By Katherine Steen, BS, MAIS, LCCE

Talking about cesarean sections and helping families in our classes to understand the reason for a cesarean and what options they might have if one is needed is an integral part of childbirth education. While almost all of the families in our classes are planning for a vaginal birth, plans change and leaving the experience satisfied is still important. Our April Brilliant Activities for Birth Educators activity honors Cesarean Awareness Month which occurs annually. Lamaze Educator Katherine Steen shares an effective activity - "Cesarean Pie" that educators can use to help families gain more knowledge about cesareans as they prepare for their births through their childbirth classes. You can find all the previous Brilliant Activities for Birth Educators posts by following this link here. - Sharon Muza, Community Manager, Science & Sensibility

Introduction

April is Cesarean Awareness Month, and I thought it might be a good time to try a childbirth class activity that covers the risks and reasons for cesarean birth. I have noticed when I teach this topic, it seemed like parents consider cesarean birth to be something that happens to "someone else". I also realized that by the time we cover cesarean birth, everyone is tired and has a hard time asking thoughtful questions and I felt like I was often rushing through the information. So I dusted off an activity I used as a teach-back for my childbirth education training in 2011 called "Cesarean Pie". I chose this name because I use pie graphs to examine the types and likelihood of cesarean birth as well as the reasons. Families work in groups to complete a worksheet, learn about risk factors, ways to minimize the risk of cesarean birth, and create a personalized plan for their "best case" cesarean.

Timing

This topic falls toward the end of our second five hour class in a three week (15 hour) series. It is the last topic before we cover the postpartum period. In this second class, we have already covered values, decision-making, the language of risk, and practiced asking key questions about the more common first and second stage interventions. The Cesarean Pie activity takes about 20 minutes, five minutes to introduce and 15 minutes of small group activity. I like to follow the activity with a video (like this one from the Mayo Clinic or Tu Duyen's birth from Injoy Videos) that shows the cesarean procedure.

Objectives

During this activity, parents demonstrate their knowledge of ways to reduce the likelihood of cesarean birth including the Lamaze Six Healthy Birth Practices. They also become familiar with the 2014 Care Consensus on Safe Prevention of the Primary Cesarean Delivery and because I am located in Seattle, WA, the Washington State Health Association Safe Deliveries Roadmap.

By the end of the activity, parents will be able to:

1. Better understand the likelihood of needing a cesarean birth.
2. Feel confident in their ability to agree to surgery or explore other options when a cesarean is recommended.
3. Be prepared to advocate for their preferences if a cesarean surgery will happen.
4. Be motivated to learn their provider's cesarean rate and discuss ways to prevent cesarean.

My "Recipe" aka How I Made the Materials

I created the graphs in Excel and printed them on 11x17 in color so they are big enough to work on in small groups. I focus on primary cesarean rates because the majority of students in my class are first time parents. Then, I cut out the pieces to make puzzles and laminated them for reuse. I made sure the graphs were clearly labeled and titled so they are self-explanatory. I created a worksheet for parents to use in small groups and instructions for each station. I placed the puzzle, instructions, and other resources in Ziploc bags for each group.

Conducting the Exercise

I do a brief introduction using the pie analogy to explain that while a cesarean birth isn't most families' favorite flavor, when a care provider recommends it, families often decide to give it a try. With education and information, if they do have a cesarean birth, they may find that it can be less upsetting than they thought and that typically they get to choose some of the "ingredients". Then the full class brainstorms the reasons for cesarean birth and puts together the "reasons pie" graph. This gives the group a chance to become familiar with medical terms like "macrosomia" and get a sense for what sorts of reasons a cesarean is recommended.

The class then breaks into three groups to rotate through three different stations. Four to six parents per group is ideal, but two will work. I keep pregnant parents and their support people in the same group because it helps for them to discuss the topics with each other in class. I rotate them through the stations by passing the materials every five minutes. I remain in the room and available, checking in with the groups as needed, but have found parents are able to move through the worksheet quite independently and the conversation that arises in their groups suggests they are thoughtfully considering the reality of what a cesarean birth would mean to them. Below are the summaries of the stations I offer.

Station 1: How Big is My Slice?

At this station, parents are asked what potential personal risk factors might be used by their health care provider when considering a cesarean. They discuss their own risk factors (gestational diabetes, breech baby, substance use, BMI, age of pregnant person, and medical conditions), look up the most recent nulliparous, transverse, singleton, vertex (NTSV) cesarean rate at their hospital using their smartphone, (in WA state, I send them here, you may want to identify a similar source in your own state or use the recently released national Consumer Reports data) and complete a pie puzzle of the national rates of vaginal and cesarean births. Their homework is to find out their providers' NTSV rate to better understand the culture and practice patterns at their chosen facility and with their selected provider.

Station 2: Ways to Reduce My Risk

At this station I give a chart (see worksheet) that lists risk factors for cesarean birth. Parents are challenged to fill in what they can do and what their provider can do to reduce the likelihood of needing a cesarean for each factor. I also provide them with a copy of the 2014 Care Consensus on Safe Prevention of the Primary Cesarean Delivery and suggestions for questions to ask their provider prenatally. I also share a copy of the "reasons pie" we completed as a group. This is often where knowledge of the Six Healthy Birth Practices comes in handy.

Station 3: Recipe for Best Possible Cesarean Birth

At this station, parents complete a pie puzzle that shows the likelihood of planned, emergency, and unplanned cesarean births. They learn what reasons are included in each of these categories and then review a list of preferences for cesarean birth (see worksheet) so they can choose their top three. I include preferences for comfort, communication, involvement and care for the pregnant person and baby.

Parent Feedback

The families in my classes have appreciated the activity, the opportunity to move around through the stations and work in small groups with other class members. They have found the activity useful and appreciated the option to get some facts specifically related to their chosen facility. Some of the comments I have received include:

"Having a cesarean birth is one of my biggest fears. I am glad to know that most cesareans aren't for true emergencies and that there will most likely be time to ask questions if my doctor recommends one."- Parent during activity

"When my doctor said it was time for a cesarean, I wasn't thrilled, but I knew it was the best option given the circumstances. I am glad we had discussed our priorities ahead of time and had them ready to go. It was so amazing when they put her on my chest and I finally got to meet her." - Parent at reunion

Why This Is an Effective Class Activity

This activity is an example how I put parents in the driver's seat. When parents discuss the recommendations from ACOG and the Safe Deliveries Roadmap in a prenatal visit, providers recognize that parents are informed and interested in preventing an unnecessary cesarean birth. When providers and parents collaborate and recognize their roles and responsibilities, they can create a culture of joint decision-making during pregnancy that will continue through the labor process. Clear communication builds trust that both parties have the same priorities and can hopefully reduce the risk of an unsatisfying birth experience or trauma from an unwanted cesarean. While no one can predict how a birth will go, parents are gaining knowledge and skills that will help them navigate the process and be active, informed participants in decisions about their, birth, including a cesarean birth. Furthermore, when they ask questions about the reasons for cesarean birth, parents help providers lower the rate of primary cesareans. When families advocate for their preferences if a cesarean should be needed, it creates a more positive cesarean birth experience by being more parent and baby-friendly.

Resources

Benedetti, T., MD, Reisner, D., MD, Knox, E., MD, & Simpson, K. R., PhD, RNC, FAAN. (2016). Safe Deliveries Roadmap. Retrieved April 24, 2016, from http://www.wsha.org/quality-safety/projects/safe-deliveries/

Caughey, A. B., MD, PhD, Cahill, A. G., MD, MSCI, Guise, J., MD, MPH, & Rouse, D. J., MD, MPH. (2014). Safe Prevention of the Primary Cesarean Delivery. Retrieved April 24, 2016, from www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2014/03/safe-prevention-of-the-primary-cesarean-delivery

Lamaze International : About Lamaze : Healthy Birth Practices. (2016). Retrieved April 24, 2016, from http://www.lamazeinternational.org/healthybirthpractices

About Katherine Steen

Katherine Steen, BS, MAIS, LCCE has been teaching childbirth classes since 2012. She currently teaches for the Great Starts program of Parent Trust for Washington Children in Seattle, WA. Prior to the birth of her daughters, she spent 10 years working as an educator in zoological parks. In addition to teaching birth classes, she loves to cook, garden, read and spend time outdoors.

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