Ep. 48 Gentle Cesarean

by dsadmin | Dec 14, 2017 | Podcast Episodes

December 14, 2017 · 57 minutes · Episode 48

About this episode

Sponsored by SleepnFeed. It’s the new multi-functional baby nesting system! It’s both a nursing pillow and bassinet in one, great for newborns all the way up to one years old. Try it today for at home or on the go! Dr. Emiliano Chavira, an OBGYN and Maternal Fetal Medicine specialist engages in the topic of cesarean birth including how the procedure is done and how women can make the experience more birth centered rather than surgery centered. 

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Key quotes

“And so I think what we have to learn to do in medicine is to appropriately apply protocols Where they're doing a lot of good and generating, you know good outcomes in generating safety and then on the other side keep our humanity and Individualize things and make exceptions when exceptions are appropriate flexibility or its flexibility So we have to learn how to apply this, you know artfully”

“So there's a period of separation between mom and baby that I think, you know, historically within the maternity care system, this has not really been thought to be a thing or an issue or a problem.”

“the requirements are that The team has to believe that this is a worthwhile thing to do and they have to be willing to do it That's really all you need. You need a mom and you need a baby And you usually have those two, you know two when you're doing a cesarean so it really is skin-to-skin, it's just a matter of of willingness and Think there are certain things that the anesthesiologist can do like the little sticker tapes for the EKG instead of putting them on”

“they are super routine most you know obstetricians have done hundreds and hundreds and hundreds of cesareans these days they have become incredibly safe and I think if you you really can I mean you can you can turn it”

“in my mind, when I remember, uh, you know, this, this, uh, this C-section, I, like, I have this image in my mind of there was a disco ball. I don't, I don't think there was a disco ball, but I sort of remember it like there was a disco ball. And, you know, it was just this really kind of fun, joyous, um, event. And it was honestly, as much as I,”

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Transcript

AI-generated transcript with speaker labels — may contain errors, especially names and medical terms. Dr. Elliot Berlin, DC appears in blue; Dr. Emiliano Chavira and Candice in orange.

Dr. Elliot Berlin, DC [0:12] Welcome to the Informed Pregnancy and Parenting Podcast. I'm your host, Dr. Elliott Berlin, and today we're talking about the concept of a gentle cesarean birth and about microbiome seeding. I have two really special guests in the studio today and I deeply appreciate both of you in general and especially for joining us for this topic tonight. You may recognize Dr. Emiliano Chavira from our episodes called Breach 101.

Dr. Emiliano Chavira and Candice [1:00] Hi.

Dr. Elliot Berlin, DC [1:01] Hey, welcome back. And preterm labor. Dr. Chavira is an obstetrician and maternal fetal medicine specialist. Welcome back to the program.

Dr. Emiliano Chavira and Candice [1:12] It's great to be back.

Dr. Elliot Berlin, DC [1:14] Also tonight, we have two guests in one. Candice is expecting her first baby and due in about a month. Candice found out a few weeks back that her baby is in a breech position and so far hasn't budged. Candice had planned for an all-natural birth but now is having to give thought to a cesarean birth if your baby stays breech. Thank you for joining us tonight.

Dr. Emiliano Chavira and Candice [1:35] Thank you for having me.

Dr. Elliot Berlin, DC [1:37] So how long ago did you find out your baby was breech?

Dr. Emiliano Chavira and Candice [1:40] Two weeks, yeah, 34 weeks and I'm 36 weeks now.

Dr. Elliot Berlin, DC [1:46] And what kinds of things have you done to try to change that?

Dr. Emiliano Chavira and Candice [1:52] So many different things, working with you, of course, acupuncture, moxibustion, standing on my head for half of the day, drinking a ton of water, I'm trying it all and I potentially will be doing a version in a week as well.

Dr. Elliot Berlin, DC [2:12] The external cephalic version?

Dr. Emiliano Chavira and Candice [2:14] Yes.

Dr. Elliot Berlin, DC [2:15] Okay, so what kind of birth, I mean, now your choices may become more limited. I always, it's funny to say that with Dr. Shavir here because he's one of the last Mohicans who still delivers breech babies vaginally around here. But if your choices do become limited, you may be looking at a cesarean birth, right?

Dr. Emiliano Chavira and Candice [2:35] That's correct.

Dr. Elliot Berlin, DC [2:36] And I know for you, that's not what you were planning for. What was your original plan?

Dr. Emiliano Chavira and Candice [2:41] My original plan, being someone, I was trying not to plan too much. I was like, go with the flow. The only thing I don't want is a cesarean. That was basically it. I wanted to go as natural as possible. I was open to an epidural. I wasn't like going to tell myself, no matter what, you can't do an epidural, but I wanted to try doing it without. I just really didn't want a cesarean, to be honest.

Dr. Elliot Berlin, DC [3:07] How come? Why?

Dr. Emiliano Chavira and Candice [3:10] First of all, I'm fearful of surgery, the recovery, the pain, and then secondly, I wanted to have almost like a spiritual experience with birthing a child. I only planned to have one, and I'm a natural girl. I do everything holistically and naturally, so I just felt really comfortable doing that.

Dr. Elliot Berlin, DC [3:38] That's a great birth plan.

Dr. Emiliano Chavira and Candice [3:41] Her birth plan? Spiritual and natural?

Dr. Elliot Berlin, DC [3:44] Yeah, everything she said.

Dr. Emiliano Chavira and Candice [3:45] It's a great birth plan. Yeah, except her birth plan only had one rule, which was no cesarean. Except it's completely, potentially out the window. Which is all parented, I think. This is what everyone keeps telling me, oh, you're just, you're baby girl is just preparing you for what parenting's going to be like, and I've been getting that line in one form or another.

Dr. Elliot Berlin, DC [4:06] Have you ever had surgery?

Dr. Emiliano Chavira and Candice [4:07] No. I've only had my wisdom teeth out. That's as far as surgery's gone for me.

Dr. Elliot Berlin, DC [4:12] How was that?

Dr. Emiliano Chavira and Candice [4:13] Well, they put me under, so it wasn't … Just the thought of being awake when the whole thing and being strapped down and I don't know, I faint when I get my blood taken. Put it that way.

Dr. Elliot Berlin, DC [4:25] Do you really?

Dr. Emiliano Chavira and Candice [4:26] I do.

Dr. Elliot Berlin, DC [4:27] No, I thought I was the only one, so I feel better now.

Dr. Emiliano Chavira and Candice [4:29] So this is a big hurdle for me.

Dr. Elliot Berlin, DC [4:32] Actually, it's probably not as startling when you faint when you get your blood taken, but when the big, hairy man comes in and sits down and I'm like, okay, go gentle on me, and then I get all woozy on it, it just feels a little worse. It's like that time my wife bought me professional hockey skates because they were on sale for like 80% off, and then I went to ice skate for the first time, and everybody thought, oh, that guy's going to be a great skater, and I'm clinging onto the wall for dear life. Anyway, I think that you came on a great night because Dr. Shabir is here. Yeah. And traditionally, cesarean section or cesarean birth was two things happening at the same time.

[5:16] There is a surgical procedure going on, and there is a birth going on. And I think originally, when we started doing them out of necessity, we had to focus 100% of the effort on the surgical procedure to keep the mother and the baby alive and to keep them safe and healthy because we weren't good at it. We learned a lot in the past 120 years or so. But now that it's sort of down to a science, it's possible to shift some of that attention and focus, some of that spotlight from the surgical procedure to the simultaneously occurring birth, which you said you wanted a spiritual experience. And I have the sense it is a very sacred, beautiful moment when your baby comes into the world,

[6:02] whether it's an inch higher or an inch lower. And I think that there's a lot you can do to shine the spotlight on that sacred moment and not miss out on that moment. So I would like to talk to Dr. Shabir a little bit, just procedurally, what are the steps of the cesarean in general? And then maybe we can talk about how it can be made more gentle or more sacred.

Dr. Emiliano Chavira and Candice [6:25] Sure. So let's pretend that we're not talking about a real serious emergency that's sometimes done very, very quickly. Let's say this is either a planned cesarean or maybe in labor something just not going well and we're deciding to go ahead and do the cesarean at that time, but not necessarily super huge emergency. So what usually would happen is you would have a conversation with the OB about the reason for doing the C-section and they run over some of the general risks related to surgery. And they talk about the anesthesia, which you may or may not have already. So if you're, let's say you're in labor and you don't have an epidural, then they might talk about giving you a spinal,

[7:20] which is a one shot injection in the back that puts you numb, let's say from the rib cage down, from the belly button down. Or you may already have the epidural in place and you were using that in labor and that epidural can be used for the cesarean as well. So you kind of, you have these conversations usually in the labor room. Most of the time you have one family member or a friend or somebody is gonna come into the OR with you, most hospitals in ORs allow one person. So the mom will usually go in first together with the anesthesiologist and they sit you on the table and they take care of the anesthesia part of it. So maybe they need to place the spinal.

[8:08] Or if you already have the epidural, they give you an extra dose to really numb you up for the C-section. They connect you to all the monitors and stuff. So this is to keep an eye on mom's vital signs. So they connect you to an EKG and a pulse oximeter and maybe give you a little oxygen through a face mask and kind of get you all ready to go. Then they have you lay down on the operating table and some places will kind of strap your arms down. Some won't. I think that really the concept is just to keep you from touching the sterile field. That's something I think that could be optional. Then they prepare the belly. So there's these different special soaps

[8:47] that are used to try to sterilize the skin. So they wash off the belly and then they put the drapes on to cover everything up. Historically, these drapes are usually not clear. They tend to be like a blue color and so you actually, when your head and shoulders are above the drape and you can't see anything going on below, so you don't see the surgery. You don't see the cutting. You also don't see the birth of the baby. So they get that all set up. Is the purpose of that drape so you don't see what's happening? Probably in part. The principal purpose of it is to protect the sterile field, to create a sterile field so that we don't get infection

[9:32] at the side of the incision. Okay, it's minimizing. But there's probably a secondary role of minimizing people seeing what's going on during the surgery, the assumption being that people are gonna freak out and maybe that's a correct assumption or maybe that's a wrong assumption.

Dr. Elliot Berlin, DC [9:53] Well, Candice, are you more worried about what you might see or what you might feel?

Dr. Emiliano Chavira and Candice [10:00] We're both. It depends. If I was able to feel something when I shouldn't be, then that would be. but My fear is if I see something that's Over the top or traumatic that I'm gonna faint that's one of my big fears and are all like go into like some convulsion or something and Basically kind of drop the ball on the whole situation. I'm afraid I'm not gonna be able to handle it That's one way I can describe it. Okay

Dr. Elliot Berlin, DC [10:26] Mm-hmm. So maybe not seeing it's probably good for some people Oh for sure not seeing it's good for some people and other people really want to see and I think yeah It'll be better for them to see it. Yeah. Yeah. All right, so there's a drape in place

Dr. Emiliano Chavira and Candice [10:41] so they put the drape and then usually we do One final test to make sure this the skin is completely numb. How do you do that? either you take a clamp or a pincher and you just Pinch the living daylights out of the skin and we listen for a scream. Okay, so if you hear a scream That's a positive sign that then we need to work a little bit more at the anesthesia If there's no scream, then we know the anesthesia is working got it so once we've You know assured that that the anesthesia is working. Well, that's usually when they bring the partner in We're just about ready to start. There's these days. There's also timeout procedures. So the OR Team will talk about

[11:25] You know who? This person is that we're doing surgery on they'll go over there You know date of birth medical record number what the planned procedure is all the details about you know Her specific case so that everybody's you know on board and up-to-date and has all the correct information Trying to minimize, you know surgical errors and so how long are you alone? It depends on how long it takes to get the anesthesia really cooking so, you know, it could be 10-15 minutes It could be half an hour. Just why do they want you to be alone for that? Like not be able to have your partner with you. Great question There's a there's a lot of of you know, lore out there about

[12:10] People witnessing People witnessing medical procedures and maybe not being able to handle it and you know, you hear things about like dad's fainting and So just kind of trying to minimize the the drama you get from lay people witnessing Medical stuff just to kind of keep keep a very I don't know What's the word just just a calm and and professional sort of atmosphere now? That that you know, there may be some good things about that but then it like everything there's the downsides, you know that Maybe the patient would be a lot more calm With some family in there and then maybe it would be you know, much more helpful

Dr. Elliot Berlin, DC [12:54] I mean, it seems like the separation of partner is traumatizing for the laboring mom. Yeah And it also seems like there's ways to To Well selectively so, you know figure out who's not going to do well who might really not do well by watching An epidural be placed in their partner Or or to sort of block that to some degree just like you do with the drape but it definitely seems like It could be less emotionally traumatizing if a woman can have her partner there Do they make the partner leave to do an epidural during a vaginal birth?

Dr. Emiliano Chavira and Candice [13:34] Commonly they do really commonly do so I would not say that that's a hundred percent universal, but it's very common. Okay Yeah, I remember an old Colleague of mine who used to Would tell this story about a father that that that fainted during an epidural placement went over backwards Knocked his head on the ground and actually had to go to the ER was very seriously injured And and you know, it's it's sort of those kind of horror stories that generate Policy the policy exactly. Yeah All right, so then the partner comes back in

Dr. Elliot Berlin, DC [14:14] okay, so so partner comes back in basically everything is ready to go and And then and then that's when you start cesarean. So you want to go through the procedure. Is that okay?

Dr. Emiliano Chavira and Candice [14:24] Canis yeah, I think this is good slowly become more comfortable. Yeah, I mean there there really are Just a few basic steps was the ceremony. It's a simple matter of you do an incision on the skin for the most part except for a unusual circumstances or special circumstances the the incision is horizontal and it's kind of just under the bikini line and You there's a little bit of fat below the skin so you go through these layers cutting cutting through those layers about how wide Maybe maybe something like 14 centimeters Some people make them smaller, some people make them bigger. Depends also on the size of the baby. So then you encounter the muscles

[15:17] and the most common type of incision, you don't cut the muscles, but you can imagine them, they're like a curtain. So you divide them in the midline and you pull the muscles laterally like you would be pulling the curtains open. Oh, and there's space in the middle. And there's space in the middle, yeah. And then your final layer, there's like a sac that contains all of your innards, the intestines and the livers, that's called the peritoneum. So you encounter that as your final layer. It's a very thin little layer and you pick it up and snip it with a scissor to open it and then you're in. Now you're looking at the uterus. And so the front of the uterus

[16:02] has the bladder on it down low. So usually we create a little incision there to be able to peel the bladder down off of the uterus. And then you're ready to deliver the baby. You take a scalpel and do another horizontal incision down low on the uterus. This is the most common incision done on the uterus. There's other types of incisions, but they're used in special circumstances. So for your routine C-section, you'll have this low transverse incision. And usually the right below that is a baby's head or face. Okay. So that you reach a hand into the incision and you really wrap around the baby's head and lift the head up into the incision so that it can start popping through.

[16:46] How do you know you're not cutting the baby? So you have to obviously be very delicate and ginger. So you really kind of go just a hair thickness at a time. My particular technique is, so I go just sort of layer by layer. And what starts to happen is the deeper layers start kind of bubbling out towards you. So instead of me going down deeper, I'm kind of letting the tissue come out toward me. And often what'll happen is you'll start to see the amniotic sac and you know you can kind of stop there and you just spread the muscles open. And then the amniotic sac is still intact. And then I'll just kind of pop that open with a little clamp. It is possible to cut the baby

[17:39] and that happens on occasion. So it's something that you have to be very careful about.

Dr. Elliot Berlin, DC [17:45] How long time-wise from the time you said we're ready to start the caesarean until your hand is around the baby's neck?

Dr. Emiliano Chavira and Candice [17:52] You know if you're kind of going leisurely, it's a first surgery, you're not dealing with a lot of scars. It can be five minutes. But this is the kind of thing if you have a big bad emergency, you can do most of this bluntly just with your hands and you're gonna have a baby out in 30 seconds.

Dr. Elliot Berlin, DC [18:13] Okay. And then once, no in the case of a breech baby, you're not gonna find a head down there.

Dr. Emiliano Chavira and Candice [18:19] That's what I was wondering too. What happens next?

Dr. Elliot Berlin, DC [18:22] So I mean let's talk about it both ways. When you find the head, I assume you just, you said you lift it out then you just lift the rest of the baby up.

Dr. Emiliano Chavira and Candice [18:28] Yeah, you kind of, yeah you guide the head up into the incision. So instead of pointing down toward the vagina, it's now pointing up towards the uterine incision. And usually at this point you'll take your other hand, put it on top of mom's uterus and just give some pressure and kind of push down. And that helps the baby kind of pop out. What does mom feel during that time usually? So mom can, you know it varies from case to case. Also particularly depending on which type of anesthesia the spinal tends to give you a lot better coverage. Epidurals can sometimes be a little more spotty. You might feel your body sort of being manipulated and moved around and you might feel a little tugging.

[19:16] You might feel the pressure on the belly. So there's definitely, you know a C-section is not a sensation free experience.

Dr. Elliot Berlin, DC [19:25] But I think it's the sensation of knife cutting through flesh that people are more terrifying about but that's something that I've never heard anybody say that they actually felt.

Dr. Emiliano Chavira and Candice [19:34] Yes and that's the purpose of the testing before you start to make sure there's no sensation in the skin before you start.

Dr. Elliot Berlin, DC [19:41] Okay, I have so many questions. Do you have any questions at this point?

Dr. Emiliano Chavira and Candice [19:45] Just what you asked, I'm just curious.

Dr. Elliot Berlin, DC [19:46] Oh about the breach.

Dr. Emiliano Chavira and Candice [19:47] The difference between the breach. If there's complications or anything like that. Or the different way you get them out. The breach, in theory you're supposed to deliver the breach the same way you do, you deliver it vaginally. So again you reach the hand in through the uterine incision and you'll wrap it around the baby's breach. So then the butt starts poking through the incision. In some cases, depending on the position of the baby, you might get the feet. That makes it a little easier because then you can just grab the ankles and tug and pull the baby out that way. But in my experience, most commonly, you get the butt, you lift it into the

[20:27] You may have to hook a couple of fingers around the baby's hips to start pulling through. And again, you're giving pressure on the top of the uterus to help the baby down. So as the baby's butt and legs and back are all kind of emerging together, you do it until most of the baby's body is out. And then you can start, this is much easier to see and it's kind of harder to describe just verbally, but you can start flexing the legs so that you can gently fold the legs out. So if you can kind of picture now the baby's head and arms are still inside, but the body and legs are now out. And then you rotate the baby to expose the arms and you can hook a little finger

[21:15] over the shoulders and slide down toward the elbow so that you can then draw the arms out. You rotate the baby the other way to get to the other arm. And then the last thing is the head. And usually what you do is you put a hand down under the face, put a couple of fingers on the cheekbones, and you put some pressure downward just to help the head flex and then, you know, gently draw the head out. Is the incision bigger usually commonly for just because it sounds like it's coming out in a different shape? You know, each individual surgeon will have their own preferences, but I don't know that you need to make the incision bigger because you're removing

[22:00] the same baby, you know, it's the same size whether it comes out head first or butt first, so I don't, that thought never goes through my mind that I need to make the incision bigger because it's a breech baby. Other people might have that thought, you know, I couldn't speak for everybody.

Dr. Elliot Berlin, DC [22:21] Just briefly, because soon we'll start talking about how we can make this a little more gentle, but what happens after that in terms of the rest of the surgical portion of things?

Dr. Emiliano Chavira and Candice [22:31] Okay, so the old school way is the, there's a pediatric team there present in the room. So after the baby is born, there's immediate cord clamping. The baby's passed off to the team of pediatric staff that's there in the room. So that could be anybody from a pediatrician to respiratory therapist to maybe even a neonatologist, but whoever the team is in the hospital. And they take the baby over to the baby warmer and they start doing suction and getting fluids out of the mouth and checking on the baby's heart rate and then they end up doing a whole full physical exam and, you know, looking for any kind of anomalies and checking the hips and taking their

[23:17] good old sweet time with the baby. So there's a period of separation between mom and baby that I think, you know, historically within the maternity care system, this has not really been thought to be a thing or an issue or a problem. They'll wrap up the baby and kind of bring over to mom and you get to kiss the baby on the cheek and, you know, meet the baby for a second. And then they'll take the baby somewhere. Maybe it was a nursery or maybe they go to the recovery room. Historically, you know, after c-section, there's been a substantial separation between, you know, mom and baby. And that could be half an hour. It could be a couple of hours.

[24:00] It could be, you know, a prolonged period of time. What's happening with her during that time? What do you still have to do? So then you have to remove the placenta and then… Literally, you take it out? There's different ways to do it. Some people actually just reach in and grab it and yank it out. Some people wait for the uterus to clamp down a little bit with, you know, some tension on the cord and kind of let the uterus deliver the placenta. So there's different, different people have different styles. And then you need to sew up the, the uterine incision and, and close up the abdominal wall. How long does that take? So that'll take, you know, a routine first c-section can all be done.

[24:44] Uh, not unreasonably somewhere like 20 to 30 minutes.

Dr. Elliot Berlin, DC [24:49] Oh, from start to finish, start to finish and you're out playing golf. Yeah. What, um, I w we're going to go to a break and then come back and talk about the gentle portion of this and the, and the microbiome seating. But, um, once we have you here, are there things that you do? should a mom be thinking about having more babies down the road and wanting to set herself up for vaginal birth after cesarean are there things that you can do to specifically promote that make that make her more suitable for that

Dr. Emiliano Chavira and Candice [25:23] the the major thing is that people talk about is when you close a urine incision a one-layer closure versus two-layer of stitching closure of stitching yeah and there are some you know as much as this talk is talked about if you really look closely at these studies it's not really a slam-dunk that there's much of a difference between one and two-layer closures but that being said I mean I tend to always do a two-layer closure there maybe some benefit to that maybe it makes the you don't closure a little bit stronger in preparation for the for the next layer but I I don't think it's an absolute requirement and let's say for example I had a woman who wanted to do

[26:09] a V back and we got her operative report and we reviewed it and I discovered it's a single layer closure it wouldn't hold you I would not use

Dr. Elliot Berlin, DC [26:16] that to disqualify her okay any question before we go to break no okay we're gonna take a quick commercial break and be right back with Candice and Dr. Emiliano Shibira talking about gentlesocerium birth and are continuing our discussion of gentle cesarean birth and microbiome seating with our guests imminently do mama Candice and dr. Emiliana Shavira and you I think really neatly laid out what the procedures like which in during the break Candice was saying that sort of helps to wrap your mind around it for you but then you said your other thing is like what about naturally there are things that take place that during childbirth that promote the health of the baby and what happens when those aren't there

[28:55] what can you do to help your baby stay just as healthy and then the other thing that we were going to talk about is how can we take that clinical model of cesarean what kind of things can you do to to create what Candice called a spiritual experience in childbirth even though it's just it's

Dr. Emiliano Chavira and Candice [29:14] a cesarean birth yeah you know there's people are really thinking about this a lot these days and some people are going way beyond thinking and changing the way we do cesarean deliveries and I think each one of those steps along the way you can think about it and find new approaches you know beginning with you know how you consent there there are ways to make it you know really scary and horrible and there's ways to be you know very reassuring about it when you go into the room whether we separate the woman from her support team that's something we have historically done I think that's something that we really can give some thought to maybe that can be done differently in the changing climate I

Dr. Elliot Berlin, DC [30:02] see it seems to be up to the anesthesiology

Dr. Emiliano Chavira and Candice [30:05] Yeah, I was gonna ask are there exceptions if you say, you know, I faint every time I get my blood taken It might be better. There's less likelihood of my partner fainting. You know something like that

Dr. Elliot Berlin, DC [30:15] Yeah, let's put less likelihood of either you fainting if you can stay together. That's right Yeah, and I I do see them allow that from time to time

Dr. Emiliano Chavira and Candice [30:23] Okay, so it's a conversation and also that I've requested to have my doula come in Not during the anesthesia if that's what they're saying, but just you said only one person is typically allowed in yeah

Dr. Elliot Berlin, DC [30:36] To that I've seen a couple of exceptions to that too in a you know in something that's a non-emergency Caesarian right, but it also seems to be up to the anesthesiologist. Yeah, who's allowed to come in there?

Dr. Emiliano Chavira and Candice [30:50] Yeah, they they they control a lot of what goes in goes on in ORs and it's really hard I could not speak on behalf of another hospital, you know another surgical team So that would be something that that you or anybody listening would have to basically, you know Speak with their specific team your multiple hospitals do some of your hospitals allow They you know, they they vary so there's some hospitals I work in that are much more traditional and there's some that are more You know accepting of you know different approaches and it kind of gets to You know the the issue of protocols and and policies in hospitals and The practice of medicine is becoming increasingly, you know regimented and protocolized and you know, everything's surrounded by policies

[31:39] now there is a an Element of that which is I think critical and essential and very important to making things safer and better and I I believe in In protocols and you want to do some really interesting reading There's a there's a there's a book by a tool go one day called the checklist manifesto Which is just an a fascinating Discussion of you know, the use of protocols at the same time the downside of protocols is if everybody becomes robotic and nobody thinks and nothing is individualized and The the the human being in question is no longer treated as a human being but it's sort of the next widget on the on the assembly line and There's There's there's a danger in that and there's a downside in that and there's also it's very dehumanizing

[32:36] And so I think what we have to learn to do in medicine is to appropriately apply protocols Where they're doing a lot of good and generating, you know good outcomes in generating safety and then on the other side keep our humanity and Individualize things and make exceptions when exceptions are appropriate flexibility or its flexibility So we have to learn how to apply this, you know artfully

Dr. Elliot Berlin, DC [33:04] Other things during during the cesarean that come up that our patients bring up all the time you mentioned hand strapping that sometimes your arms and legs are strapped down and I See some some facilities do it and some don't but our patients definitely report back that if even one hand But especially both are free. It's a much different experience than if they're totally strapped down When you're doing a cesarean, you know, I don't know what you were planning Candice about Delayed cord clamping or not delayed cord clamping or if you have

Dr. Emiliano Chavira and Candice [33:37] Can you do this did you say you can do that with you absolutely can do cord clamping during cesarean delay it Delayed cord clamping. Yeah That that's been looked at and you know, the the concern from the traditional obstetrician is while I'm Delaying the cord clamping Meanwhile, the incision that I've made in the ures is bleeding and bleeding and and this is gonna be dangerous for the mom That's the that's a theoretical concern But it turns out, you know, they've done studies on this and when you do delayed cord clamping It doesn't really seem to generate any adverse effects on the mom. It doesn't you know, increase blood loss It doesn't increase the frequency of transfusions. So it appears to be a safe thing to do

[34:24] Well, you're talking about a couple of minutes delay. It's not like we're gonna delay it for half an hour Yeah, I mean the the bulk of the benefit of the transfusion and most babies gonna happen in a minute. Mm-hmm so you know if you Have a policy of delaying a cord clamp for one minute after the the birth You're gonna give the bulk of the benefits of delayed cord clamping to those babies without you know

Dr. Elliot Berlin, DC [34:50] Putting the mom at any any significant risk and the benefit we're talking about is blood from the placenta moving into the baby The clear screen you mentioned that for a mom who wants to be more involved and see the birth that she could Potentially ask for a clear screen clear drape Of course sometimes with a vaginal birth moms don't want to see what's happening either. So it's right individual

Dr. Emiliano Chavira and Candice [35:14] Yeah, what their needs are but you know, I I think There's there are all kinds of permutations of of this. So in some cases they have a traditional blue drape and What teams have done is just lowered the drape so that the mom can see the baby being born Mm-hmm, and that's been something that that, you know a lot of moms have really enjoyed and then they've invented these clear drapes so you can just see through it so that There's no longer an obstruction and I've even seen some cases where they gear up the mom and sterile gear and put her in a surgical gown and And Put gloves on her and I've seen cases where they drop the drape and mom reaches down and actually

[35:57] Brings her baby out pulls the baby out of her body. I was wondering about that, you know So that's that's a thing that can be done easily during a vaginal birth, you know Mom can reach down and and you know deliver her own baby and You know, I've I've had some experiences with that where the mother describes this as just the most incredible thing ever And it's something that actually, you know can be done in a cesarean now. I think at this point in time They're probably gonna be very very few Operating room teams that are set up to do with it set up to do this and are comfortable doing this So I don't want listeners to think you can just ask for that and it's gonna happen

[36:41] You you're very likely to get the response. What are you crazy? We're not doing that but This is an idea that people have and have actually done It's a thing that you know, there's some some precedent for it So so people are kind of thinking outside of the outside of the box these days

Dr. Elliot Berlin, DC [37:00] And then after the baby comes you mentioned usually a neonatal team taking the baby to another area of the room To do their analysis and their suction But we're seeing more and more that you could actually do safely skin-to-skin right after birth Or is there is that something that you would have to prepare for differently?

Dr. Emiliano Chavira and Candice [37:21] What's the downside of skin-to-skin? No, I don't think you have to prepare for it different differently it really it just needs to the requirements are that The team has to believe that this is a worthwhile thing to do and they have to be willing to do it That's really all you need. You need a mom and you need a baby And you usually have those two, you know two when you're doing a cesarean so it really is skin-to-skin, it's just a matter of of willingness and Think there are certain things that the anesthesiologist can do like the little sticker tapes for the EKG instead of putting them on The front of the chest. Maybe they put them on the back

[37:59] And they read mom's EKG from the back interesting so that the chest can be you know, bear when the Something to do with the sterile environment Yeah, but when you're above the drape that part is not Sterile, right? So if the baby is born once the baby's out through the surgical Incision right and then we pass off to the pediatrician or the pediatric team and then they walk around To the other side of the drape where doesn't affect either mom and her right It doesn't think and then you just hand the baby to the mom because I did bring that up to my doctor and it seemed like it had something to do with sterile environment Interesting interesting. Yeah, that that's true. I think you're just sort of seeing a

[38:46] Just sometimes there's a knee-jerk reluctance to do things differently and and Well, they may not even know what the concerns are the other concern I hear doctors bring up is that mom may be weak in in your arms and not be able to support the baby in Which case somebody else sort of holds the baby on your chest for you. So you have to You know, it would be a it would be a horrific thing for a baby to fall off of the operating table and you know Land on the ground. Mm-hmm. That would be horrific so So some so you have to pay attention and you have to put some thought into this If you have a mom, let's say that is, you know, very uncomfortable During the c-section and they give her a different additional medicine

[39:35] Medications to kind of deal with the pain of the c-section and maybe she's not completely alert Maybe that's somebody that you don't not a great, you know, not a great candidate But if that's not the case if mom is fully alert and you know The an epidural or a spinal really should have no effect on the arms If you're weakening the arms, you are also weakening the lungs and the mom is not breathing and you're gonna be putting her under general anesthesia that you almost never see. It's called a high spinal. But really, if you're breathing and you're awake, your arms should be fine. Mom also should have somebody with her who can kind of help you an extra set of arms and make sure that you know, all the more

[40:25] reason to let your doula in. I mean, there's usually somebody, you know, there are cases where you're in there with the mom alone and doing the c-section that always kind of feel sad about that. But most of the time, there's somebody with mom. So as long as we're being careful and paying attention and it's a mom that's completely awake and alert, and you're careful about maybe this particular situation, let's just keep the baby on the warmer, that's going to be safer. Again, you're individualizing to the situation. But there's no reason you need to say as a blanket rule that skin-to-skin is a, you know,

Dr. Elliot Berlin, DC [41:00] dangerous thing to do. I think other things that people do to try to make their birth more sacred, and I can shine the spotlight on the birth and not so much on the surgery, is to refer to it as a birth rather than a section or a procedure and to sort of get everybody in the room. How many people are in the room typically when this is happening?

Dr. Emiliano Chavira and Candice [41:21] You'll have one anesthesiologist or maybe sometimes there's two setting up and one will be walking in and out. But so it'll be one or two anesthesiologists. Usually you're going to have doing the delivery itself. There's going to be two surgeons, the primary surgeon, the assistant, and then there's an OR technician or they call them scrub techs. So this is the person that's, you know, handing the instruments back and forth to the… And then there's another person in the room called the circulator and they get equipment and supplies and bring it to the sterile field. And then you'll have whatever team you have for the pediatrician, for the baby. So there's a good handful of people. No less than eight people, it sounds like,

[42:07] in the room from the medical side and then whoever, mom and whoever she brings in. And of course at the end there's another one who pops out of you. So… Well, they were in there

Dr. Elliot Berlin, DC [42:17] at the beginning as well. That's true. Yeah, but now they're out and about.

Dr. Emiliano Chavira and Candice [42:21] That was one thing that Maidula mentioned that definitely did affect the way I'm perceiving this is she said, from now on we refer to it as a cesarean birth, no more c-section. So it just, it still feels like you're having a birthing experience as opposed to… Because you are. A surgery. I realize that now, but before I was not feeling that way. Right,

Dr. Elliot Berlin, DC [42:44] because you call it a c-section. I just, I don't even know if there's another surgical procedure called a section besides cesarean section. It's just a harsh word. But again, that focuses on the surgical element. Exactly. And you can call it cesarean birth, abdominal birth. It's a birth. It's very much a birth. It's that sacred, beautiful moment where your baby comes into the world. And if you can get those other 10 people in the room to also refer to it as a birth. And I think sometimes it becomes routine for teams of people who do this all the time, for circulators who are always in there doing a birth, it becomes work. And they're not so touched by the sacred moment that's going on. But

[43:24] to take a moment and remind everybody that this is a birth and we'd like to really focus on that and to, and now I see you can have your music playing and, um, you know, do they

Dr. Emiliano Chavira and Candice [43:34] allow… You can still do that. You can still play your music and have all your mood stuff. I'll tell you a story about music, but regarding the choice of language, that's probably a good thing to put into your birth plan because that's not necessarily a concept that all practitioners will be attuned to. And they may just be used to saying delivery. And so if that's something that has an effect on you, you put in your birth plan, you know, I really wanted to describe my birth as a birth. So, you know, please use that word just to alert them to that, you know, you like that regarding the music. I remember there was a couple I took care of with the, they, they were having twins and, um, uh, you know,

[44:18] I really love twin vaginal births, but they just had zero interest. I mean, really they just wanted to do a C-section. And, um, but on the day of, I mean, they came in with the, with the stereo and they had chosen music and they were going to do this like a party. And, in my mind, when I remember, uh, you know, this, this, uh, this C-section, I, like, I have this image in my mind of there was a disco ball. I don't, I don't think there was a disco ball, but I sort of remember it like there was a disco ball. And, you know, it was just this really kind of fun, joyous, um, event. And it was honestly, as much as I, you know, there was a part of me that was kind of like, oh man, we're not,

[44:58] you know, doing a vaginal birth. It was really, uh, it was really fun and wonderful. And we, you know, uh, we still you know, birth to this day.

Dr. Elliot Berlin, DC [45:07] And that's true. I think with vaginal birth too, it's important to point out sometimes people want a fun experience. Sometimes people want a more sacred and then, you know, a quiet experience, serene experience.

Dr. Emiliano Chavira and Candice [45:17] Having the music would be a big game changer for me when it comes to this because it just distracts your mind.

Dr. Elliot Berlin, DC [45:24] I think you can have your music. And I also think if you want to do, you just have earbuds where you're in your own little world with your music. And also I see people bring in essential oils now, like lavender and a little washcloth that you put near your face. And, you know, you can close your eyes and sort of get it in there.

Dr. Emiliano Chavira and Candice [45:40] That makes me really happy to know that you can still do that kind of stuff. I thought all the little extras that I wanted were on the table. Music is pretty typical in ORs. Really? Yeah, I would think that would be something that in most cases, if you talk about that, you would get the yes. Now you may have come across some old curmudgeon who's like, we don't have music in our OR. I can't say that's impossible, but I think most people would be very accommodating.

Dr. Elliot Berlin, DC [46:05] That's great. That little Bluetooth speaker. All right, I want to talk about microbiome seeding since we promised that we would. And it's an interesting topic. We don't have a lot of time to talk about it, so we might do a whole episode on it down the road. But there's a lot of things that nature has in mind during this rite of passage of childbirth. And we don't fully understand a lot of it, but we do understand some of it, and we're understanding more and more all the time. And one of the things that happens when a baby comes through during a natural birth, during a vaginal birth, is that the baby becomes exposed to its mother's microbiome to her bacteria vaginally.

[46:43] And colonizes that bacteria, because we need bacteria. We have good bacteria in our body that helps us do things. Colonizes that bacteria and starts to create their own normal bacterial floor. And it doesn't happen the same way in a cesarean birth coming out of dominantly. So there's this concept of vaginal seeding. Can you tell us more about that?

Dr. Emiliano Chavira and Candice [47:06] Yeah. So it's very clear that the bacteria that the baby inherits, the bacteria that ends up setting up shop is different between babies that are born vaginally and babies that are born by cesarean. And this is really a very rapidly developing area where a lot of research is going on and people are starting to discover things. So there's a lot of attention paid to the long-term health outcomes in kids that are born by cesarean versus kids that are born vaginally. And they're starting to find a little bit higher chance of certain health issues after cesarean birth. So these are things like allergies, rheumatologic disease. This would be things like lupus,

[47:58] inflammatory conditions, juvenile arthritis. One really big one is obesity, asthma. And so one of the questions is, could it have something to do with the difference in the microbiome that the child inherits as a consequence of their mode of birth? And I don't think we know 100% that that's the explanation. It's probably a little piece of it and there's probably multiple other factors. But so the idea that has occurred to some people is, well, if the baby needs the bacteria that are in the vagina and we don't get that through a C-section birth because we bypass the birth canal, how about taking some of that bacteria and putting it on the baby after birth

[48:48] to see if that colonizes the baby the way it would have been had there been a vaginal birth? So that's sort of the concept. Usually it's done with maybe putting a gauze inside the vagina so it kind of soaks up the maternal fluids. At what point? Before the C-section. So on the day of? Yeah. There might be a lot of different ways of doing this. It might be right before the C-section. You might even do it after the C-section. We don't really know if this works, if it's a good thing to do, and if it is, what's the optimal way of doing it. Then what do you do with it afterwards? Then you basically wipe down the baby with it. You don't put it in the mouth?

[49:35] So there's not a protocol for this. It's, you know, what's described is kind of wiping around the baby's mouth and on the skin.

Dr. Elliot Berlin, DC [49:48] Babies have other access to your microbiome also. There's some of your bacteria during breastfeeding, for example, that they get exposed to. It's not the only way, but it's sort of a new concept.

Dr. Emiliano Chavira and Candice [50:06] understand is that we're seeing a difference in babies and the bacteria that they inherit whether by mode of delivery vaginal versus cesarean but after that it's sort of all new and experimental trying to figure out how we can give that baby more of your exposure and to your you know to bacteria it's fascinating how new is this because I thought it was gonna that was one of my main questions like isn't there a way to like rub whatever all over the baby it makes I wasn't sure if it'd be silly but no it's it's well it's ingenious and it makes perfect sense you know the the microbiome has been studied for many many decades but what's happening now is because

[50:50] technology regarding the ability to study you know genetics that we're we're actually much better able to study us now so it's just exploding the thing about the vaginal seeding I mean I don't know who is the first person who came up with this idea and and and and when that was but my view of it is this is a brand new thing this is a new idea it's a new concept if you look in the medical medical literature there is one study that has been published and there were 11 women that had a cesarean section and they took four of them and they did the vaginal seeding so it's an enormous study vast that's right took 17 years to complete and you know it was an interesting finding

[51:40] because these four kids that that underwent the vaginal seeding procedure when they did tests later to analyze their microbiome they were more similar to the kids that were born vaginally so it it kind of seemed to have an effect however one one lesson that we have learned over and over and over again in the history of medicine is if you have a study that's based on a small number of cases you can get really really misleading results sure so I think you know from from a scientific point of view there is a lot of reason to think that there might be something to this but we don't really know if this works you know yeah does there's a downside to

[52:33] it well yeah yeah absolutely and and and so the American College of OB GYN their official point of view is we don't recommend that people do this and initially my first reaction to this was like oh god I mean ACOG just never wants anybody to do anybody and I thought for crying out loud like we're fine letting the mother actually pass the baby physically through the vagina but it bothers us to you know to put a little swab on the baby but I you know I re thinking through it you know I've been thinking about this you know for the past few months and then and when you read their statement it actually does make a lot of sense because it's it's possible that doing

[53:16] the seeding may not actually colonize the baby the same way a vaginal birth does and there is a potential maybe you could put pathogens on the baby you know like GBS or herpes or chlamydia or something I STD so so I think being fair about it there is a potential risk and we don't really know how beneficial it is so I think it's fair to say we don't really have good data on this and you know whether it's overall you know more

Dr. Elliot Berlin, DC [53:46] helpful or harmful something to think about and and there is more investigation going on so hopefully over time we'll have a lot more information on how we can use this beneficially without doing harm we're at the end of our discussion do you have any other questions I do have some

Dr. Emiliano Chavira and Candice [54:08] questions I guess what would help me is to just get a little tidbit from you of just how routine a cesarean is like how basically just try to make me not feel so scared of it yeah I I could say a lot to reassure you I mean they are super routine most you know obstetricians have done hundreds and hundreds and hundreds of cesareans these days they have become incredibly safe and I think if you you really can I mean you can you can turn it birth and put all of the things in into it that you know spiritually that you wanted to have you know you can put them into birth and as you're you know nurturing and raising this baby you're gonna same things that you are gonna do anyway you know you're you're you're

[55:10] gonna be a wonderful mother and you the baby's gonna be fine and it's all it's

Dr. Elliot Berlin, DC [55:15] it's it's gonna work out lovely you're you're so healthy in general like you said you're holistic you're natural like you take good care of your mind and body so I think that you're also going to recover in in a way in a very healthy way strong healthy recovery afterwards I think when somebody is not in shape like if I had a C-section disaster but for you I think I'll be just fine

Dr. Emiliano Chavira and Candice [55:39] the the the other thing that the comments you made earlier on as we were talking you know worried about freaking out and fainting and all these things it really it's a non concern you will not faint but if you did the anesthesiologist is there to take care of it it would be fine yeah once in a while we we do a C-section and the mom is freaking out you know anxious and and freaking out and you know what happens you just you do the C-section you you get through it like you're not gonna you're not gonna cause a complication in the surgery you're not gonna okay it's it's that's really not a thing you need to worry about okay that is reassuring

Dr. Elliot Berlin, DC [56:20] yeah I think once you wrap your mind around it you're gonna make it awesome well hopefully this little one should you have one I know my partner's like quit talking about it it's not gonna happen I think what you're doing is looking at it as there's a chance of there's always a chance it was gonna happen and that's true but you brought up something before we started recording which is that this is strange because you know about it weeks in advance like how do you wrap your mind around it then and how do you prepare for it then but I sort of think if you you with the homework that you're doing and and even how relaxed you are about it now compared to a week

[57:00] ago or ten days ago I think if you if you realize that you're gonna do it you'll get your mind around it you'll get ready for it and you'll make it an amazing experience for you guys yeah well you dr. Berlin have been so

Dr. Emiliano Chavira and Candice [57:14] helpful in easing that for me and also dr. Shabara you as well thank you so much for this conversation it has made me feel much better

Dr. Elliot Berlin, DC [57:25] all right well we'll come back at some point and tell everybody how your birth went mm-hmm okay thank you so much for being here I know it's not easy for you to talk about these things and and you are our listener a lot of our listeners are in the same shoes that you are so it's really helpful that you're here to ask questions on their behalf and dr. Shabara thanks as always for being here your point of view on things is really unique and refreshing and I appreciate your sharing them and I appreciate being able to refer clients to you so that they also don't have to freak out I always love chatting with you yes great questions thank you at home

[58:06] thanks for listening to the informed pregnancy and parenting podcast if you have a topic you'd like us to discuss drop us an email at info at informedpregnancy.com and then go visit us online for more pregnancy and parenting media at informedpregnancy.com

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