A Family-Centered Cesarean Birth
by Stacy Hirsch
I was 34 weeks pregnant when we learned our little one was breech. An ultrasound confirmed the positioning and showed a nuchal cord (a cord around the neck). I had never worried about the possibility of a breech baby and in that moment the nuchal cord sounded more alarming to me. Our midwife assured me that many babies have the cord around their neck at some point during the pregnancy and this typically does not present any complications. The larger, more pertinent issue didn’t register for me immediately; I didn’t know enough to know that if our baby didn’t flip we were unlikely to have a vaginal birth.
We had chosen a midwife for our prenatal care and we had always planned to have a home birth. For me, home is where I reconnect with myself. It is the place where I can easily let my mind rest and where I can feel my body vibrate at a softer frequency. Having a home birth meant being surrounded by warmth, history, familiarity and love. It meant having our child born into an environment full of intention. The idea of not having a home birth was at first devastating. It seemed so unfair. To feel the vision I held for our birth slip away was incredibly painful. Unpeeling the layers of this disappointment took time.
I had already purchased a majority of my home birth supplies and they were neatly organized and labeled in brown paper bags. I was beginning to envision myself giving birth in our home and I eagerly began designing each detail for the event. The birth tub was ordered and I even planned the snacks I would have for our midwife and her assistant: hummus, herbed cheeses, hearty breads, fruit and vegetables slices, olives, nuts and seeds. All of my favorite finger foods that could easily be prepared ahead of time without a lot of fretting. The home would be warm, inviting and full of welcoming hearts, and the nourishing food would ensure my supportive team would have the strength to go the distance with me.
I soon learned that in our region, as in many other parts of the United States, there really weren't many options for vaginal breech delivery. Providers typically view a breech presentation as having a great enough risk to necessitate a cesarean birth. Our midwife knew that it was possible and safe to deliver a breech baby vaginally but did not have the expertise to do so. We considered trying to find someone trained in breech delivery, even if we needed to travel to another state. It wasn’t difficult to find stories on the internet of women delivering their breech babies vaginally. I imagined these women as strong, rebellious, heroic, articulate and confident. They lived their lives with a silent certainty and they always achieved their goals no matter how big the fight. I envied these women.
My life is full of blessings, yet I am also a worrier. At times I posses all of the attributes I imagined these other women having but I often need a little extra support to overcome the fear that passes through my mind. I wanted my doctor or midwife to have training in breech vaginal delivery. I wanted the system to agree that it was a safe and sane choice. I wanted to know I was doing everything I could to give our daughter the very best start in life. I wanted to eliminate doubt and worry. The idea of choosing a vaginal breech delivery and then having a negative outcome was difficult for me to consider. It seemed like a choice with too much risk and not enough support.
We were concerned about the breech presentation but optimistic that with a little more time our baby would flip. We did our research and tried everything to gently encourage her to make the journey 'head down'. Our efforts included chiropractic techniques, homeopathy, acupuncture with needles and moxabustion, craniosacral therapy, hypnosis, counseling, swimming, biking, inversions/pelvic tilt, Rebozo, coaxing, vibrations and a bright light low on the pelvis, online prayer groups of various denominations, laughter, tears and finally an external cephalic version (ECV) performed under medical supervision at a hospital thirty miles from our home. An ECV is a procedure where the obstetrician manually attempts to rotate the fetus into the proper position while the mom and baby’s vitals are monitored. It is a relatively short procedure and, in our case, was unsuccessful.
We tried to hold it all lightly as we ultimately put our trust in our daughter, knowing that birth was a natural process and if she could flip, she would. With each appointment or technique I would go through a range of emotions. Part of me felt certain whatever I was doing in that moment was going to work and another part of me was slightly afraid of how it would feel to have this little creature flip-flop 180 degrees in my belly. Each day was a dance. Some days I felt I was the lead partner but on most days all I could do was follow.
Trying all of these techniques and connecting with all of these wonderful healers had a secondary effect. They were all women, all mothers and they all became an important part of our birth. They helped me to see that birth was not a single act. They reminded me that our birth experience began many months prior to finding out our daughter was breech. They opened my eyes to the larger process of birth. They also helped me to realize that this was my baby’s birth as much as mine. This was the first but it would likely not be the last time my daughter and I would have differing opinions about how to proceed through a life event. I could give up and settle for what the system had to offer us or I could let go, regroup and create the birth we wanted for our daughter within the system.
As the weeks disappeared, and our due date rapidly approached, a medically necessary cesarean seemed unavoidable. I had heard stories of women traumatized by their birth experience, and I was determined that this would not be me no matter what obstacles we faced. We needed to be informed. We decided to research our options for creating a cesarean birth that would honor both mother and child and allow us to not stray too far from our original intention. Our midwife was very supportive and helped us sort through all of the new information. She connected us with a midwife-friendly obstetrician in our region and a facility that would allow us some latitude in our birth choices. She also encouraged us to draft a birth plan. We went online and found a white paper on family-centered cesarean birth from the International Cesarean Awareness Network. Using the paper as guidance, along with other resources, we crafted a birth plan that offered us the best chance of giving our daughter the gentlest birth possible given the circumstances.
Version one of the birth plan sounded something like this: “I really wanted a home birth and I am only here because the system says this is where I need to be but there is a chance she will flip once we arrive at the hospital, and if that is the case, I want to leave so we can birth our daughter naturally in our home.” Version one also outlined a plan for a vaginal hospital birth and included a smaller section for a non-emergency cesarean due to the breech presentation. I was still struggling to let go. I didn’t fully identify with women who choose cesarean or even hospital births but I also had to let go of identifying myself as someone who was having a home birth. I felt very alone. I saw these sides and I didn’t belong to either.
A few days after we drafted version one, and after a few more days of processing, I was ready to revise the plan and mostly let go of the hope we would have a vaginal home birth. As I began to accept the cesarean, I was able to see more clearly what was possible. Our requests became more specific and I was able to differentiate which pieces I could and could not create. It began to feel I could still have most of what I wanted for our baby: gentle hands to welcome her into the world, being surrounded by loved ones, never leaving our side, nursing soon after delivery, no shots or pokes or vaccines, not even a bath. It was all possible if we used our imagination. I, on the other hand, would be undergoing major surgery. I was worried a bit but I was a mother now and mothers do whatever they need to in order to ensure the health and well-being of their child. I was healthy and fortunate to have lots of support. I would be fine.
Our next step was to discuss our plan with the birth team. My husband called the obstetrician, anesthesiologist, and charge nurse. With each conversation we carefully reviewed the details of our plan, learned more about what to expect from the upcoming process and made compromises as needed. Success! We had a green light for those items most important to us. In addition to the father being in the operating room we were granted permission to have our midwife present. I was to be administered an epidural, but requested not to have additional antibiotics or pain medications. I wanted to be awake and coherent so I could fully experience the birth of my baby. We were allowed to take pictures and video, my arms were not to be tied down, and we asked that extraneous conversation be limited during the birth. Initially, we also asked to have the lights lowered at the time of birth so the environment would feel a little warmer and less shocking for our new baby. But in the end we let this go when it seemed their version of dim was not much different from regular lighting. We had also hoped that our baby might be delivered onto my chest and even begin nursing while the sutures were being placed, but with the surgical drape and the protocols for keeping the environment clean and sterile this was not possible.
Picking a date for the cesarean birth was a bit surreal. How do you choose a date for your baby to arrive when you want to honor the natural process? From our research we knew that contractions, and subsequent labor, induced a release of stress hormones in mother and baby. This was seen as beneficial to the new baby as an early survival technique and impetus into the external world. It was our hope that the little one would experience some of the benefits of those contractions. After conferring with our midwife, our obstetrician was amenable to a 42 week gestation. Knowing we couldn’t go too much past 42 weeks helped us to narrow the window and we selected a date, July ninth. Although I never went into labor, the last week was full of gentle contractions.
On the day we went to the hospital my contractions were more frequent and more intense. Our daughter seemed to be letting us know she was ready. I don’t remember much about the actual drive to the hospital. We arranged for my mother to stay at a nearby hotel and we prepared food for her to bring to us for each meal. The three of us arrived at the hospital and completed the necessary paperwork. Shortly after they showed me to the pre-op room, our midwife arrived. Our delivery team came to our room and we reviewed the birth plan one last time to ensure all voices had been heard. The stage was set and our little one was about to make her big debut.
As I lay in the operating room, life simplified for a moment. My husband and I had been on a rollercoaster for the past eight weeks. Now our only job was to welcome our daughter into the world. Time had been our friend, allowing us to lay the groundwork for the type of birth we both wanted when our original plans were no longer an option. All of my awareness was focused on being present; I didn’t want to miss a moment of this life-changing event. I was nervous, excited and deeply grateful for the support of my husband. He would be the one to first touch and hold our baby. He would be our advocate if necessary. I needed him to be where I couldn’t. I trusted him to take care of us as we navigated this new territory.
As the obstetrician gently guided our baby into the world, the anesthesiologist held my head up so that I could watch her little red bottom emerge from me. Once our baby’s head was out the doctor quickly unwrapped the umbilical cord from around her neck and body and gently held her upside down for the natural removal of mucus from her air passages. (Typically, this piece is done with suctioning.) Within moments there was a tiny cry followed by several more substantial cries. She was here, she was healthy and we were all happy. The cord pulsed while the proud papa held our baby and the Apgar scores were assessed. The nurse brought warm blankets and a hat. My husband cut the cord once it stopped pulsing and carried our baby to me and placed her next to my face. She gently suckled on our fingers and on my husband’s nose while the doctor stitched me up. She was so at peace in our arms, patiently waiting to nurse. Our midwife took beautiful pictures and video of our first moments as a family. Forty minutes later we were in our hospital room and our daughter was latched to my breast. The charge nurse for the neonatal nursery said to our midwife, “You know, there really isn’t any reason why all cesarean births couldn’t be like this one.” Hearing this made us feel something even larger could come from our daughter’s birth.
We stayed at the hospital for two days. As part of our birth plan we also drafted a section on infant care. We requested our baby never leave our side and, that all routine exams be delayed until after we had time to bond with our child; we did not give permission to bathe her, use eye ointments, vaccinations or injections of any kind; and we informed them that our baby was only to receive breast milk and no formula. We brought a small lamp from home so our room could remain dimly lit and my mother brought us nutritious food for each meal. We asked for our privacy and did not consent to examinations that had more to do with hospital policy than with our health. The staff was very accommodating even when it seemed we had taken them out of their comfort zone.
I am filled with gratitude when I recall our amazing journey and everything it took to bring our daughter into this world. I will never forget the intention and care provided by everyone involved. I thank our midwife for supporting us and the vision we held for our birth through lots of change and uncertainty. Having been through this experience I strongly believe that every parent should have access to resources that empower them to create the type of birth they want for themselves and their child no matter what circumstances. I believe that those who facilitate birth —midwives, physicians, nurses —play a critical role in making this happen by cultivating trust and meaningful working relationships with one another at every level. At 34 weeks we didn’t have time to change the system for our birth. We didn’t have time to advocate that every obstetrician and midwife have training in delivering breech babies vaginally. What we did have time to do was to work with our team to create the most beautiful experience possible for our family.