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Anne Drapkin Lyerly, MD, MA Headshot

Expecting a Good (Cesarean) Birth

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"If I don't see you again before the big day," said Ali, a midwife I'd just seen for an OB appointment, "have a safe birth."

Of course safety was at the front of Ali's mind. I'm headed within a couple of weeks for my fifth cesarean, and the "five-peat" (as we obstetricians are known to call fifth cesareans -- as in repeat, three-peat, etc.) can be a veritable challenge, surgically speaking, and can keep even seasoned surgeons up worrying the night before.

If Ali were sending off a first-time mom (or anyone) expecting to deliver vaginally, she'd say something different, like "you can do it" or "enjoy your special day" -- or more to the point, "have a good birth."

Surgical challenges aside, I want that too. Not a vaginal birth, but a good birth -- one to be celebrated and cherished. I have four boys, am expecting a girl this time, and getting it right goes far beyond "thinking pink" once I've got her safely home. My bag is packed, my fancy camera is charging, my husband Kim and I are full-bore excited as my surgery date approaches.

To the extent that this seems strange, I'd offer it reflects instead entrenched (and outdated) ways of understanding birth and how we value it. Consider in contrast the openness brought to thinking around the other bookend of life, in which a depth of research reveals that "good deaths" can take many forms and happen in many places. This seems to be something we've missed when it comes to birth: the presumption is that good births are the "natural" (and vaginal) ones -- the best lack anesthesia and come complete with orgasm. Let's just say I don't expect either.

Yet those of us who've given birth know that mode of delivery (vaginal or cesarean) doesn't in fact determine whether a birth is good or not, and there is such thing as a good birth that involves anesthesia -- and even, yes, a scalpel.

In researching for my book, A Good Birth, I heard from more than 100 diverse women who told me about their births -- what made them good, what made them bad, what they'd do differently the next time. Sure, I heard about euphoric vaginal births in candlelit settings and cesareans that women came to mourn. But I also heard about traumatic births at home, and hospital cesareans that fell squarely in the category of "good," even "great."

I've since opened a space on my website called "Your Story" for women to share their experiences, offer what a good birth means to them. Laura, who delivered twins by cesarean, recalls the "pure joy of holding both babies in my arms" after her recovery, and offered, "I'm confident that they entered this world the way they were supposed to." She joins the chorus of women who know the good in birth should be ours to define.

No doubt there are things providers can do to help. In fact, a group of doctors from the UK and Australia have pioneered a technique they (controversially) call "natural cesarean." It is an effort to dispense with unnecessary surgical rituals and bad habits (like talking golf) and reorient cesarean birth around the delivering woman, her partner and her baby. Their approach involves early skin-to-skin contact, a slower more "physiological" delivery, and most importantly to my way of thinking, "engaging the parents as active participants in the birth of their child." Doctors at the Massachusetts General Hospital in Boston have picked up on this, and offer women clear surgical drapes so they can actually see their baby emerge through their abdominal incision.

These particular adjustments if intriguing aren't right for everyone (in the same way that many women giving birth vaginally don't want to watch what's happening in a mirror). In fact the use of the term "natural" reflects still the antiquated view that marks "natural" birth as an ideal, and all else as something less.

In truth sometimes technology makes birth better -- experientially and otherwise. Sometimes it is necessary, even lifesaving. Mara discovered as much when her baby emerged blue after an uncomplicated vaginal delivery and was whisked away for resuscitation, no early skin-to-skin for her and her little boy. But, she offered wisely in a your story post, "What truly made my experience so positive was not the technology or the medicine, but the compassionate, quick-footed work of a truly gifted physician."

It's time for us to dispense with the battle lines that have marked conversations about birth for decades -- and that have led us to neglect the important task of finding and facilitating the good in cesareans and other births where technology is desired or needed.

Yesterday I was back for another OB appointment and saw the doctor who'd be doing my surgery. "Let's talk about your delivery," she said, and together we chatted not just about the risks and challenges of a "five-peat," but who I'd like to have there, my hopes (and fears), and how to make me feel not just safe but connected to my daughter and involved in the delivery. I brought our conversation home to Kim and together we began imagining our impending birth experience -- the amazing process as well as its sweet reward.