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The 'Natural caesarean'

1 April, 2010

The 'Natural caesarean'

Imperial College Healthcare NHS Trust's senior midwife Jenny Smith consultant anaesthetist Felicity Plaat describe a more holistic approach to the caesarean surgical procedure.

Imperial College Healthcare NHS Trust's senior midwife Jenny Smith consultant anaesthetist Felicity Plaat describe a more holistic approach to the caesarean surgical procedure.

Midwives magazine: April/May 2010

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In several countries worldwide, caesarean section (CS) rates have reached near pandemic levels (>30%) (Sreevidya and Sathiyasekaran, 2003; Department of Health, 2006) and there is concern about increasing numbers of CS in the UK, 14% had been requested in 2000 because of a previous CS and 7% because of maternal request (RCOG, 2001).

The ‘natural caesarean’ (Smith et al, 2008) does not address issues around decisions about mode of birth. It is an attempt to enable well women who undergo surgical delivery to experience the women-centred, family-friendly approach used at vaginal birth, by adopting a less regimented, less staff-orientated practice.

Although in their CS guideline, NICE recommends early mother-baby contact (NICE, 2004), this is not the same as the technique we employ. Although surgical technique is unchanged, it is augmented by practice that puts the parents at the centre of events enabling them to witness the slow, gentle birth of their baby, discover his/her gender, and experience immediate skin-to-skin contact. The technique does not compromise either safety or sterility.
Antenatal preparation
The approach is discussed in antenatal classes, with video clips and photographs available.

Women are encouraged to bring their own music into theatre and also their own button opening top to wear after the regional block has been inserted.

In theatre
Preparation is routine – the baby’s heart rate is continuously monitored by cardiotocograph prior to skin preparation. Music is played if the couple wish.

Following insertion of the regional anaesthetic, the clothing is removed from one of the woman’s arms so the baby can easily be placed skin-to-skin following birth. The blood pressure cuff is covered in a clear plastic cover to keep it clean.

The pulse oximeter is usually placed on a finger, but could be placed on a toe to free the woman’s hands to hold the baby. The intravenous cannula is situated as normal in the non-dominant arm for ease of holding the baby.


The surgery starts as normal. As soon as the surgical incision is completed and the surgeon has started to bring the baby’s head out to the surface, the screen is lowered and the head of the theatre table raised so the mother can watch the birth. It is important at this point that the mother’s head is high enough to see the baby and the drape sufficiently lowered. At this stage, the midwife remains at the abdominal end of the table near the surgeon.

Once the baby’s head is out, the surgeon pauses to allow ‘auto-resuscitation’ of the baby. Once the baby’s face is exposed to the relatively cold room air, she/he will be stimulated to begin to breathe through the nose and mouth, while the body remains in utero, still attached to the placental circulation (like a vaginal birth when the head is delivered). The baby’s head is usually facing to the side and, after a couple of moments, lung fluid is usually clearly visible, draining from the baby’s nose and mouth as a result of pressure from the uterus as it begins to contract down, and from the mother’s abdominal wall, on the chest.

Once the baby begins to cry, the shoulders are freed from the uterus by the surgeon, the baby’s head is gently turned to face his mother and the baby is born, assisted by uterine contractions. Frequently the baby releases its arms itself, through a vigorous extensive reflex. The surgeon then supports the baby as it wriggles out.

Following the birth, the midwife, maintaining sterility, goes to the ‘head end’ to receive the baby, after the cord is cut by the obstetrician, and to place the baby directly on the mother’s chest. The midwife, partner/birth partner and anaesthetist observe the baby on the mother.

The midwife at this stage ensures the baby is snuggled closely up against the mother’s skin to keep the baby warm and the towels covering the baby are changed (if damp) to prevent cooling from evaporation exacerbated by the theatre ventilation system. Bubble wrap can be applied over the towels to enhance heat retention. It is vital the midwife stays in close at this point, to observe the baby and support her partner.

Immediately following the birth, the anaesthetist administers oxytocin and antibiotic drugs and, with the rest of the team, promotes mother-baby interaction.

The baby’s name label is applied, vitamin K is given and the cord re-cut by the partner once the plastic clamp is applied, while keeping the baby in skin-to-skin contact on the mother’s chest. Occasionally the baby starts suckling at this stage, while surgery is ongoing.

The criticism that the natural caesarean promotes abdominal delivery is not supported by the evidence and we reject as unethical the implication that CS should be kept unpleasant for parents, so they will strive to avoid it (National Institute of Health, 2006; Newman and Hancock, 2009; Smith et al, 2009).

Our experience has shown all childbearing women need nurturing (Edwardes, 2009; Smith, 2009). By introducing some ‘normality’ to a profoundly abnormal situation, it is hoped that this can be achieved for more women, their babies and partners. A holistic approach to birth is essential, regardless of its mode. A study is being planned to evaluate this approach and will
look at women’s, partners’ and staff’s experiences, as well as obstetric outcomes. 

Department of Health. (2006) NHS maternity statistics England: 2004 to 2006. HMSO: London.

Edwardes C. (2009) The new ‘natural’ caesarean. The Times See: www.timesonline.co.uk/tol/life_and_style/health/article6028478.ece (accessed 24 March 2010).

National Institute of Health. (2006) State-of-the-science conference statement: cesarean delivery on maternal request 27-29 March 2006. Obstet Gynecol 107(6): 1386-97.

Newman L, Hancock H. (2009) How natural can major surgery really be? A critique of ‘the natural caesarean' technique. Birth 36(2): 168-70. 

NICE. (2004) Caesarean section clinical guideline 13.
See: www.nice.org.uk/nicemedia/pdf/CG013fullguideline.pdf (accessed 25 March 2010).

RCOG. (2001) The National sentinel caesarean section audit.See: www.rcog.org.uk/news/national-sentinel-caesarean-section-audit-published (accessed 26 March 2010).
Sreevidya S, Sathiyasekaran BW. (2003) High caesarean rates in Madras (India): a population-based cross-sectional study. Br J Obstet Gynaecol 110: 106-11.

Smith J. (2009) Your body, your baby, your birth. Rodale: London.

Smith J, Plaat F, Fisk NM. (2008) The natural caesarean: a woman-centred technique. Br J Obste Gynaecol 115(8): 1037-42.

Smith J, Plaat F, Fisk NM. (2009) The natural caesarean technique. Birth 36(4): 356.

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