The name is still evolving, but the idea of a more patient-centered cesarean delivery is beginning to take root in American hospitals.
At Cedars-Sinai Medical Center, where roughly 35% of the 6,500 deliveries each year are by cesarean, an obstetrics-gynecology “customization of care” task force is working to standardize what is being referred to nationally as gentle or natural cesareans, as well as family- or patient-centered cesarean delivery.
Central to the approach is parent involvement, keeping mothers and infants together, and transferring the baby onto the mother’s chest for early skin-to-skin contact after delivery.
“When they find out they have the option to do skin-to-skin, it relieves a lot of the anxiety, especially if the C-section is unplanned,” said Dr. Paola Aghajanian , director of labor and delivery and the Maternal-Fetal Care Unit at the Los Angeles–based hospital.
During a traditional cesarean, it’s at least 30 minutes and in most cases up to 60 minutes before the mother can hold her baby. But with a gentle cesarean, Apgar testing is performed on the mother’s chest, while warm blankets are used to maintain the infant’s temperature.
At Cedars-Sinai, they are working to reduce maternal sedation and eliminate extraneous conversations in the operating room. The hospital is also in the process of ordering clear surgical drapes so that mothers and their partners can watch the birth, Dr. Aghajanian said. The use of clear drapes has been popularized by Dr. William Camann , director of obstetric anesthesia at Brigham and Women’s Hospital in Boston, who said the idea came to him after watching open heart surgery at another hospital where the drapes were used to enhance coordination and communication between anesthesiologists and cardiothoracic surgeons.
The clear drapes have been met with tremendous approval, particularly from mothers, and reduce the potential risk for infection, though it is already very low, said Dr. Camann, an early adopter of what the Brigham calls “gentle cesareans.”
Over the last 4 years they’ve made other adjustments, including moving ECG leads from the chest to a more lateral position, shifting monitors so mothers can have more mobility to interact with or breastfeed the baby, and liberalizing policies so a second support person or doula can be present.
There’s more traffic and sharing of the “real estate” at the head of the bed for surgeons and anesthesiologists and a different rhythm in baby care for pediatricians and nurses, Dr. Camann said, but the changes don’t require more space or add to the cost of the procedure.
“It’s more of a change in attitude, thinking a little bit outside the box,” he said. “A phrase I often use is ‘When you enter a cesarean delivery, turn off your surgical mentality.’ Even though it’s still an operating room, and it’s still a surgery, there are some different things that we can do that really just have to do with the attitude of everyone in the room, basically re-engineering the way we think about some of the traditional practices that go along in an operating room.”
Shifting those long-standing practices requires buy-in from around the hospital and multiple simulations to ensure everyone in the room understands their new role, family physician Dr. Susanna Magee , another early adopter of the approach and director of maternal child health at Memorial Hospital of Rhode Island in Pawtucket.
“This is absolutely a paradigm shift,” she said. “This is different from other operations, and it’s a difficult thing for surgeons, anesthesiologists, or nurses to get their heads around.”
The hospital recently published its experience with 144 “gentle cesarean births” from 2009 to 2013, and has seen no increase in complications, operating room times, or infection rates ( J. Am. Board Fam. Med. 2014;27:690-3 ).
Beginning in 2011, they implemented gentle cesarean even in nonscheduled or urgent cesareans, recognizing the potential for false-positive fetal monitoring and the probability of a healthy infant even in cases of a persistent category II fetal heart tracing, Dr. Magee said.
Immediate skin-to-skin contact after cesarean is now the standard of care at the hospital and has prompted some women who knew they would require a cesarean delivery to transfer care to the Rhode Island hospital, according to Dr. Magee. Gentle cesareans have also been an selling point for the Brigham, Dr. Camann said.
“I suspect there will be some marketing from hospitals who are looking to say we can offer this, but my suspicion is hospitals would be in a better position to market that their cesarean section rates are at or below the national average,” said Dr. Wanda Filer , president-elect of the American Academy of Family Physicians. “The gentle C-section in and of itself is not going to be their competitive advantage. It would be interesting to see if they choose that because I think there could be upsides, but also opportunities for backlash.”
Sources interviewed for this article were all quick to point out that they are not advocating increasing the number of cesarean deliveries, but instead trying to enrich the experience for women who are already candidates for an operative birth.
“Some people have said you’re actually making cesareans so pleasant that you might change the cesarean section rate, maybe encourage people to have a cesarean, and I want to directly address that by saying it is simply not the case at all,” Dr. Camann said. “A cesarean should be done only if there are appropriate medical indications, nothing to do with the whole concept we are discussing here. But if there are appropriate medical indications for a cesarean, we can do certain things to make it a better experience.”
The new approach reflects the move toward more patient-centered care across all specialties and rising demand over the past decade for more natural birth processes, both Dr. Aghajanian and Dr. Magee observed.
“It was truly patients that brought it to our attention, and I think that’s important. It’s a patient-centered technique,” Dr. Magee said, adding that the highest compliment came from a mother who remarked, “I know you did surgery on me, but this was a birth.”
Some recent media reports have cast the approach as a major shift in cesarean delivery, but there’s nothing radical about it, according to ob.gyn. Dr. Jeff Livingston and certified nurse-midwife Ms. Rachel Zimmer , both with MacArthur Medical Center in Irving, Texas.
“We’re making minor adjustments with the patient and her family’s interests at heart, always doing it safely, but making it a more personalized and individualized experience,” he said.
For many patients, the most appreciable difference about their “family-centered cesarean” is that they get to actively participate and plan their birth, just as they would with a vaginal birth, Ms. Zimmer said.
For Dr. Livingston, the biggest change is pausing after the baby’s head enters the abdominal field to allow external compression from the uterus to help expel lung liquids, a technique described in an early report on “the natural cesarean” by obstetricians in the United Kingdom and Australia (BJOG 2008;115:1037-42).
An opaque surgical drape is lowered and the mother’s head elevated by the anesthesiologist to let parents watch the birth, but not all patients choose to do so, he said.
Overall awareness of family-centered cesareans is low among new mothers, and they are performed upon request, not as the standard of care, Dr. Livingston noted.
And the trend is being seen outside large urban centers, as well. In Peoria, Ill., Dr. Michael Leonardi of OSF Saint Francis Medical Center, said patients at his hospital are requesting family-centered cesareans. At the same time, the hospital continues to get referrals for the management of placenta accreta from women who’ve had too many cesareans, reflecting the need to have the “bigger conversation” with patients about what they and the hospital can do to safely avoid the primary cesarean and interventions that increase cesarean risk, such as induction of labor with an unfavorable cervix, he said.
“A piece to patient-centered care is not me telling the patient what to do and being paternalistic, but making sure people have the information they need, in a way that makes sense to them, so they can make an informed decision,” Dr. Leonardi said.
