'Gentle' C-sections are growing in popularity
Posted June 13
A woman is lying on an operating table. In front of her is a big curtain, usually blue, that separates her from the surgical field: her own pregnant belly.
Beside her, near her head, her partner is sitting. During a cesarean delivery, neither can see what is happening to her belly. Behind the curtain, the doctor makes an incision into the woman's abdomen, cuts into her womb and pulls out a baby.
After being born, the baby is immediately taken away, to another part of the room or another room entirely, where pediatricians do some initial examinations. The partner will usually leave the mother to take pictures of the baby and then return to show the photos to the mother.
"Isn't this odd that the first time a mother sees her baby is on the screen of a camera?" thought Dr. William Camann.
As director of obstetric anesthesia service at Brigham and Women's Hospital in Boston, Camann had observed this same sequence of events countless times during C-sections he performed. And so, Camann imagined using a clear curtain instead of a blue one, so the mother could see through it and watch as her baby was born. This way, the mother "could be much more involved with the baby in a visual sense much sooner," said Camann.
This happened more than a decade ago, around the time doctors around the world began tweaking a mother's experience during a cesarean delivery. Today, this ancient surgical procedure, which is depicted in ancient Chinese etchings and referred to in Greek mythology, looks quite different from how it once appeared.
At least on the surface.
The shift toward 'natural' C-section
Life-saving cesareans, in which the mother's abdomen and womb are cut open and her baby is removed rather than birth through the vaginal canal, are generally performed when mother or child is experiencing an emergency condition. These include fetal distress, obstructed labor (when the baby is positioned feet-down) and maternal medical conditions such as infections and diabetes.
Cesareans can have more complications than vaginal births, including excessive bleeding, infection or ruptured uterus.
Since it is a surgical procedure, a natural C-section cannot entirely dispense with the safety rules of an operating room, but it allows women to bond with their babies as they would during and after a vaginal birth, according to a presentation delivered at the Euroanesthesia conference in Geneva, Switzerland, on Sunday.
A gentle C-section, as the reinvented technique is sometimes called, is as safe as the traditional form, said Dr. Felicity Plaat, who presented the research and works as a consultant anesthetist at Imperial College Healthcare NHS Trust in London.
In 2008, she and her colleagues developed a technique at Queen Charlotte's Hospital in London to help the many women who give birth via C-section: up to a quarter of all pregnant women in the United Kingdom and about 32% in the United States. Compared with cesarean section, vaginal birth provides more maternal satisfaction and has better bonding and breastfeeding outcomes, according to Plaat.
"We said, 'Could we import these aspects of vaginal birth into the operating theater? And would they be safe, and would they have the same advantages?' That's what started it," said Plaat, who credits Jenny Smith, a midwife and co-author of a study published in BJOG, An International Journal of Obstetrics & Gynaecology, as the "moving force" behind the development of this technique.
In the UK, the natural C-section begins in essentially the same manner as the traditional form. Once in the operating room, though, doctors lower the obstructing drape so that both parents are able to see their baby's birth. The baby is slowly removed from the abdomen. Parental wishes, such as lowering lights or playing music, are respected as much as possible within the bounds of safety.
More research is needed, said Plaat, and a randomized controlled trial has already been carried out at Charit- University Hospital in Berlin.
Comparing gentle C-sections with the traditional form, the German researchers found no increase in complications for mother or child, but the "gentle" procedure improved breastfeeding rates and provided an overall better experience for the mothers. Cumella said that with no medical differences between the two, there's no doubt both are equally safe.
The German study also found no increase in the rate of maternally requested C-sections. Plaat said the same is true in the UK, while Camann emphasized that "no one is trying to increase the C-section rate." Instead, "if you need to have a cesarean, for whatever the medical reason is, at least we can make it a better experience for you."
"As far as the anesthetic is concerned, what we want to do is obviously make sure the mum has got sufficient anesthetic so she's completely comfortable, but we don't want to make her sort of more numb than she needs to be," Plaat said. "Particularly, we don't want the anesthetic if possible to affect her upper body or her arms, because she will have a baby to look after and cuddle."
Producing a local anesthetic effect is not a precise science. The technique Plaat uses is a combined spinal epidural: The mother gets a spinal block -- a single injection of anesthesia into the spinal fluid -- and an epidural, in which anesthesia is administered, either continuously or periodically, into the spinal cord to provide numbness in the abdominal region. The epidural allows the anesthesiologist to top off the original injection and keep the anesthetic going as long as is needed.
"It just means you can be more subtle with the doses," Plaat said. So instead of giving a large dose to start, a doctor can give the mother a moderate dose and add to it if necessary.
Across the pond
Camann, who teaches at Harvard Medical School, said the combined spinal epidural is used for all C-sections, traditional and gentle, performed in the United States. He has been doing his own version of C-section for a decade or so.
Along with a clear curtain to allow for visual interaction, "we put the EKG leads on the side, very far laterally, so they're not right on the mother's chest, so the mother's chest could be free of these electronic monitoring devices," Camann said. This allows the mother to interact with or even breastfeed her baby immediately.
The mothers all love it, he said, while the partners "have some great photo ops."
Dr. Angelo Cumella, fellow of the American College of Obstetricians and Gynecologists at Northern Westchester Hospital in Mount Kisco, New York,-has been doing "gentle C-sections" for about two years.
"It's basically trying to integrate the patient as much as possible into the traditional cesarean section," said Cumella, who also uses the clear drape, "so from the very beginning, it's less claustrophobic." He also tries to get the baby immediately over to the mom so that they can bond, skin to skin, he said. "If they want to breastfeed, they can, right in the OR."
Cumella has been in practice for 30 years, so he's delivered babies for women who have had both the traditional and updated C-sections. Mothers who have had both kinds appreciate the transformation. "It's just a better experience for them," Cumella said of the gentle version.
Shannon Schoenfeld, a 36-years-old from Phoenix, Arizona, is one such patient.
Eight years ago, she had a traditional C-section in New York when her daughter was born breech. Though Cumella held the newborn "up over the curtain," Schoenfeld did not get to hold her new child immediately.
Six months ago, Schoenfeld once again gave birth. A gentle c-section brought her third child into the world. "I'm fortunate I was able to experience that," said Schoenfeld, who explains that because of her past history, this was a planned C-section, not an emergency.
"I did enjoy the gentle C-section more, because I got to see the baby immediately," said Schoenfeld. While she did not watch everything happening during the birth, she said, but "they gave [my baby] to me while they were still operating on me -- I was nursing on the table."
"Personally, I was concerned about breast feeding cause I am older," said Schoenfeld. "Though I have two other children, they're 10 and 8, so it's been awhile. It's a relief to have that immediate connection."
'I didn't know any better'
Some mothers, such as Srebrenka Robic Ingram, a 42-year-old from Decatur, Georgia, learned the benefits of a more natural cesarean only once she compared notes with her friends.
"My goal was to have a natural vaginal delivery," said Robic Ingram, a professor of biology at Agnes Scott College. "I had a doula and everything, so that was my plan A, and then I went into labor, and it was taking a long time."
In fact, after about 24 hours of unmedicated labor, her doula made a suggestion. "And you know it's a sign when the doula says, 'Maybe we should talk about options,' " Robic Ingram said, laughing. After an epidural and 10 more hours of labor, her baby started going into distress.
"His heart rate was going down to the point that everyone got concerned," Robic Ingram said. She discussed it with her doula and her obstetrician, and they decided it was "probably best to just take him out."
Both her husband and doula went with her to the operating room, and the doula commented that often she is not permitted to attend women during C-sections.
"That was the first more positive part of it," Robic Ingram said.
Though she wasn't able to see the birth because of the drape, "as soon as they were taking him out, I was able to see him, and then I needed to be stitched up, obviously," she said. During the 20 minutes of stitching, her baby was taken away, but her husband remained with the child.
Once she was wheeled into the recovery room, "we were all in the same room together: my husband, the baby, my doula and I," said Robic Ingram, who immediately attempted to breastfeed her son.
Later, a friend who had a traditional C-section told Robic Ingram that she was not allowed to see her baby for a few hours, an experience the woman speaks of as "traumatizing."
Only after the fact, then, did Robic Ingram recognize her C-section must be considered "a family-friendly, gentle version."
"I didn't know any better. I didn't know any other way," she said.
Cumella said almost all the C-sections he performs today are the gentle kind. "More and more physicians here at the hospital are incorporating it, so I think it's a definite trend," he said. Though not entirely different from the traditional version, one thing that is necessary is to bring everyone -- the anesthesiologist, the neonatologist, the nurses -- on board from the get-go.
"It is a cultural change for the physicians themselves," Cumella said. "There are certain small changes that need to occur -- but all are easily accomplished."
Camann said he's often asked whether a gentle C-section costs any more: "And the answer is, 'No, it doesn't cost any more, because really it's just a change of behavior.' "
Ultimately, every doctor, hospital and birthing center that uses this technique has found the same thing, said Plaat, the anesthetist in London. "The women loved it because it changed the traditional cesarean, (which) is quite cold and clinical, into a sort of event that reflected how important one's child's birthday is."