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C-Change: Women are Pushing for "Gentle" Cesarean Sections 

click to enlarge Terra Heilenbach and her son Ellis - COURTESY OF TERRA HEILENBACH
  • courtesy of terra heilenbach
  • Terra Heilenbach and her son Ellis

When I was pregnant with my son seven years ago, I was fascinated by the sensations of him kicking and hiccupping inside me. And my plan was to push him out into the world naturally.

So it was tough for me to hear that I needed a cesarean section — that his birth would be a surgery, concealed behind a drape, where he'd be pulled from my numb body.

Don't get me wrong — I was and am very thankful that I have access to modern medicine. It may have saved my son's life. I survived his birth and had a healthy baby. And 21 months later, his sister was born the same way.

But I'll never feel like I gave birth — not for lack of enduring something intense and transformative, but because I was a passive participant. I missed out on watching the moment my babies emerged; having them placed right on my chest; breastfeeding them immediately; soothing their first cries.

I don't have any photographs of my son's birth. During my first C-section, I didn't know if it was allowed. Rather than something I should record, the experience felt like something I should forget.

I wish my gratitude had neatly ushered out any negative feelings, but it's not that simple; not for me, nor, it would seem, for many other women in the U.S. who have C-sections each year — roughly 1.2 million in 2014, according to the Centers for Disease Control and Prevention. Statistics show that women who have C-sections are at risk for higher rates of postnatal depression, increased difficulty with breastfeeding and a decrease in maternal satisfaction rates. I wager that in feeling like a failure, I am far from alone.

I've since made peace with the surgeries as concessions toward having healthy babies — I wrote about that process in an essay for the 2014 Baby & Maternity Issue of Kids VT — but I was still excited recently when I heard that hospitals were experimenting with a new approach to C-sections. Known most commonly as a "gentle" C-section, the procedure uses small modifications to the standard cesarean model in an effort to bring baby and mom together as quickly as possible. Skin-to-skin contact increases maternal bonding, breastfeeding success and postpartum healing times, and there are plenty of statistics to prove it.

Gentle C-sections invite the mother and partner to be more active participants in the process. In essence, to make the operation more like a birth.

Most of the C-section modifications are simple — like having skin-to-skin contact in the operating room; placing the IV in mom's nondominant hand to make it easier to hold baby; placing ECG leads, which monitor the heart, off of mom's chest; and raising the head of the bed and using a clear drape or mirror so mom and partner can watch as baby is born. The most complex modification is placing baby directly onto mom's chest after birth, because it requires an additional team member to pass baby to mom and monitor the situation.

The modifications themselves are not groundbreaking; some of them have been practiced widely throughout the country for years in hospitals both small and large and in private practices at the discretion of individual obstetricians. What is remarkable is that, collectively, these changes are something women can ask for by name.

Or, more accurately, names. Early in my research, I realized that there's more than one: "natural," "family-centered," "gentle" and "skin-to-skin."

A 2008 article in the British Journal of Obstetrics and Gynaecology describes a "natural caesarean" as including the above modifications, but it also details "walking the baby out," where the baby's head is guided out but the trunk is left in utero for the lungs to be squeezed of amniotic fluid. The baby then wriggles out and is delivered directly onto mom's chest. As opposed to having the baby pulled out, the umbilical cord cut and the baby whisked away to be examined, the "natural" cesarean birth claims to be slower, more calm and mimic what happens in a vaginal delivery. The study notes the lack of quantitative data but states that, "In qualitative terms, the natural caesarean has been positively received by the couples involved, with no adverse comment in more than 100 procedures."

Gentle C-sections aren't currently offered in hospitals within the UK's publicly funded National Health Service, but they're the subject of a trial starting this year at the University College London Hospital under the name "skin-to-skin" cesarean.

They don't walk the babies out at the University of Vermont Medical Center. Kelley McLean, assistant professor of maternal fetal medicine there, questions that technique. But McLean said they have been offering something very close to a gentle C-section for a long time. What's new, McLean said, is "watching delivery and direct skin-to-skin contact." Clear drapes are currently on order; in the meantime, the solid drape is dropped entirely if parents want to watch.

Those clear drapes were pioneered by William Camann, director of obstetric anesthesiology at Brigham and Women's Hospital in Boston, which did its first gentle C-section in 2013 and now estimates that 20 to 30 percent of their C-sections are "gentle." On their website, the procedure is introduced in an article titled "The Gentle Cesarean: A New Option for Moms-to-Be at BWH," which established "gentle" as the familiar term in the states. McLean would prefer to call it a "family-centered C-section." Calling it gentle implies that other C-sections are not, she said. And it's inaccurate, since the operation itself is no different. "There's no gentle way to have a baby, it turns out, whether it's vaginal or C-section," she added.

McLean first heard the term in October 2015, during a "Gentle Cesarean Section" talk at a Northern New England Perinatal Quality Improvement Network conference at Dartmouth-Hitchcock medical center in New Hampshire. Soon after, a patient requested one. "It forced our hand to mobilize," McLean said.

UVM Medical Center doesn't have numbers on how many gentle C-sections they've done, but McLean estimates around five. However, that number only counts gentle C-sections that "follow each and every step," McLean said in an email. If they were to include "people who have most steps done, and skin-to-skin as soon as the baby has been evaluated, then we would also have a very high rate of gentle C-sections."

A patient also inspired the first official gentle C-section done by the doctors at Maitri Health Care for Women in South Burlington, said obstetrician and gynecologist Amy Thibault. (Full disclosure: She delivered my daughter.) "This is something that a patient brought to us and said, 'What do you think of this? How can we make this happen?' It gets us all thinking about why we do things the way we do, and is there anything we can do better? Anything we can do differently?"

Thibault was receptive to the gentle C-section because it fit well with Maitri's low-intervention, patient-centered birthing approach. In fact, they were already offering some of the modifications, like using a mirror to watch the baby emerge and providing skin-to-skin contact in the OR soon after birth.

click to enlarge Amy Thibault (right) delivering Ellis as mom, Terra, watches in the mirror - COURTESY OF TERRA HEILENBACH
  • courtesy of terra heilenbach
  • Amy Thibault (right) delivering Ellis as mom, Terra, watches in the mirror

Colleen Whatley, perinatal clinical specialist at Dartmouth-Hitchcock, said that they have always followed a "shared decision-making philosophy" with families, and that skin-to-skin contact in the operating room is something they've been doing "before even connecting it with a gentle birth." Patients haven't asked for gentle C-sections by name, Whatley said, but they've requested the modifications that define it, like watching the birth and direct skin-to-skin contact. The medical center offers clear drapes and has an extra OR hand to accommodate those requests, and Whatley estimates they've done five to 10 gentle C-sections in the past year.

Asked about "walking the baby out," Whatley said "it looks lovely," but they don't practice it. Whatley echoed that more research is needed. "But who knows, maybe in five years we'll be walking babies out of the abdomen?" she said, adding that they might someday get a resident who wants to research the technique.

In some nonemergency cases, when vaginal births turn surgical, birth plans can be tailored to the OR, Whatley said. So it makes sense for patients to think, "What are the things that I wanted to do? Can I still do [them] in the OR?" she explained.

At Central Vermont Medical Center in Berlin, many patients come with a birth plan that includes components of a gentle C-section, explained Monica Cerminara, a registered nurse in their women and children's unit, in an an email. "But only a few ask for the delivery option by name," she wrote. They offer direct skin-to-skin contact for cesarean births and place the IV and ECG leads in areas that facilitate that process. They don't use clear drapes, but Cerminara said they are looking into it.

If these changes are relatively simple and beneficial, why have doctors been slow to adopt a more family-centered approach?

In short, convention. And there's a valid reason for that convention: because it works to control infection. "The thing that takes it from a birth to a procedure is the need for sterility," Thibault said. Especially in the crucial moments right after the baby is born. "You're delivering the placenta, you're controlling bleeding, you're making sure that you've turned this birth into a safe procedure," she said.

That need for sterility is a major hurdle to innovation. Members of the team —obstetricians, residents, nurses, pediatricians and anesthesiologists — may be hesitant to change their routines, which are built around reducing risk. "Thinking about things differently is hard in medicine, because the way that you do things is often because they work," Thibault said. "But a lot of times in medicine, you do things because it's what you've always done ... Innovations happen when people think outside the box, in new directions."

Logistically, the most difficult change is getting baby directly from incision to mama's chest. That's because it requires an extra person — usually a nurse or midwife — who is scrubbed and ready to take baby from the doctor to the mother, and to closely monitor the baby there. Some providers, including Maitri, don't yet have that extra sterile person to offer direct skin-to-skin placement. In the meantime, babies are brought to the warming table for examination, then placed skin-to-skin.

Because most of UVM Medical Center's gentle C-section patients come from that hospital's in-house midwife practice, a midwife is available to bring baby directly to mom's chest. Another recent advancement: Rather than have pediatricians at every C-section, their presence in the OR is risk-based. This "makes it a little bit more intimate, because the nurses who are going to be taking care of the baby while it's born are the same nurses who are going to be in the room afterwards," Thibault said. Given that pediatricians sometimes bring a team, doing away with unnecessary pediatric support can also mean up to four fewer strangers in the room during the operation.

It's important to note that gentle C-sections are only appropriate in very specific circumstances. "We're talking about a small number of C-sections, where you're not doing this in an emergency, you're not doing this when a labor has not succeeded, you're not doing this in a breech delivery," Thibault explained. "You're talking about the absolute lowest-risk babies and lowest-risk moms, and that's where this is really appropriate." And even when a gentle C-section is the plan, flexibility is important, because things can change at any moment. For example, if a baby shows signs of distress at birth, skin-to-skin contact may be delayed so the pediatrician can do an examination.

Since Thibault did my second C-section — a planned, repeat procedure — I couldn't resist the urge to ask if I would have been a good candidate for the gentle version. She thought I could have, but even just five years ago, gentle C-sections weren't part of the discussion.

Fortunately for Terra Heilenbach, they are today.

When Heilenbach had her son Finch in November 2011, she'd planned on having a home birth. But when pain prevented her from eating or drinking, she transferred to UVM Medical Center, then Fletcher Allen Health Care. She later developed an infection, and when labor wasn't progressing, her doctor recommended a C-section.

"We were very shocked going from home to full-on C-section in the hospital with people we didn't know and that whole vibe," Heilenbach said. With her son Illo, born in May 2014, she tried for a vaginal birth and pushed for three and a half hours, but her history of infection, coupled with the fact that the baby wasn't descending into the birth canal, sent her back to the operating room.

Like me, she missed seeing the moment her first two babies were born. "I felt very disconnected from my body for the first time in my life," Heilenbach told me. "I felt like I was cut off, and that's been something to heal from for me: How do I reconnect to my body, that I thought could do anything?"

Toward the end of her third pregnancy, Thibault, Heilenbach's obstetrician, mentioned having a gentle C-section. Heilenbach hadn't heard of it but wanted to try. I talked to her one morning in early April, just four days before the operation. "I'm looking forward to seeing whatever I do see," she said, "just to see that kid come out."

As her third son, Ellis, was born on April 5, Heilenbach watched in a mirror. "It was so awesome," she told me afterward while snuggling her 10-day-old baby. A resident was able to take photos on the other side of the drape, and as we scrolled through them, Heilenbach recounted the experience. "I had been worried that I would feel anxious," she said of watching him emerge from her body. "But I didn't care at all. It really connected it, to see him in that raw form, not tidied up and all that." He went to the warming table to have fluid cleared from his lungs, then was placed on Heilenbach's chest where he breastfed for a bit while they sewed her up.

Could all nonemergency C-sections be "gentle" someday? The fact that they are being done at teaching hospitals like UVM Medical Center and Dartmouth-Hitchcock suggests they might. "In a big teaching hospital, when it's adopted as a policy ... it sanctions it, or adds weight to it," Thibault said. It also educates residents about alternative ways of thinking. "As with most innovations in obstetrics, that training trickles down to outside hospitals," she said.

Birth plans, it seems, may increasingly make their way into the operating room. McLean predicts that "as the term 'gentle C-section' is better understood by patients, providers will more commonly make these small modifications."

The changes may be small, but, cumulatively, their impact has great potential. "The intangible outcome — the idea that women can feel more comfortable with their birth and were a part of it — is just as important as anything else," McLean said.

Learning about gentle C-sections made Heilenbach aware of options she didn't know she had, and in preparing for the birth, that made a huge difference. "I get to still be a player," she said. "I'm not just succumbing to whatever is going to happen."

Gentle C for Me?

New, so-called "gentle" C-sections involve small modifications to the standard cesarean model in an effort to make women and their partners more active participants in the experience. Interested in having one? Here's what to ask your obstetrician.

Am I a good candidate for the procedure?
Gentle C-sections are only appropriate in low-risk, nonemergency situations where mom and baby are healthy and show no signs of distress. Women having repeat, planned C-sections often fall into this category. Discuss it with your obstetrician long before your due date so you can make preparations.

Can I have the baby placed directly onto my chest after delivery?
This requires an extra, trained person in the operating room to deliver baby from the obstetrician to mom's chest and to monitor baby there. Not all providers have the resources to offer this. If it's not an option, ask for baby to be placed on mother's (or partner's) chest as soon as possible after birth. This is an opportunity to initiate breastfeeding during the end of surgery. If you want skin-to-skin in the operating room, request that:

  1. The IV be placed in the nondominant hand. This is to allow for moms to more easily hold their baby in the operating room.
  2. The ECG leads be placed off mom's chest. This is so they are not disturbed by, and don't interfere with, skin-to-skin contact.

Can I watch the delivery?
There's no medical reason why mom and partner shouldn't watch their baby's C-section birth. However, obstetrician Amy Thibault suggests that patients be educated about what they'll see: "By its very nature, we are assisting in the delivery of the baby by elevating the head and then pushing from above." Thibault makes sure to tell people that they'll feel a lot of pressure as the baby is delivered, "but for them to actually see it, that it's not as gentle of a process as they have in their minds, I think that requires education."

Can I have my music playing in the OR?
This varies by provider, but it's worth asking. The concern is that music could add more noise to the OR that might distract the surgical team or interfere with their ability to communicate. "We usually have [patients] use their phones by their head so they can enjoy it, versus the whole room enjoying it," said Colleen Whatley from Dartmouth-Hitchcock medical center.

Can the surgical team refrain from "shop talk"?
Your C-section may be routine for the surgical team, but that doesn't mean you want to hear about what they had for breakfast while your baby is being born. Best to set intentions early and ask to keep things focused on the birth.

Can I have a doula at the birth? A birth photographer?
This varies by hospital, but Whatley said that, with advance notice, Dartmouth-Hitchcock has had birth photographers in the OR. They have also had doulas, and even an extra family member, present at nonemergency C-section births. With increased demand, this may commonly be included in the coordination of care.

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