Episode 39 - Maternal assisted caesarean section
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host,
Mel:
[0:03] Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD. And each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey. All right. Welcome today, everybody. You are here at the Great Birth Rebellion. And Natalie Elphinstone is here with me today because we're going to talk about maternal assisted cesarean sections. And I was desperately clawing at trying to find information about this because I've heard of it, but I didn't know any of the research. And so I turned to Google to see if there was anything more that I could find outside of the academic world. And your name came up in a magazine article and I was like, oh, I know, I know how to find her.
Natalie:
[0:55] I think my poor secretary was like, there's somebody on the phone who wants to have you on a podcast? And she didn't know what to do with that. I know.
Mel:
[1:04] She's like, what? I'm like, I'm trying to prepare this podcast and I need her.
Mel:
[1:09] So here you are. Thank you so much for giving me your time.
Natalie:
[1:13] You're very welcome. Yeah, here I am. I don't know that I can replace Bea, but I'll certainly chime in on some information about maternal assisted cesarean.
Mel:
[1:20] Thank you. No one can replace Bea. She's irreplaceable.
Natalie:
[1:23] Yeah.
Mel:
[1:24] Well, can you introduce yourself to our listeners?
Natalie:
[1:29] Yeah. Well, you know, my official title, of course, is Dr. Natalie Alpenstone, but I very rarely would ever go by that. My patients call me Natalie. I am an obstetrician and gynecologist, although not currently doing gynecology because obstetrics is more of my passion. And I work privately and publicly on the Mornington Peninsula down in Victoria.
Mel:
[1:52] Beautiful. Yeah, here in Australia. that's right yeah beautiful and yeah the reason why I wanted you on as I said is that actually when I reached out to you you were like oh my gosh I listened to your podcast and I thought what why who
Natalie:
[2:09] Doesn't know about the great birth rebellion.
Mel:
[2:11] I don't know who doesn't know I just sit here in my little office here with my microphone and be on zoom you know in my very best hoodie, uh, recording content. And then apparently we're going all right.
Natalie:
[2:26] Yeah. I think you're doing all right. Look at the guests that you've had on. Oh my gosh. Now I'm a guest on here. Oh my gosh. It's true.
Mel:
[2:33] It's true. Now you're a guest. And so I have a question. Why would an obstetrician listen to the great birth rebellion?
Natalie:
[2:44] Yeah. I listen to the Great Birth Rebellion because I feel like I'm on a personal journey to be part of the Great Birth Rebellion myself. And I know that that's perhaps a strange thing to say as an obstetrician because of, you know, the general understanding is that we are very much the system that you're trying to actually rebel against. But I think the whole point is you're trying to show that balanced approach, all of the different options. And I would suggest that often, say, as obstetricians, we might fail to give a balanced approach, which is a failing on us. And I think that comes from a lot of reasons. I think for a start, we actually ourselves are so indoctrinated to the system that we don't actually understand that we're not giving a balanced approach. So yeah, so anyway, that is the journey that I'm on, is trying to understand myself a more balanced approach.
Natalie:
[3:42] And so podcasts like The Great Birth Rebellion help me to do that as well.
Mel:
[3:47] Yeah. And I think all maternity care providers have been somehow indoctrinated into a system that tells us how to do things. And a lot of our care is expected to be culture-based, based on where you are and based on what everybody else is doing, rather than evidence-based or what the woman actually wants. So I think every maternity care provider is on an unlearning journey to undo the things that we've been indoctrinated about so that we can provide care that's woman-centered and evidence-based and culture-based. So good on you for identifying it because I think a lot of clinicians don't realize what they're in and they really genuinely believe they're doing the exact right thing because that's what everybody else is doing and that's what the system tells them to do. So I think it's unique to be able to see that where, you know, the context that we're sitting in.
Natalie:
[4:43] Oh, for sure. I think it's always a point to be made when, for example, there is, say, an anti-obstetric voice out there that I'm sitting on the other side of that, hearing that and going, my view is never to hurt a woman or harm a woman. I feel like I'm coming from this place of wanting to do the very best for her. But perhaps my indoctrinated system of belief would say that the way to get the very best for that woman is to trust in my knowledge of what I know about that disease for example or that situation and to enforce that upon her but I'm doing that because I believe that I am doing the best for her so it does take a massive step back to go but doing the very best for the woman isn't just about making her do what I think she should do. It absolutely has to be about listening to her and understanding where she's coming from and talking to her and offering her the options and then allowing her the choice to make the choice that she feels is best for her and then supporting her in that choice rather than making my choice.
Mel:
[5:55] Super challenging when their choices don't align with what choice we would make.
Natalie:
[5:59] Oh yeah, yeah, that's difficult. Yes.
Mel:
[6:02] Yeah, but it really takes self-reflection to go, right, that's not what I would have chosen, but I can understand why she's chosen that, so that's what we're going to do.
Natalie:
[6:13] Yeah.
Mel:
[6:14] Yeah.
Natalie:
[6:15] And then we learn from that because when, you know, everything that I've ever seen in my experience, for example, has suggested that we do, you know, X treatment, for example, and then she chooses something else and it still turns out okay. And I go, well, oh, well, I've just never seen that before. But, hey, it turns out that that is a viable option for people. So now let me be able to offer that in the future.
Mel:
[6:43] Yeah, and feel a bit more comfortable with it this time. Yes. Amazing. Thanks for sharing that because I realised there will be some listeners out there who are questioning the decision to have an obstetrician on the Great Birth Rebellion, but I think we're all sisters in the rebellion. It doesn't matter what our role in the maternity care is.
Natalie:
[7:01] And that's it. At the end of the day, like it or not, obstetricians are part of maternity care and we do still need them. It's undeniable that not every pregnancy and birth will go as easy, if you want to use that word, as it should, and we will still need obstetricians. And so we actually need to be on the same page. The whole point, I think, is that we need to all be on the same page in terms of, yeah, wanting the best for the woman, respecting each other's, you know, say belief systems or experience, et cetera. So that means us as obstetricians, understanding the value of midwives, but vice versa, other healthcare workers, doulas, support people, the whole spectrum around that woman and actually working together as a team. And we can only do that if we do understand where each other's boundaries and expertise, you know, should be. The problem, of course, is that the way that the system currently works is that, you know, obstetricians are thought to be at the top of this hierarchy and that filters down into areas where we're not actually the most experienced person. And so we, I feel like we need to take a step back as obstetricians, but yeah, come together. So it is about understanding each other.
Mel:
[8:18] Yeah, yeah. And like you said, that, you know, I think what you're trying to describe is that in a lot of systems it's assumed that an obstetrician or doctor should be involved in every single woman's birth, whereas, you know, the realm of normal is not necessarily you would insert an obstetrician or a doctor.
Natalie:
[8:41] Yeah, that's right. You know, we've obviously come to this place now where we have these growing rates of cesareans and inductions and medical interventions. But like, how can that possibly be true about our population? How can it possibly be true that, you know, 34% of women require a cesarean in order to give birth and therefore need to have an obstetrician? We have to get back to the understanding that, you know, whatever that statistic might be, the vast majority of women, if they're left alone, they will be fine without an obstetrician.
Mel:
[9:16] Yes. And usually without a midwife, you know, I mean, I'm a home birth midwife, so we are on completely two ends of the spectrum. And, you know, and I even tell my clients, you know, if everything is going beautifully, even I'm superfluous in that space. And I'm just there to identify anything that's unusual, that's deviating from the path of physiology, do what we can to help correct it, and then refer you on to somebody else if what we can do is not working.
Natalie:
[9:51] Yeah.
Mel:
[9:52] Most of the time, I don't do a whole lot except for provide reassurance and reminding everybody in the room that this is normal.
Natalie:
[10:00] It's okay.
Mel:
[10:00] We're just going to keep going.
Natalie:
[10:02] Yeah.
Mel:
[10:02] Yeah. So let's dive into maternal assisted cesarean section. So we were speaking before I started recording about how, you know, I do, I love to research. I like to find all the papers and find out what they all say. And when I searched for maternal assisted cesarean section in the academic databases, you know, the dark hole of the academic databases, there only came up one paper and it was written in 2021. And it wasn't even really a paper. It was kind of a, it was introducing the idea of maternal assisted cesarean section and they just kind of described it. So I thought it would be helpful for me to describe it to our listeners, just so you all know what we mean when we're talking about maternal-assisted cesarean sections.
Mel:
[10:50] So I'll kind of read it word for word. It was only very short, and I'm sure it was actually a conference presentation, actually, by the look of it. So it says, maternal-assisted cesarean sections allow the mother to aid the obstetrician in physically delivering the baby from the uterus and with a spinal block. So if you heard the episodes that we did in the last few weeks, you'll know about the different anesthetic options for cesarean section. So maternal-assisted cesarean sections are done for women who actually have use of their arms and who are awake. And they actually assist the obstetrician to physically bring the baby up out of their uterus. So in this paper, it says, we describe a case of maternal assisted cesarean section under spinal anesthesia and the standard operating procedure developed to achieve sterility, safety and optimize multidisciplinary teamwork.
Mel:
[11:48] So the case is a 30-year-old woman having her first baby. She presented at 39 weeks for an elective cesarean section after two traumatic vaginal births. So they're giving us a bit of context as to why she's elected for cesarean section. So before the cesarean section, the anesthetic and obstetric teams met with the woman and partner to discuss their expectations, consent for the increased risk and logistics of the procedure, and the standard operating procedure was created to optimize teamwork, ensure sterility and safety was maintained for the woman and the baby.
Mel:
[12:26] The standard operating procedure was reviewed by the whole team who was going to be there in the theatre on the day. Additional theatre time was planned to allow for the case and simulations before the patient arrived were done. It was imperative that the woman underwent full surgical scrubbing to maintain sterility until delivery of the placenta. So two anaesthetists were required to ensure this, one to remain scrubbed with the patient and the other to perform the spinal and manage infusions and drugs. The patient was cannulated in the antecubital fossa to allow for scrubbing. So that's up closer to her elbow rather than her hand to allow for. So scrubbing for anybody who's not in the medical world is the process that surgical staff use to sterilize their hands and arms before putting on sterile gloves before surgery. So it's kind of the idea of trying to reduce bacterial and viral counts to prevent infection.
Mel:
[13:28] So the patient was cannulated knowing that she would be scrubbed in. So after the spinal anesthetic, the patient was positioned. The top gloves were removed, so they must have double-gloved her, were removed and replaced by long surgical gloves, which would have, I imagine, gone all the way to her elbows. The surgical drapes were dropped in front of the woman. So again, if you heard the previous episode, we talked about that drape that goes in front of the woman so she can't see the procedure. So the surgical drapes were dropped and the patient sat up before the uterine incision the patient's arms were placed over the drape and guided by the obstetrician to deliver the baby once the head and shoulders were already delivered the baby was pulled directly up onto the mother's chest supported by a scrubbed in midwife so the midwife was also wearing sterile gloves and did the whole scrubbing procedure and once the patient had delivered the placenta the drape was reinstated put back up and the sterol gown was cut to allow skin to skin and the patient stated it was the best birthing experience ever.
Mel:
[14:36] That is all that is written in the academic research about maternal assisted cesarean section and we can see there that the woman had a willing team, an anesthetic team and midwife who was invested in actually creating a standard operating procedure to directly serve her needs.
Mel:
[14:59] So then I was curious about what other hospitals were doing. So that was not in Australia, that was in the UK. And so when I had a look at what's happening here in Australia, the only real thing that I came across was a information sheet put out by the Government of Western Australia Health Service, so the Western Australia Country Health Service, and it's effective from the 23rd of August 2021.
Mel:
[15:28] And it says that across all Western health sectors, there's been an increase in the number of requests for maternal assisted cesarean sections. And then they said Western Australia Community Health Service does not, in bold, support this and recommends an alternative approach. Then they stated some evidence, which they don't have a reference for, so I can't tell you where their evidence is from, but it says, while evidence does not appear to suggest that maternal-assisted cesarean sections increase the rate of infectional bleeding, these studies are small, retrospective, and have only been carried out in larger hospitals. So as I was saying to you before, Natalie, I'm pretty sure that they've confused the terms maternal assisted caesarean section with some other literature about gentle caesareans or what some people call natural caesarean. So that's a totally different thing, but there is actually no research. So this particular information sheet, although it hasn't provided any references, it's made some claims that maternal assisted caesarean sections don't increase the rate of infection or bleeding, but we don't actually know that. So basically they've said, yeah, no, we're not doing it until we know a little bit more. And that's the end of what's available for clinicians as they start to consider how to offer or provide maternal assisted cesarean sections.
Natalie:
[16:54] Yeah.
Mel:
[16:54] So I wondered, have you found anything more?
Natalie:
[16:59] No. Every time I've tried to do a search for that as well, because obviously it'd be really good if I could actually find some evidence that was strong enough to prove or to say that there's no increase in harm to women. Because that's clearly important that we need to make sure that any perhaps new procedure is not doing harm, but I can't find it. And I can imagine that it will be really difficult to be able to generate that kind of research just in terms of, needing the amount of numbers of cases to be statistically significant to be able to prove an outcome one way or another. I think at the end of the day, the problem is, of course, we've just stopped, like they've just stopped there and said, we don't think there's any harm. But we're not going to do it. And okay, that's a good first step. But how about then that whole next step of, but we want to do good. Can we do good? Can we do better for women? And I think we can do better. I think that for some women, a maternal assisted seizure is better for them than what our standard approach would be. And so if we're going to say, we can't see that it's going to do harm and we do believe it's going to do good, why wouldn't we do it?
Mel:
[18:24] And as they described all of those scrubbing procedures and the sterility that they maintained for the woman, you know, theoretically, everybody else has scrubbed in in the same way as she has. Yes. Theoretically, it's not going to increase infection if those procedures are followed.
Natalie:
[18:45] Yes, that's what I would like to believe. That's what I would like to quote or do quote to people as well, because there's nothing that the woman is doing any different to what I'm doing as the operating obstetrician. So therefore, it shouldn't make any difference to things like infection rates at the very least.
Mel:
[19:05] Yeah, and I feel like this really plays into the current discourse today is that medical professionals are the experts and then women couldn't possibly
Mel:
[19:19] fill any of the expertise that's required for having a baby. And so we need to trust the experts and do what they say because they've got the skill, they've got the technology, they've got all the apparatus to keep this safe. So I feel like, and then all of a sudden when you scrub a woman in and give her the sterile gloves instead of a midwife or a scrub nurse or an anaesthetist, we go, oh no, maybe that could increase infection. Maybe that could increase bleeding. and it's like, hey, hang on, you've got just another pair of hands in sterile gloves. And I feel like this really allows for the blurring of the lines between that that expectation that we sit here as medical professionals in some kind of increased level of expertise over the woman. So I really, I love that it flies in the face of that and that the questions that we're asking based on that belief that the woman couldn't possibly have any skill or expertise and therefore will likely increase the risk of infection or a complication by being old.
Natalie:
[20:25] And I think that's especially true when you then start talking about birth in an operating theatre because we're obviously much happier to say blur those lines when we're talking about a physiological vaginal birth where clearly we trust in the woman to be able to have that power and expertise as if you want to call it that to birth vaginally but when you then go into an operating theatre there's a whole nother realm of rules if you like that come into place the minute you step forth into an operating theatre. And I literally mean even to step forth into an operating theatre, there's a whole bunch of rules that you have to know and have to follow, which are there to try to maintain safety.
Natalie:
[21:11] And so the minute you then talk about an untrained woman, if you like, and her giving birth in the operating theatre, this is very unfamiliar territory to anybody who is working in theatre. You know, when I brought the idea of doing maternal assisted caesareans to powers that be, if you like, in my hospital, it was definitely the surgical people that had the biggest problem trying to comprehend this, because it just was difficult to comprehend how, you know, the patient, if you like, who, when we're doing an operation, a standard operation, A, you know, they're typically asleep, so B, they have zero power in that situation.
Natalie:
[21:57] And here we are talking about still doing an operation, a surgery.
Natalie:
[22:02] But giving the patient herself all of this power to sort of help with it. And that's where they're just like, but, and the jokes that I get are like, are you going to give her the scalpel and is she going to do it herself? Is she, you know, if you teach her to do this, you'll be out of a job because I can just do it at home. And, you know, these are clearly jokes, but, like, really?
Mel:
[22:26] I know. They start to make fun of the idea that a woman could have some autonomy in this space. And, you know, I mean, even as like I trained as a nurse first, that was our very first lesson is how to maintain sterility, scrubbing into things. You know, it's not that difficult. You know, you follow the steps, you understand the idea of contamination and sterility and boom, you've nailed that skill. So, and I love having that example on the case study. They actually, they talked through every little step of how they maintain sterility, the double gloving, the scrubbing the woman in the extra anesthetist, all of this for this woman who then after two previous traumatic vaginal births described this as the best birth experience ever. Yeah.
Mel:
[23:18] And so could you talk me through what was your journey towards maternal assisted cesarean section?
Natalie:
[23:26] How we got there? I think it, this is not mind-blowing, how I got there was to start listening to women. And as that paper pointed out, getting increasing requests to do something like this from the women themselves. So the very first time I had this request from a patient, I sat up and listened to it and it had never been done at my hospital. I had never done it. I'd never even seen it before, not in real life. I'd seen it on social media like a lot of us have seen it on social media. And so when she asked me about whether or not she could potentially have this for her upcoming planned caesarean, it would have been a very easy answer just to say to her, like, no, we can't do that because it's never been done before and I've never done it before and our hospital doesn't do it. So no, we can't do that. But it dawned on me that I possibly could make this happen if I put some effort into it, because that's another thing, right? Like it did require work and effort on my behalf because it hadn't been done at the hospital before. And we like to have a bunch of rules around stuff in hospitals. So it needed to have, like when we start a new procedure, if we're going to introduce a new procedure, and this was sort of classified as a new procedure, even though, of course, cesareans have been done for many, many, many, many, many.
Natalie:
[24:55] Decades and centuries, that we need to have a written policy and written procedure.
Natalie:
[25:03] Of what all of those steps are going to be. And it is important that we do that just in terms of needing to remember that it is, of course, a surgical operation. So it is important that we maintain sterility, et cetera. So it was about finding these ways of how we're going to achieve that. So it required me in the next step to do things like write a procedure. And then I had to present that sort of procedure to get approval from, say, the powers that be. So there was a couple of committee meetings that I needed to go and present this new idea to them to let it be passed at the sort of board level, if you like. And then that was...
Mel:
[25:39] Had you found any other procedures that somebody else had written?
Natalie:
[25:44] Yeah, yes. There are, so this, for me, this journey started in 2020 and other hospitals certainly have performed maternal assisted caesareans before. In fact, the first maternal assisted caesarean in Australia that we can sort of put evidence on, if you like, was performed as early as 2005.
Natalie:
[26:05] So it's actually been around in Australia for probably a lot longer than what people would actually understand. It tends to of course be done at say private hospitals in you know set circumstances and it's therefore not sort of a widely known or widely done variation but there are there were already written policies from other hospitals so it was actually that part of it was fairly easy actually it was just to adjust that to our environment and and the tweaks that I thought we could make for our hospital. So that side of it was relatively easily passed. Really, it was the idea of it where people were struggling to comprehend why we would want to do this. Like, why change something that works perfectly well in the eyes of the medical professionals? You know, we've had a fairly set standard procedure for doing a cesarean for however long. And as far as we can see, there's no flaws in that. So why would we want to change that and introduce this whole new variable that might create harm? And that's where that was more challenging to try to communicate why women might find this really important.
Mel:
[27:20] So this client who motivated you to start this journey... Did she give some insight as to why she wanted a maternal assisted cesarean section to sort of answer that question of, you know, why would we do this? Because obviously not all women will want to be involved in their cesarean section, but why would women want it? Yeah.
Natalie:
[27:42] And that's obviously really variable for different women. I think it ranges anything from wanting that feeling of a bit more control over the situation. I think very traditionally, of course, the way that we think of caesareans or the way that they're traditionally performed is that whilst the woman might be awake, she's still very much sort of this inanimate object in the whole experience. She lies there, the curtain's up, she can't see anything. We, you know, we perform this operation. It just so happens that a baby comes out of her. We might show it to her if we're lucky. We probably, though, just give it over to the pediatricians or the midwives and they do their thing and it then might come back to her at the end all bundled up and ready to present to her. But, you know, is that birth? I mean, it's absolutely birth. It's, you know, her baby being born. But in terms of the way we would usually think of birth, it is very much, of course, woman centered. It's women in her power. It's women achieving this spectacular event that's full of love and joy and triumph and all of those sorts of emotions.
Natalie:
[28:52] And certainly that's what we expect and anticipate at a vaginal birth. And in fact, that's the magic of it, right? But then at a cesarean, the way we traditionally do it is, yeah, she just lies there and we cut this baby out of her. So one thing is about women bringing back some of their own sense of control in this situation and their own sense of participating.
Natalie:
[29:12] And so I think it's about trying to achieve some of those things that we might value at a vaginal birth where she's able to still have this powerful moment of bringing this baby out of her body and being able to hold it, feel it.
Natalie:
[29:31] It strikes me mind-boggling that so often when I do these maternal-assisted cesareans for women who've had perhaps previous cesareans before, that often they respond by going, oh, the baby's warm or the baby's wet. These are the words that come out of their mouth. And I go, of course the baby's warm and the baby's wet. It's just come out of your body, but that hasn't been their experience before, which is a crazy thought. So, yeah, so I think it's important because we're now starting to be able to achieve some of those things that we would achieve at a vaginal birth, at a cesarean birth. It is not a replacement for vaginal birth. I never want this to become an idea that a maternal assisted cesarean is the perfect birth and that that becomes a selling point, if you like, for choosing a cesarean. If you feel like a caesarean birth or the circumstances suggest that a caesarean birth would be a better option for you than a vaginal birth, then possibly a maternal assisted caesarean might be another better choice for
Natalie:
[30:39] you over a traditional caesarean, if you like. But let's never confuse the idea that a maternal assisted caesarean is the gold standard of birth.
Mel:
[30:48] It's...
Mel:
[30:50] And you make a point to, you know, these maternal assisted caesarean sections are really only reserved for these elective pre-planned, no it's going to happen kind of caesarean sections.
Natalie:
[31:03] Yeah, at the moment, certainly a policy that I helped write includes this as part of the criteria. And it included that from the perspective of needing to make sure that we do have enough time in advance to be able to prepare the woman both, you know, say emotionally or knowledge based and whatnot before the day. So to be able to discuss with her about what it's going to look like to be able to do the surgical scrub and how she's going to have to hold her hands and how she can't break sterility, all of these sorts of rules need a bit of pre-preparation beforehand. It does then need extra time and preparation on the day as well to be able to do things like that surgical scrub and have the extra sterile gowns and gloves and drapes and all of the rest of it.
Natalie:
[31:52] Perhaps extra time in theatre perhaps extra staff in theatre all of those things that need to be arranged it certainly needs to have a supportive team in theatre as well it's not just about what the woman and myself as the obstetrician have decided is okay it needs to be supported by the anaesthetist and the rest of the theatre staff and the pediatrician or whoever else might happen to be in theatre as well so all of that just needs extra time and so that's more difficult to obviously do on the fly and perhaps, of course, is not the best option if this was, say, a true emergency caesarean where time is of the essence. So at the moment, our policy talks about it only being sort of available in a planned elective caesarean that's been booked at least two weeks in advance.
Natalie:
[32:41] I would like to see it changed in the future, though, to be able to be offered in the non-emergency unplanned area. And because the more we've sort of now done it, it turns out that, you know, now that we've, for example, in my operating theatre, we've done it so many times that the vast majority of the theatre staff are now quite familiar with this. And now we're a bit more well-practised at it, that it actually doesn't take that much more time on the day and doesn't really, for us, need extra staff now or extra operating time, that hopefully we would have the ability in the future to be able to do this in a more non-urgent caesarean as well. But at the moment, these are just for planned caesareans.
Mel:
[33:24] Yeah. And what were the other criteria for kind of qualifying, I guess, to consider a maternal assisted cesarean section in your policy?
Natalie:
[33:34] Yeah, well, interestingly enough, that's sort of all I really sort of ever wrote down, which has been good because it's allowed me a little bit more leeway. For example, you know, the patients that have maybe a more complicated pregnancy, if you like for example I've now done maternal assisted cesarean at a twin pregnancy before I've had requests for it at a breech presentation cesarean I've done one I don't even know if I should say this but I have done one at a placenta previa I.
Mel:
[34:09] Was gonna ask that's what that was I was gonna ask about because I know that some elective cesarean sections are still really time sensitive like previa ones. So, and I guess that's where your individual expertise would come in to know which ones are absolutely time sensitive and which have got a little bit of wriggle room.
Natalie:
[34:30] Yeah, that's right. Certainly, the reason I hesitated to say that is because I certainly would not suggest that it would be standard to be able to offer a maternal assistance cesarean at a placenta a previous situation because that, depending on the circumstances, can be very time-critical in terms of safety for mum. And certainly when I did this with this woman, we'd had very many conversations in preparation that we might be able to plan for this in her circumstances, but I wouldn't be able to know if it was safe to continue with it until we literally started the incision on the uterus. If she was about to start hemorrhaging, then it wouldn't be a safe idea to continue with the more, it does still take more time for the woman herself to be able to lift the baby out, et cetera. And that. Wouldn't necessarily be a very good idea if she's currently losing, you know, half a litre of blood a minute, which is what can happen in a placenta previa operation.
Natalie:
[35:36] So we were very much on the edge of, I might start this and have to say, no, we can't, can't do it. But in that circumstance, the placenta wasn't thought to be in the way of the surgical incision And the risk of hemorrhage then mainly comes with the delivery of the placenta. So as far as I was thinking in my mind, it shouldn't necessarily stop her from having that extra time of being able to help birth the baby.
Natalie:
[36:06] And that's what we were able to do. But yeah.
Mel:
[36:09] That's amazing. And feel free to say no, but there is an assembly of rebellious midwives coming up, which is the online community that goes with this podcast. It's launching in July and in there's going to be a whole lot more information for people more than we can offer them on the podcast I wondered if you could supply your policy that you wrote and and operating procedure for others who would love to kind of motivate obstetricians in their hospitals to maybe make some steps and to show them actually this has been done before here's the papers yeah feel free to say no I don't know if that's involved like there's some kind of confidentiality around those but oh
Natalie:
[36:48] Well certainly I am very happy to.
Mel:
[36:51] Help women
Natalie:
[36:53] Or health care professionals wherever possible to be able to share my experience of how we've been doing it I don't think that this sort of stuff should be a secret we should be able to share our medical knowledge wherever possible to help be able to inform and educate and and help to achieve this And I've been really privileged to be in this situation where I often have contact from women around the world and healthcare professionals around the world who, you know, reach out to me. And I've been able to help lots of people around the world to be able to achieve it for the first time in their hospitals. And that's a really amazing, just what a privilege, right? To be able to share our knowledge and help empower other people.
Mel:
[37:36] Yeah, so cool. So I interrupted you with a question at the point where you'd written the policy and you'd brought it to the powers that be in your hospital, management, whoever they are. And then what happened next when you presented this idea and this operating figure?
Natalie:
[37:52] I was laughed at. I was ridiculed. I was... Threatened is a strong word, but I was certainly suggested that I was going to cause harm to women. I had to face that sort of criticism, but ultimately it was passed by the majority of people in this hospital. So this was talking about in my private hospital where I work, where currently I'm trying to achieve the same thing in my public hospital, but facing those same sorts of criticisms and pushback and haven't been able to achieve it yet at my public hospital. But I was at my private hospital. And so it passed and then it came time to do it for the very first time. And, you know, the pressure was on, right? I knew that in particular for this first one, it needed to go as straightforward as it could possibly be because certainly I was thinking, you know, if there's some kind of hiccup here, if there's some kind of problem or complication, then that's going to be it. I'm never going to be able to do it again. But luckily, with all of, and I say luckily, but there was a lot of planning and preparation and similar to what that paper talked about. You know, we did simulations with the women. And I made sure that all of the theatre were on board with what it was going to look like and where everybody was going to stand and what they were going to do and what we needed and all of this sort of stuff. And we did it for the very first time and it could not have gone smoother. It was amazing.
Natalie:
[39:20] And it was in that moment where it happened and the theatre staff were able to see the, the emotions on the woman's face and what, you know, what she did, et cetera. And suddenly they kind of went, oh, now I understand. Look at that. I even had, you know, my scrub nurse. So the, you know, the person that's handing me the surgical instruments for that, for that first case was a well-experienced scrub nurse who's been in that role for, I mean, I don't want to guess her age, but let's say 40 years of doing this role. And she came up to me afterwards and she said, you know, I've been doing this for a really long time. To be honest, my view of cesareans was no different from any other operation that we ever did. You know, it's cold and it's sterile and whatever. But that just reinstated my belief in birth, she said. And you can see the video, I posted this very first video, she cried in it. She actually, you can see her like clapping her hands in the background excitedly when this happened. And so if that's affecting the other people in the room, imagine what it's achieving for the woman and her partner and her family and yeah, it's powerful.
Mel:
[40:41] And you know, it allows the opportunity for oxytocin to enter the birth story again.
Natalie:
[40:48] Yes.
Mel:
[40:48] Because often in a cesarean section, women miss out on that incredible oxytocin opportunity because there's nothing to facilitate it yes and so this almost gives an opportunity to fill that gap that cesarean leaves and yeah you know give some semblance of what you feel when your baby comes out and how meaningful and important that is for long-term bonding and for breeding yes the strength of the family and so you know you ask the question of why not why wouldn't we pursue this as the new standard as the new normal with obviously the option to kind of go oh actually in a really big hurry and and unfortunately we're going to have to just go as fast as we possibly can you know there's Yeah, it sounds like there's a massive gap in the research. And this is the one time where I'm excited that we can sometimes introduce things into care that have no research whatsoever. There's so many things that we've introduced that we've since realized, oh, we really prematurely introduced that strategy and now we can't let it go. So this is a success story of that tradition in medicine of just kind of, yeah, let's do it without much really good research.
Natalie:
[42:07] Yes.
Mel:
[42:09] Yeah, that's so amazing.
Natalie:
[42:11] And what I think is important too is, you know, so if we're going to talk about what's the importance of doing this maternal assisted cesarean, and yeah, we can absolutely talk about the importance of it psychologically, but, you know, a lot of the medical professionals do want, say, hard medical facts, but we have that ability to, you know, there are very firm guidelines in place to talk about immediate skin-to-skin contact and delayed cord clamping, for example. Those are two things that the WHO, the NICE guidelines, the Australian guidelines, the UK guidelines, like every guideline now talks about the importance of skin-to-skin contact and delayed cord clamping for good medical reasons as well as good psychological reasons. And when they talk about, say, skin-to-skin contact or delayed cord clamping, there's never any proviso that says we should only do that at a vaginal birth. It doesn't have that criteria. So if we're going to achieve those sorts of things at a cesarean birth, how are we going to achieve those things? Well, this is one way. This is one way that we can achieve that immediate skin-to-skin and delayed cord clamping in a fairly straightforward way. So there's some medical research behind it as to why this might also be important from those perspectives as well.
Mel:
[43:33] Yeah, good point. And it does offer the opportunity for a complete package of maternal autonomy and involvement. And then immediate skin to skin and then delayed cord clamping.
Natalie:
[43:44] Yeah.
Mel:
[43:45] I'm really excited about this because I just feel like it's a result of having listened to the needs of women and understanding the impact of cesarean section on a woman's parenting journey and trauma. And so, yeah, I think, just why not?
Natalie:
[44:07] And that's the question. Yeah, why not? Why not? I think when women come to me saying, I want to approach my healthcare provider with the request for a maternal assisted cesarean, what information should I give them? And I say, you know what, probably a lot of you are going to be met with an answer that says, no, we can't do a maternal assisted cesarean. And then I suggest to them that if that is the answer that you're given, then what I want you to ask is why not? And just, you know, just ask it gently, just ask it respectfully, not demanding my rights kind of situation, because that usually will only make people defensive and they might push back and say, because of all of the problems with we don't have a policy and whatnot. But if we're having a respectful conversation with your healthcare provider and they say, no, we can't do that, then ask why not? Because perhaps the answer is because we don't have a policy about it, et cetera. So then ask them, can we write a policy? What's the hurdle there?
Natalie:
[45:15] Maybe actually their no answer is because they don't understand why it's important to you. So then talk to them about why you think that this would be really important for whatever reason that might be. Maybe their no answer is because they know it will take effort on their behalf to change. Like it takes effort on my behalf, if you like, to change the way that I'm used to doing things. And we all know we're not perhaps really good with change. So an easy answer is to say no, because I don't want to have to change what I'm doing as the healthcare provider. So maybe, you know, look at that. And maybe the answer is no, because in your particular situation, it might not be a safe idea, for example. So there might be, say, legitimate medical concerns why it might not be good in your situation. And so you can explore that as well to see if there is a way around that situation as well. But it's just about having conversations. Yeah.
Mel:
[46:15] And I think there needs to be a champion who firstly has the time to commit and the passion to make it happen. And for any other rebellious obstetricians out there or anybody with any clout or authority in the hospital, this process could be started before women actually are requesting it and have a policy just sitting there. And rather than having to respond to somebody at the last minute of trying to scramble together a policy and a standard operating procedure. And do you think it's unrealistic? Like I don't want to give women this unattainable goal of, hey, if you need to have an elective cesarean, let's make a maternal assisted one. I can see a lot of barriers that, you know, if you're at a public hospital, that would be a lot more challenging than if you have a private obstetrician
Mel:
[47:08] who has some autonomy over their practice and can pivot like you did.
Natalie:
[47:13] Yeah.
Mel:
[47:14] What What could women realistically expect if they're hoping to have internal assisted cesarean section in terms of pushback or like the possibility that it could be?
Natalie:
[47:25] Yeah, that's right. I think unfortunately at the moment, this is still a fairly niche situation, if you like, where it is happening or it has happened, if you like, at some public hospitals. But on the whole, my understanding is it's mainly only ever happening at private hospitals. I think it's the way of the future for public hospitals to get on board as well, but I think there's a lot more hurdles perhaps in the public system just in terms of the way the system is currently set up whereby.
Natalie:
[47:59] You know, for example, when I do theatre lists, so when I'm operating in the public system, I'm typically only meeting those women on the day of the surgery, so I don't have any sort of preformed relationship with them. And so who's educating these women beforehand to go through the procedure? Who's choosing whether or not these women are perhaps the most appropriate candidates for this? So I think from a public hospital perspective, for them to put a blanket procedure in place that allows, if you like, the floodgates to open, they're a lot more hesitant to that. And there's some good reasons behind that. And there's some just resistance to change reasons behind that as well. So yeah, unfortunately just needing to be realistic that there are a lot of hurdles to overcome, especially in the public system. So if you're birthing publicly and you would like to have this happen to you, number one, just start the conversation really early and maybe and unfortunately be expecting that it might not happen in your pregnancy journey. But I would still encourage you to ask that question because the more women who are requesting it, I feel like eventually the floodgates are going to have to open just by pure pressure of consumers.
Mel:
[49:22] Yeah. And it's not dissimilar to the experience women are having at the moment trying to achieve reach vaginal birth. The more pressure we collectively put on, the more inspiration there is for people to start making change. So unfortunately, it feels like you would be in quite a privileged position to be able to navigate this journey. But like anything, I think women always experience better outcomes and clinicians are a lot more comfortable when there's relationship-based care and continuity of care, because it sounds like this really relies on you trusting the woman and the woman trusting you because you're working together to keep the whole process safe. So that's really difficult to have a trusting relationship
Mel:
[50:08] Relationship-based care with somebody you've never met yeah you know it's yeah I think it's a real hallmark of continuity of care which we know is the gold standard for outcomes yeah incredible look I feel like I've learned a lot more about maternal assisted cesarean section having chatted to you and I really appreciate your generosity and giving all this info and for those who are more interested in pursuing this path or changing things in your hospital I'll put Natalie's details in the show notes here, but also we're going to expand on this conversation in the Assembly of Rebellious
Mel:
[50:41] Midwives for those who are involved in that. You can get access to, you know, the actual steps and procedures and policies. And, you know, that really takes away blocks when we're implementing this kind of thing, because, you know, we don't have to reinvent the wheel. We're thankful for the work you did ahead of time.
Natalie:
[51:01] Well, I count it definitely as a privilege every time I get to be involved in the birth of any baby and especially kind of privileged that it feels like I've been able to make one small step to improving care for some women. And it's not the choice for everybody. I still certainly have plenty of my own women who know that I do maternal assistance. I've offered them a maternal assistance area and they still say, no, that's not the choice for them. And that's fine because that's the whole point, right? It's about offering options and for allowing each woman and her family to be able to choose what they believe is the best option for them. And then for me to support them in that choice, regardless of what it looks like.
Mel:
[51:44] Yeah. Incredible. Is there anything I haven't asked yet about maternal assisted cesarean sections that I should have asked?
Natalie:
[51:50] No, I don't think so. I think you've done really well at covering all of the key ground.
Mel:
[51:55] Amazing. Amazing. Well, thank you so much for joining us here at The Great Birth Rebellion and we will see you all, including you Natalie, in the next episode of The Great Birth Rebellion. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com and to support the work of this podcast, wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanieTheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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