Photo by Monet Moutrie—monetnicole.com

The Mindful Cesarean

Editor’s note: This article first appeared in Midwifery Today, Issue 121, Spring 2017.
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While most placentas move as the uterus grows, this one didn’t. It was covering Renee’s cervix, obstructing her baby’s exit. Her doctor was certain that a cesarean would be the best and safest way to birth this long-awaited baby.

I have been a labor support doula for over a decade and, like other couples I’ve worked with who faced similar news, Renee and her partner struggled to orient themselves to the idea of a cesarean. We worked together to prepare and then, when the time came, they found their way through their baby’s cesarean birth with peace and conviction. It was an honor to stand at their side and offer tools to enhance the natural hormones of birth and remind these parents with an unwavering faith that birth is sacred, no matter the circumstances.
In many parts of the world, a quarter to half of all babies are born by cesarean. Too often women who birth by cesarean feel unprepared, frightened or left with a sense that they didn’t actually give birth. As a doula, educator and fellow parent, I help couples who might birth by cesarean ready themselves for the healthiest birth and recovery possible. To that end, I frame the stages of a cesarean in the language of birth and suggest practical things to do at each stage to activate the body’s endocrine system, thus enhancing the body’s felt sense of birth. Renee and other clients have urged me to make these tools and this perspective more widely available. So I launched The Mindful Cesarean project, which has inspiring birth stories, practical tips and a downloadable toolkit featuring a cesarean birth visualization and other materials.

The Mindful Cesarean: Optimizing Healthy Birth Hormones

“Modern medicine has the important goal of helping mothers and babies survive. But nature wants more. Nature wants mothers and babies to thrive.” (Buckley 2014)

When conditions are as nature intends, that is, when labor begins on its own timetable and unfolds without interference, when mother and baby remain together after birth, the intricate and long-evolved dance of childbearing hormones—oxytocin, beta-endorphin, prolactin and catecholamines—can best orchestrate what nature hopes for: mothers and babies who are healthy, happy, well-adjusted, breastfeeding and bonded.

But sometimes birth is interrupted. Sometimes interventions are needed. Sometimes—for survival—the tools of surgery are essential. When a cesarean is needed, certain aspects of birth are skipped, including those that involve hormones that have been part of birth since human time began—and for ages before. With a cesarean, especially a planned cesarean, mothers and babies often experience lower levels of these important hormones, including oxytocin.

The question I ask at The Mindful Cesarean is: When a baby must be born by cesarean, what can families do to optimize healthy birth hormones to best ensure that mothers and babies thrive? Throughout The Mindful Cesarean I detail many oxytocin-enhancing practices with the goal of helping families who birth by cesarean to what nature intends: mothers and babies who are healthy, happy, well-adjusted, breastfeeding and bonded.

I am pleased to share excerpts from The Mindful Cesarean: on why skin-to-skin with a cesarean, and on how. I am grateful for the contributions of Dr. Nils Bergman and his wife, Jill Bergman, to this project.

Kangaroo Mother Care: Our Species’ Best Medicine for Parenting a Baby Following a Cesarean

“Cesareans are good for many reasons,” says Nils Bergman, a South African physician and international promoter of Kangaroo Mother Care (KMC). “Yes, if medically indicated, cesarean is good. But the separation of a mother and her baby following a cesarean, now that is something altogether different.” (Bergman 2016)

Years ago in Zimbabwe, Dr. Nils Bergman introduced a protocol to keep low-weight preterm infants on their mothers, skin to skin, while every other aspect of care remained the same. They found that survival rates for these babies surged from 10 to 50%. Dr. Bergman later conducted a randomized controlled trial and found that preterm newborns in skin-on-skin contact with their mothers for the first six hours after birth were 100% stabilized. For babies in incubators, fewer than 50% had stabilized within six hours. (Bergman and Jurisoo 1994)

Dr. Bergman became convinced that ongoing skin-to-skin contact is what our species expects at birth, reflecting millions of years of evolution and yielding significant physical and emotional health benefits for babies and their parents. His findings have launched an international motherbaby skin-to-skin revolution. Dr. Bergman now lectures throughout the world about the neuroscience behind KMC. He is challenging health care providers and parents to comprehend what is normal for nature—and for our natures—regardless of what is normal for Western culture.

Dr. Bergman considers skin-to-skin contact essential for babies born by cesarean. He explains that infants born by cesarean do not experience the same post-birth spikes of important hormones such as norepinephrine, which wakes the baby’s brain and activates pumping actions that clear the lungs of fluid. Additionally, mothers who birth by cesarean and babies born by cesarean experience lower levels of oxytocin than when babies are born vaginally. (Swain 2004) But the real problem, as Dr. Bergman describes it, is that after a cesarean a mother and baby are more likely to be separated from each other for long or short periods, further disorganizing the natural hormones of birth.

Separation Is Stressful!

Dr. Bergman and his colleagues conducted a study to understand the effect of even short-term separation of a newborn from his mother. They measured deep sleep and heart rate variability (as an indicator of central anxious autonomic arousal) in 2-day-old newborns as they slept skin to skin with their mothers and when they slept alone in a nearby crib. During the time the babies were separated from their mothers, the babies’ autonomic arousal averaged 176% higher and quiet sleep 86% lower than when they slept skin to skin with their mothers. (Morgan, Horn and Bergman 2011)

“We made a startling discovery,” Dr. Bergman says. “When babies sleep separate from their mothers, heart rate variability triples, deep sleep is significantly reduced and there is no sleep cycling.” Furthermore, he says, “The absence of the mother, even for a short period, doubles cortisol for full-term infants. In preterm NICU babies, cortisol is 10 times higher for babies in incubators than for babies skin on skin.”

Dr. John Krystal, Chairman of the Department of Psychiatry at Yale, commented on the study’s findings: “This study highlights the profound impact of maternal separation on the infant. We knew that this was stressful, but the current study suggests that this is a major physiologic stressor for the infant.” (Science Daily 2011)

Keep Your Baby Close

With KMC, or continuous skin-to-skin contact between a mother and newborn, stress is reduced and oxytocin levels soar. Oxytocin’s benefits are many. Babies stabilize faster. They cry less. Breastfeeding is likely to go better. High oxytocin levels are good for mothers, too. Human and animal studies tell us that oxytocin activates positive changes in mothers’ brains to reduce stress, promote healthy social connections and prime reward centers to imprint pleasure with caring for her newborn (Leng, Meddle and Douglas 2008; Bell, Erickson and Carter 2014). As Dr. Sarah Buckley puts it in her important report, The Hormonal Physiology of Childbearing, “Oxytocin enhances hormonally-driven mother-baby bonding.” (Buckley 2015)

Of course, sometimes a baby must endure unavoidable separations or stressful procedures. Dr. Bergman’s wife—doula and author Jill Bergman—says, “When separations occur, the question is how quickly can we restore the baby to what she anticipated with oxytocin-enhancing skin-to-skin and breastfeeding?” (Bergman 2016)

Kangaroo Mother Care is one of the ways nature ensures that a mother and child get off to a healthy, bonded start. When a baby is born by cesarean, KMC may be one of families’ most effective tools to compensate for the lower hormone levels associated with a cesarean. Following a cesarean, Dr. Nils Bergman considers continuous skin-to-skin and hourly breastfeeding a necessity.

KMC just celebrated a victory on the international stage: Six major international health associations endorsed its universal use for preterm and low-birthweight infants. Increasingly, we can expect KMC to become the standard of care for these vulnerable newborns. But KMC is not yet a standard of post-cesarean care. To prioritize skin-to-skin contact in the sensitive hours, days and weeks following a cesarean, families may have to ask nurses and doctors to do things differently to assist with ongoing skin-to-skin contact. Extra help may be needed from family, friends, a doula or a kangaroula.

Kangaroula Support? What’s That?

As Nils and Jill Bergman describe it, “Kangaroo Mother Care plus doula equals kangaroula!”

The work of the Bergman’s foundation, Neuroscience for Improved Neonatal Outcomes (ninobirth.org), conducts research into and advocates for conditions that support optimal brain development for babies at birth. Jill Bergman now also trains birth attendants to offer what she and Nils Bergman call kangaroula care. Doulas trained in this approach understand the importance of skin-to-skin, breastfeeding and a low-stress birth environment for the health of mother and baby, and do their best to help families get off to a strong start, no matter the circumstances of the birth.

To gather practical tips on offering families KMC in the days and weeks after a cesarean, especially if extra medical attention is needed, I got in touch with Jill Bergman at her home in Cape Town, South Africa.

Skin-to-Skin with a Cesarean: Interview with Author and Doula Jill Bergman

Mary Esther: First of all, I would like to thank you and your husband, Dr. Nils Bergman, for the work you have done to promote skin-to-skin contact between mother and baby as a new—but, of course, very old—norm. When it comes to cesarean, you and Dr. Bergman are integrating what is biologically ancient—skin to skin—with our technologically new surgical births. I’d love to ask about how you support families to maximize KMC during and following a cesarean. To start, how would you describe the particular benefits of skin-to-skin contact after a cesarean?

Jill: Sure. In a vaginal birth, a baby comes from a warm, dark peaceful place with mum’s familiar voice, heartbeat and smell, into a normally brightly lit room with nurses and doctors and noise. This takes a lot of adjustment for the baby.

In a cesarean, the adjustments are even greater for a baby. The operating lights are acutely bright. The room smells of antiseptic and is colder than a regular delivery room. The baby may have had no preparation from contractions to prepare him for the birth, so the sudden transitions are even more scary for him. He is held by doctors with strange-smelling plastic gloves, examined on a resuscitation table with extremely bright birth lights and then often routinely placed into a warm incubator and wheeled away to the nursery for “observation.” This is separation from everything that is familiar to the baby. This causes instability in the newborn.

However, if the baby is placed on mother’s chest while the mother is being sewn closed, mother’s familiar voice, heartbeat and smell will calm him. Her chest will warm him and he will stabilize physically much faster. The smell of colostrum will draw him to move toward the nipple and he will self-attach and start to breastfeed. In the strange operating environment, he has the “buffering protection of adult support.” The contact also helps the mother to bond with her baby. It helps her to be less anxious about the operation as she focuses on her baby on her chest. She can skip the worry of seeing her baby being wheeled away.

Mary Esther: Do you have any tips for how partners can help mothers hold their babies skin to skin in the operating room, even as the surgery is still underway?

Jill: Partners are very important. Partners can support by holding the baby on mum’s chest. Remember, mum’s one arm has a drip and the other has a blood pressure cuff. Partners can also check baby’s breathing and color and make sure he is covered by a blanket.

Mary Esther: Dr. Bergman discusses the importance of enhancing oxytocin for mother and baby for the first 1000 minutes after birth. Following a cesarean, a mother is in the first stages of recovering from surgery and simultaneously figuring out breastfeeding and how to parent her baby. What helps families keep babies skin-to-skin during this sometimes challenging time?

Jill: A mother recovering from a cesarean knows she has to look after her baby and this helps the recovery. All of her maternal instincts will be focused on her child, but she needs help. If she has just had a cesarean, she won’t be able to pick up her tiny newborn, so there needs to be someone to assist her, possibly her partner, another family member or a kangaroula. If both parents are allowed to stay in the unit for the first days, it is hugely helpful for the mother’s recovery as they share the load and work out together how to care for their baby. It makes father much more part of the family and care. Fathers have a special role to play as the baby can sleep on him without the stimulation of the smell of breast milk. The baby is born, but in this way, the family is born, too!

Mary Esther: You mentioned support by a doula known as a kangaroula. What is kangaroula care? How does a doula trained in this approach help make the time after the birth as oxytocin-rich as possible for mother and baby?

Jill: Doulas care for and support a mother in labor and focus on her needs. A kangaroula does this as well but is also a voice for the baby’s needs. For example, she might help a mother delay or avoid an epidural to minimize the transfer of drugs to the baby; she might help a woman avoid an unnecessary, planned cesarean since this is unexpected and stressful for the baby.

As the baby is born, a doula trained to offer kangaroula support will be thinking about the baby’s experience as well as the mother’s and do what she can to limit stress on the baby. She will dim the lights or cover the baby’s eyes, ask for quieter voices and set up a gentle environment for the baby and mother. Most of all, a kangaroula will advocate for the baby not to be separated from mother unnecessarily and will support undisturbed time for the first two golden hours to bond and start breastfeeding. A kangaroula will also help new parents transition to parenthood by helping parents understand ways to protect togetherness and minimize interferences in the days to come.

Mary Esther: There are many reasons why a baby born by cesarean might be taken to the NICU, some for observation and others for needed medical care. In most US hospitals this means we now have a baby and mother who are separated, sometimes for days, with scheduled visits, every two to four hours, although sometimes more frequently. Usually skin-to-skin and breastfeeding are permitted and often encouraged during these visits, but the baby remains in the nursery while the mother stays in her recovery room or at home. Dr. Bergman speaks to this point directly, saying, “[The incubator] is the wrong place for the baby. Incubators destabilize. We bring needed medical care to mother and baby whenever possible.”

Jill: Yes, absolutely. The design of the NICU as a separate space from the maternity ward needs to be challenged as it makes the start of breastfeeding nearly impossible and negatively impacts early bonding. We need the baby on the mother’s chest nuzzling at the breast, stimulating breast milk production and the hormones that we know promote healthy bonding.

Mary Esther: Do you have any tips for parents who feel strongly about maximizing skin-to-skin contact if their baby is in a NICU in a typical US hospital, where separation is the norm and contact is scheduled, especially if medical attention is needed for the newborn?

Jill: Of course, some babies need medical care. The answer is to bring the medical support to the right place: the mother’s chest. There is always room for a chair next to an incubator, even a fold-up deck chair so the mother can lean back and rest. We have to ask doctors to adapt their practices so care is available to the baby on its mother’s chest.

Mary Esther: Change can come slowly to hospitals. What have you seen on this front in South Africa?

Jill: I’ve seen parents and doulas change hospital practices by asking questions and being assertive. I’m thinking of a father who politely refused to leave the recovery ward because his wife needed help with breastfeeding. Eventually they allowed him to stay and now they have put up more curtains between beds and fathers are permitted to stay. When I first asked the Ob/Gyn for permission to attend cesareans at one of our local hospitals five years ago as a doula, it was unheard of. Now partner and doula are allowed in routinely. But some hospitals are unbending. In those cases, it makes sense to switch hospitals, if possible. I recently had a mum needing a third caesarean who phoned me at 40 weeks because she would not be allowed to hold her baby in the operating room, and her baby would be taken to NICU. We found another doctor and another hospital where she could breastfeed her baby in the operating room and [they could] remain together. She was very pleased with the change.

Mary Esther: Because women are usually on pain medication that can affect their mental clarity and alertness, hospital personnel are often concerned about women sleeping with their newborns on their chests in the days following a cesarean. They insist the mother place the swaddled infant in a nearby bassinet for sleep. Given what we are learning about how stressful this separation can be for a newborn how do you think about this issue?

Jill: Let’s keep in mind that the baby needs the smell of mother to sleep-cycle properly. The baby does need to be carefully observed and mum and baby should not be left alone. The baby can be tied on safely to the mother’s chest with the airway open. We have developed what we call a kangacarrier for this purpose. This is what we do even for preterm babies. It makes a tremendous difference.
Mary Esther: When the family gets back home, what tips would you offer to support ongoing skin-to-skin contact?

Jill: Get a carrier that is non-stretchy and carry your baby when you are home. Mothers can undress the baby and place her in skin-to-skin contact on her chest. Fathers can wear the baby, too. Get lots of help so you can focus on the baby!

Mary Esther: I’d also like to ask you about small, frequent feeds. Dr. Bergman describes one-hour sleep cycles syncing up with one-hour feed cycles as what nature intended. We often think in terms of feeding a newborn every two to three hours, and many NICUs invite moms to nurse every four hours.

Jill: Babies inside the mother are swallowing amniotic fluid every 40 to 60 minutes. After birth, the sleep cycle is about 60 minutes. When the baby is born, keep to this one-hour cycle. The size of a newborn’s stomach is only five ml, which is about one teaspoon. But the baby needs this small amount every hour or so. This is very natural if you keep your baby close to you with lots of skin-to-skin contact. With frequent feeds that follow the sleep cycle, the baby will learn food security as she sleeps and wakes and nuzzles on the breast and feeds and falls back asleep.

Mary Esther: If a separation does happen, do you have any tips for reconnecting and recovering from the separation?

Jill: Yes. If a separation has happened, the question we can ask is, “How quickly can we get mum and baby together again?” As soon as that happens, undress the baby and mother’s chest and let them lie together for hours, giving the baby a chance to go through the wriggling and nuzzling towards the breast. Let the baby latch supported, but undisturbed, for as long as it takes for both of them to calm and settle and be together, even for days. This is healing for both of them!

Mary Esther: Thank you so much, Jill.

References:

  • Bell, A, E Erickson and C Carter. 2014. “Beyond Labor: The Role of Natural and Synthetic Oxytocin in the Transition to Motherhood.” Journal of Midwifery & Women’s Health 59 (1): 35–42.
  • Bergman, Jill. “Kangaroula Support.” Lecture, Birth Day Presence, New York University, New York, New York. October 2016.
  • Bergman, Nils. “The Neuroscience of Breastfeeding and Skin-to-skin.” Lecture, New York University, New York, New York. February 2016.
  • Bergman, N, and A Jurisoo. 1994. “The ‘Kangaroo-Method’ for Treating Low Birth Weight Babies in a Developing Country.” Tropical Doctor 24:57–60.
  • Buckley, S. 2015. “Hormonal Physiology of Childbearing.” J Perinat Educ 24 (3): 145–53.
  • Buckley, Sarah. “Hormonal Physiology of Childbearing.” Lecture, New York University, New York, New York. November 2014.
  • Leng, G, SL Meddle and AJ Douglas. 2008. “Oxytocin and the Maternal Brain.” Curr Opin Pharmacol 8 (6): 731–34.
  • “Maternal separation stresses the baby, research finds.” 2011. ScienceDaily. Accessed February 22, 2017. https://www.sciencedaily.com/releases/2011/11/111102124955.htm.
  • Morgan, B, A Horn and N Bergman. 2011. “Should Neonates Sleep Alone?” Biol Psychiatry 70 (9): 817–25.
  • Swain, J, et al. 2008. “Maternal brain response to own baby-cry is affected by cesarean section delivery.” J Child Psychol Psychiatry 49 (10):1042–52.

About Author: Mary Esther Malloy

Mary Esther Malloy holds a MA in anthropology. She is a doula, Bradley educator and mother of three children. Please visit themindfulcesarean.com for her newest project! You will find additional articles and recordings by Mary Esther at mindfulbirthny.com. If you are interested in the neuroscience of skin-to-skin and breastfeeding, she invites you to visit her blog thebirthpause.com where you will find her popular post “Kangaroology: The First 1000 Minutes” about Dr. Nils Bergman’s 2016 talk at NYU. Mary Esther is proud to announce that she recently certified with Jill Bergman to offer Kangaroula Care. She can be reached at info@mindfulbirthny.com.

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