Maternal Assisted Caesarean

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So Natalie, thank you so much for coming on the FitNest Mama Podcast, I feel really lucky to have a chat to you all about Maternal Assisted Caesarean births. So thank you. To start off with, can you explain why like how you got into this area of Maternal Assisted Caesarean sections? Like how do you do what you’re doing? Like how did it come to be? Cause I know not all obstetricians offer it.

DR. NATALIE ELPHINSTONE

You know, the first time that I even started thinking about this (maternal assisted caesarean births) was actually and this is always actually even one of the first points that I like to make is, how did I get into this? I got into this because a single patient asked me if I would do it. And instead of having perhaps the response, which would be really easy, which is to say things like, well, you know, I’ve never done one or our hospital doesn’t have a policy for that. And so to just say no. I said, Well, yeah, why can’t we do that. And then, of course, there was actually, there was a bit of a process, of course, that I had to go through in order to be able to make it happen. Luckily, you know, this patient gave me enough morning, like she started talking about it at say, I can’t quite remember. But let’s say 28 weeks or so, which gave us enough time to be able to start jumping through those hoops and starting to talk about writing policy and having procedures put in place and to prepare, like essentially everybody to make this happen. But we got to and we did make this happen. We did make a policy, we did make procedures, we did do all the formal stuff that you know, most hospitals, most I’m sure all hospitals need to sort of have in place to be able to make this happen.

KATH BAQUIE

Yeah, and I’d love to dive into that a little bit. Because I know there are also a lot of health professionals that do listens this podcast, or perhaps you’re a mum who’s interested in this and your obstetrician doesn’t offer it. So I do want to ask you a few questions about that. But first, can we take a step back? And do you mind letting us know what is, like let’s take it back to basics, what is a Maternal Assisted Caesarean Section?

DR. NATALIE ELPHINSTONE

I think anytime we just talk about the word Maternal Assisted Caesarean or of course there are some other alternative terms. Like for example, it doesn’t necessarily need to be the mother herself. It could be her partner, or you know, her support person. So we also talk about say, paternal assisted cesars or a partner assisted cesar, and that’s just simply to say that the mother or the partner or the father, or whoever is going to play an active role in delivering the baby themselves. And so a lot of the time, it’s mainly more talking about a maternal assisted cesar or the mum herself. And what that essentially just means is that at a caesarean delivery, myself as the obstetrician is still going to be performing, you know, the majority of the standard technique of a caesarean. So we’re going to deliver the baby, which is usually in a head first position, we’re going to get the head of the baby out of the abdomen as we normally do, and we’re going to get the arms or the shoulders out of the abdomen as we would normally do. And then instead of say, me, the delivery person, pulling the rest of the baby out, it’s going to be the mother herself, or whoever, then reaching down and being able to hold the baby and pull it up out of herself, perhaps a very similar thing that what she may have been able to do a vaginal delivery, but at a caesarean delivery instead. The thing here is about number one that she does get to be involved in this herself. So that’s really empowering for women. And I know we’re going to talk about all the benefits. So you know, we’ll get into that in a lot more detail. But it’s also just about her be there to be the first person really to be able to touch her baby, and to have that sort of instant bonding with her baby as well. And that’s really such a powering and inspiring thing to get to witness.

KATH BAQUIE

It’s just, it’s beautiful. And we were just talking off air, how I felt, a lot of women have told me after a caesareansection, they did feel quite powerless, and maybe it was an emergency or whatever it may be. And I just love the sound of this, because it’s just helping to put more control however small or big that is, back to the mum. And I think it’s beautiful.

DR. NATALIE ELPHINSTONE

Absolutely. I think in the past, the caesarean, even though say, you know, it’s the birth of your baby. But caesarean has still been very much in the realm of it’s a surgical procedure. And so you are a patient instead of you are a mother. So you lie there. And we as the doctors and the health professionals, and the nurses and whoever else are going to do stuff to you, including pulling out your baby and then doing whatever we want with the baby. And instead, this is a way of being able to really play an active role in the birthing experience. Because it is still the birth of your baby and the birth of your baby should be one of the most amazing, joy filled, inspiring moments of your life. And it’s going to be something that you are no doubt going to remember for the rest of your life. And so in the past, you know, when it’s been perhaps seen as something that is yeah, just this medical procedure, or perhaps it’s even kind of traumatic for you. And you felt so powerless and, and plenty of people have, for example, given the stories of we don’t sort of tend to do this in Australia, but in other countries where they’ve talked about literally being strapped to the table, they talk to me about having their arms strapped down so that they can’t physically move. And I just can’t imagine how powerless that would feel to literally be lying there, and having other people just have their way with you, including delivering your baby. And so we are really wanting to completely turn the tables on this experience and try to pull it right back more into the realm of what you might have been able to achieve in a vaginal delivery, even though it’s in the operating theatre, and it’s a caesarean delivery instead.

KATH BAQUIE

Wow. I’ve never heard of what you’ve just described of women whose arms have been tied down.

DR. NATALIE ELPHINSTONE

I’ve had more than one person tell me that on Instagram, you know, I’m not going to make a comment about sort of which countries or whatever, but that that’s obviously part of their sort of standard technique. And I’m sure that they’ve got reasons for that. I think their reasons will be things like with a spinal anesthetic, sometimes you may not have as much power in your arms or your upper body and they’re just trying to make it safe. Or of course, they’re wanting to just be very mindful of say, the sterile field and so not wanting the mother to sort of inadvertently reach up and grab the baby. Because this is the other thing that I’ve noticed even when we’re not doing a Maternal Assisted Caesarean and we’re doing what we would classify as our, you know, stock standard caesarean, when you lift that baby up and show it to the mother or the parents, it is so instinctual that they will want to reach out and take their baby, which makes obvious sense, the problem being when it’s an operation or a sterile field is that the mother of course is typically not sterile. And where’s the operating surgeons and the baby itself is currently sterile at this point, and we’re wanting to avoid cross contamination. And again, for good reasons, because we don’t want to be introducing bacteria into you know, the open abdomen that’s going to be there and increasing her risk of infections and things like that. But it’s really, really difficult when, as I say, you know, if I’ve lifted up this baby, and I’ve shown it to this mother, and she automatically goes to reach out to grab her baby, and then me instinctually has to pull the baby back from her so that she can’t touch it. And that’s heartbreaking. But anyway, so I think where I was going with this is, that’s perhaps one of the reasons why they might strap women’s arms down just to stop them from being able to do that. But obviously, that just really disempowers that person from being able to have any role in the birth of her baby.

KATH BAQUIE

So what stage in as you say, a stock standard caesarean section with the mother then take the baby like, why is it that you pull away? Like at what stage can they have it?

DR. NATALIE ELPHINSTONE

I think there are a few answers to that. Because I think even if we put Maternal Assisted cesar at one end of the spectrum and our stock standard cesar, you know, the way that we’ve kind of traditionally been doing it for years and years and years. At the other end of the spectrum, there are some finer points in the middle, where different hospitals might be doing it differently. But if you do your, what I call the stock standard caesarean, and the way that it’s probably being done for decades, whereas I say, you know, the surgeon or the obstetrician has performed the caesarean, and we may or may not have lifted up this baby. But as I say, the baby is still technically sterile at this point in time. And so then we would do sort of that instant cord-cutting, and then be able to pass the baby over to an intermediate person who is sort of sterile as well. So might have sterile gloves on or be ready with a sterile drape. And so whether or not that’s a pediatrician or a midwife. And so we as the operating person would pass the baby to them first. And then they would take the baby outside of the sort of sterile field. So whether or not again, that’s a different place in the same theatre or whether or not that’s even outside of the theatre. And then of course, now the baby is no longer sort of considered to be sterile. And so now the mother would be able to touch it. But perhaps in our sort of traditional caesarean, maybe the mother is still not being given much of an opportunity to be able to do that. And it’s mainly only after she has come out or even the recovery area after the operation. And she’s back up on the wards. So people will traditionally talk about, you know, it was an hour or more before I got to touch my baby after sort of standard caesarean. In the meantime, some of our places have been starting to evolve some of those steps. So for example, at the public hospital, where I work, we would now often do this thing, where we would be able to perhaps put a sterile drape down onto the mother’s chest, so we can place the baby still onto her chest, in sort of a sterile fashion, whilst we’re waiting to do this sort of delayed cord-cutting. And that she would be able to have this opportunity then to be able to touch her baby still sort of instantly. But still without her sort of touching any of the sterile drapes. And it’s really, really tricky. And so often, this is a bit of a point of controversy, because sometimes there will still be that cross-contamination. And so that would be one sort of modification that we’ve made. Or another modification, which is perhaps easier in terms of trying to maintain the sterile field is that, again, we wait for delayed cord-cutting, but with holding the baby’s still definitely within that sterile field, and maybe she can see it, but she’s not sort of able to sort of reach out and touch it. But after we’ve cut the cord, then again, we give it to that intermediate person, and then that person can either sort of instantly take it to the mum, and now she can do this sort of skin to skin whilst we’re still on the operating table and finishing the operation. And so we’re tending to do a lot more of that stuff, even at our standard caesarean, and if you’d like and even at our emergency caesareans, wherever that’s possible to do.

KATH BAQUIE

Can I just clarify that really simplistically, just so that we can understand? So you’re saying during his like any operation, there’s a sterile it’s like a bubble, like everything has to be sterile when it’s in that bubble sort of thing. So you’re talking about how do we get that baby from that sterile environment out of the bubble onto the mum, and the different ways of doing that.

DR. NATALIE ELPHINSTONE

Definitely, again, remembering the main aim here is that it is for protection of the mother, we are absolutely wanting to maintain sterility so that we can minimize the risk of introducing any kind of infection into what is her open wound, essentially, whilst of course trying to remove this baby from her and out into the non-sterile world. And there’s lots and lots of rules set up if you like inside a theatre about how you become sterile. So as the operating surgeon, you know, we go through that whole big hand washing exercise and then we have to do that in a certain way. And we can only touch certain things after that. And then we’ve put on this sterile gown and we’ve put on these sterile gloves. And after we’ve done that, again, we’re only allowed to touch other sterile things. And the second we touch anything that’s not sterile, like if I actually gently touched the mother, you know her face or whatever, then I’m no longer sterile. And so as the operating surgeon, the only way I can then go and make myself sterile again, is to take off all of my gown and gloves and go and start the whole process again. So start the hand washing thing again. And all of that takes time. So we’re always so cautious about trying to not allow if you like that cross contamination, because obviously, it interrupts the whole flow of things so that we can be trying to maintain sterility at all times. And that’s been really tricky when you’ve got this object, I have the baby, that you’re wanting to take from the sterile area into a non-sterile area. And how do you do that without having cross contamination?

KATH BAQUIE

Yeah. Wow. So when you describe it like that, it does make me realize it’s more complicated than just letting the mum pull out the baby, which sort of sounds simple, right?

DR. NATALIE ELPHINSTONE

Exactly. And I think that’s why I tend to still get a lot of questions again, on Instagram, when I posted these videos about people questioning why the mother is in so much gear, like, why is the mother in all of this gown and gloves, because if you’re really trying to empower women, wouldn’t it be really nice if she could just grab a baby with her bare hands. And I agree, that would be really, really nice. But in order to be still maintaining this whole idea of this is a surgical procedure where she has an open wound, and we are wanting to minimize the risk to her, we need to still follow some of those very good, basic rules of maintaining sterility. So we, we have to have her in the gown and gloves while she’s in that sterile area. Once the baby’s out, and it’s on her and she’s not going to be reaching down again into the sterile field, then we can forget the rules, and then she can take her gown and gloves off and stuff.

KATH BAQUIE

Yeah, that makes sense. Thanks for explaining that. I think that hopefully helps a lot of questions for those that are listening, that apart from what we’ve talked about, do you offer this as a routine care in your practice? Or is it something that the mum has to ask for?

DR. NATALIE ELPHINSTONE

Yeah, I think that’s a really good question. I think now that we do have, you know, these policies and procedures in place at my hospital, it means that it can be offered, wherever that’s a practical thing to offer. But I think the other thing to keep on remembering is that this is still not something that everybody wants to do, like even people, of course, that are having an elective caesarean delivery, not everybody is interested in doing it this way. Because there are still, let’s be honest, some confronting ideas here. And sometimes mothers, or their partners, whoever is a little bit worried about maybe not wanting to sort of see the blood and guts of it all, as they would often describe, or they’re worried that they will do something wrong, or what they call wrong, or they’re worried that maybe they’ll drop the baby or something like that. So, this whole idea certainly doesn’t appeal to everybody. And I guess, most of the time, I’m waiting for patients to ask me about it or bring it up. But now that they’re seeing it happen regularly, it’s then a very sort of common thing that they’re asking about. Or when I’m doing private practice, of course, one of the best things about private practice is being able to have this ongoing relationship with the parents to be and so that I can gauge with them where this may be something for them to consider. So for example, if I’m seeing parents who, last time they had a baby, they ended up with an emergency caesarean, for example, and that they found that story of their birth to be sort of very traumatic, and part of the reasons perhaps why they found it traumatic was because of their lack of control over that situation. And so this time around they opt-in for a caesarean birth, then they may be a very good couple to sort of offer this option to because they may find this as a way of kind of healing from some of those sort of past hurts. And so it’s definitely gauging together who may be relevant to offer this to but very happy for anybody to ask for it. Because let’s have a conversation about it for sure.

KATH BAQUIE

Okay, so are there any researched benefits? How new is this? How long has this been happening for? Surely not much research has happened, but is there anything? Yeah, tell us about that.

DR. NATALIE ELPHINSTONE

This is where this starts to get perhaps a little bit controversial sometimes, because some of the reasons that people would have for not doing it would be because of the idea, or at least the perceived idea that maybe it is going to increase risks to the mum and for the baby. And a common sort of objection would be that it seems like it would increase the risks of infection to the mum. And so then of course, the way to try to counter Some of those arguments is to look for evidence. The problem is, as far as I can tell, there is no evidence. There’s lots of sort of cases out there where we’ve done this, but no sort of, well, obviously, you can’t, for example, do a randomized controlled trial, because you can’t randomize people to whether or not they’re going to have paternal assisted caesarean or stock standard caesarean, for example. So there’s no good evidence that I can see or find out there, and I’m happy to be corrected on that front. But nothing that I can see that kind of proves our point one way or another, there’s definitely I would imagine, or I would believe, or I would suggest great benefits to offering this to people, though, for lots of lots and lots of reasons. And for one example, is we know that rates of what we call birth trauma are going up and up and up. And that there are some very alarming statistics at the moment that talk about maybe up to one in three women would describe their birth as traumatic, and that’s a really complex area to get into. And there are many reasons why people might describe it as traumatic. But definitely one of the key components, there would be people feeling like they’re out of control, or that the situation that involved in an unexpected way. And so I would then try to suggest that one of the ways that we can aim to undo some of those statistics or heal some of those traumas for people is to give them back a whole sense of control over their situation. And that this may be one way of doing it. But in terms of how long has maternal assisted caesarean has been around, it’s probably actually been around for way longer than we imagined. I think there are definitely cases that I can see that trackback at least sort of 10 years ago. So I’m certainly not going to suggest that I am in any way an expert in this or that I’m the first person to do this, it’s definitely been gaining momentum, just in the last sort of a couple of years, though, perhaps in line with things like social media, where we can now see birth so much more readily, and see that this is an option that people are offering.

KATH BAQUIE

Yeah, and I think podcasts as well have allowed mums and health professionals and a lot more people to tell their story. So it’s great that there is more awareness around this. At the time of recording, COVID is going crazy. Has this impacted how you perform caesarean or you know, anything with the maternal assisted caesarean section? Like if the mother has COVID or any of those protocols?

DR. NATALIE ELPHINSTONE

Yeah. There’s definitely, I mean, right now, as you say, it’s particularly hard without growing rates of COVID. And, you know, the whole COVID situation in hospital births has been a very evolving situation where we continue to make more rules, and then new rules, and then we change the rules. And then we make different rules again, this year, for example. So this is the 10th of January, when we say this, so far, my hospital has changed the rules, about COVID precautions, so to speak, on no less than at least three or four occasions. And that’s in 10 days. So it’s a definitely, it’s a really hard thing to try to keep up with where we’re at currently. What has been really excellent is that for us here in Victoria, Australia, in the hospitals that I’ve worked at, throughout the whole of the COVID situation. So since the whole COVID thing started is that at no point, have we ever restricted the ability for the birthing mum, to have a support person with her. The only kind of restrictions there would be things like assuming that her support person was not sick or unwell or tested positive for COVID, or in isolation or any of those kind of rules. But So assuming that post support person is well, she can certainly still have a support person.

Now, the downside of that is saying that most of the time, throughout all of the COVID restrictions, we have been restricted to sort of only suggesting she can have that one support person. So we’ve sort of taken out the whole idea of maybe she can have multiple people around her. But it’s always been at least one person. And so that has never changed, thankfully. And so the majority of say the woman’s care has been not being affected too much, by the COVID situation, at least not in the hospitals that I’ve worked out.

KATH BAQUIE

Great. That’s good to know. So, to wrap up, are there any words of wisdom that you’d impart anyone listening today that’s pregnant? Who’s listening to this and thinking, oh, yeah, that sounds interesting. What would you suggest?

DR. NATALIE ELPHINSTONE

Yeah, I think the big key here is to talk to your healthcare provider. Like if this is something that you’re thinking you might be interested in, approach it early with your healthcare provider. So it doesn’t matter if you’re going through, say a public hospital or a private hospital, or obstetric care or midwifery care while you’re planning a home birth or whatever. Talk to your healthcare provider about should you be opting in for an elective caesarean delivery, and this is something that you’re interested in doing is bring it up with him and say, is this an option at this hospital to do this? And if the answer is no, which currently is for probably most hospitals, then ask why or why not? Why can’t we do it? And then if the answer is something like, well, we don’t have a policy for that, then you ask why, why not? Why can’t we make a policy for that? Because the only way that these things are going to change is number one, somebody up higher in the ranks of whoever makes policies has to understand that this is something that people are wanting to do. And then they can talk through all the sort of the logistics of how we write a policy and what hoops do we need to jump through to make it happen. But as I said, like, even just for me, I helped to start it at our hospital because a single patient asked me if she could do it. And so the more obstetricians, for example, are hearing that their patients want to have an option like this, then that’s got to be the impetus for making change in more and more hospitals across not only Australia, but across the world.

KATH BAQUIE

So if you’re listening, you want to hear a birth story with someone who’s had this, check out the FitNest Mama Podcast Episode No. 18. I’ve just been scrolling, frantically looking for it which number it was. So Episode 18, Spilling the Milk with Claire, because what you just said Natalie is exactly what Claire said is she encourages if you’re interested, just ask, ask. Yeah, it’s really interesting. You both say exactly the same thing. And that just brought up another question. If it sounds like you’re only doing this for elective caesarean at the moment, is that right?

DR. NATALIE ELPHINSTONE

That’s right. And I think that’s a key point that I would still like to get across as well is because it does take a bit of pre-planning from a number of fronts. So for example, when I’m planning up with the woman or the couple themselves, I will be talking them through beforehand about what that day is going to look like. Say the day of the caesarean. So what she is going to need to do so teach her for example, how to do that proper surgical hand scrub beforehand. And talking her through all of the rules, if you like, like once you ask, grab, you’re not allowed to touch this and then allowed to touch that and her partner can’t touch you. And you know, those sorts of things as well. So it takes a bit of preparation before the day, it takes preparation on the day. So for example, part of our policy at my hospital will be things like we need to allocate extra time in theatre to allow this to happen, that we need to have an appropriate say anesthetist and pediatrician who were on board with this idea as well, because not all of them are yet we need to have say extra staff in theatre. So for example, we allocate an extra nurse who will just be watching the woman after she scrubbed to make sure that she’s not accidentally breaking any of the rules. So it takes a bit of extra time to prepare all of this stuff. And so at the moment, we’re sort of strictly saying at least in our hospital, that this will only be performed in an elective caesarean scenario.

And you can imagine also, that sometimes in an emergency caesarean scenario, it just wouldn’t be practical to have extra time to sort of allow all of these things to happen. And so, unfortunately, that means that if you’re somebody, for example, that is aiming for a vaginal delivery, but it ends up being a caesarean and that’s of course, going to be classified as an emergency caesarean, and then probably this is going to be not able to be done at that point in time. So this is strictly at the moment something where, if you know that you are planning on an elective caesarean delivery, this could be a valid option for you.

KATH BAQUIE

Yeah, well, thank you. I feel really honoured to be able to sneak in this recording because I have managed to get you when you’re isolating at home and you’re not working.

1. NATALIE ELPHINSTONE

That’s right, I’ve got plenty of time to kill right now.

KATH BAQUIE

Could you please let everyone know how they can find you if they’d like to learn more about you?

DR. NATALIE ELPHINSTONE

Yeah, absolutely. My main sort of social media outlet is my Instagram. And so that is @drnatalieelphinestone. That’s all one word. And it’s easy probably if you just put a link up rather than me trying to spell that really long name.

KATH BAQUIE

Definitely the link will be in the show notes. And whereabouts do you operate? Or do you work out of?

DR. NATALIE ELPHINSTONE

Yeah, so I’m working down on the Mornington Peninsula area, just on the outskirts of Melbourne, Victoria.

KATH BAQUIE

Yeah, beautiful. Thank you so much, Natalie. I really do appreciate having this really enlightening and informed chat today. It’s a beautiful topic to discuss.

DR. NATALIE ELPHINSTONE

You are very welcome. It’s been an absolute pleasure. And thank you very much for having me.

KATH BAQUIE

And before I sign off, remember my team and I will be putting together the show notes for this episode with all the links including how to connect with Dr Natalie Elphinstone at fitnestmama.com/podcast. And don’t forget to send Dr Natalie Elphinstone and myself a DM on Instagram. We would love to hear from you. Have a fabulous day everyone and I look forward to you joining me next week for another episode of the FitNest Mama Podcast.

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