example. But I think we’ve got to drill into that information and find out exactly what they meant by that. I think that that World Health Organization figure is often sort of misquoted as being a caesarean section rate that we should aim for. And I don’t believe they are for meant any such thing by that. But what they were saying was that if you look at caesarean section rates up to 10 or 15 per cent, then there’s a clear benefit by doing those caesars that you reduce maternal deaths and neonatal deaths. But above about 15 per cent you can do more sections, but you don’t save more lives by doing them.
Brigid [00:06:56] But that’s not our only consideration really is?
Patrick [00:06:58] And well, that’s the problem right? That is that these days in Australia in 2019, you and your baby’s surviving the birth is the absolute bare minimum. And there’s a lot more expected of the birth process in in Australia in 2019 than just the mum and baby will survive. So the World Health Organization, were making a recommendation that in a developing country, their caesar rate should be AT LEAST 10 percent. Because if it’s not, women and babies will be dying in labour.
Brigid [00:07:35] Yeah. And we had a really interesting talk by Dr. Andrew Browning, who came to Ballarat and he’s an obstetrician in Africa. And, you know, I can see that 10 to 15 per cent means less maternal deaths in that developing country. It means less obstetric fistulas, which is what he was talking about is just incredible. So it’s it’s something that is so vastly different from our expectations here in a very well medicalized world here.
Patrick [00:08:04] Well, a highly medicalized world.
Brigid [00:08:07] So it is that the caesarean rate is rising, though, like, you know, we’re talking 10 to 15 per cent is the bare minimum. But, you know, some places and hospitals sort of talk about it being a lot higher than that do you think it’s rising?
Patrick [00:08:21] Yeah, I think it is rising. And I think that it’s rising for a number of complex reasons. But I’m not seeing women set out to have a caesarean section. Very few.
Brigid [00:08:32] We’re not too posh to push are we?
Patrick [00:08:34] No I don’t think that’s a thing.
Brigid [00:08:37] I’m had that said to me once.
Patrick [00:08:38] By a very brave person.
Patrick [00:08:42] I I don’t think that’s a thing that I’ve had in 10 years of private obstetric practice. I think I’ve probably had one or two people say, I want a section. That’s because that’s what I want.
Brigid [00:08:54] Yes. And that could have been based on a real fear of the birth process.
Patrick [00:08:58] Yes, that’s right. It doesn’t mean that for that person there was no reason. Yes.
Brigid [00:09:02] That’s got its own term, hasn’t it? Tocophobia or something.
Patrick [00:09:06] That’s it. Yeah. Yeah, that’s right. Fear of labour Yeah. Yeah. Which is a real thing.
Patrick [00:09:09] So that it’s not that it’s not that that person had no logic behind their decision. So. So yeah. I don’t I don’t see that there’s a rise in anybody asking for caesarean sections. I think there’s a rise in genuine indications, genuine reasons for doing caesarean sections. And we’re not dealing with the same obstetric cohort that we were 50 years ago. So there’s no doubt our patients are older. Obesity is a much bigger problem. And the other things that it brings along with it, like gestational diabetes. And there’s also a different philosophy in the community these days about our expectations that things will always go perfectly.
Brigid [00:09:54] And how we will be afterwards. The woman who’s had the baby, you know, her pelvic floor. Yeah. Yeah.
Patrick [00:10:01] So 100 years ago, the community might have been quite happy with a low rate of of maternal mortality and a low ish rate of perinatal mortality. But these days, people expect every single woman to survive the birth process. And so they should, they often expect every single baby to survive the birth process. And so they should. But as we try and get our data each year closer and closer to perfection, the cost of that is a rising caesarean section rate to get every single woman and baby over the line, discharged, both in good condition, will do more caesars than they used to.
Brigid [00:10:42] Well, can I just go back to increasing age, maternal age? Because it’s not just about fertility, is it? Why is increasing maternal age a problem and be implication for caesarean section?
Patrick [00:10:58] Well, there’s some data that suggests that we know that it’s a little harder to get pregnant in the first place. The older the woman is, and that’s some something we’ve learned to live with. And various some technologies have been developed to help us with that. But there are also things that can happen during a pregnancy that are just more likely to happen if the woman’s a bit older.
Patrick [00:11:17] And some of those things are more likely to lead to caesarean section.
Brigid [00:11:21] And things such as some collagen in your ligaments. And I can imagine I’m feeling my age right now and I just had to get out of the chair and I’m like getting out of chair like a little old lady, but I’m only 46, so. Yeah, sure.
Patrick [00:11:34] So, I mean, you know, do 42 year olds labour as well as 22 year olds? Probably not. I’m not saying a 42 year old shouldn’t have a baby. Of course she should. But we might need to accept that for that woman during that labour that she’ll have a higher risk of caesarean section.
Brigid [00:11:50] So I’m going to just talk about things that I’ve seen coming through my Instagram feed, and that’s sort of around the birthing centres or particular groups saying that they’re able to have a low caesarean section rate in 10, 15 percent.
Brigid [00:12:05] Well, what’s why are there rates so much lower or their stated rates so much lower?
Patrick [00:12:11] Look, I think if a birthing unit has a low caesarean section rate and good perinatal outcomes, then that should be that should be praised. I think that’s fantastic. I think we do have to be a little careful, though, to make sure we’re comparing apples with apples. If you’ve got a birth centre, midwifery led centre, then that cohort of women giving birth in that centre will be, to a certain degree, a selected low risk population, and a lot of the times if your book in a birthing centre with midwifery led care and a low intervention philosophy, then you might be removed from that program if you develop a significant complication during pregnancy and go across to a more medicalized public hospital birthing unit. Where interventions are more likely and where caesarean section is more likely. Now when we got to make sure that we’re running a fair comparison. Bottom line is I don’t think it’s extraordinary. If a if we have a population of low risk, a very low risk, women who none of whom are obese, none have diabetes, don’t have pre-eclampsia and none have complex obstetric histories.
Brigid [00:13:23] Where is this magical world?
Patrick [00:13:25] Exactly. So if we took this magical group, maybe a section rate of a rate of about 15 for that group is reasonable. So. Well, when people hear about that, they should be cautious about that comparison.
Brigid [00:13:36] Yeah. Yeah. And so, you know, that leads me to this question, which is, well, what do you think is an acceptable caesarean section rate?
Patrick [00:13:44] So it’s a complex question. I try not to have a rate in my head for my practice. I try and treat each patient in front of me according to their own circumstances. And I try and give them the very best care I can in their circumstances, regardless of how many sections I’ve already done on other people that year. If people ask me, though, I do say that I think it’s quite reasonable that if you’re having your first baby in Australia in 2019, it’s quite reasonable for you to have a figure in your head that about one third of those babies will be born an unassisted vaginal birth. About one third will be born as a forceps or vacuum. So an assisted vaginal birth and about one third will be delivered by caesarean section. And I think that’s a nice round, easy to remember figure that people should have in their head. And it reinforces to me that the value of patients learning a little something about vacuums, about forceps and about caesars because these are not rare outcome.
Brigid [00:14:57] I would say that a lot of people actually just they say they had a vaginal birth but may have had it forceps or the vacuum. So they’ve actually had an assisted birth, but they’re still counting. Well, as they should. It is a vaginal birth. But I think that that can set the caesarean births aside as well. But it actually its a third, a third, a third.
Patrick [00:15:18] Yeah. I’ve always found that a nice, easy to remember figure. And also a reminder that we should probably learn something about those other things.
Brigid [00:15:27] Yeah, and we’re gonna do it instrumental birth podcast for sure. Yeah. Because it is very important. All right. So that leads us into, well, why do women have a caesarean section?
Patrick [00:15:39] Well, there are a lot of reasons why caesarean section might be recommended and undertaken. And I think if we divide them up into the planned ones that we know about in advance and what we call emergencies, which are the ones that arise during the labour, and thankfully most of those are not an emergency emergency. Yeah, it happens in a calm way where we come in. And I might come in and assess a patient at midday and her progress is three centimetres and the labour doesn’t look like it’s going well. And then I might see her at 4 p.m. and and despite everything we can to try and push her along a little bit, she’s still four centimetres and we might give some more time. And I come back at 8 p.m. we’re still 4 centimetres. And that’s a common non progressive labour type picture. So that woman is going to have a caesarean section. But because it’s happened during labour, it’s classed as an emergency. But it’s not an emergency emergency.
Patrick [00:16:31] You know, we’re plenty of time to bring theatre and to consult with the anaesthetist and get a paediatrician and go to a theatre when we are ready.
Brigid [00:16:38] That happened to me in my second pregnancy, where I was trying for a VBAC, vaginal birth after caesarean. And my time I had just reached my time limit. And so it was it was a very it was classes and emergencies caesarean. But it was a very calm emergency, the calmest emergency I’ve ever been in.
Patrick [00:16:59] And then there’s a few true emergencies, something like a bad haemorrhage or a cord prolapse. That’s the lights and sirens jump on the trolley, scoot down the theatre.
Brigid [00:17:09] I did have one of those in my first pregnancy. Yeah, racing down. But that wasn’t a prolapse or anything like that. It was just, um, Dempsey had gone into fetal distress.
Patrick [00:17:18] So the non reassuring fetal heart rate trace on the on the monitor where the babies looks like it’s saying to us, I’m not happy. I’m not happy. That would be one of the one of the most common reasons for a sort of a lights and sirens. Let’s get downstairs. And get this done. Yep. So of those plan ones, a lot of them are elective repeats
Patrick [00:17:35] A lot of them are women have had caesars before and for whatever reason are not suitable for a vaginal birth in the subsequent pregnancy or have been advised against it or maybe they have had two ceasars before. So they they’ll just be booked in as an elective repeat. And then there’s some problems related to how the baby is going during the pregnancy. Common things like fetal growth restriction.
Brigid [00:18:02] You might see that as an acronym IUGR isn’t it?
Patrick [00:18:06] Yeah, yeah. Yeah. Intrauterine growth restriction.
Brigid [00:18:09] Oh is that how you say it “IUGR”?
Patrick [00:18:13] No that is me just talking too fast!
Patrick [00:18:16] Or we might have a situation where a baby is known. Premature babies still in the premature phase, but the baby is known to be growing very poorly. Placenta is known to be working very poorly. Perhaps the pregnancy is complicated by preeclampsia.
Patrick [00:18:30] And we just say, look, we know this baby is now better off out than in. Based on all of the parameters that we’ve measured and we’re still only 32 weeks. And if we and we know that if we break break your orders and try for a vaginal birth, that this baby is very unlikely to cope with that vaginal birth. And so we’re better off doing a planned section and that happens. And then there’s conditions where vaginal birth just isn’t possible, like a major placenta previa, where the placenta covers the top of the vagina and the baby can’t get out. And then there is some special circumstances where caesarean section might be recommended over a vaginal birth. For example, for breech at term or twins where vaginal birth may be possible, but for various reasons, caesarean section may be recommended. So that’s all the planned ones. And then under that under that rough heading of emergencies, there’s things like non reassuring fetal heartbeat trace, which we’ve discussed, non progressive labour where we’re just not, the cervix is just not dilating despite everything we can do to try and help with that. And then rarer problems like a haemorrhage or a cord prolapse, as we’ve discussed before.
Brigid [00:19:41] All right. So for those that have already listened to our breech birth podcast, we touched a little bit on how caesarean sections were performed historically. But can we talk about that now in more detail?
Patrick [00:19:55] Well, yeah, I think it’s worth mentioning this because one of the reasons why caesarean sections used to be rare and your grandma says, really, back in my day, hardly anyone had a caesar because they used to be dangerous.
Brigid [00:20:08] I remember a little story about that and it was Mrs. Hill and Mrs. Hill would always sit on their front pew at church, and every year she seemed to add another baby. But they were from caesarean section. And being the good Catholic family that we were, we would we would pray for Mrs. Hill with her caearean sections.
Patrick [00:20:26] She might survive. She might survive. So they used to be dangerous, perhaps even before way dangerous even before Mrs. Hill. They hadn’t developed spinal anaesthesia. So you had to you had to have a general anaesthetic and having a general anaesthetic, on your back with a big pregnant tummy with the baby inside, it could cause stomach acid to come up into your throat and potentially down into your lungs. So this was a complicated day, day at work for the anaesthetist, changes in circulation, all sorts of things made giving an anaesthetic for a caesarean section complicated. And surgically many years ago, the technique was different to the one we use now. It involved a lot more bleeding. It was more likely to need major things done to stop that bleeding. And it came with the risk of hysterectomy, which would mean that the woman couldn’t have any more babies. So wisely enough they kept caesarean sections for major, major, major problems where the caesar, despite its risks back then, was a better chance than the rescue might have been taken by having a vaginal birth.
Patrick [00:21:35] Of course, what’s changed over the last 50 years or so is that we’ve fixed most of those problems in caesarean section by comparison has become incredibly safe. And it’s one of the reasons, for example, why we don’t do that many vaginal breech births anymore, because the caesarean section has rocketed up the charts in terms of safety. And it’s now safer to do a section, give or take, than to have a vaginal breech birth in most in most circumstances, whereas 50 years ago it would’ve been the other way round.
Brigid [00:22:06] And actually part two of this podcast, we’re going to talk about how to recover from a caesarean section. So we’ll leave that there. But you know what, actually? Without going into any I don’t know, maybe people want to hear the gory details. So if you if you if you’re a little bit weak in the stomach, maybe just fast forward a little bit. But can you describe the process?
Patrick [00:22:24] I think everyone should know roughly. Okay. Roughly how it’s done.
Brigid [00:22:27] Right. Hold on to your hats. Everyone.
Patrick [00:22:30] As we discussed before, this is not rare. This is something that may well happen to you, even if you’re having your first baby in your late 20s and in perfect health with no obstetric complications, that might still happen. So how do we do it? If we’re doing that? Let’s talk about a planned section. You and your partner will come around together from the ward to the operating theatre. There’s usually a little room next to the operating theatre, which is the anaesthetic room, and in a seated position with your back bowed out like a like a stretching cat.
Brigid [00:23:02] Oh, hang on. There’s one step that I always panicked about beforehand, not getting the little bung in my hand.
Patrick [00:23:07] A little drip in the back of your hand is true. Yes, that’s true.
Patrick [00:23:11] And then the anaesthetist will pop the spinal block in, which is a part of it that people stress out about.
Brigid [00:23:19] And to be honest, if you’re listening and starting to stress about that, I didn’t feel that at all. Like they were sort of uncomfortable because you got a big belly and you’re trying to lean forward.
Patrick [00:23:27] Yeah, they pop a little bit of local anaesthetic in the skin first with a very small needle and then they wait for that to work before they put the spinal needle in. And people worry about the safety of all that.
Patrick [00:23:40] But that’s actually the safest part of the whole thing. The anaesthetists have perfected this over time. So that what that does is create a very dense block, much denser than an epidural. We use epidurals for labour ward pain relief for a labouring woman. But for a caesarean section, we want a denser block to do an operation. So from about the nipple line down, you feel completely, completely numb.
Brigid [00:24:04] And is it a bit sick for me to say I really like that feeling like you feel it go in and it just feels like this beautiful, warm feeling that was for me. I’d love to hear if that was your experience. Well, if anyone else has a spinal block.
Patrick [00:24:18] Well, the people who like it, I don’t often hear that from people having a planned section. But if someone’s having an emergency section at the end of a long and difficult and painful labour,
Brigid [00:24:27] Oh yeah that is bliss too.
Patrick [00:24:28] The bliss they can get from suddenly being out of pain can be really something special. Moving to the operating theatre and once we’ve tested the block and everyone’s good to go, wash the tummy down, put the drapes on and make a cut a sideways cut across just above the pubic bone. Go down through the layers of the skin, fat under the skin. There’s a thing called the sheath, which is a strong layer of tissue around our muscles that helps keep our insides in. And next is you see the bladder, push the bladder down out of the way. Next is the uterus. Open the uterus. Hear that sound as we use this sucker to suck the water around the baby up and then push on the top part of your tummy to squeeze the head out and then rest the baby out, placenta out, close the uterus up in a couple of layers and do it all in reverse. Back up to the skin again.
Brigid [00:25:21] And as a woman who’s had four caesarean sections, what you’re feeling at this stage is quite a bit of sort of tugging, pushing, pulling, but you’ve got no pain. But it is you do feel when the baby’s finally sort of pulled out of your tummy, you do feel this kind of weight lifted. It’s a interesting feeling.
Patrick [00:25:43] Yeah. So you definitely pull you feel pulling and tugging. Absolutely. But it shouldn’t be painful. Yeah. And the anaesthetist is there and you. You’re going. You okay?
Brigid [00:25:51] Yes, I’m feeling OK. And taking photos as ours was. Yeah. Yeah, yeah. That must have been going well.
Patrick [00:25:58] So we still you know. So that’s roughly how it’s done. About 10 minutes from to get the baby out and about another 20, 30 minutes to sew back together again.
Brigid [00:26:06] Yeah. Apart from like I’m gonna talk about it. It’s the guilt or maybe societal pressure or or like what I had with the first two babies, this feeling of failure. Some women have and we’ll talk maybe about their emotional and psychological healing in that part two. But what? Are there any other problems with having a caesarean? Why don’t we all have caesareans?
Patrick [00:26:30] Yeah, that’s probably a topic for another day. I don’t think we should all have caesareans by any stretch. I just think we should know about them in case they happen to us. There are some risks from having a caesarean section they’re the risks of any operations. So there is a risk of heavy bleeding requiring blood transfusion. There is a risk of infection requiring antibiotics. There is a risk of deep venous thrombosis or blood clot in your leg that can go to your lungs. Pulmonary embolism, serious stuff that used to complicate caesarean sections back in the day. There is a small risk of accidental surgical damage to your insides, mostly to the bladder. And we’ve got really, really great at minimizing those risks and preventing them. So, for example, we prevent wound infection very effectively by giving a single dose of antibiotics. We prevent deep venous thrombosis very effectively by using preventative doses of blood thinners from the evening of the evening after the caesarean section. And each evening the woman’s in the hospital until she goes home. Those complications are all, of course, much more better prevented than treated.
Brigid [00:27:32] And is that the little injection you have in your tummy?
Patrick [00:27:35] The clexane.Yeah.
Brigid [00:27:37] So we’ve got a lot better at it. And those risks, whilst they’re still there, are minimal. And there’s one there’s another very important risk that’s related to women who have multiple caesarean sections. And that is that the placenta in a subsequent pregnancy can become abnormally attached to the scar from the previous caesarean sections, not on the skin, down your insides. So the more caesars that you’ve had, if the placenta forms at the front near those old scars, the more likely it is to become stuck there. So then you have another pregnancy of another baby, that baby by caesarean section and it’s super, super hard to get the placenta out.
Brigid [00:28:19] So what are we talking about? I do like my stats, but so what are we talking about with the other risks that you talked about, like the anaesthetic in your skin, the blood clots and all that? What sort of. That’s like an immediate risk. So what are those? What’s the chance of you having one of those?
Patrick [00:28:34] Are all of them? Well, less than 1 percent. Oh right. Because they’re prevented by good surgical technique, good anaesthetic technique and preventative medications. Yep.
Brigid [00:28:43] And for the anaesthetic, we hope to get our good mate on who’s an anaesthetist very soon to sort of talk about that. Yeah, that’s going to be great. So Mitchy will come in here with us and talk about that.
Brigid [00:28:53] In a little podcasting room he’ll snuggle in somehow fit him in his own. He’s quite big. What about accreta? Because I know that that was my issue, having four caesarean sections. I think we were sort of aware of that, weren’t we?
Patrick [00:29:06] Yes. So we’re trying to there’s some there’s some better data now coming out about accreta. And what we know is that probably the riskiest situation is a woman who’s had multiple previous caesarean sections, who’s got a low lying placenta that’s at the front so that the placenta is actually sitting over the scars from the previous from the previous caesars. And the more previous caesars that she’s had, the more likely that that placenta is to be adherent.
Patrick [00:29:36] And so we’re sort of moving towards a situation. They are all things that we would know in advance, right. We would know how many seasons the women have had. We know from ultrasound where the placenta was located. And then therefore, we’d be able to use the data to say, well, if you’ve got those set of circumstances, your risk of Accreta is, accreta is where the placenta is abnormally attached.
Patrick [00:29:54] It is so many percent. And it may be that on the day that that woman has her caesars, we might have two or two consultant obstetricians present. We might have worded up the anaesthetists about the possibility of major haemorrhage. We might have a cell saver machine in theatre which washes your blood so we can put it back in again and we might have rung the blood bank and said, can you have ten bags of blood ready for us and prepared a lot more for something that the stats would tell us would be a much more complicated caesarean section than the standard Wednesday morning list of list of planned caesars in and out.
Brigid [00:30:29] But it’s not that common.
Patrick [00:30:31] No, that’s really rare.
Brigid [00:30:33] So we see it, don’t we? And I don’t know whether it’s a bit of a psychological boost for women that are having a cesarean or what it is, but we do class it as a major abdominal surgery. You know, we hear that well I’m recovering from major abdominal surgery, I think I might have said that many times.
Patrick [00:30:51] When I wasn’t helping enough?
Brigid [00:30:53] Yeah. Yeah.
Brigid [00:30:53] So is it major abdominal surgery?
Patrick [00:30:58] Well, as someone who performs major abdominal surgery for other reasons. No, I don’t think it is. I think sometimes it’s called major abdominal surgery by people who were in an effort to try and drive the Caesar rate down. Don’t have one for no reason. It’s a major operation. Well, I don’t think there are people out there having one for no reason anyway. And I don’t think we need to to scare the people who do need one by saying it’s major abdominal surgery. If you look at major surgery on any part of the body, the further the structure that you’re operating, operating on is from the skin, the more you have to do to get down to that thing, to fix it. And if we look at the things that are major abdominal surgery, the things that make the major from the patient’s point of view is having to push other organs out of the way to get to the organ you’re looking for. So if we have to pack bowel out of the way, for example, the bowel will go on strike for a couple of days and that person might be pretty sick for the first couple of days in the hospital. And how long the operation takes, if you look at caesarean section, we don’t have to pack anything either way because the uterus is the first thing you get to when you open when you open the belly.
Brigid [00:32:03] Just push the bladder a little bit you said.
Patrick [00:32:05] The bladder a little bit downwards. The first thing you get to otherwise is the uterus itself. Yeah. So you don’t go looking for it. It’s because they’re big for any uterus yet. Open it up, push baby out and so forth. So I mean it’s easy. It’s easy when you know how. But I worry about that too. Major abdominal surgery. I think if you ask most surgeons involved in major abdominal surgery, they wouldn’t rate cesarean section as their hardest operation.
Brigid [00:32:30] I think what we do need to do is acknowledge that that woman’s had a baby and needs time to recover.
Patrick [00:32:36] Yes, and an operation and an operation.
Patrick [00:32:38] I’m not I’m not I’m not trying to downplay it. I just don’t think we should apply it. Yeah, I think we should be seeing it as in 2019 in Australia, a common, safe and reasonable way to have a baby if the circumstances suggest that that’s the best thing to do.
Brigid [00:32:54] Yep. Yes. I think what we need to do is just give women the time to heal regardless of whether, you know, they had a vaginal birth or a Caesarean birth. This is where we don’t have to justify having rest.
Patrick [00:33:07] No, we’re not. The rest is critical, but we’ll get to that in part two. Yes, there are parts of recovering from a section that are different to recovering from a vaginal birth.
Brigid [00:33:17] All right. So I wanted to mention that in our Grow my baby program, we actually have a template for the birth plan, which includes how to have a caesarean birth. It feels I don’t want a closer to having a vaginal birth, but it it feels like you’re more involved in that birth. But we’ll just briefly mentioned some of the things here so people know what they can do if they don’t. You know, hopefully everyone comes on board with their growmybaby program. But if they don’t show this, things such as they can still do delayed cord clamping can’t they?
Patrick [00:33:48] Yes. So we do this all the time. If there’s a so glad cord, clamping is the practice of just waiting until the cord stops pumping before we before we clamp it with the idea that the blood that’s in the cord is better off in the baby than in the bin with the placenta. And usually that’s still possible.
Brigid [00:34:05] I just felt a bit sad. Placenta in the bin. Well, somebody will take it home and a few go to pathology, but. Yeah. Yeah. The rest going to be. Yes, it’s done. A very good job well done placenta. That’s right. So yes.
Patrick [00:34:17] So so that controlled cord clamping is still possible, that caesarean section. As long as the baby comes out in good nick, big strong cry and doesn’t need immediate resuscitation from the pediatricians. And as long as the woman’s not bleeding too much because the uterus will only really stop bleeding when you get the placenta out.
Patrick [00:34:38] So if it’s a pretty dry caesar and the baby is in good nick, I’m happy to wait. That’s something the people should know about. So that if that was part of their birth plan to have cord clamping, that they maybe they still can.
Brigid [00:34:50] Yep. So we also talked about skin to skin contact. That’s possible to after a caesarean, isn’t it?
Patrick [00:34:56] Yeah, absolutely. So. The thing with babies born by caesarean section compared to babies born by vaginal birth is they do come out with lungs that are wetter. They don’t get rung out as much by the birth process. And it’s more common for caesar babies to need a little bit of resuscitation before being wrapped up and returned to mum. And that’s why at a caesarean section, there’ll be a paediatrician there every time, whereas a vaginal birth, they’ll be on call, but not necessarily present. And that that process can often be very fast where we can have quickly the paediatrician can have a quick look at the baby once over, make sure the baby’s pink, that the vital signs are normal. And then we tend to wrap the baby’s a bit because it’s cold in the operating theatre. Yeah, there’s reason there’s good reasons for it to be a bit cold in the operating theatre, trying to minimize infection, but pretty fast that baby can be returned to mum. And if what mum wants is a skin to skin contact, then the baby partially unwrapped pop on mum’s chest and then put a blanket, a warm blanket over the two of them.
Brigid [00:36:01] Yeah, they come back to you like wrapped up like a little burrito don’t they. And you can just ask the midwife that’s near you to sort of unwrap them a little bit so that among a chance to put their chest to yours. Yeah. Yep. And partner involvement also. You know they’re still part of it aren’t they?
Patrick [00:36:18] Yeah, absolutely. One of the things that I like the dads to try and do it a Caesar is to be be down with mum holding hands. Yes. Providing the support. Yeah. And I remember when when our youngest two were born I found that very strange to be down the head of the table and sort of experiencing that for the first time. I must say, I feel more comfortable up the driving end. Obviously I wasn’t you to do your section, but you know to me that we were comfortable with the things that we do every day. Yes. Yes. And it was weird.
Brigid [00:36:53] It was a brand new experience for you.
Patrick [00:36:54] Yeah. Yeah. So yeah, for the dad to be provide for their job at the start to be very much to be providing support to the woman, especially during a weird time at the start of the caesar where baby is not out yet. Patient woman might be feeling a bit anxious. And then of course when the baby comes out and is passed over to the paediatrician with their resuscitation trolley, Dad should go over there. And at that point and you have to sort of turn around and say the woman, yep, baby looks good, nice and pink, and talk mum through that difficult phase where the baby’s out but not in her arms yet.
Patrick [00:37:28] And then we bring the. Dad and the baby back and keep those. Keep the the mom, dad and baby together as a unit.
Brigid [00:37:37] From from that point onwards and we have used dad here, but we just acknowledging that it could be support person, partner. Female partner. Yep. Yep, yep. Whoever is with you.
Patrick [00:37:48] Whoever whoever is with you, that’s sometimes grandma. Sometimes a same sex partner, sometimes whatever.
Brigid [00:37:54] All right. And we did briefly touch on the maternal assistant caesarean. And again, in our Grow baby program, we’ve got a print out form on what your provider can tell the theatre about how to get ready for maternal assisted cesarean. Because there’s a few people involved in getting it through. It’s not a not a everyday procedure.
Patrick [00:38:13] Yeah. So yeah check it out on our Instagram. This is not for everybody, but it’s a it’s a process by which a woman undergoing a cesarean section does a surgical scrub at the start of the case, her hands are surgically clean. And then you lift up gloved up in a surgical gown so that she can assist in the in the delivery of her own baby by putting her hands into the surgical field and helping the head out and to literally be the first person to hold the baby. And it’s a remarkable experience. And as you said, it’s not for everybody, but for the people who are keen on it. We’ve put together a document about how you could help to bring that about, but it needs the agreement of a lot of people.
Brigid [00:38:57] Yes. Sometimes it’s pushing the boundaries of the theatre.
Patrick [00:38:59] Needs to be your birthing team and the theatre the anaethetist. But we hope that something that that’s more possible for the is that that are not emergencies, that the elective repeats. Where are it’s not time critical situation.
Brigid [00:39:13] You got a bit of time to plan it. Absolutely. All right. Well, I think that’s all that was on my list of caesarean sections. As I said, we’re going to go on to part two and talk about how to recover from a caesarean section. But hopefully that’s giving you lots of information to think about. And and also it’s about putting your mind ease. If it is that you’re expecting to have a caesarean or you’ve been told that you having a caesarean or even for those, as we said at the start. The people who are planning their pregnancy, hoping for vaginal birth, but being incredibly organized and learning all about caesarean section as well.
Patrick [00:39:47] I hope that’s the spirit in which people take this that they say set out very rare to set out for this to happen. But if it does happen to me, I feel well informed. I feel like I have an inkling of how commonly this happens. And I feel like I know something about how it would go down if that’s what happened. And I hope that that for people can lead to less of a sense of the bewilderness or disappointment. Yeah. If that’s what actually happens on the day.
Brigid [00:40:16] Yep. And now we’re gonna put women this episode goes live. We’ll put a post up on our Instagram, which is @grow_my_baby, and just let us know what you think and whether we covered everything, whether we missed something, whether it helped you. We are getting, you know, really good feedback on how people feel that that our poddys are helping, which is great because we love doing them, don’t we? We do. Yeah.
Brigid [00:40:38] So if you haven’t already, please subscribe. And importantly, tell a friend, because I’m sure many of your friends need this sort of information, too. It’s it’s interesting, isn’t it, how we all go along the same route together. If one gets pregnant, the whole group has like a cascade.
Patrick [00:40:53] All right. Well, we’ll go on to our next podcast and we’ll see you next week. See you then.
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