Credit: The Toronto Star
An experimental program at Sunnybrook Health Sciences Centre allows mothers to hold their babies skin-to-skin immediately after a C-section birth.
After two labours that ended in emergency C-sections, Shannon Connors decided her third child was going to have a more natural birth.
The 41-year-old Kingsville, Ont., mother delivered her eldest daughter, Priya, by an emergency caesarean at Toronto’s Mount Sinai Hospital on May 1, 2006.
Priya was born healthy but there was something missing in the experience for Connors.
“I felt this crazy separation. They gave (Priya) to me in the recovery room, but I couldn’t hold her because my arms were frozen,” she says, adding that this happened because she had been over frozen from the epidural.
After Priya’s birth, Connors tried to learn as much as she could about vaginal birth after caesarean section, or VBAC. “I wanted to make different choices. (Priya’s delivery) wasn’t the way I wanted to experience birth.”
When Connors went into labour with Tallulah, her second child, this pregnancy also ended with an emergency C-section on June 13, 2010. “Nobody was talking. Then I realized, ‘She’s not crying,’ ” says Connors, adding that Tallulah swallowed meconium and was born not breathing for two minutes.
“After this experience, we decided a scheduled (caesarean) was the safest option if we (had) another baby,” she says. When Connors was next expecting, her midwife Nicole Romeiko told her about a technique being studied at Sunnybrook Health Sciences Centre that allowed mothers to hold their babies skin-to-skin immediately after a C-section birth while still in the operating room. Leif, born Dec. 10, 2013, was Sunnybrook’s first skin-to-skin caesarean.
Connors is not alone in her early experiences. One in three Canadians are born by C-section, up from 18 per cent 20 years ago, making this Canada’s most common major surgery. Yet, despite this increase, and research stating the importance of mother/child skin-to-skin contact immediately after birth, hospitals have been slow to adopt this method after scheduled C-sections.
However, this is changing. Dr. Jon Barrett, chief of maternal-fetal-medicine at Sunnybrook Health Sciences Centre and the Fred Waks research chair, has performed 20 skin-to-skin births since delivering Connors’ son in 2013. While Barrett acknowledges there are situations — such as after an emergency C-section — when skin-to-skin contact is not appropriate, he is sharing his results and hopes the technique will be adopted across the country.
“The skin-to-skin method brings the process of birth back to caesarean section,” he says. “It feels more intimate, like a normal birth does. When you do a (standard) C-section you lose the birth part, the emotive experience.”
The skin-to-skin method is already the standard of care for planned caesareans in the United States. Memorial Hospital in Rhode Island founded its “Gentle Caesarean Program” in 2009, the first of its kind in the U.S., and performed 144 gentle caesarean, or skin-to-skin C-section births, between 2009 and 2012. According to this hospital’s statistics, complication rates have been similar to, or even lower than, those for standard caesareans.
Generally, C-sections negatively affect early parenting outcomes. They also increase the mother’s risk of infection, hemorrhage, damage to her intestines or bladder and place excess strain on the health-care system.
Research shows that C-section births in Australia and the U.K. have been associated with more dissatisfaction and psychological distress than vaginal births, and between one-quarter and one-third of women suffered acute emotional trauma symptoms.
Charlene Dormady, 28, of Toronto, relates to these mothers. Her son, Logan, was born by an emergency caesarean at Toronto East General Hospital on Dec. 23, 2013.
“I actually didn’t get to see my son for the first nine hours,” says Dormady. “I didn’t get to breastfeed him, hold him, or do any skin-to-skin. I definitely suffered some trauma, as did (Logan) for sure. We weren’t able to bond at all.”
Even after they got home, it took a long time for Dormady to figure out Logan’s sleeping and feeding queues and she still struggles sometimes.
“I did not have the confidence that I could have had in caring for him,” she says. “Once I got home, I felt like I was starting from scratch because (we) didn’t have that time in the hospital. Up until recently, when I worked through it with a therapist, I (had) days where it really (affected) me in my ability to parent and be calm.”
The fact that Canada has been slower than other countries to adopt the skin-to-skin method can largely be explained by differences in primary obstetric care, says Barrett.
“In the rest of the world, the midwifery and the medical model are integrated,” he says. “They didn’t develop along these separate paths we’ve (created) in North America. It’s not without paradox that (Sunnybrook’s) first (skin-to-skin C-section) was a midwifery patient.”
Romeiko agrees that midwifery practices differ depending on the country.
“The role we play in an operating room in Canada is quite different from being actively involved in the surgery, let’s say in New Zealand,” she says. “Staffed midwives are expected to perform certain steps, whereas here, at least in Ontario, when it comes to the surgery, my role (is) to observe, and then I’m responsible for the baby.”
Barrett hopes the skin-to-skin caesarean method will give these babies and mothers the benefits already proven for vaginal births.
“Skin-to-skin contact has improved hard health outcomes for the baby and the mother,” he says. “Less jaundice, better bonding, more breastfeeding (and) less hypothermia. Those are undebatable. Yet, one-third of our babies are not getting that.”
This realization prompted Barrett to start working on a skin-to-skin program at Sunnybrook that he hopes will mean fewer mothers and babies miss out on skin-to-skin with each other even when C-sections are necessary.
Caesarean birth is carried out by a physician who delivers the infant and another health-care worker who receives it. Normally, the doctor hands the newborn to the health-care provider because the physician has to stay sterile to stitch up the mother. The baby is taken to be examined, cleaned, tagged, weighed and swaddled.
In a skin-to-skin C-section, instead of turning around and handing the baby off the table, the surgical drape is lifted and the doctor passes the infant underneath to the other health-care worker who places it on the mother’s chest.
“(That) was the best moment in all three birth experiences for sure,” says Connors. “It was completely different than my other two births when my baby was immediately whisked away to the other side of the room.”
Leif stayed skin-to-skin with his mother for the next few days. “I didn’t know that those small changes in the C-section procedure would make such a big difference, but they did,” says Connors. “It felt the way birth is supposed to be, the way I’d always imagined it.”
The additional associated manoeuvres known to be helpful to infants, such as delayed umbilical cord clamping that improves newborn blood flow and breathing, are also important and do not happen during standard caesareans.
“If the baby is up there on the mother’s chest, there’s no reason to quickly clamp and cut the cord and pass (it) off,” says Barrett. “It’s still attached to the mother. There’s no real rush, you just leave the baby alone like nature does.”
Overall, health-care professionals at Sunnybrook have been receptive to the general skin-to-skin C-section principle, although there has been some pushback around the procedure’s terminology and breaking the surgical field.
“The skin-to-skin method was initially called a ‘natural birth caesarean,’” says Barrett. “That’s an oxymoron because it’s not a natural birth.”
He has delivered 20 mothers by the skin-to-skin method. But says some doctors are still unconvinced it makes a difference.
“I don’t know if all my colleagues are completely on board,” says Barrett. “I’ve done it with several, but some (remain) skeptical.”
Physicians’ skepticism is based on concerns around a possible increased risk of infection for mothers.
“There is more chance of your hands touching something nonsterile as you lift the drape,” says Barrett. “Therefore, as soon as we’ve done (the) hand-off we change gloves and gowns before going back to the surgical field.”
Romeiko, who has attended two skin-to-skin C-sections in Canada, as well as several others internationally, thinks it’s also important to differentiate between the two ways this method can be done.
“There may be more risk where the cord is left intact (since) it remains connected and continuously stays on both sides of the surgical field until the placenta is born and the cord is clamped,” says Romeiko. (But), I agree with Dr. Barrett that the risk, if there is one, would be almost negligible,” adding that the Canadian women whose surgeries she attended did not get infections even though the cord was left intact.
The doctor’s mindset also plays a role in the hesitation of some to change a surgical practice that has been done the same way for decades.
“Caesarean is a surgery, whereas natural birth is not,” says Barrett. “The sterility is different.”
Romeiko says that transitioning to the skin-to-skin method has also been difficult for anesthetists because it directly impacts access to the mother’s upper body.
“(It’s) taken some adjustment,” she says. “Usually it’s not a family event to attend a surgery. The mentality is completely different in a birth setting.”
There are resource issues too because the skin-to-skin method requires an additional health-care worker.
“An extra person has to be there to hold the baby on the mother’s chest and make sure it’s safe rather than just wrapping it up and leaving it on the warmer,” says Barrett.
Romeiko agrees that the availability of additional health-care providers is an important aspect of using the skin-to-skin method more widely in Canada.
“There’s one trained staff person missing in the operating room (for) families who don’t have midwives as their primary care providers,” says Romeiko. “There’s no one there to receive the baby, be responsible for (its) well-being, assess (its) transition to breathing, or make sure (it’s) held in a safe way and kept warm in the cold operating room.”
Moreover, C-sections are often done in emergencies when the doctor is worried about the newborn’s condition.
“In those situations, you don’t want the baby on the mother’s chest,” says Barrett. “You want (it) on a resuscitare. There are many C-sections where (skin to skin) is not appropriate. You can’t do it in every caesarean.”
The safety of the skin-to-skin C-section will have to be confirmed in Canada before national policies will change, says Barrett. This is why he is working on a qualitative study that will look at the surgical childbirth experiences of 15 women by comparing their perceptions of the standard method to their skin-to-skin experiences.
“As long as there’s manpower and no concern to baby, this could be, and should be, the standard in suitable cases,” he says. “There’s no reason not to as long as we prove that it’s safe and that the baby has the benefits of skin-to-skin contact, especially if it’s a better experience for the mother.”
Connors is sure Canadian women would prefer this method if they had a choice, although she questions whether they really do.
“I believe any woman would choose this way over a normal caesarean if they (could), but I don’t think they (can) because Dr. Barrett is booked up and he’s the only one doing (skin-to-skin C-sections) right now.”
But it’s only a matter of time before skin-to-skin becomes the standard, as well as a choice for Canadian mothers, says Romeiko.
“A psychological or cultural shift within the obstetric and anesthesia world to promoting a more humane type of birth (is happening),” she says. “It is a surgery. There’s no getting around that. But, it’s not an ordinary surgery (and) there are ways to make it more humane that are still safe.”
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