Posts Tagged ‘C-Section

Recently, I was talking to one of our Healthy Mother Labor and Childbirth program participants who had gone to her parents’ house in Kerala to spend the rest of her pregnancy. During a routine check up at the local hospital four weeks before her due date, her baby’s heart rate was seen to be fluctuant, accompanied by significant decelerations. Her OB suspected that there may be cord entanglement, and immediately admitted her to the hospital. With severe decelerations of the baby’s heart rate continuing, her doctors  decided to immediately take her for an emergency C-Section. Soon after her delivery, the doctors found that her baby had significant difficulty with breathing, and the pediatrician counseled the parents to admit him to the Neonatal Intensive Care Unit (NICU).

However, neither the hospital in which the baby was born, nor any other hospital in the vicinity, had NICU facilities. Thus began a ten day emotional and physical rollercoaster ride for mom and dad. The baby was shifted to the nearest hospital with NICU facilities, which was about 6 hours away. Mom could not be discharged from where she was for the next 3-4 days, and baby was 6 hours away in NICU. Dad shuttled between the 2 places daily, until mom was finally discharged and was able to see her baby. In adition, the hospital practices where the NICU was located were not mother-friendly, so mom was not allowed to touch or hold her baby for several days. She could only see her baby from outside the glass walls of the intensive care unit.

Finally the baby was discharged from the NICU in good health, and as I write this mom and baby have been at their home for several days, and both are doing well. Since the mother had continued to pump breastmilk while her baby was in the NICU, she is now nursing her baby without much difficulty. Way to go, mom!

As I was speaking to this couple, I thought I would re-emphasize the importance of choosing the right hospital for your baby’s birth. Not only is it important to choose a hospital that provides you with the best possible support and care that can promote a natural childbirth, but it is also important to check whether they have good emergency backup and post-delivery care infrastructure such as NICU facilities, should your baby need it. If not, at least you should check to see whether there are hospitals in the vicinity which offer NICU facilities, so that mother-baby separation can be kept to a minimum. Over and above this, there are several questions that you need to ask of your doctor and/or hospital, so that you can ensure the best possible birthing experience for you and your baby.

The Coalition for Improving Maternity Services (CIMS) is doing a remarkable job of advocating mother-baby friendly practices in US hospitals and medical facilities . I have adapted some of their recommendations in a document after making them relevant to the current Indian conditions. You can download the document here (Points to consider about your hospital).

In my next post, I will write about how Lamaze is helping women and their families in rethinking the different aspects of labor and childbirth.

Dr. Vijaya Krishnan

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December 19th, 2008: I had known this mom since her 4th month of pregnancy. She had joined one of our antenatal programs early, since she knew she would be traveling to her hometown of Assam, in northeastern India within the next couple of months and would remain there for her delivery. However, the very next week she was discovered to have placenta previa and was put on complete bed-rest. After a month and a half , she was allowed to be up and about, as her placenta started to pull itself up. Mom and dad finished the rest of their sessions and headed for Assam. After the 7th month, mom started practicing her birth fitness exercises – by this time placenta previa was no longer an issue. She continued to remain in touch with me after every OB check up, and was waiting for labor to start on her due date of Dec 14th.

Dec 14th and went, and there were no signs of labor. On December 18th, mom was admitted to the hospital and was started with gel priming and induction protocol. Since her cervix was not ready to begin with, even after several hours of induced labor, it could finally open up to only 1-2 cm when her baby’s heart rate started to show decelerations. Finally, on December 19th a healthy baby boy weighing 3.5 kg was delivered via C-Section.

Lessons learnt: In this case, mom’s delivery was done by a family member who is an OB. Mom felt that she did not have much say in the process. In my opinion, waiting for labor to start on its own would have been the ideal plan of care, especially considering that mom and baby were both doing fine. Since natural hormones had not yet started to cause the cervix to ripen and be ready for birth, induction failed, leading to a C-Section that could have potentially been avoided.


  • Current practices in most hospitals in India separate mother and baby after birth. After a normal delivery, hospitals should follow evidence-based and WHO recommended guidelines to allow mother and baby to be in skin-to-skin contact, and encourage the practice of nursing within the first hour of birth. The American Academy of Pediatrics also strongly advocates starting breast feeding within the first hour after birth.
  • In case hospitals feel the need to clean and dry the baby (mother’s skin happens to be the best body warmer for baby), they should at least not clean the insides of the baby’s fists. In my experience, minimum baby care procedures, pediatrician checks, Vit K injections etc, should not take more than 20 minutes. The staff should then hand over the baby to mom to start the process of mother-baby bonding and breastfeeding.
  • Research has also shown that swaddling a newborn is not really needed. Although it is common practice for baby’s comfort, swaddling appears to be counterproductive when breastfeeding. It seems to calm the baby down so much that he sometimes forgets to nurse, and has to be repeatedly reminded physically to restart suckling. Research2 has also shown that babies who are tightly swaddled have more weight loss, three days after birth. Feeding cues are best when the baby is not swaddled, or is lightly wrapped, and in skin-to-skin contact with mother.
  • In case of a C- Section, hospitals can follow similar procedures. They can provide continued analgesia to mother, but not sedatives or narcotics immediately after surgery, so that mother-baby contact and nursing can begin within, or as close to the first hour as possible. We at Healthy Mother teach alternate holds and positions for good latching in case mom’s surgical pain is hampering her from using traditional positions for breastfeeding.
  • Recent research1 has also shown that the optimal position for the release of primitive neonatal reflexes that stimulate breastfeeding is a semi-reclined position for mother and not flat on her back. During the Lamaze International Conference held in September 2008, I saw repeated evidence of the benefits of the semi-reclined position in research shown by Dr. Christina Smillie, an authority on Breastfeeding Medicine. I have since adopted this technique for nursing initiation by the infant in two moms. These moms were unable to nurse their babies without pumping or artificial nipples, due to ineffective latching by their babies. It is important to note that both moms had undergone C-Sections. With patience, and good positioning, both these babies were able to latch on – one after 8 days of birth; one after 20 days of birth. Both of these infants are now nursing well, and moms are enjoying their nursing sessions.
  • Current hospital breast feeding techniques are aimed at teaching mothers, not allowing babies to learn. Mostly, I see what Dr. Christina calls “Ready, Aim, RAM”. This leads to no or poor latching, tight painful grasp or bite, suck dysfunction and eventually feeding shutdown. On the part of the mother, there are sore breasts, feelings of distress for their infants, and eventually premature weaning or initiation of “top-feeding” or supplementing with artificial milk substitutes.
  • Babies breastfeed, not nipple feed. Baby should be able to have chin-to-mom’s breast contact, naturally. Mom should be encouraged to keep her baby’s hips and shoulders well supported, and use minimal support around the neck. She must be shown the value of a slight head tilt for baby as he tries to latch on. She should be encouraged to talk, stroke and have eye-contact with her baby. All this will ensure good latching and a pleasant experience of nursing for both mother and baby.
  • Mother should also be told that if she experiences pain, however minor, during nursing her or her baby’s positioning needs to be readjusted. Pain at nipple indicates poor milk flow, and a crushed nipple. She should be shown and allowed to try a variety of positions, including reclining, with her newborn placed on his stomach vertically at her chest. This position has been found to be more beneficial in helping baby to self-initiate latching versus the traditional “horizontal cradle holds”..
  • If baby has experienced distress at breast, and his breastfeeding experiences have not been great in the first few hours and days after birth, and/or he has been bottle fed, he will be seen to cry and arch away from the breast whenever it is offered. It is still possible to re-initiate nursing with patience and encouragement of all involved. Let the baby be skin to skin with the mother before every nursing. Let him realize that mom’s breasts are an area of comfort, not distress. In the meantime, keep pumping and feeding. Slowly, but surely, after a few of these trials, they baby will gravitate himself toward the breast and latch on. I have been honored to help some of my post-natal moms with this, and know the power and joy that it gives to mom when she experiences that first true suckle and nursing by her baby!
  • Breastfeeding takes time and adjustment in the first few hours and days after birth. Please know that there is always help available in case you are having problems with nursing. Contact your doctor/hospital if there is any soreness or inability to nurse your baby even after you get home. In many parts of India, lactation consultants (wet nurses) may be available to help you through this phase. Do not initiate bottle feeding, if necessary use a breast pump and feed with a spoon. Breast milk has about 200 compounds that until today, no artificial milk substitute or formula has been able to replicate. Sometimes, the road to nursing effectively may take a longer time, but remember that with patience and confidence, you can do it, and can ensure lifetime benefits to your newborn.

Here are some sites on the Internet where you can get good information on breastfeeding:

www.workandpump.com Along with great information, this site also has a link to Dr Jack Newman’s breast feeding clinic. Here you can view some great clips on good positions and holds that help with breastfeeding

www.kellymom.com Another great source for good all round information on breastfeeding as well as post-partum concerns

How have your experiences with breastfeeding been? I would love to hear your stories, comments, questions and concerns. I am always available if you need advice, references, or support for your breastfeeding issues.

References:

  1. Colson SD, et al. Optimal positions for the release of primitive reflexes stimulating breastfeeding. Early Human Development 2008, Jul;84(7):441-9
  2. Bystrova K, et al. The effect of Russian Maternity Home routines on breastfeeding and neonatal weight loss with special reference to swaddling. Early Hum Dev, 2007;83(1):29-39
  3. Smillie, CM. Baby-led latching: A neurobehavioral model for how infants learn to latch on. Plenary Session Invited Lecture at Lamaze International Conference, September 14, 2008.
  1. Smillie, CM. Baby-led breastfeeding: the mother-baby dance. DVD.2007. Los Angeles: Geddes Productions.

Just yesterday, I got this email form one of my recent class participants. This mom-to-be has just finished her sessions, and in the meantime, visited her friend who has recently given birth in one of Hyderabad’s “super-specialty” hospitals. I am quoting her verbatim (with her permission) below:

Dear Dr,

One of my friends recently delivered at xxxxxx Hospital which I wanted to let you know so that you can share this with women who might be considering this hospital for their delivery. (My Note: For those of you who wish to know which hospital it is, please write to me and I will let you know).

My friend’s water broke at 3:30am on Friday morning and she rushed to the hospital since the baby’s head had not engaged and was in transverse position. She was informed that she would have a c-section delivery. Since the doc had a planned c-section her FHS was monitored and she was finally operated at 12:30pm at which time there was not a drop of amniotic fluid left.

She is then blind folded and given an epidural. The baby is delivered and she is informed that it’s a boy while she doesn’t get a chance to see him. She can only hear the doctors and nurses speak and hear her baby cry. She is then shifted to an ICU where she is kept for 1 day for monitoring. Baby and mom have not been in contact for 1 whole day.

On day 2 she is shifted back and is given pain medications and is asked not to feed the baby since she is taking medications. Baby is brought from the nursery and shown to the mother on day 2. Mom is finally allowed to feed her baby from day 3 after the IV and pain medicines are stopped. Obviously she has issues on day 3 feeding her baby since for 2 days he was on bottle feed. I visited her on day 3 and did teach her some techniques that I learnt in class – about the latch, and the football hold which did help her to some extent.

I remember you mentioning to us during the c-section class about blind folding and both Divya and me were shocked. To see that this is being practiced in a “good” super specialty hospital is unbelievable!!  I hope no mom has to go thro’ this – not being able to see your baby for 1 day and not being able to feed your baby.

Reading this mail, I was shocked too. Even though I have seen such questionable procedures practiced during C-Section surgery and during immediate post-surgical recovery, hearing that mom and baby were kept apart for one whole day, made me quite upset. The fact that the baby was not allowed to nurse until the 3rd day was a shocker. It is no wonder that breastfeeding becomes a big concern, and that many first-time mothers are unable to breastfeed well and eventually give up nursing their babies, especially after a C-Section.

So what are the factors that promote effective breastfeeding in the first hours after birth?

I will be writing about this and many more aspects of successful breastfeeding, over the next couple of posts. In the meantime, if you have any questions, concerns or experiences to share, please do write in.

Dr. Vijaya

A lot has happened this past week and I thought it would be good to put down some of the happenings for future reference, both for myself and for my moms and dads.

Firstly, two new babies joined our growing Healthy Mother family. The first baby, was a healthy baby boy, weighing 3.5 kilograms. Mom had a normal delivery. Mom went into labor around midnight, and labored at home until about 8 a.m. next morning. She reported that her contractions were about 15 minutes apart and were very manageable with breathing, relaxation and active movements/upright labor positions. She went into the hospital when her contractions were about 6-7 minutes apart (we had discussed this in our sessions as a part of her birth plan, since she lives very close to her delivery hospital). After active labor of about four and half hours, she was fully dilated, and had her baby within the next half an hour (transition and pushing together lasted for half an hour).

She did not need any pain medications, and was able to manage the active as well as transition stage with focused breathing and good labor support. The only medical intervention that she needed was 1 bottle of glucose/saline drip for hydration, since she was vomiting during her late active stage. She was able to nurse her baby within one hour of her baby’s birth, and continues to nurse her baby exclusively. Way to go, mom!

This birth, highlights to me all that is crucial for a normal birthing experience. Mom was religious in practicing her birth fitness exercises from 7th month onwards. She used all the labor positions and breathing techniques to get her through her labor pains. She had the knowledge, confidence and labor support (from her family) to let her body do its work of birthing. And finally, both she and her obstetrician had patience and confidence in mom’s ability to give birth naturally. It worked, because it was allowed to work!!

Our second baby girl, weighed a healthy 3.4 kilograms, and was delivered by C-Section, due to multiple high risk circumstances. When mom checked in to her hospital, she was having labor pains, and was 1 cm dilated. However, she was found to have high blood pressure. Further, even after Pitocin administration, her labor failed to progress efficiently, and a subsequent decrease in fetal heart rate was noticed. At this point, it was decided to go in for a Caesarean Section, in order to avoid further complications and risk to baby and mom. When the baby was delivered, she was also found to have the umbilical cord around her neck.

What do we take away from this? Medical procedures can sometimes be life-saving for baby and mom. Surely a normal delivery would have been preferable, but in this circumstance, the risks outweighed the choice of a normal delivery. With outcome priority being a healthy baby and healthy mom, delivery by C-Section was the only option. At parents’ request, I did do two post-partum visits with them, mainly to establish a good nursing relationship between baby and mom, as well as for post-partum/ neonatal care. Baby and mom are both doing fine as I write this piece. Congrats to new mom, dad and family!!

In addition to these wonderful babies, I had a host of concerns and queries from my moms-to-be. Some of them were easily addressed; others seemed to require a lot of intervention, rest and consultations in order to deal with their concerns. One such concern came form a mom who was diagnosed with a cervical shortening at 34 weeks. This can become a risky situation, and can cause preterm labor. I will address this condition in detail in my next post.

Until then … take good care of yourselves. As always, write your queries, comments, thoughts or questions that you may have.

Dr. Vijaya Krishnan

One of the oft repeated questions that would-be moms in my ante-natal programs ask is: What is the chance of my having a Caesarean Section (C- Section), and will I be able to deal with it?

While this is not an easy question to answer, research, clinical studies and reported rates of C-sections in hospitals across many countries show that the most common reasons for Caesareans are:

  1. Failure of labor to progress, due to improper positioning of the baby’s head, as a result of which the baby’s head appears too large to pass through the pelvis
  2. Breech positioning of the baby, i.e., when the baby is positioned to come out feet, knees or buttocks first.
  3. Fetal distress picked up by electronic fetal monitoring.
  4. Amniotic fluid tinged with meconium (the baby’s first stools), when the bag of waters is ruptured. Under these circumstances, some obstetricians may also choose to speed up labor by using a drug called Pitocin first, and then opt for C-Section, if the labor still does not progress satisfactorily.
  5. Maternal diseases such as active herpes, severe hypertension or kidney disease.

Sometimes, C- Sections are planned to avoid the pain of labor, or because they can be conveniently scheduled. While one cannot avoid C-sections done in medically necessary situations, it is important for would-be moms to know that a Caesarean is a major surgical operation. It takes at least six weeks to recover and involves cutting through abdominal muscles that tend to bulge and sag afterwards. When these muscles are then not properly strengthened after recovery, it is likely that the woman may suffer from backache at a later stage.

In the US, the most usual reason for a Caesarean is diagnosis of prolonged labor. However, many studies have found that a long labor does not necessarily mean that there is anything wrong. In fact, when women in long labors were cared for by family members and labor support persons, and when they managed contractions throughout labor with breathing, massages, and were well hydrated, they were likely to have a normal birthing experience. If everyone is patient and has confidence in the mother and her body’s ability to give birth, the mother is more likely to deliver normally, with better outcomes for both herself and her baby.

What can you do? Wellness and birthing programs such as Healthy MotherTM are a good option to enroll in. Remain active throughout your pregnancy. Follow the exercise programs and practice the positions that are recommended and taught to you in your childbirth education program. Some of these exercises and positions, actually assist in helping the baby settle into your pelvis and moving the baby down the birth canal, once your labor starts. This in turn, facilitates labor and reduces your pain perception. Along with the breathing and relaxation techniques that you have learnt, you are then able to handle the labor pain with more confidence and ease.

Learn as much as possible about what birth is like in the hospital or health care facility that you have chosen. Pregnancy wellness and childbirth education programs such as Healthy MotherTM, provide you information about various aspects of medical interventions during labor including Caesareans, and engage you in conversations about pain relief in labor. They empower you to talk to your obstetrician about your preferences, and to ask them about the possible advantages and disadvantages of any recommended medical procedures, including Caesareans. Let your obstetrician know, that if a Caesarean does become medically necessary, you would still like to be involved in the decisions regarding your care, as much as possible. Understand that even with the best planning and care, labor and birth do not always go as expected. Under these circumstances, a healthy baby and healthy mother become the most important outcome. Once you are mentally prepared, you will perhaps feel more in control of the circumstances surrounding the birth of your baby, and be able to celebrate the most important event in your life.

As usual, please send in your comments, questions or experiences.

Dr. Vijaya Krishnan

Our older son turned 10 the other day. Phew!! it has been an exhilarating, and fulfilling 10 years.While I was carrying him we did not know much about what childbirth entailed, both from a physical and psychological perspective. Though our doctor and nurses at the Southern New Hampshire Medical Center (in Nashua, NH, USA) were very helpful, actually experiencing those emotions and physical changes was nothing like what we had heard and read (especially in books such as “What to expect….”).

After our older one was delivered via emergency c-section, I was determined to have our next child the normal way. Believe me, it took a lot of effort in terms of being mentally and physically prepared. But I finally succeeded with our younger son. We now have two adorable and active kids who are a constant source of joy.

As I started to practice physical therapy again after our older son was born, I had a chance to work a lot with mothers-to-be. That kindled an interest in applying my training to helping would-be-mothers to prepare for the childbirth process and to help them understand that it is a normal process.

All expectant parents want the same thing: a healthy baby. But, what are the steps to having a healthy baby? The Healthy Mother(TM) Program believes that a healthy baby begins with a healthy pregnancy and normal birth. It builds upon the well-established principles of Lamaze International to promote, support and protect normal birth through a mix of hands-on wellness programs, as well as by providing reliable, vital information to expectant parents about what is perhaps the single-most important event in their life.

Childbirth is a wonderful, joyous journey. When parents are prepared and well-informed about this natural process, the woman’s confidence in her ability to go through labor and childbirth increases dramatically, and she is able to enjoy this incredible phase in her life!

Watch out for my next post on early pregnancy. Until then, feel free to join in, and discuss anything that’s important to you about your pregnancy and childbirth. Share your experiences and ask questions. I will try to answer as accurately as possible.

Dr. Vijaya Krishnan