Why you should always have a plan C (for caesarean) in your birth preferences

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When I support couples antenatally, I always encourage them to write a birth preferences document. I do not like the word “plan” because if a plan goes to pot, then you’ve left with nothing (I love this article on the topic).

I liken writing your birth preferences to going out for diner in a restaurant: you need to see what’s on offer before you can decide whether you fancy a set menu, a la carte, or just a starter and a pudding. If you don’t see the menu, you just get given the dish of the day, which might not suit your tastes at all.

Similarly, I like to remind parents that the people working in the restaurant are there to serve them, not to serve themselves.

I sometimes meet resistance from parents who say that you cannot plan birth, and that they would prefer not to have one in case they end up disappointed. I understand that point of view, which is why I like to suggest to parents that they have a plan A, a plan B, and a plan C, as part of their birth preferences. It isn’t a box ticking exercise by the way, it is the process of thinking about all the options and writing them down which is useful. The midst of labour, when you might have been awake for hours and maybe stressed as well as tired, isn’t the best time to weigh up options about interventions you have never heard about.

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It also helps your medical caregivers, who you will be meeting for the first time during your labour, to establish rapport with you and know how best to support you.

Again going back to the restaurant analogy, if you came to dinner at my house and you hadn’t told me you were vegetarian, and I had cooked a beef stew, this wouldn’t be great for you, but this wouldn’t be comfy for me either.

So plan A might be your ideal birth scenario: for example a natural birth, in a low key tech environment (home or a birth centre), using a birth pool and/or relaxation and breathing techniques for comfort (this is just an example by the way-I have been in the birth field long enough to know that birth prefs are like marmite and that one woman’s dream plan may be a low key vaginal birth and another a planned caesarean, and this is totally fine by me).

Plan B might be looking at things like: what if your labour is induced, what if you have complications that require you to be in the obstetric unit and have constant fetal monitoring, what if you need an epidural, what is your baby needs instrumental help being born. By looking at the interventions and the scientific evidence behind them you will truly be able to make an informed decision about what is right for you.

Plan C covers what you might want to think about if you baby needs to be born by caesarean, be it planned or during labour (the term “emergency caesarean” is the biggest misnomer of all times-it conjures an imagine of blue lights flashing and medical people running down corridors, when most of the time(crash sections are very rare) is it decided calmly and takes more than 30 min or so to setup-it should really be called an “in labour ” caesarean), what may happen in the few hours after birth and what recovery might look like. Again there are many options, for example you can ask for the cord clamping to be delayed so that your baby received an optimal level of blood, you can have skin to skin in theatre and even feed your baby then if you want to. This is known as a “natural caesarean” (watch the video here, and here is a brilliant natural cesarean birth preferences blog post by doula Lindsey Middlemiss) and if you do not know about it then you might be given the type of caesarean that your obstetrician is used to performing, which might be different.

It is something I find tricky to navigate and completely follow the couple’s lead, because I am also aware of the school of thought that by talking about interventions, you are also prepping your mind for it (if I say “don’t think of a tree-what pops into your mind?), but I am also aware that our current maternity statistics have very high intervention rates (the UK caesarean rate for 2014/15 is 26.5% which means that 1 in 4 woman is likely to have a caesarean), and that it is therefore realistic to prepare for this eventuality.

I remember supporting a couple who had planned a birth centre water birth. When after pushing for a long time there was no sign of baby and it became obvious baby needed to be born by caesarean, they had a part of their birth preferences covering that. They had the kindest doctor, who took the time to read their preferences and facilitated most of it. Later on the mother told me how much she had hated writing this part of the document because she didn’t want to entertain the idea that her baby would be born by caesarean , but that when it came to it, she felt that she had a positive birth experience because of it.

The main reason behind the planning and the thinking is that research shows that it isn’t how the birth unfolds, it isn’t how the baby ends up being born that makes a positive birth experience or not. It is HOW THE PARENTS WERE MADE TO FEEL during the experience. The parents who feel respected, treated with kindness, and with whom the decision making process is shared with their medical caregivers, tend to have a positive birth experience regardless of the process.
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