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Maternal Assisted Caesareans - Another exercise in critical analysis

by lizzi (follow)
Helping plant the seeds of positive birth. www.sproutbirthing.com.au
Birth (105)     
There have been two very recent stories getting around about maternal assisted caesareans (MACs) which happened here in Australia. Every single birth group and page that I am on has been sharing both stories – even the anti-natural childbirth group! It seems that the promotion of MACs suits everyone’s agendas; as much as it is an oxymoron, everyone likes this idea of a “natural caesarean”.

I am excited that these women were able to have more positive caesarean experiences; in fact, one of these women is a friend of mine, which adds further reason to my excitement. The photos of the second of these women who meets her baby with tears of joy are just amazing and beautiful testaments to the power of motherhood. These stories are every bit as amazing and beautiful and powerful as any birth story – as well they should be, because meeting your baby for the first time should be a special and beautiful moment no matter how or where it happens. And, these MACs should be celebrated for precisely that reason.



Mushroom
Meeting baby for the first time should always be beautiful no matter where it happens...even in a war zone. Image courtesy of Wikimedia Commons.


So, in amongst all the jubilation and excitement, why do I feel like the stick in the mud?

Here’s the thing – this social media interest in MACs isn’t just in the sharing of these women’s beautiful stories and photographs. Instead, these two births are being celebrated as an amazing new technique for the modern era and, in more woman-centred dialogues, as another awesome birth option for mums.

As much as additional birth options are good, it pays to put them into the big picture and assess them critically before jumping on board. MACs aren’t a “third birthing option” as I read somewhere. They aren’t an “alternative to vaginal birth and caesarean birth” - MACs ARE a caesarean. They are an alternative to a standard caesarean, but just as a waterbirth is still simply a vaginal birth an MAC is still simply a caesarean. An MAC comes with all the same risks as a standard caesarean and many commentators seem to be forgetting that it is still major surgery.

I’m really concerned about the number of women who are saying what a great option this is. That if their VBAC doesn’t work out, they will be asking for this. What an awesome option this is for those women who do genuinely need a caesarean.

My problem with this is the very large number of women who are going to be disappointed when they find that this simply isn’t an option for them. For a start, very few care providers and hospitals are going to be okay with this option. And, if you don’t feel comfortable going in to fight for a VBAC (which is a relatively common birthing option) do you really feel that fighting for an MAC, a procedure that is seen as very new and risky, is going to be easier? It can require talking to heads of obstetrics and anaesthetics at the hospital you plan to use as well as seeking second opinions from other hospitals. My friend needed to work hard to be able to welcome her babies via an MAC. She needed to negotiate and research and fight. It was tough to get her care provider on board, but she had gotten a care provider on board for a VBA4C in the past…so she was certainly up to the challenge of high level negotiations. Most of us have trouble negotiating such common things as no vaginal exams or no continuous monitoring – an MAC is going to be a much harder negotiation.



Mushroom
Image courtesy of Wikimedia Commons.


And then there is the question of just how negotiable this is. If the OB or hospital say no it is going to be exceptionally difficult to force them to perform the procedure. There is much precedent for women to decline procedures but to be unable to force a provider to perform a procedure that they are not comfortable to doing. A prime example of this is induction of labour - many women decline this procedure but find that if they want this option they need to find a care provider who is willing to perform it. And while a doctor can say that they will not attend a vbac, a vbac can still happen without them present – for example at home, or with a midwife or in the car on the way to hospital. An MAC requires that an OB is present. The care provider needs to be willing to perform it. Therefore it’s not really a “negotiation” or a tool of empowerment. The woman still has to ask if she is allowed and the doctor holds all rights to say no. The power still rests with the care provider and hospital.



Mushroom
The power still rests with the OB and hospital. Image courtesy of Wikimedia Commons.


The other reason this won’t be available for a huge number of women is that the number of women it is appropriate for will be quite low. It cannot be done as an emergency surgery. So you can’t fight for your VBAC and then choose this if your VBAC doesn’t work. In order to be able to have an MAC as an option you will need to forgo trying for a vaginal birth. If you are 24 hours into labour with an epidural already placed an MAC is unlikely to be a suitable option. For a start – you need to be able to “scrub in”. Any hands going that close to an internal incision in your body NEED to be sterile. Getting sterile and maintaining a sterile field while in active labour is going to be tricky and I can’t see many surgeons being willing to take that risk.

I would also hypothesise that if there are health concerns for either Mum or Bub then the surgeon is not going to be okay with adding to the risk. And putting another pair of hands in and around the incision adds to the risk. I’m not convinced that it adds greatly to the risk of infection, although another set of hands is another opportunity for a bug to get in. However, you know what too many cooks does? That’s right. Putting another pair of hands in and around a delicate operation increases the risk of an accident happening. My highly skilled surgeon managed to give me an accidental additional vertical tear in my uterus during my caesarean – I shudder to think of the increased risks of these types of accidents during an MAC.

And then we get to my biggest fear in regards to the wide promotion of MACs. The potential for misuse and coercion. So many women are already told that their “just in case” caesarean plans will only be allowed if they consent to an elective caesarean. They are told that skin to skin and breastfeeding in the OR, having a doula or photographer present or delayed cord clamping can only be allowed if the woman consents to book in an elective caesarean. Despite the fact most emergency caesareans aren’t actual emergencies and these things can often be accommodated.

I’m an incredibly cynical person, but I see MACs being of more benefit to private OBs than to the women they are supposed to be serving. We have already seen cases of private OBs “selling” caesareans as the safest and best way to birth for all women. Now they have an even bigger argument for them. Because why would you want to potentially go through days of labour only to end up with a standard caesarean when you could book in and have this beautifully planned birth? It’s still not hugely common for women who have a vaginal birth in hospital to pull their babies up from their body and onto them, but this is “guaranteed” with this type of surgical birth.



Mushroom
Caesar's Mushroom. Image courtesy of Wikimedia Commons.


Sadly a lot of women don’t realise that there are NO guarantees with birth. I assisted a woman in putting together an elective caesarean birth plan because her OB had told her that her vbac would fail and this way they could plan a more pleasant birth. For her “positive, healing birth” it took six goes to get the spinal in and by that stage the woman was in so much pain she was throwing up on herself. Her baby was taken immediately to the NICU for breathing difficulties. Which brings me back to my first point. An MAC or any elective caesarean is still a caesarean. It is still major surgery and it still comes with the same risks. You still need an epidural or spinal which carry their own sets of risks. You could still have bleeding issues and require a transfusion or hysterectomy. The baby can still be cut by the scalpel. And the baby can still have the breathing difficulties that are more common when born by pre-labour caesarean. And given that women will be more keen than ever not to go into labour and miss out on their opportunity for an MAC, I am going to take a guess and say that these surgeries will be planned earlier than usual, thereby increasing the risks of iatrogenic prematurity.

These types of caesareans could be a great option for the small number of women for whom they are appropriate. They need to be on the landscape and women and hospitals need to be aware of how to make these available and as safe as possible. I can see MACs being of great benefit to women who are choosing a caesarean due to a history of sexual abuse or past birth trauma. Or for women who have non-emergent health conditions requiring that they not go into labour. I might even suggest that the emotional and mental health risks for an MAC would be lower than a standard caesarean and that, for this reason alone, they are certainly worth looking into. But, the number of women this will be an option for is significantly smaller than we are led to believe. And promoting them as a brilliant birthing option for all women need a caesarean is dishonest and misleading. As always a little critical thinking goes a long way.

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