I have had quite a few friends planning cesarean births here in town, likely due to the fact that our St. Mary’s does not accommodate VBAC births (it is definitely a bummer... check out my post on the overly-exaggerated risks of VBAC here).

With a planned cesarean however, the good news is you can have a lot more control over how it is done than you would in an emergency scenario. So I accumulated a comprehensive list of tips and suggestions for planning a cesarean to make it as gentle as possible. Some of this comes from Penny Simkin’s Pregnancy, Childbirth, and the Newborn - definitely a recommended read.

Before the Surgery:

Be sure you understand and agree with the reasons for the cesarean (i.e., malpresentation of the baby, or a medical problem for you or the baby).

Learn about the procedure. You can read about it in Pregnancy, Childbirth and the Newborn by Penny Simkin et al., ask your doctor about it, and/or watch a video explaining it here: https://www.youtube.com/watch?v=ax-2mRGaU3I

Learn about your anesthesia choices and how each is administered. General information is available in the book mentioned above. If possible, however, meet and discuss medications with an anesthesiologist along with any concerns you have. A spinal or an epidural are the most common types of anesthesia when a cesarean is planned in advance, but there are other possibilities. (See “Anesthesia and other medication issues" below).

Learn the layout of the operating room, particularly where the baby will be taken for initial care. Will she be in the same room or an adjacent room? Will you be able to see or hold her? Can your partner move back and forth between you and your baby? Is there a post-op room separate from your recovery room? Will your baby need to go to the special care nursery? Can it be delayed?

Discuss the possibility of waiting until you go into labor and then going to the hospital to have the cesarean. The advantage is that the timing for birth is more likely to be optimal for the baby (less risk of undeveloped lungs or unexpectedly small size). The disadvantages are that you might not know the doctor on call who will do the surgery, and that you cannot plan ahead (which is the same as with most vaginal births).

If you do not await the onset of labor, you will need to make an appointment for the surgery. Consider being the first on the day's schedule for two reasons: there is less likely to be a delay (from earlier surgeries taking longer than expected); and you will not be as hungry if you do not have to wait all day. You will probably have to avoid eating from the night before.

Ask you doctor about doing a ‘gentle cesarean,’ which would allow time after the head is born, for the baby to be pushed out slowly by contractions of the uterus without needing to pull baby out, similar to what would happen in a vaginal birth. This can help ensure that the uterus is contracting to decrease the possibility of hemorrhaging, decrease the tearing and movement around the incision during the birth, and possibly lessen nausea associated with the tugging motions of the surgery.

Ask your doctor about “seeding the baby” with mother’s microbes. The procedure allows the baby to pick up some of the mother’s important microbes (ie: beneficial bacteria that help protect the baby from harmful bacteria) which vaginally born babies get as they pass through the birth canal. While it may at first seem bizarre, you may want to read this and discuss it with your doctor. Here is how it is done:

As long as you do not have Group B strep or other disease causing microbes (ask your doctor), one to two hours before you go to the operating room, a sterile pad is unfolded and inserted in your vagina, where it will remain for at least an hour before surgery.

Then, just before the surgery begins, the gauze should be removed and placed in a sterile container.

As soon as possible after the birth, the gauze is wiped over the baby’s mouth, face, and body. In this way, your baby can get some important protective bacteria that a cesarean-born baby would otherwise miss. This link has an excellent discussion of this topic.: http://www.healthygutbugs.com/babys-microbiome-expectant-mothers- care/ 

During the surgery and repair:

Ask if at least one of your arms can be left unrestrained. Restraining may be more important for an emergency cesarean, but a planned one should allow some leeway.

Have your partner put some pleasant-scented essential oils on your face or their wrist. Lavender can be calming for anxiety, and peppermint can help with nausea. Because some staff members may be allergic to certain scents, you should ask if this is okay.

Bring your own music to listen to during the surgery. Music that is familiar and that you love is most soothing. Many operating rooms have CD players, or check whether you may use your own earbuds or bluetooth speaker.

Plan to use relaxation techniques and rhythmic slow breathing (like sighing) during the surgery.

Hold your partner’s hand.

Ask them to lower the screen when the baby is lifted from your body so that you can see the birth. Some hospitals may provide clear plastic dividers so that you can watch your baby being born, but it isn’t common unless you ask for it.

If you are brave enough, you can ask for a mirror to be placed above for you to watch the surgery as well! Or, if you’d rather not, you can ask your anaesthesiologist or a scrub nurse to ‘sportscast’ events, by letting you know which stage of the procedure you are at at all times.

Whether you are religious or not, ask if you can say a prayer at the baby’s moment of birth. This might help you get more time to leave the umbilical cord uncut, and it might help the birth overall slow down a bit so that everyone is reminded to take a moment to recognize that birth is sacred, and this birth deserves the same respect and reverence any vaginal birth would get.

Ask if they will delay clamping your baby's umbilical cord for AT LEAST one minute after birth to allow the baby's blood that is in the placenta to return to the baby. The cord and placenta at birth contain about 30% of the baby’s blood and stem cells, and allowing a little time for this to flow to the baby has many long-term health benefits for your baby.

During the repair procedure, some doctors lift your uterus out of your abdomen to inspect it and then replace it, while others believe this is unnecessary and possibly problematic. This procedure may cause greater nausea, and more severe gas pains than if the uterus is not lifted out. You might wish to discuss this with your doctor beforehand. Ask about the advantages and the disadvantages.

Be sure that you get a low, transverse incision, and one as small as possible, if you plan to allow better chances for the possibility of a vaginal birth any time in the future. Ideally the doctor will use a dissolving stitches to seal the incision that will absorb into your tissues over time, and not staples that would have to be removed later.

Ask about picture taking during the surgery or afterwards. There sometimes are policies restricting photography.

Once your baby is born, it is likely possible with a planned cesarean to have him or her placed on your chest, skin to skin. This practice is crucial to getting breastfeeding off to a good start, and the skin to skin contact helps warm your baby more effectively than an isolette, and allows him to feel your touch and smell your familiar smell. Plus it’s yummy. :)

If you don't get the baby right away, your partner may be able to bring the wrapped baby back to you for your first contact. You can nuzzle, kiss and talk to your baby. Ask if you will be able to hold her or breastfeed at least until you leave the operating room. Ideally a ‘golden hour’ is best for breastfeeding.

You and your partner might talk or sing to your baby. A familiar voice often calms the baby at this time, and seeing the baby’s response is a poignant moment for you both. If you sing the same song aloud to the baby daily for a few weeks before birth, it soothes the baby at birth and long afterwards when hearing your voices and the familiar song.

Anaesthesia and other medication issues:

The spinal block has many advantages for a planned cesarean, which make it the usual choice. It is quick to administer and to take effect. It usually involves only a single injection, and does not require a catheter in your back as does an epidural. It causes numbness that lasts a few hours. You remain awake and aware. It hardly affects your baby. The injection may also contain some long-acting narcotic such as morphine that provides good postpartum pain relief without grogginess for up to 24 hours after the surgery. If you have been in labor and already have an epidural, they will likely add medicine to the epidural for a cesarean to increase the numbing effect. There are some concerns about spinal and epidural blocks that might be disturbing or frightening:

It is not uncommon to have a period after the block is given when you feel breathless or as if you cannot breathe. It can be scary. This sometimes happens because the anesthetic may numb the nerves that let you feel your breathing, while the nerves to the muscles that make you breathe are probably not blocked. In other words, you are breathing, but cannot feel it.

What to do: Say that you cannot breathe. The anesthesiologist, who is at your head, will check and reassure you. Your partner should coach you with every breath, watching closely and saying, “Take a long breath in -- yes you are doing it, and now breathe out. Good.” Your partner might also hold your hand in front of your mouth so you can feel your breath, and reassure you, “You are breathing, even though it doesn't feel like it.” This feeling does not last for the entire surgery.

On very rare occasions, the level of anesthesia rises high enough to involve the muscles of breathing, so that you really are not breathing. You cannot talk either. The anesthesiologist, who is watching the monitors closely, discovers this and takes measures to assist your breathing. You and your partner should also have a signal. If you can’t breathe and can’t talk, blink your eyes many times. That means, “I can’t breathe!” Your partner should be watching you, and if you blink in that way, says, “I think she can’t breathe!” This may alert the anesthesiologist a few seconds before he would pick up the problem.

On other rare occasions, the anesthesia is not adequate, and you feel the surgery. This is very scary. The doctors will probably want to make sure your reaction is not an anxiety reaction to the surgery, and may seem not to believe you at first. If you are feeling the surgery, tell them to stop. Your partner must help you with this. Make them give you better anesthesia before proceeding. This might mean they would repeat your block or give you a general anesthetic so that you are totally unaware of what is going on.

During the repair, you may feel nauseated and shaky for a period of time. These are normal reactions to major surgery and vary from feelings of queasiness to vomiting, and from trembling to shaking and teeth chattering. There are medications to ease these symptoms. They are often put into your IV without you knowing, which may be okay with you. They may, however, cause amnesia (e.g., Versed), or make you very sleepy. They can keep you from being able to nurse your baby (or to remember that you did), and to remember the first hours of your baby’s life. If you want to stay awake for this time, discuss this with your anesthesiologist ahead of time. You might ask the anesthesiologist not to give you anything for nausea or trembling unless you ask. You may very well be able to tolerate these temporary symptoms, but if you cannot, then you can ask for the medication.

Post-operative pain medications are available to help you during the days and weeks after the birth. Some women try to avoid using them due to worries about possible effects on the baby. However, since very small amounts reach the baby, the effects seem to be minimal. The baby nurses and remains awake and alert for periods of time. The downside of avoiding pain medications is extreme pain, which greatly reduces your ability to move about and to care for, nurse, and enjoy your baby. With adequate pain relief, you can have more normal interactions with your baby.

The first few days:

Most hospitals have a bed available for the partner so he or she can remain in the hospital with you. This is lovely for many reasons. You are together as a family. Your partner can share in baby care. If your partner stays, your baby can probably room in with you the entire time. If he or she is not there, you will need help from the nurse to change the baby’s diapers, move him from one breast to the other, and carrying him, even for short distances. In some hospitals, the baby spends more time in the nursery if the partner is not there.

Breastfeeding is definitely possible! There can be some challenges after a cesarean, however. Nursing positions such as sidelying, and the “football” or clutch hold avoid painful pressure on your incision. Using a pillow over the incision also reduces pain while holding your baby on your lap. Ask for help from the hospital’s breastfeeding consultant (IBCLC) in getting started with nursing.

Rolling over in bed can be very painful if you don’t know how to do it. The least painful way uses “bridging.” To roll from back to side, first draw up your legs, one at a time so that your feet are flat on the bed. Then “bridge,” that is, lift your hips off the bed, by pressing your feet into the bed. While your hips are raised, turn hips, legs, and shoulders over to one side. This avoids strain on your incision.

Help at home is essential to a rapid recovery. If possible, someone (relative, friend, or postpartum doula) in addition to your partner should help keep the household running smoothly. If that person knows about newborn care and feeding, all the better. All three (or more) of you need nurturing and help during the first days and weeks to ease and speed your recovery and help you establish yourselves as a happy family.

As you can see, there are many possible options for a cesarean birth. Some are personal touches and personal self-care measures that will improve your satisfaction and self-confidence. Others are measures that involve the support of the hospital staff and your doctors. After thinking about your own preferences, prepare a birth plan, review it with your caregiver, and bring it to the hospital for the nurses to read.

I hope these suggestions will help you have the best cesarean ever!