TRANSCRIPT EPISODE 67 – All About Pregnancy & Birth With Dr. Nicole C. Rankins

Transcript episode #67: Having A Planned Cesarean Birth And What To Know About C-Sections

Transcript

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(00:00):

This episode is all about planned cesarean birth. You need to listen to this episode whether you plan to have a cesarean or not.

(00:15):

Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a practicing board certified OB GYN who's had the privilege of helping hundreds of moms bring their babies into this world. I'm here to help you be knowledgeable, prepared, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at www.ncrcoaching.com/disclaimer. Now let's get to it.

(00:55):

Welcome to another episode of the podcast. This is episode number 67. Thank you for being here with me today. So in this episode I'm talking about planned cesarean birth. This isn't something that is talked about a lot, I feel, and in some ways I think women who are having a planned cesarean are kind of left out when it comes to talking about giving birth. I don't think that's intentional. It's just that most women have a vaginal birth so you know that's just what gets discussed most of the time. But in this episode I am showing some love to my fellow cesarean mamas. I myself had two cesareans. The first was unplanned and the second was planned, so I'm going to help you get ready for that planned cesarean birth. Now, it's actually important though to listen to this episode whether you're having a planned cesarean or not, because most of the description of what happens is pretty much the same as if you end up having a cesarean while you are in labor.

(02:06):

Now, I know a lot of people will say that if you want a vaginal birth, don't even entertain any discussion about cesarean and I disagree. It's important that you're prepared for that possibility of a cesarean birth. The truth is that cesarean is the right option sometimes for your health or for your baby's health and we usually cannot predict ahead of time when that will be the case. I know that you'll feel a lot better if you have some idea of what to expect if you happen to end up needing a cesarean birth. It is not likely that that will happen because most women do have a vaginal birth, but again, you want to be prepared just in case. So in this episode I'm going to talk about the reasons for a planned cesarean and I'm going through the reasons because the timing of the cesarean differs based on the reason for the cesarean. And then you'll learn what cesarean is like from the very beginning, from the pre-surgery preparation to what happens in the operating room, including anesthesia and then the recovery phase.

(03:26):

Now first things first before we get started, let me do a quick listener shout out. This is from IT202 that's what is the name of the person who did the review. I'm curious to know what that means, but the title says great podcast and the review says, "the host Dr. Nicole is knowledgeable, science-based, well-organized, thoughtful and fun. Love the selection of topics and guests from regular moms to experts in various fields. I also like her summaries at the end of each podcast as well as the touch her own practice and motherhood add to the stories." Thank you so much for that lovely review . I don't know why I love that for some reason. I really appreciate those kind words. That review was left for me in Apple podcast and I always so appreciate folks leaving reviews there. Of course, I love to hear what you have to say. I love giving shout outs to folks and it helps the show to grow. So thank you. Thank you. Thank you for that lovely review.

(04:36):

And then another quick note before we get into the episode, I've gotten a few emails from people who listen in various podcast apps and they show the episode show notes differently. So when I say the link is in the show notes, they don't always see that in their podcast app. So I just want to remind everybody that you can always get the show notes or any links that I refer to for every episode at my website, www.ncrcoaching.com/podcast or if you just do www.ncrcoaching.com that'll get you there too. You can look in the menu and get to the podcast or if you want to go directly to any episode's specific show notes page, it's going to be www.ncrcoaching.com forward slash episode spelled out and then the episode number, so for this episode it would be www.ncrcoaching.com/episode67. So that's how you can always get to the show notes for any episode. They're always there through my website.

(05:45):

And while you are at my website, you can check out some of the other great stuff that is there. There are free downloadable resources like pain management, guide to labir, you can check out my Affirmations for a Beautiful Pregnancy & Birth. Of course you can check out my signature online childbirth education class, The Birth Preparation Course that ensures you're knowledgeable, prepared, confident, and empowered to have a beautiful birth. And you can also register for my free online class on how to make a birth plan, including information on how to adjust your birth plan in light of COVID-19. You know, when this COVID thing first popped up, I really thought this was going to be like a one or two months thing and we would get past it. But this is going to be with us for awhile, I think really honestly through at least the end of the year. So you really need to know how to adjust your birth wishes in light of everything that's going on. So do check that out. So head to my website, you can get the show notes, get those other resources, lots of good, great stuff for you there.

(06:52):

Okay, so let's get into the episode about planned cesarean birth. First I want to talk about some of the most common reasons for planned cesarean birth, and then tell you a little bit about each one and then the timing of the cesarean based on the reason. So the most common reason for a planned cesarean birth is usually what's called an elective repeat cesarean. And what that means is that you had cesarean birth before and you are choosing to have a cesarean birth for your next pregnancy. Those cesarean sections are usually done between 39 and 40 weeks. We choose that as the time because 39 weeks is when we know that the vast majority of babies, if not all babies, are pretty much ready and they're going to do well when they're born and not have any problems. So usually we hard stop it, do not do it before 39 weeks and sometime between 39 and 40 to avoid going into labor. Now I also will add the category of forced elective repeats cesarean section. And by that what I mean is that you've had a cesarean before and you've had one or two prior cesarean. However, your provider or your hospital does not support VBAC or TOLAC. TOLAC is trial of labor after cesarean, VBAC is a successful TOLAC, so vaginal birth after cesarean.

(08:29):

So if you are in that situation where your provider or your hospital doesn't support VBAC, then this is when they're going to talk about having a repeat cesarean, again between 39 to 40 weeks and that's an elective repeat cesarean or what I call a forced elective repeat cesarean and I'm going to have another episode coming up in a few weeks talking all about VBAC, so we'll touch back on that topic a bit later.

(09:01):

All right. The second most common reason for a planned cesarean is breech presentation. There was a study back in the day a few years ago, gosh, it's probably been at least 10 now that showed that for babies that are breech, the outcomes are slightly better if they are born by cesarean birth. There were some issues with that trial, but we've kind of adopted the philosophy of doing cesarean birth for breech babies. Not a lot of doctors know how to do vaginal breech birth. I actually talk all about breech babies in episode 19 of the podcast, so that's www.ncrcoaching.com/episode19 if you want to learn more about that. But these C-sections are also usually done between 39 and 40 weeks. Again, 39 weeks is when we know that babies are ready, but we don't want you to go into labor. So we try to do it before 40 weeks and 40 weeks is the due date.

(10:03):

All right. The next most common reason is multiples. So twins or more, if there're more than two, there's almost no one who will be comfortable doing a vaginal birth. So three or more babies, almost no one is going to do a vaginal birth, they're going to feel way more comfortable doing a cesarean. Some folks will do vaginal births for twins if both heads are down and then a smaller percentage will do vaginal birth for twins if the first baby's head is down and the second baby is breech, but almost no one will do vaginal birth for twins if the first baby is breech. So twins or multiples is the next most common reason you may have a planned cesarean birth, typically these are done no later than 38 weeks, so a little bit earlier because multiples tend to be ready earlier. Outcomes start to worsen after 38 weeks for twins. So twins, we typically in the pregnancy, or recommend, you know, delivery at 38 weeks for more than twins. That may be even earlier than that. So no later than 38 weeks for multiples.

(11:23):

And the next category will be indicated repeat cesareans. And that is when you have three or more prior success cesareans. In that case, it's recommended that another cesarean is the safest thing to decrease the risk of uterine rupture. Uterine rupture is when the incision from the old cesarean breaks open. And that can be catastrophic when it happens, and the more C-sections you have the higher risk of that. So three or more prior cesareans, that's an indicated repeat, a reason to have a repeat cesarean, and that is done between 39 and 40 weeks. However, for an indicated repeat for different reasons and the other, the two main reasons are a prior classical incision. Classical incision on the uterus is when there's an up and down incision on the uterus. Typically when we make the incision on the uterus to get the baby out in a C-section, we do it low and we do it straight across, so from side to side, right to left for lack of a better way to describe it.

(12:30):

So that's a low transverse incision. When we do that type of incision on the uterus, then you can subsequently go on and try for a vaginal birth if you want to. However, if you have a classical uterine incision that goes up and down, so straight up and down, then a classical uterine incision increases the risk of uterine rupture by quite a bit. And in that case then we recommend that you have a repeat cesarean. And so I know I'm saying a lot, but if you have a prior classical incision on your uterus, then we , a repeat cesarean that's an indicated repeat cesarean. And that is going to be between 36 and 37 weeks because we do not want that uterine rupture to happen again. Similarly, if you've had a uterine rupture before and a prior cesarean where your old cesarean scar on your uterus opened up, then we recommend doing a C-section even earlier between 36 to 37 weeks in order to reduce the chances of that uterine rupture happening again. Okay, and this is not related to the incision that's on your skin. This is the incision that is inside on your uterus. You can't see it. We have to know it from your operative report.

(13:53):

Okay. Now, the last two are placenta previa. Placenta previa is when your placenta covers the opening to your cervix, and this can be very dangerous because as your cervix opens up, the placenta is very vascular. It's responsible for transporting all of the blood between your uterus and your baby. And there's tons of blood flow through it. So as the cervix opens it up, that part of the placenta that's sitting over the cervix that's exposed, it's going to bleed and it can be a lot of bleeding. It can be very quickly and it can be life threatening, especially for babies because it doesn't take a lot of blood for babies to lose before it can be really bad for them. So if you have a placenta previa, then we recommend that you have your cesarean, your planned cesarean birth between 36 to 37 weeks. So a bit earlier.

(14:54):

And then the final category of reasons why you may have a planned cesarean birth is an elective primary C-section, meaning that you have decided that you don't want to try for a vaginal birth, you just want to have a cesarean birth straight out the gate. And I have to be honest, I used to be kind of, I don't know, for lack of a better way to put it, not so supportive of this. I really couldn't quite wrap my head around why anyone would want to go straight to a surgery when knowing that vaginal birth was safer, so I did not always feel good about doing this at all. However, I've come around and now understand that with appropriate counseling, as long as women know the risks and the benefits of their options, if they want to go straight to a cesarean birth right off the bat, then that is certainly within their choice and I will support that.

(16:02):

If they have all the information and they want a primary cesarean, then that's fine. A lot of times I've seen that women say that because they have this huge fear of vaginal birth and when you talk through the fears then they don't necessarily want that cesarean anymore. But some women, honest to goodness, just want a cesarean birth right off the bat. It's not common, but it does happen. And if that's something that you want, then that should be supported. Okay, so that is it for all of the reasons why you may need a planned cesarean birth. Now, although I listed all the reasons and all the timing of when you may have a planned cesarean birth, it is really important that you keep in mind that your planned cesarean birth may not happen when planned. Just because we schedule it, it is no guarantee that it is going to happen on that specific day.

(17:01):

I have done many a C-section in the middle of the night that was scheduled for a day or two later because labor started or because water broke or because there was bleeding. So yes, a planned cesarean most likely or is going to happen on the date that you select, but be prepared for the possibility that it may not. I've seen so many women who were like, I had this day schedule and I had this day picked out and they thought that because things were scheduled that it was automatically going to happen that way and that is not the case. So please still maintain that flexibility and know that it's possible that your planned cesarean may not happen when planned.

(17:48):

Okay. Let's talk about what you can expect with a planned cesarean. So the first thing that we do is something called preadmission testing or planning. A planned cesarean is a surgery and just like any other surgery, we do some things to prepare ahead of time to get you ready. So usually for cesarean and involves meeting with the nurse, talking through your history, making sure we have everything straight. This can be over the phone or in person. And you may also need to come in to get some blood work done to get your blood type done and get your blood count done because the risk of losing blood is higher with a cesarean birth. Again, it's a surgery. We kind of know what your blood count is, your hemoglobin and your hematocrit. That's a measure of how much oxygen carrying capacity you have in your blood. We want to know those numbers so we know what we're starting with and know if we need to do anything special to help prevent any additional blood loss.

(18:46):

You may also get some places do a preoperative body wash where they give you a special soap to bathe in the night before your surgery. Not all places do that, but some places do, and you may also meet with anesthesia if you have a particularly complicated health history. So for example, if you have heart problems or lung problems, if you have scoliosis, those may be reasons to meet with anesthesia before the day of your surgery so that we can plan and have everything ready on the day of your C-section. Okay, so on the day of your C-section, you're going to be asked to arrive probably one to two hours in advance. You'll get an IV, get dressed, the nurse will come in and ask you a bunch of questions. You will meet with the anesthesiologist again if you met with them before and if you haven't didn't meet with them at that preadmission testing, then you will meet with them that day.

(19:44):

They will go over the risk of the anesthesia. Most often it's a spinal anesthetic, which is a one shot needle to your back, but it could be general anesthesia where you're put to sleep completely, so they're going to go over that risk with you as well. When the day of that surgery, you may be asked before we go back to the operating room to do special wipes to clean your skin. There's a special soap called chlorhexadine and we know that washing with that helps reduce the risk of infection when your skin after surgery. So if you didn't do the body wash the night before, then you may be asked to do the chlorhexidine wipes in the bathroom before your surgery on that day of the surgery. Or you may even be asked to do both. Every hospital has a little bit different protocol and then you just kind of sit around and wait until everybody is ready.

(20:40):

The operating room, the surgeon, of course your surgeon will come in and meet you before you go back as well. So the operating room, the surgeon has to be ready, the anesthesia needs to be ready, the staff needs to be ready, so once everything is ready, then the nurse will walk you back to the operating room. You shouldn't need to be wheeled in a bed or wheeled in a wheelchair. You should be able to walk back to the operating room. Now at this time, most of the time you're going back to the operating room by yourself and your partner is not going to come back there until a little bit later and I'll explain at what point in the process your partner will come back. Now if your partner does come back with you, then very often they're asked to wait outside until the anesthesia is placed until after that spinal anesthesia is placed and everything is ready to go.

(21:27):

But every hospital is a little bit different. Some hospitals, I would say a handful, a few will have the partner in the room while the spinal anesthesia is being placed, but not a lot of hospitals do that. The partner is usually waiting back out in the main area or waiting just outside of the operating room. Okay. Now once you get into the OR, the first thing you're going to do is get that anesthesia. It's called a spinal and we do that first because it takes a little bit of time for it to get set up. And the spinal, and by setup, I mean working, so the spinal anesthesia is a single injection of medicine into a specific place around your spinal cord and it numbs everything from a certain level of your spine down. Usually it's like just under your breast and numbs everything from there down.

(22:29):

Now getting the spinal is usually not terribly painful. It starts with a quick pitch to numb the area where the anesthesiologist has to put the medicine. Then after that they put in the medicine and you don't really feel that and it doesn't usually take very long. Now a spinal is different than an epidural. An epidural is a catheter that's left in place and it can have medicine placed through it that's used continuously through labor. It's put in a different spot around your spine, whereas the spinal is put, is just a one shot deal. It's not a catheter that's left in place and it lasts for roughly two hours or so where you're numb again just about from your breast down. Now placing the spinal may take longer if you have different anatomy, for example, if you have scoliosis or it may take longer. If you are obese, if you're carrying a lot of extra weight, what happens is an a spinal, the anesthesiologist or it could be a certified registered nurse anesthetist as well.

(23:42):

So anesthesiologist is a physician, an MD or a DO, a certified registered nurse anesthetist is a nurse who has gotten specialized training to do anesthesia. It can be either one of them doing it and they have to be able to feel the bones in the spine in order to know the exact right place to insert the needle. And it's really important that the spinal is placed in the right spot. And this is the same for an epidural to actually that it's placed in the right spot because you want to have the level high enough that there's enough numbing action, but you don't want to have it too high because if it's too high, it's going to block the muscles that you use to breathe and you won't be able to stay awake during your surgery. So it really needs to be in the exact right spot.

(24:42):

And the way that they do that is by feeling with their hands and feeling your anatomy. So if your bone, your spiny structure is different, or if there is a lot of tissue there, a lot of fat tissue there, then it is simply harder to feel the bones and feel the right spot. And quite frankly, it may take quite a bit longer with multiple attempts to get that spinal anesthetic in the right place. So I'm not trying to offend anyone. I know the term obese can be tricky. So I'm just trying to convey a true picture of what happens. And I've seen it happen that people don't understand like why is this taking so long? And it's usually because of the anatomy or it's difficult to feel the bones to put it in the right space and spinal anesthetic is much preferred for cesarean section because number one, we want you to be awake for the birth of your baby so you can experience that when it happens.

(25:51):

And then number two is that it's safer than general anesthesia. General anesthesia is when you are put completely to sleep. There is a tube down your throat, you know breathing for you, you're not awake at all and general anesthesia increases the risk of something called aspiration. Aspiration is when the contents of your stomach will come up and go into your lungs. When you're awake, you will naturally protect yourself from doing that. So if something comes up from your stomach, like if you vomit, then you're going to naturally protect your, your airway and your not your gag. You're going to make it come out of your mouth and not into your down into your lungs. However, if you are asleep, then you don't have that same protective mechanism available. So it puts you at higher risk for if stuff comes up into your stomach, it's going to go into your lungs and aspiration pneumonia is bad.

(26:53):

So we much prefer spinal for cesarean section and pregnancy increases the risk of aspiration. So that adds another factor to it as well. And speaking of aspiration, I forgot to say before your planned cesarean, you will be asked not to eat or drink anything for at least six hours, preferably eight hours before your surgery. And the reason for that is so that your stomach is empty and that if that small instance happens where you have aspiration, then there's nothing to come up. Okay. So you'll be asked to not eat or drink for six to eight hours before your surgery. Okay. All right. So once this spinal is placed, we will lay you down on the operating table. It feels a bit awkward because you're kind of strapped down and your arms are usually stretched out to the side. So you're in a T position on the or table.

(27:56):

And I'm sitting here at my desk as I'm recording with my arms sticking out in a T as if you all can see me, but you're laying on the or table and your arms are after this side and the T position. And as you're laying there, you'll slowly start to feel the numbing medicine kick in. So as the numbing medicine starts to kick in, the nurse is going to do several things. She will shave your pubic hair if there is any that's in the area where the incision would be made. And that is to prevent infection cause hair being around where we're working in, where we work increases the risk of infection and you should not shave beforehand because that will actually increase the risk of infection. So you really want to let us do it just before the surgery. That's the best timing for it.

(28:52):

The nurse will also put a catheter inside your bladder to empty your bladder and we put on something consequential compression devices on your calves in order to prevent blood clots from forming in your calves. Surgery and laying around and being still for a long period of time increases the risk of blood clots forming in your legs. That could travel to your lungs and be life threatening. So these squeezy devices called sequential compression devices will help prevent that from happening. Now you should not feel most of this. You won't feel the shaving, you won't feel the catheter going in your bladder, you won't feel the SED's is going on, your numbing medicine should have kicked in by them. So the next step, the nurse is going to scrub your belly with the surgical soap. That helps to prevent infection. You can't touch the area of your belly once that soap is on because it will contaminate it and once the soap is dry, usually that takes about three minutes, then the blue surgical drape goes up. Then you're just about ready for surgery.

(29:51):

So a couple more things that'll happen as all this is kind of going on, is that you'll get an antibiotic through your IV that's going to help prevent infection of your, your skin incision. And there'll be something called a timeout where everyone stops, we confirm who you are, why you're having the surgery done, if you have any allergies and that you're received the antibiotics. So the timeouts are done routinely before any surgery in order to make sure that the no mistakes and everyone is on the same page. Okay, so you've gotten back to the or you've gotten the spinal, you've gotten the prep, you've gotten everything ready, you're laying there, the blue drape has come up.

(30:32):

Now the surgeon and everybody should be there. The two people that are assisting and what we do first is test to make sure the anesthesia is working in. That was something called an Allis clamp. So that's like a really sharp instrument that pinches your skin and to make sure you don't feel pain with that. Now you will feel touch with cesarean birth and you will feel pressure. It's kind of a weird sensation. You know that something is going on down there, but it's not painful. So once we pinch you with that sharp device and you say, yes, I know I'm touching you, or you may not feel it at all and we know that your anesthesia is working, then your support person comes into the room. Now, usually we allow one support person in the room and I say we, it's actually the anesthesiologist who makes the decision.

(31:28):

It doesn't affect me how many people are up there at the head of the bed with you sitting and supporting you. But there's like machines and everything there for the anesthesiologist. So some of them are a little finicky about having more than one person there, but you can have certainly have one and maybe two people can be there with you as well. Right now in the age of COVID, it's going to be one person, but in general sometimes it can be two. And again, you should not feel pain. For me personally, for my first C-section, when they did this Allis clamp test, I felt it and it was painful and they didn't really think that I was, I don't know. I don't know. They didn't believe me, I guess. But it was painful. They continue to go ahead with the surgery and I felt, you know, I felt at all.

(32:23):

It was quite traumatic actually. I've talked about that in my birth stories before in one of the episodes of the podcast. So you should not feel pain with that Allis clamp test and if you do be very vocal that it feels painful now again you'll feel it touch but it shouldn't feel painful. I'm actually quite sensitive to women when they feel that because of my own experience. Okay. And then the last thing real quickly is who is in the room? It's a lot of kind of stuff going on in the room. Usually there are two nurses. One is the circulator nurse and what she does is she helps get me anything that I need during the surgery that needs to be pulled from the cabinet. So a specific suture or anything like that that needs to be pulled from the cabinets. We have a set like kit that we use, but sometimes you need extra stuff so that's what the circulator does.

(33:19):

She's also there to take help take care of you. Then there's a baby nurse who's going to take care of the baby and evaluate the baby once the baby's born. So usually two nurses, there's an anesthesiologist who's responsible for watching your anesthesia. Then there is the surgeon and then I will have, or the surgeon will have two assistants. So I have one person across the table from me who's assisting me who like holds things, cuts things, holds retractors, that kind of thing. And then there's a surgical tech who hands me, all my instruments hands me the things that I need when I ask for them. Now if there is a concern about your baby, then there may be even more people. So that basic team again is going to be two nurses, the anesthesiologist, the surgeon, and then two assistants. I'm doing the math on my hand.

(34:07):

So that's one, two, three, four, like six people at least. And then if there's a concern for your baby, there's going to be a neonatal team there as well, who will probably be three or four people. Okay. Now as far as what a C-section feels like, again, it should not feel painful. You'll feel tugging, pressure, but it shouldn't feel painful. If you feel like you can't breathe, that may be an indication that your anesthesia is a little bit too high. The anesthesiologist will monitor you very carefully, but usually most women don't have problems with that. I will say that some women are exquisitely sensitive to movement of their uterus. It's actually a really interesting phenomenon to me where they don't feel it when it's cut, they don't feel necessarily the tugging or stretching of the skin or the tissues that needs to happen, but they can be very exquisitely sensitive to the uterus being moved. And it's not necessarily a whole lot that we can do to prevent that except being mindful of not moving it around a lot. But some women, it's like I said, interesting to me, exquisitely sensitive to the uterus being moved and then there's no good way to predict that ahead of time.

(35:32):

So let's talk about now a family centered cesareans. So the family centered cesarean approach has been developed to help really improve the experience of women who are having straightforward, uncomplicated cesarean births. And this is an attempt to help or try and replicate some of the features of a vaginal birth in order to make cesarean birth more family friendly. So some of the components of a family friendly cesarean birth may be that background music is played in the background of your choice during the delivery may also dim the lights as much as we can and keeping things safe.

(36:21):

Of course there's going to be OR lights on the table because we have to see in order to operate, but dimming the lights down if that's something that you want and just kind of reducing a lot of the extraneous noise and keeping a calm or quiet environment. Some places use clear drapes or position the drapes to allow you and whoever is there with you, your partner support person to either watch the birth that they want to or be able to see the baby as soon as possible after birth. Definitely avoid giving moms any sedating medication so that you're awake and alert and able to experience the birth. Keeping your hands free like we used to kind of tie mom's arms down to the side. That's not really necessary when you're awake. So keeping your arms and hands free and keeping your chest or your breasts clear from monitors and things so that once baby is born we can do immediate skin to skin contact or skin to skin contact as soon as possible and you can hold the baby nurse, the baby in the or even if you want to.

(37:32):

So those are the components of a family centered cesarean. Also some things that I would add are you can still do delayed cord clamping so you can ask for delayed cord clamping to be done at least 30 seconds to a minute if not longer. And then also if dad really wants to cut the umbilical cord, we can leave the umbilical cord long for dad to trim later that cannot do the initial cutting of the umbilical cord, whoever the support person is because it's up on the sterile surgical field. But we can however, leave the umbilical cord longer and dad can trim it after the baby is born. And if you're interested in having a family friendly cesarean, if you want the music or the clear drape or skin to skin contact, delayed cord clamping, for sure, for sure. Talk about that ahead of time because that is not the standard for every single hospital.

(38:33):

So definitely, definitely ask about that. It's getting to be more prevalent, but for sure you should ask. And also, I know this sounds crazy, but tell the surgeon that you want to see your baby as soon as possible. Okay. That's a moment that you will definitely, I think remember, at least for me personally, I remember those moments very distinctly from our first baby who was a 32 week preemie. She came out, they held her up. I demanded to see her actually. And she looked like a little monster. She was just had a little hands held up like claws and she looked like a little fighting monster. And then my second baby was just very loud. She was like screeching. She was pretty pale, especially for a little black baby. And she had a head full of very dark black hair. So I remember those moments distinctly.

(39:26):

I don't think we intentionally don't show parents their babies, but I don't think we always appreciate how important those first moments are you and how you've been growing this baby for so long and you're so excited to see the baby. So definitely ask to see your baby as soon as possible. And if after your baby's born and they haven't shown you your baby brought your baby over or given you any kind of update, then don't be afraid to ask or have your partner ask, you know, Hey, when will I see my baby? I want to see my baby as soon as possible. Please go ahead and speak up and ask. Don't be afraid to do that. Now as far as how long the surgery takes, the surgery itself can take anywhere from 30 minutes to an hour. It can be even longer depending on if there is scar tissue to get through or if there's bleeding that needs to be fixed.

(40:16):

It could be longer than that. And I do have a particular pet peeve. I'm gonna just go ahead and say it. It's not something that a lot of people do, but occasionally, sometimes people will ask, how much longer is this going to take? That question annoys me to death. It is going to take as long as it takes to close your body back up the right way. I am not dilly dallying up there. We're operating and quite frankly, you don't want us to rush it, right? I don't think you do. So usually if it's taking some time, I personally, I can't speak for every surgeon, but I'll give moms an update. I'll say, Hey, it's taken a little bit longer to get to the baby because he has some scar tissue. Or Hey, I'm down here. You're having a little bit of extra bleeding. I'm working on getting the bleeding stop that everything's going okay.

(41:09):

So I will give an update, but please do not ask how much longer it's going to take, it's going to take as long as it takes in order to do the surgery safely. All right. Now once the surgery is done, all the drapes are removed, the nurses and the OR staff will move you to a regular bed. You will not be able to move yourself because again, the numbing medicine lasts for one to two hours. You'll go back a room to recover. It may be a special recovery room and maybe the room that you were in before surgery and you're going to remain there until the numbing medicine wears off and you have feeling back in your legs. Your baby should be with you during the whole time of recovery. And then after that you are moved to a regular post partum room. Now for the recovery, we are moving towards something that's called ERAS, enhanced recovery after surgery.

(41:58):

And these are things that have been shown in general surgical literature that help people recover faster and we're starting to adapt a lot of those principles in cesarean birth. So first things first is pain management. So you get a long acting anesthetic through your spinal. So with through that injection of medicine that you get in your back, there's one of them that's a long acting narcotic that lasts for about 24 hours. So that gives you nice, good, longterm relief. And then very soon we start you on a scheduled dosing of oral pain medication so that you don't get behind in pain. We try to stay ahead of it so we're not trying to catch up. It can be a nightmare if you're pain is really bad and then we're trying to catch up with it. So in those first two to three days, we're really trying to stay ahead of it as you're getting adjusted and recovering.

(42:53):

So we do scheduled doses of ibuprofen and acetaminophen and alternate those two, so that's Motrin and Tylenol, so scheduled doses of alternating those two medications. There's lots of evidence that they work together synergistically in order to help treat pain. And then we use narcotic medicine, something stronger if needed. Other things that we want to do. I get you up and moving around as soon as possible after the surgery. So within a few hours we want to get you up and moving. That's been shown to enhance recovery. You can eat right away. Just use common sense. A lot of places will start folks on liquid diets first. There is no evidence to support that you really can't eat straight away after surgery to help get your intestines moving. Help get things back to normal. Just again, use common sense, nibble on things you don't want to be super aggressive about eating and actually chewing gum has been shown to help get your bowels moving and stimulate it.

(43:54):

So chewing gum can help as well. So those are the enhanced recovery things that we do. Scheduling your pain medication and trying to limit narcotics to only when needed, get you up and moving away around as soon as possible and in eating as soon as possible. Now, just before you go home, depending on your incision, if you have staples, those will get removed prior to discharge. If you have a what's called a low transverse incision or a bikini cut, which is what most people have, the staples will get removed just before you go home. But a lot of times we're using things like absorbable sutures or skin like suture under the skin that doesn't require being taken out. So you may not have staples. There's actually evidence that those absorbable sutures will heal up a little bit nicer and recovery really honestly varies from person to person.

(44:43):

I was fortunate enough that I had very easy recoveries from both of my C-sections. I didn't go home on any narcotics at all. I was up and moving around quickly. I was driving within a week after both of them. But then you have some people who it requires much more recovery. It can be a little bit slower, they need narcotics for a longer period of time. Their activity and their mobility is a little bit more limited for longer. So it really just depends and it's going to be individualized, but most people recover just fine. And then as far as recovery, some things that you'll have to do that are different for cesarean. Lifting, nothing heavier than the baby for six weeks and that's just allowing the tissues inside of your body to come back together and heal appropriately. And then you can drive and I get this is actually for if you're on narcotics period from a vaginal or cesarean, you can drive when you can turn and look over your shoulder comfortably and when you can slam on the brakes in an emergency.

(45:45):

Okay, so that's it. And just to recap, the reasons for planning cesarean and the timing varies. They include elective repeats cesarean or what I call that forced elective repeat cesarean. Breech birth or an indicated repeat cesarean with three or more C-sections or the elective primary cesarean, those are all gonna happen between 39 to 40 weeks. Multiples are not going to be later than 38 weeks. Some of the indicated repeats like a prior classical cesarean section or a prior uterine rupture, that's going to be 36 to 37 weeks or a history of plus. Or if you have placenta previa, that's going to be 36 to 37 weeks. As for the procedure itself, definitely asked for the family centered cesarean if that's important to you because that is not necessarily the standard at most hospitals. The recovery from a cesarean birth really varies.

(46:36):

Most women do fine. It may take you longer to recover the more cesarean births that you have. Now, one thing I didn't talk about is things to look out for once you get home. I have a free download for any warning signs you can look out for after birth once you get home. That's www.ncrcoaching.com/warningsigns. We'll link that up in the show notes and you can grab that whether you're having a vaginal birth or a cesarean birth, that has information for both. And then the last thing I want to say about cesarean is that if you have a cesarean and you really wanted to have a vaginal birth, it's okay to be upset. We have a tendency to say, Oh, just be happy. You're healthy and your baby's healthy, but you are allowed to be thankful that everything went well, that you're healthy, that your baby's healthy, you're allowed to be thankful and be that you had a C-section.

(47:30):

You can do those things at the same time, I would just encourage you just to not let being upset, interfere with the experience of being a new mother and enjoying that baby that is in front of you. If you're so focused on being upset that you're having a cesarean, that you can't focus on the joy of being a mother, then please ask for help because you are not a failure. If you had a cesarean you still gave birth, your body grew a whole entire human being and that cannot possibly be a failure. The way that that baby arrives is not a reflection of your worth. Okay? So that's it for this episode of the podcast. Please subscribe to the podcast wherever you listen to podcast. Leave a review in iTunes particularly that helps women find the show and helps the show to grow.

(48:29):

And of course, I love leaving shout-outs. Another way to learn about new episodes, and so you don't miss any episodes other than subscribing is getting on my email list. I send weekly emails. It's a newsletter called My Beautiful Pregnancy & Birth and there's like tips in there, there's links to that to this week's podcast episode, so get on my email list if you want to be notified and not miss any episodes as well. Now next week on the podcast, we will have a birth story of someone who gave birth during this COVID-19 pandemic, so you will definitely want to come on back next week and until then, I wish you a beautiful pregnancy and birth.

(49:14):

Thanks so much for listening to this episode of the all about pregnancy and birth podcast. Head to my website www.ncrcoaching.com to get even more great info, including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class on how to make a birth plan as well as everything you need to know about the birth preparation course. Again, that's www.ncrcoaching.com and I will see you next week.

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