Episode 220 Dr. Natalie Elphinstone + Maternal-Assisted Cesareans

The VBAC Link

“Let’s make every birth the best possible version of that birth that it can be.”

Dr. Natalie Elphinstone is a true trailblazer! When one of her patients asked about the possibility of a maternal-assisted Cesarean, she listened intently, took the idea to heart, and advocated for change by creating a new hospital policy to allow this beautiful procedure. Dr. Elphinstone is creating a whole new experience for Cesarean moms as they get to deliver their babies, hold them first, have uninterrupted skin-to-skin time, and feel like birthing women instead of patients on an operating table.

Dr. Elphinstone shares how she was able to make this change, how we can implement this procedure in our areas, and even offers some VBAC tips as she is a big VBAC advocate as well! We are SO honored to have her with us today.

Additional Links

Dr. Elphinstone’s Instagram

Dr. Elphinstone’s Introduction Post

How to VBAC: The Ultimate Prep Course for Parents

Full Transcript under Episode Details

Full Transcript

Meagan: Welcome to The VBAC Link, you guys. This is Meagan, your host, and I am so excited to be here with you today. Today’s guest is an amazing OBGYN in Australia. She has caught over 1500 babies and believes in supporting women and families to make individual choices that feel right for them. You guys, she is making such a big impact in Australia and I am just so excited to pick her brain and hear more of her journey about how she has been changing the norm in Australia.

Review of the Week

We have a Review of the Week so of course, I’m going to jump into that before we start with Dr. Natalie.

Okay, so today’s review is actually pretty short. It’s from Dr. Steven Roushar who is amazing. We actually have him on a podcast probably back in the early one-hundreds. He is a chiropractor and his wife has also had a VBAC. He said, “The VBAC Link is phenomenal. Great podcast content and training for birth workers.” Thank you, Dr. Roushar. We are so happy that you love The VBAC Link. We love you and believe in chiropractic care so much.

As usual, if you have not had an opportunity to leave The VBAC Link a review, we would love that. I love getting these reviews. It makes me smile and we love reading them on the podcast. So push pause right now, and head over to Apple on iTunes. You can leave us a review. A 5-star review would be awesome along with a written review. You can do it on Google. You can do it on Facebook or you can email us. Wherever it may be, we would love your reviews.

Dr. Natalie Elphinstone

Meagan: Okay, Dr. Elphinstone, we are so excited to have you. We are so grateful for you. I know your time is precious in OB-land. You are obviously seeing a ton of births. So grateful to have you. Again, thank you so much for being here. In the birth world, we get these comments sometimes, “You’re The VBAC Link, I have a girl crush on you.” I am girl-crushing on Dr. Natalie Elphinstone. She is the freaking coolest. You are so cool. I am so honored to have you on the show today and I’m so honored for her to share with you her knowledge because you guys, you are going to fall in love with her too.

If you don’t follow her Instagram, right now, press pause and go check her Instagram. Do you have a Facebook too? I think we just follow you on Instagram.

Dr. Natalie: Yeah, sadly I just do the Instagram thing.

Meagan: That is okay. You are @drnatalieelphinstone, right?

Dr. Natalie: Yep, all one word. One really long word.

Meagan: One really long word, but you guys, it’s amazing. I want to do a little bit of a background. This is how I found her. I actually found her off a video. You may have seen these going around of a maternal-assisted Cesarean delivery. It brought me chills. It made me cry. I was just like, “Oh my gosh. I want to do this. I want to have this option here in the U.S.” She is in Australia too, so not here in the U.S.

I don’t even know. Your page just started blowing up and this video started going viral. I shared it and I think I wrote you. I think I just wrote you and was like, “Wow, this is amazing,” or something. Crazy enough, we had some crazy emails coming through like, “That’s fake. That’s not real. It’s a simulation.” I was like, “What? No.”

Anyway, so I wrote Dr. Elphinstone and I just said, “Hey, I would love to have you on the podcast.” She is so gracious and said yes, so we are going to dive right in. I always say “dive right in” but we are diving right in to learn more about what she does and how she is truly changing the birth world in Australia. Okay.

Dr. Natalie: Thank you, thank you, thank you so much for even thinking of having me come and talk on a podcast that of course, tends to be concentrating on VBACs, yet yes. I am getting known for this maternal or parent-assisted Cesarean. And so to be honest, it took me a little bit by surprise that you thought maybe I would be somebody to talk to. I mean, the whole thing took me by surprise.

When I started off just sharing some of the videos of my maternal-assisted Cesareans, it was not with any kind of intention of trying to be this game changer. I actually just wanted to show something that we did that was really, really awesome and maybe with it, that idea of, “Well, if we can do it here, then maybe it can inspire other people to open up their mind to this possibility as well.” And then, it kind of just blew up as you said. It started getting reshared. I started getting contacted by people all around the world asking for my help and my advice on how they could possibly do it in their country.

I’m super, super honored to be able to share my journey and my knowledge. To date now, I can say that– I was just contacted today by another country over the weekend who contacted me to say, “Thank you very much for the information that you shared. It was able to allow me this opportunity to do a maternal-assisted Cesarean for possibly the first time in my country.” This was Ireland, so I’m pleased to say that Ireland is the sixth country that I’m aware of that I’ve been able to help impact at least one individual person. This is just mind-blowing to me and I feel so privileged to be able to not do anything special. I don’t think I’m doing anything special. I’m just open to changing my practice and then sharing it so that it is seen that it is something that is possible.

When you then get people that say, “That’s fake,” I mean, oh. That actually just makes me really sad. It makes me really sad that this idea of what I’m showing, a maternal-assisted Cesarean, is so far removed from what they believe to be reality and what they know in their world that they think it must be fake. That’s actually sad to me.

Meagan: I’m with you. Me too. It does. It breaks my heart that this world has come to the point where we are so blinded, we are so closed-minded, and just looking down this tunnel that we can’t see the possibilities outside of the norm.

Dr. Natalie: Yeah, yeah. That’s what it is for me. This is just me thinking with an open mind, “Can we do something different?” If the answer is yes, then why don’t we? Why can’t we and how do we make that happen? So that’s how I started.

Meagan: Right, I know. That’s what I love. It’s going to take someone to get it started for it to happen. Here you are. You’re doing it. You are doing it and you are changing it. It’s hopefully just going to trickle on down and spread throughout the world to see that Cesarean birth can be different. It can be different. Each video, they are all different. Sometimes, I have seen that you’ve got videographers or someone in the OR even on the other side. You’ve got two different views of baby coming out. You have mom reaching down and pulling baby out, and then we have the other side where the amniotic fluid is pouring out. It’s just so dang cool. It’s so dang cool. I love it.

For my second Cesarean, I watched it in a mirror. I wasn’t able to be a part of my birth in the way that you are creating people to be a part of their birth, but I saw it in the mirror and it was really cool and really special. That right there, that and the skin-to-skin that I was able to get made the difference and created the healing for an undesired Cesarean birth that I had. It truly created that healing aspect. I’m just going to shoot it out there. How? You’re seeing it in your head and you’re like, “We’re going to do this.” What kind of flack or backlash did you get or pushback did you get in your space there in Australia? What did you get there and how did you personally push back?

Dr. Natalie: Yeah. It’s a really good question because I think everybody who has wanted to pursue this journey comes back and says, “But I’m getting met with these challenges and I’m getting met with these accusations. I’m just getting shut down.” I think that probably everybody will meet some of those challenges. And yes, I’ve met those challenges too.

My journey of how this happened to me, and I always tell this story because I think it’s a really important part of this story. This wasn’t on my radar. To be honest, I didn’t think of it myself. I had a single patient come to me who I was looking after for her antenatal course. It was her first baby. She had decided for various reasons that a Cesarean birth was the way that she was going to go. She came to me and said, “I’ve seen on somebody else’s social media this idea of a dad-assisted Cesarean, a partner-assisted Cesarean.” She said, “Can we do that?”

I said, “Well, I’ve never seen that happen before in real life. It’s definitely never been done at this hospital. I don’t know that it’s ever been done anywhere in my area before,” and so one easy spot to stop there would be for me to say, “So no, we can’t do that,” and that would have been a really easy answer. But instead, I went, “Well, maybe. Why not? Why can’t we do that? That does seem pretty cool. That does seem like it might be a really valuable thing if that’s something that you want to do. So how do we make that happen?”

So my point is, number one, this whole thing started with one person, one patient herself coming to me saying, “Can we do this?” It can start really, really small. I was in a privileged position where I had the opportunity to go basically straight to the top of the hospital. So I’m talking about working in a private hospital in Australia for this scenario, so I literally just went to the CEO of the hospital. I asked her, I said, “I don’t know how to make a new procedure happen. Tell me what I need to do to be able to make this happen.” I mean, number one I asked her, “Are you on board? Can I make this happen?”

To be fair, I was expecting to be shut down at that point, but my gosh, she said yes. She said, “That sounds like, yeah. Why not?” A very quick answer would be that when it always comes down to new procedures, is there a value in it? Is there an importance? Does it achieve something so to speak? And then the second thing, is it dangerous or are there risks or are there concerns about that? If you can tick off those two boxes, then yeah. We can do a new procedure. But there are some hoops to jump through. She told me what those hoops to jump through were. I had to write a policy. Hospitals always want to know this very streamlined checklist of how you do this new procedure.

And then I had to get that policy approved by the various levels of boards if you like at the hospital, so I had to present this to a couple of different meetings. That’s where things got really interesting. I can write a policy. I can write a protocol. That’s just me sitting at the desk and talking stuff out, but then presenting this idea to boards of people to get a general consensus that this seems like a good thing to do, I guess I was really naive going into that. I guess I believed that this was a really important thing to do, so I probably expected that everybody else would as well, but clearly not.

That was definitely my naivety at play there. I then got met with challenges from the people hearing it. Everything they just laughed off like, “That sounds like the most ridiculous thing in the world.” I guess when you are talking to surgeons for example, surgeons, yes. We operate. People are asleep and we cut them open and we do a procedure. There are a lot of these rules around that to keep it sterile and to keep it clean and to keep it safe. To be fair, here I am suggesting that this woman who is awake and having her operation is going to literally reach down into her own open wound and pull out her baby. So yeah, okay. I get why it might sound ridiculous if you don’t have the understanding of the fact that this is birth rather than it being an operation. I think that’s a really important part to remember.

I hope that none of us ever forget when we are doing any kind of Cesarean or any kind of instrumental birth or whatever that this is not just a procedure that we are performing on somebody. This is their birth. This is the thing that they are going to remember forever. So even if this is the 5th Cesearean I’ve done this morning and I’m getting a bit hungry or I’m a bit bored or whatever, oh my gosh. That’s not the point. The point is to remember that this is the most astounding thing that has ever happened in this woman’s life and in this family’s life so let’s make it really, really special. Anyway, I digress. I digress.

Meagan: Absolutely. You digress in a good direction though because it’s so true. I’m sure. I’m not a provider. I don’t know. I’m sure it just gets repetitive, right?

Dr. Natalie: Yeah, it can.

Meagan: Walk in. Catch a baby. Walk in. Have a Cesarean. But if you can, if you can walk in. If you are a birth worker and you are listening, and that goes for all birth workers, walk in and truly hold space for that person and be there for that person because it is something that they are going to remember forever. You probably aren’t going to remember two months down the road, but they will.

Dr. Natalie: I think that’s something that hopefully every provider continues to keep in the forefront of their mind. I think I’ve certainly had the times where let’s be honest, sometimes I haven’t honored the birth experience, or perhaps it’s a Cesarean and often we then think that the woman’s really distracted now. The baby’s out. She’s focusing on the baby and we’re just getting on with the rest of the operation and closing her up, and often, let’s be fair, I am just having a conversation with my colleagues around me. I’ve had that not come back to bite me because I don’t think I’ve ever said anything inappropriate in that situation, but the women and the partners have come back and said, “Oh yeah. We heard you chatting about other things.”

Actually, a lot of the time when they are telling me that, they are telling me that they were kind of reassured by that because they knew that if I was just perhaps having this general chitchat then clearly I wasn’t worried about anything in their operation.

Meagan: Yeah, I can see that. It is interesting though because, with my first baby, that’s what I remember. I don’t remember my baby’s cry. I don’t remember seeing my baby. I remember the doctor and the assistant on the other side of the curtain talking about how terrible the storm was outside and how one just got back from Hawaii and was so depressed. That’s what I remember about my birth.

Dr. Natalie: Yeah, yeah. I don’t quite know what the answer to that is because it is going to be this balance between definitely wanting to honor that birth space, but yes at the same time, we are humans too and it is our job. We love our job, but sometimes yes. Part of that job is bonding with our colleagues as well.

Meagan: Talking on the job. Yeah, talking on the job. That’s what you do.

Dr. Natalie: That’s always a wake-up call for us to always be really mindful of even just what that general chitchat might be that, okay yeah. Let’s talk about our holidays. That’s a good memory, but maybe let’s not complain about something else like another colleague down the road. Let’s keep that somewhere else.

Meagan: Yes.

Dr. Natalie: Oh gosh. So yeah, I did definitely meet with some criticisms as I said. Just that general not understanding of the importance of birth and this incredulity of the ridiculousness of the things that I was asking for. And then there was the stuff you would expect like the actual medical concerns that the other people might have like, is this a danger to the woman? Does it increase her infection rate? Is it a danger to the baby? The baby might get too cold and the pediatricians can’t get access to the baby quickly. There were those sorts of concerns actually coming from a genuine place of still wanting to do the absolute very best for our families but of course, there is an answer to all of those questions.

And then there were the people who I’m not sure what their motivation is. Maybe it was a threat to them. Perhaps other providers have always done things a certain way, so anytime you’re wanting to change a procedure, number one you’ve got to realize why it’s important to change the procedure. So with a Cesarean for example, we’ve been doing a fairly stock-standard way of doing this Cesarean for who knows how long. Certainly, for as long as I’ve been training, it’s always been done a certain way and possibly I imagine, it’s been done pretty much in the same way for many decades, so why would I change something that I can’t see a problem with?

In most providers’ eyes, there’s no problem with this. There’s no danger in this. There’s nothing going wrong apart from all of the things we know certainly can be a danger and can go wrong, but we accept those risks. But why would I change and certainly why would I change into a direction that might become more complicated, especially more complicated for me as the provider having to change the whole way I do things? Because let’s be honest, we’re people. We might not really like change especially if we’ve been doing something the same way for a really long period of time.

So I definitely also got this pushback from maybe the people who felt challenged by that and who came back to me with even some threats. I don’t even know. It was sort of ridiculous and if you weren’t in a really serious board meeting, I would have laughed at these people who were coming to me claiming wildly with no evidence behind it things like, “You’re going to kill women doing this.” What? What? Where is that coming from?

And then the other really one that did actually make me laugh out loud, I certainly got one threat if you like or they thought it was a threat. They said, “But once you do it once, that woman is going to tell her friends and she’s going to put it on her Facebook and you’re going to get other people asking for this.” I went, “But that’s the point.” That is why I want to do it.

Meagan: You want to make this change. That is what we are doing.

Dr. Natalie: So yeah, I thought that was funny, but that’s definitely not where they were coming from with that. Anyway, that is what happened so they were right.

Meagan: They were totally right. Here we are. All of us are totally in here loving it and wanting to talk to you about it because you are willing to. Like we were saying earlier, it’s sad to know that so many people are so closed-minded. “Oh, well if you do this, then it’s going to get it.” It’s like, well yeah. We’re not doing this as a secret. I’m not going through all of this to keep it a secret. We want to make this change. We want to make Cesarean birth better. My slogan is “Make Birth After Cesarean Better”, but to be really honest, sometimes our VBACs don’t end up going exactly as planned, or maybe we decide in the end that we want a scheduled Cesarean, so let’s have a healing experience, a beautiful experience and let’s incorporate these moms as you are doing because it’s truly going to make a difference.

I don’t know how many of these you have done, but I would be so curious to start learning what it does for the postpartum period, where it’s taking us in postpartum, and how we are viewing these births. So many of these people that I talk to, and you can only imagine, have had very traumatic Cesareans, very terrible experiences, ones that they truly have to process and work through before they can even fall pregnant again. It makes me wonder with this even if it is a Cesarean and even if it wasn’t desired, in what ways would it change our view? Have you had a lot of people talking about their experience of how they are viewing this? What are your patients saying?

Dr. Natalie: I would really love to be able to do, if I had time in the world, to do an in-depth study basically of what the feedback was from all of the families that so far have had this procedure, this maternal or paternal or whatever you want to call it assisted Cesarean. Certainly, one thing I know for a fact is that I definitely have never had anybody come back to me after they have done this and complained or actually had any concerns. I have not had anybody ever come back saying, “Oh, yeah. Well, maybe next time I won’t do that” or “I wish I hadn’t done that.”

Nobody has ever said that. It has definitely always been a really positive experience for them. Some families and mothers are only having their first baby and doing it this way, so perhaps they don’t have anything to compare it to but that doesn’t matter. What they know from this experience has been that it was really empowering for them and that it achieved a lot of the things that they would be imagining from a vaginal birth anyway.

And then I’ve had all the way up to somebody having her fifth Cesarean and her four previous Cesareans had been with other providers and had not been any kind of maternal-assisted Cesarean. In particular, her fourth Cesarean before she came to me was a really difficult, traumatic experience for her because of things that happened at that time. This was an unplanned pregnancy, so this wasn’t meant to happen in the first place, but happy about it and accepting it for sure. She was acknowledging that certainly she was going to have a fifth Cesarean.

So she came to me and we performed this maternal-assisted Cesarean. We had spent an extensive period of time talking about what all of the very specific things that had been difficult for her in her previous Cesareans and how we could overcome that and what we could do differently this time around. She has this fifth Cesarean which she then says is so dramatically different from all of the other experiences that she had and so healing for her that she could now say in retrospect she hadn’t even processed perhaps how difficult the other Cesareans had been until she had this experience where she could now see the difference. She’s like, “Now, I can actually rest happy that this was my final baby now. The fifth one, we’re done. We’re taking permanent measures.” But this then was so healing for her that she can rest on the knowledge that this is her lasting impression of what birth is now, that it was this rather than the previous one in particular that had actually been really, really difficult.

She had the insight to say that even the postpartum bonding period with her baby was so impacted by the difference in her Cesarean experiences that yes, she knew this baby from the very beginning. She got to be the first person to put hands on her baby. She got to have that immediate skin-to-skin with her baby and that uninterrupted bonding time. It often takes the women by surprise, perhaps they haven’t thought about these details but they often will say things like, “Whoa. This baby’s warm and slippery and wet.” I’m like, “Yes, of course, it is warm and slippery and wet. I don’t know what you were imagining otherwise.” But that hadn’t been their experience before because previously, the first way that they had experienced their baby was only after the providers had dried off the baby and wrapped it up in a blanket and maybe now given it to them, so they’ve only got the view of this little face and all they’ve gotten is “I can touch your cheek” kind of deal.

So yeah, it has taken them by surprise that it turns out when you first lay hands on your baby, it’s warm and wet and slippery.

Meagan: It’s kind of crazy though. I had the same thought. With my VBAC, I pulled him up from my vagina and pulled him onto my chest and he was. I was like, “Am I going to drop him because he’s so slippery?” Before, I was strapped to the table and didn’t really get that. So it is. It’s such a different feeling and you wouldn’t think about those little details being dramatic, but they are going to leave an impression.

So how can we as listeners and people who are going for a VBAC, or maybe just a scheduled Cesarean, maybe going for a VBAC which ends in Cesarean, are there any tips you can give, or is there anything that we can start doing, especially if the hospital is not doing what yours is doing, to try and get this going like your patient did? If any providers are out there listening, do you have any tips for anybody?

Dr. Natalie: I think it definitely can be achievable to make a change in the space of your own pregnancy, but perhaps start that early. So perhaps if you knew that a Cesarean was the way that you were going to go, start that conversation early with your care provider to say, “Okay, well if it’s a Cesarean, can we make it look like this?” Perhaps it’s not necessarily going to be to that extent of the maternal-assisted Cesarean because that does take all sorts of hoops to jump through and it will take time. I was incredibly– I don’t know if luck is the right word, but in a privileged position to make those changes in the space of only a few months in my hospital to introduce this new policy and to be able to achieve it for that one woman who had asked for it.

But I know that for a lot of hospital workers trying to change policy usually takes much, much, much longer than that. But it’s got to start somewhere. So if you as a mother are wanting to make that change, it is possible, but if it’s not going to work in your pregnancy journey, you could still be a voice for future mothers if you start the process at some point. It’s got to start somewhere. The really easy first start is to start talking to your care provider. Just say, “This is what I want it to look like in whichever way it may be a maternal-assisted Cesarean, or let’s lower the curtain down so I can see the baby emerging from my uterus.” Perhaps because I think a lot of care providers are going to take the easy way out and say, “No, you can’t do that because we don’t do that here.”

The next step in that conversation to ask gently is, “Why can’t we do that?” I say gently and I don’t mean that you should be pleading or begging, but confrontation often doesn’t achieve what you want it to achieve, so just have an actual, sensible conversation with your care provider. So if they come back and they say, “No, you can’t do that,” then perhaps you can say, “Why can’t we do that?” to actually find out what the legitimate reasons are if there is a legitimate reason because if the answer is, “Well, we don’t have a policy for that,” then you can ask the next one.

Meagan: How do we create one?

Dr. Natalie: Exactly. How do we go about creating a policy? If the answer is something like, “My belief is that it’s going to increase maternal infection,” then you can come back and say, “Is there evidence for that? Can you show me the evidence for that?” because I actually don’t believe that there is any evidence for that. Whatsoever the answer might be, just keep the conversation rolling so that hopefully at some point, there might be this little click in the care provider’s mind that says, “Oh, well maybe you’re right. Maybe this is a legitimate question to ask and possibly I could maybe even be that change in this woman’s life.” Maybe again, perhaps not. Maybe that care provider is still just not going to be open to change and not willing to make that personal effort that it takes, so if you’re in the position of having different care providers or you have the ability to request a different care provider, then go to the next person and ask the same question.

Maybe again, this is not perhaps going to achieve it in your pregnancy journey so to speak, but if then I as a care provider have multiple people coming to ask me the same thing, I would think that at some point, there’s going to be a realization where I say, “Huh.”

Meagan: This is desired. This is desired.

Dr. Natalie: Exactly. Because if there is that desire, then maybe it is worthwhile actually making that effort to make a change. If I also believe this because I think it does take this understanding on the care provider’s behalf to have that insight to say, “Actually, this is an important thing to do for our women and their families.” It takes an open mind for that, so maybe you’re not going to get that with the first care provider, but ask for another one and just keep going.

Meagan: And just keep going. Yeah, because the more that it is asked like you said, the more it’s going to be in our heads as a provider and then maybe a provider one day is going to say, “Okay. Let’s look into this.”

Dr. Natalie: Yeah. You can always ask to go up that chain of command so to speak as well. If the obstetricians themselves are perhaps not able to change, then you can ask that question of, “Can I get the contact details of who the clinical director would be?” or perhaps what the titles are of the people in the hospital who are in charge of making that change. So just go up the pipeline. You can do that as a consumer. You can directly approach the director or in my case at the private hospital, the CEO. Just write them an email. Don’t knock on their door, but gently ask in an email, “Perhaps is this something that we can work on?”

And it is happening. All of those countries that I’ve said have come back to me and said, “We were able to achieve this for the first time in our country,” a lot of the time, that started with the patient herself asking her care provider and then hopefully meeting a care provider who is amendable to that challenge and who will take up with that in themselves. They’re going to be more powerful going up that pipeline to make change happen. It’s possible. It is possible. It is happening.

Meagan: It is. It is happening. Your page has all of the proof.

Dr. Natalie: Yeah. They’re not fake videos. I don’t have time for that.

Meagan: Fake videos, I know. Like I said, it just makes me sad that people would even question that they are fake. Okay, we’ve talked about your journey of how this happened and now this is how we as consumers– I love how you said that we are consumers. We are really in a place where we can implement this. We can get things going and that’s simply just by putting the idea in a provider’s mind.

I love that so much. You recently posted an introduction of yourself and something that stood out to me is in your post, you talked about, “What if we do nothing? What if we change the care and stop intervening and do nothing?” Then you prefaced it with, “I don’t mean literally doing nothing, but I’m meaning continuously supporting, loving, educating, and empowering.” It really resonates with me. I love that so much. I love your words in that post. In fact, we will link it in the show notes so everyone can find it really easily. It’s just beautiful and I love what you’re doing. I really love it so much. I can’t even tell you how grateful I am. Like you said, we are a VBAC podcast. I am doing these Cesarean episodes. Yes. I would like to see the Cesarean rates go down substantially. That is a huge goal of mine in my personal life. I would love to see Cesarean birth percentages going down, but at the same time, I do understand that they are needed. They are desired and there is that to be said.

One of the questions I was going to ask you before I let you go is a lot of these videos look very calm and very planned. Sometimes Cesareans aren’t calm or planned. Are there restrictions there, pre-restrictions that have to come into play before a maternal-assisted Cesarean delivery could happen?

Dr. Natalie: Yeah. One thing I always definitely want to say because I’ve had this crisis myself as well going, “Am I getting known as a Cesarean doctor?” I don’t want to.

Meagan: I can see that.

Dr. Natalie: I don’t want to be that. I certainly don’t want to become that person who then only does Cesareans and maternal-assisted Cesareans, but if a Cesarean is the right choice for the woman in her situation, then yes. Let’s make it the best possible version of a Cesarean that it can be. That’s the internal catchphrase that I say. Let’s make every birth the best possible version of that birth that it can be. Whether or not that’s a vaginal birth or whether or not that’s a Cesarean or whether or not that’s anything, a forceps, let’s make it the best possible forceps that it can be. Okay, that’s not on the top of the list of whatever you want to plan for, but if it’s going to be that, then let’s make it the best possible version of that that we can be.

So yes. In a Cesarean situation, how can we make that calm– I mean not even calm, right? It’s about that connection. It’s about the instant connection of the mother and her baby, so how can we try to achieve that where she can be this integral part of her own birth rather than it being that she is a patient having an operation? It’s about changing that viewpoint.

I think that there are then so many little elements of that that we can achieve that even if it’s not necessarily straight up to the maternal-assisted part, that there are so many other steps that can be important that we can do without necessarily having her scrubbed and putting gloves on and putting her hands in her belly. Let’s lower the curtain. Let’s do direct skin-to-skin. Let’s do delayed cord clamping. Let’s not take the baby away from the mother. All of those things can still be achieved as well perhaps even and mostly still very achievable in an emergency Cesarean situation.

We use the word emergency Cesarean a little bit willy-nilly because it’s not often an actual emergency.

Meagan: Yes. I love that you pointed that out. But sometimes when we use that emergency word, it triggers people and they think that it was a life-saving thing, so I love that you said that. We have a lot of people say, “Oh, we had an emergency C-section.” I’m like, “Oh, what was the reason for your C-section?” “I didn’t dilate past a 3 for a few hours, so we walked down to the OR.” That wasn’t an emergency C-section.

Dr. Natalie: I think in our hospital, and I know most other hospitals in Australia have a very similar classification system, but we either call it an elective Cesarean meaning that it’s planned and booked well in advance, or if it’s an unplanned Cesarean, it gets called an emergency Cesarean. But we have then six different categories of how we classify how urgent that emergency Cesarean is, but they all then come under the banner of an emergency Cesarean. A category 5 is that it just needs to be done within the next 24 hours. It’s still called an emergency Cesarean, but clearly, if we’re happy to wait 23 and a half hours, it’s clearly not that urgent. But it still gets called an emergency C-section.

Yeah. There’s a very wide degree of how urgent an emergency Cesarean might be. So yes. At my hospital where I am able to do maternal-assisted Cesareans because I’m not at all of the hospitals that I work at, but at the one where I am able to do it at, at the moment, our policy is written in such a way that it is only for these planned, elective Cesareans. That’s got to do with a whole range of factors. It’s got to do with me being able to prepare the woman and her family ahead of time to know what this is going to look like. We go through all of those nuances of how she is, for example, going to become sterile because it is still an operation, so we do need to actually play by those rules to make sure that it is safe.

I often get questions or comments on my maternal-assisted Cesarean videos saying, “Oh, isn’t it a shame that she’s got gloves on? If it was truly a bonding experience, she would touch her baby without gloves.” I go, “Yes, absolutely. That would be really, really nice.”

Of course, it would be preferable to be able to grab her baby with her bare hands, but we have to keep in mind that this is still actually an operation, so from that perspective of we need to keep it safe for her, yes. She needs to have gloves on. I can’t see a way around that at this point in time.

Once the baby is out of her, once the baby is on her chest, once the baby is not in that sterile field so to speak, then of course, take the gloves off. She can touch her baby straightaway. That’s what you’ll see in those videos is that I often then lower her gown down so that she can put her baby directly onto her skin, onto her chest and then I’d be very happy for her to take her gloves off. They often just don’t in that instant because they are holding their baby and they don’t want to move from that moment.

Part of the reason why it’s currently only getting performed in an elective Cesarean situation is that pre-preparation where I’ve told her all of these rules of maintaining sterility so that she doesn’t inadvertently break any of those rules. She has to follow the same rules that I as the operating surgeon have to. We go through the same handwashing process. There is a little technique to putting on the gowns and the gloves and whatnot.

Meagan: Yep. I’ve seen it.

Dr. Natalie: Yeah, you’ll see it. Hands up in the air.

Meagan: They get their hands up in the air and everything goes on. The gloves go on. Yeah.

Dr. Natalie: Exactly. She can’t then touch anything after that point that’s not sterile. It’s all of that pre-preparation and it’s the pre-preparation of what it is going to look like and what it’s going to feel like for her to put her hands on that wet, warm, slippery baby and to be able to lift it out of her. I get that if she starts to lift and she’s like, “I can’t do it. It’s stuck.” You have to be reasonably firm because I try to make hopefully only a small enough hole that you can get the baby out, but it’s not hip to hip so it’s a little bit of a squeeze. But yep, pop it out.

Meagan: That was a question I wanted to ask you. Since you’ve been doing this, have you seen any special scar situations with a mother assisting meaning any extensions, J’s, or anything like that?

Dr. Natalie: No, I haven’t. I really haven’t. Again, that’s a question that we get. I get the question from people. I think this comes from their previous expectations of what they’re being told perhaps in previous Cesareans that isn’t it going to damage her abdominal muscles if she sits up like that? If she’s reaching and grabbing? She’s lifting her head up. People have told me before that in their previous Cesareans, they’ve been very much guided to not lift their heads up. In fact, I’ve had people tell me from other countries in particular that not only were their arms strapped down to the table but their head was strapped to the table as well.

Meagan: I’ve heard that as well.

Dr. Natalie: So they can’t move their head and they have a system where they have to lie down flat for six hours after a Cesarean so that they still can’t lift their head up or sit up for hours after the Cesarean because of this idea of things like a spinal puncture headache. I don’t even know what those rules are because they don’t make any sense to me. But if that’s what people’s experiences have been, then, of course, that’s why they are questioning the validity or the safety when they see then what I’m doing that they themselves might think that this is dangerous. But no, there’s no abdominal muscle trauma in excess of what a Cesarean does anyway.

No, there’s no risk to women of lifting their heads up off of the table. There’s no risk to women of bending so to speak and lifting their baby up at the same time as a Cesarean. Yes, it can be a little bit more difficult because of course, they are anesthetized, but we are there still. She is not going to drop this baby. I’m still very much within catching range, supporting range and you might see on some of these that yes, I do still give her that helping hand to pop its bottom out, but once she’s got that baby, you can just then watch their faces.

You watch those videos and sometimes blur out the rest of the stuff that’s going on, and just watch her face. It’s really powerful to watch her have this, first of all, maybe this anxiety that’s building. That would be an obvious response. Here she is lying down for this operation and then we lower those curtains and there’s this wonderment of what this is going to be and then she touches her baby, and then she lifts it up. There’s that moment of pure joy on her face every single time. Often, you’ll see the tears that come with that too. It’s just powerful. That’s what birth should be like every single time.

Just because it’s now in an operating theater, that doesn’t mean that we can’t achieve all of those same things.

Meagan: Right, yeah.

Dr. Natalie: We might as well stop after that, right?

Meagan: I love that. I love that. One day, I’m thinking, okay. I totally get that. You have to pre-prep and talk about this in a planned situation. I hope that maybe one day the conversation can be had in prenatal appointments where it’s like, “Hey if you don’t have a vaginal birth or if you don’t have a VBAC or are a first-time mom, there are these options. Here, sign this form if you would like to be educated on this, and let’s educate. Assuming it’s all calm and it’s not a true emergent baby out in seconds, but a very calm decision where everyone is making their way to the OR, maybe we can start implementing it there too because I do know for sure it would be so healing in so many ways for all of these moms that maybe wanted a VBAC and didn’t have their VBAC.”

Dr. Natalie: For sure. I think that’s so true. I am definitely like that where I’m constantly pushing the boundaries at my hospital. That’s where I next want to take it because as I said in my policy, it’s written that this can only be performed on elective C-sections and I wrote that policy. That’s a shame. If I could go back, I would take that out. I mean, it’s got to be that way to start off with because we did want to do this in a really controlled way because we were introducing a new technique, but now that we’ve seen it and all of the reasons that we believed we would need all of this extra time to be able to plan for this, now that we’ve done enough of them that we’re all practiced and experienced at them, it literally maybe takes an extra five minutes to the time of the operation just to get it ready.

So there’s no particular reason that I can see that we then couldn’t achieve that same sort of thing for the vast majority of unplanned Cesareans as well. That would be a game changer because obviously, the unplanned Cesarean is in particular where the woman might come out traumatized at the other end if she’s not getting what she was aiming for.

Meagan: Yeah, absolutely.

Dr. Natalie: Wouldn’t that be powerful if we could still make it then the best possible version of the emergency Cesarean that we could do?

Meagan: Absolutely. Well, I want to be conscious of your time. I know that you’ve been up all night for multiple nights on call doing the amazing things you do. I would love to leave with– since it is a VBAC podcast, is there anything that you would like to share about VBAC or anything cool that you’ve seen or anything that you’ve been implementing with VBAC or any tips or anything as a provider who is making a change in birth in general? I do want to focus on that. I don’t personally see you as the Cesarean birth provider.

Dr. Natalie: Great.

Meagan: That’s one of the reasons why I just think that you are amazing. I do think that is an amazing thing that you have done because you have started something that is really tricky. It’s a really tricky thing and you’ve started it. That’s where we start making changes just to start but I see all of your other posts too. I see all of your beautiful, amazing posts. I mean, I’m pretty sure you just shared a home birth after a Cesarean video.

Dr. Natalie: The HBAC, right?

Meagan: Yes, the HBAC. A lot of providers even in a hospital setting would be like, “Nope. Big no-no. That is terrible,” and you’re still out there sharing it. You’re still out there educating. Is there anything else you’d like to share for VBAC?

Dr. Natalie: Yeah. I think that’s right. I definitely am still very, very much in support of basically every woman being able to be empowered and informed to make the best possible choices for her in the situation that she’s facing because whilst yes, aiming for a VBAC is a really lofty goal, sometimes that isn’t going to be the best possible choice for her in whatever situation for whatever reason that might be. So yeah, number one is always having enough information being given to you or that you’re finding out yourself that you are equipped to make a decision and probably multiple decisions that feel right for you.

That’s difficult sometimes, I think, to know where to go for that information, so thank goodness for places like The VBAC Link that can actually give you appropriate medical advice, research, and the studies and the actual, accurate information so that it’s not just fear-based information that’s getting thrown your way.

Meagan: Yes.

Dr. Natalie: And then it’s about always advocating for yourself which is unfortunate that it has to become that way, but the hospital system, in particular, is a fear-driven, litigation, consent place so you’re often not necessarily going to get that unbiased opinion on what your choices are. You probably are going to have to go to external places to get that information, but then you just have to be really careful about where you’re going for that information. Trust your sources.

Also, my other tip is always going to be about looking at that whole birth mapping thing. So, okay yes. We are going to aim for a VBAC. For example, that might be your choice, but what if X happens? Then what’s going to be my choice in that situation? If Y happens, then where am I going to diverge now and what’s going to be my choice in that situation? We know that a lot of birth trauma comes from a situation that wasn’t prepared for. The woman comes back at the other side and says, “Well, I just didn’t consider that that could have happened to me,” so the unexpected or unplanned thing that happened is perhaps where a lot of birth trauma can come from.

Having that fine line between considering all possibilities but not needing to dwell on those scary ones. There are fear-based ones, but knowing what if you then need a hospital transfer? What if you need a Cesarean? What are your choices going to be in that situation? So that you can continue to make it the best possible version of that now that you can possibly make it.

Meagan: Yeah. I love that. It’s something that a lot of our followers will say when they had their initial Cesarean. “It was traumatic because it wasn’t even in my mind. It wasn’t even a thought that that was a possibility” or “I was so focused on this birth plan, this one route that I wanted to go and then it did diverge and it diverged completely over here and it threw me for a loop and now I’m processing.” I love that just in general for anyone going in to have a baby. Even with a planned Cesarean, we want to have an open mind because birth takes weird turns sometimes. Having an open mind and having all of your ducks in a row and having the education because you may not ever get there, but if it’s there, it’s going to help you if it comes. So I love that. I love that tip. Thank you.

Dr. Natalie: Yeah.

Meagan: Okay, well thank you so much for sharing how you have got this implemented and how it started, and how we as people can try to implement it in our lives and in our cities, states, and countries because we have people listening from all over the world. I love hearing that it is slowly creeping out there and having it put in place. Thank you for all that you do, for your hard work, and for your support in all types of birth that you support. I really do. I just appreciate your time so much.

Dr. Natalie: You are very, very welcome. I am always keen and passionate to of course continue to advocate for change wherever we can. I’ll always give a little shoutout and say if you are a pregnant woman or a provider considering this as a change and you need a place to start, you can very much reach out to me via Instagram. You can send me a DM and I can email you information like the policy and some information that I’ve generated that may be able to help you along in your journey as well. I’m very open to that.

Meagan: Awesome. Thank you so much.

Dr. Natalie: You’re welcome. Thanks, guys.

Closing

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