Reviews
The gentle family-centered cesarean
2016 Volume 4 Issue 2 Pages 48-52
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2016 Volume 4 Issue 2 Pages 48-52
Cesarean delivery is both a major surgical procedure and a momentous and miraculous event in the life of a family. Historically, the rituals and processes common to major surgical procedures have dominated the cesarean birth process. For vaginal delivery, many obstetrical units have developed mother, baby and family-centered birth processes that emphasize immediate skin-to-skin (STS) contact and the early initiation of breastfeeding. The gentle, or “family centered” cesarean delivery is an approach to operative delivery that reduces the emphasis on surgical rituals and processes and increases the clinical focus on the mother, the baby and the family. Is it possible to transform a surgical procedure such as a cesarean delivery into a mother, baby and family-centered experience? For many cesarean delivery procedures the answer is a resounding “Yes”. Refocusing the clinical processes that surround the cesarean delivery requires the commitment and cooperation of many disciplines. Obstetricians, anesthesiologists, pediatricians, and maternity nurses are the leaders who must work together to facilitate this important practice change.
Cesarean delivery is both a major surgical procedure and a momentous and miraculous event in the life of a family. Historically, the rituals and processes common to major surgical procedures have dominated the cesarean birth process. In contrast, for vaginal delivery, many obstetrical units have developed mother, baby and family-centered birth processes that emphasize immediate skin-to-skin (STS) contact and the early initiation of breastfeeding. Nonetheless, many babies born by cesarean delivery are brought to a resuscitation stand, examined, cleaned, identified, administered medications, weighed and swaddled before being introduced to the mother. In cesarean deliveries early STS contact and early initiation of breastfeeding are not common. Research indicates that many mothers report that these surgical rituals and processes prevent them from connecting to important physical and emotional aspects of the birth process.1) In addition, practices that slow the early maternal-infant bonding and slow the initiation of breastfeeding may result in lower breastfeeding rates at 6 months of life and impact maternal behaviors.2,3)
The “gentle”, or “family centered” cesarean delivery is an approach to operative delivery that reduces the emphasis on surgical rituals and processes and increases the clinical focus on the mother, the baby and the family.4,5,6,7) The change in perspective celebrates the momentous birth event and encourages early mother-infant bonding. This concept has also become known as “kangaroo care”, owing to the methods that marsupial animals use in the early care of their young.8,9) The essential element of kangaroo care is early and consistent STS contact with the infant. Numerous developmental benefits have been demonstrated when kangaroo care is implemented as part of the care for both term and preterm infants.
The gentle cesarean may not be ideal for emergency cesarean deliveries or if the baby is at risk for a low Apgar score. The concept is most likely to be beneficial when the cesarean delivery is scheduled, such as an uncomplicated primary or repeat cesarean; or for a cesarean delivery following failure to progress in labor and a reassuring fetal heart rate tracing.
Recent research indicates that the gentle family-centered cesarean concept is safe for both mother and baby.6,7) No increases in maternal or neonatal complications were found, including surgical site infections, maternal blood loss, requirement for blood transfusions, or any neonatal parameters. One study7) showed a shorter time to hospital discharge (4.0 vs. 4.4 days, P<0.001) with the gentle cesarean vs. a traditional cesarean, and fewer instances of hospitalization more than 4 days (17% vs. 30%, P<0.001). That study also showed fewer neonates admitted to neonatal intensive care unit (NICU) after gentle cesarean vs. traditional cesarean delivery.
The perioperative use of music is used in many instances of the gentle cesarean. Music has been shown to reduce anxiety, enhance comfort and satisfaction, and even possibly contribute to perioperative hemodynamic stability during cesarean delivery. Mothers may bring a music device of their own, if they wish, or, in my hospital, we have capability in our cesarean operating rooms for music to be played during the procedure. Encourage the mother and family to select music to be played in the delivery room that they would find soothing.10,11) It has been noted that there tends to be excessive noise in many operating rooms during cesarean delivery. Much of this noise is not conducive to a calm, soothing environment, and may distract clinicians from important tasks and safety procedures.12) Our hospital is embracing a “culture of quiet” during cesarean deliveries, to enhance safety and also to enhance the gentle cesarean concept. It is likely that an appropriate level of perioperative music may facilitate a quieter atmosphere with regard to other sources of noise during these procedures.
Anesthesia considerations: Free the dominant arm and chest for contact with the newborn by placing the oximeter, intravenous catheter and the blood pressure cuff on the non-dominant arm. Place ECG leads on the back or far laterally to facilitate early chest contact of mother and baby. Figures 1 and 2 indicate ECG lead positioning to facilitate STS contact during cesarean. Recent evidence does not support neonatal benefit of supplemental oxygen for routine uncomplicated cesarean delivery; hence consider allowing mother to breathe room air without the bothersome mask.13,14) Permit the patient and her support people to view the birth of their baby as active participants. Use clear drapes to permit the patient to view the birth of the head of the newborn, or drop the drapes prior to the birth of the head of the newborn. Figures 3, 4, 5 show a typical operating room scene during a family-centered cesarean, including use of clear drapes and intraoperative breastfeeding and STS contact. Figure 6 shows a mother enjoying close interaction with baby immediately after birth. Raising slightly the head of the operating table can facilitate the mother’s view of the birth of her baby.15) For mothers who have enlisted the support of a doula, consider welcoming the doula along with one other support person into the operating room for the birth.
Lateral and posterior ECG lead placement to facilitate a clear chest and intraoperative skin-to-skin contact.
Lateral and posterior ECG lead placement to facilitate a clear chest and intraoperative skin-to-skin contact.
Intraoperative view of clear drapes and skin-to-skin contact during cesarean.
Intraoperative view of clear drapes and skin-to-skin contact during cesarean.
Intraoperative view of clear drapes and skin-to-skin contact during cesarean.
A mother enjoying close interaction with baby immediately after birth.
Surgical considerations: Slow the delivery process by delivering the head and leaving the infant’s body in the uterus for a few moments. Some authorities believe that the contraction of the uterus around the body of the fetus, along with the initiation of breathing and crying will help clear the fetal respiratory system of fluid. Delay cord clamping for 1 to 2 min to permit autotransfusion.16) Immediately, or as soon as possible, transfer the baby to the mother’s chest. If mother’s chest is not available or accessible for any reason, consider early STS with the father.17) Figure 7 shows intraoperative STS contact with a father. Infant identification and vitamin K administration can be performed with the baby on the mother or father’s chest.
Skin-to-skin contact with father during cesarean.
Encourage intraoperative breastfeeding: Early contact between the infant’s lips and the mother’s nipple are associated with increased initiation and duration of breastfeeding. Breastfeeding should be started as soon as a possible after birth, preferably within the first hour of life.18,19) Weighing, measuring and routine care for the infant can be delayed until after the first feeding is completed.
During transfer out of the operating room at the conclusion of surgery, rather than separating the mother and newborn, the mother can have STS during transport to the post-anesthesia care unit and upon her transfer to the recovery bed.
Newborn respiratory status: Scheduled cesarean delivery, compared to vaginal delivery, is associated with an increased risk of transient tachypnea of the newborn.20) In a review of over 29,000 deliveries the incidence of TTN was 3.1% with scheduled cesarean delivery and 1.1% with vaginal delivery. The plan to promote early STS contact and keep the newborn with the mother may need to be altered if the newborn needs more intensive support at the resuscitation table for symptoms of transient tachypnea of the newborn. TTN is often apparent at birth or is diagnosed within two hours after delivery. A respiratory rate >60 breaths per minute is the most prominent feature. Infants may have cyanosis, increased work of breathing including nasal flaring, intercostal and subcostal retractions and expiratory grunting. The syndrome typically resolves within 12 to 72 hours after diagnosis.
Thermal regulation: Although preterm infants are at greater risk than term infants for hypothermia, some term infants will become hypothermic.21,22,23,24) Careful attention to ensuring that the baby is not left exposed to the cold operating room temperatures is helpful to reducing the risk of hypothermia. Early STS may actually facilitate maintenance of neonatal thermoregulation.23) Efforts to maintain maternal intraoperative normothermia will enhance maternal comfort. Warm intravenous fluids, intraoperative (or even preoperative) warm blankets or forced air devices, or warm blanket applications are commonly used modalities. Moreover, maternal normothermia in combination with STS contact will enhance maintenance of neonatal normothermia.21,22,23,24)
Safety of the baby on the mother’s chest: If the cesarean surgery triggers an episode of nausea and vomiting, the baby may need to be removed from the mother’s chest until the episode is resolved.
Traffic congestion at the head of the surgical table: Moving the initial care of the infant to the mother’s chest increases the number of clinicians who need access to the head of the surgical table. The culture of the operating room needs to adapt and embrace this concept. The anesthesiologist and nurse will need to cooperate to share this space, and also to include any support persons. Moreover, the operating obstetrician and assistant will need to understand that the area above the surgical field may be a bit busier than they are used to. Obviously there may be limitations in the event of any surgical or anesthetic instability. However, as long as the procedure remains uncomplicated, as most cesareans are, then early infant care at the head of the operating table or even directly on the mother’s chest is a very achievable goal. Educational efforts directed at all stakeholders, including anesthesiologist, obstetrician, pediatric and nursing staff, will facilitate the introduction of this model of care.
Is it possible to transform a surgical procedure such as a cesarean delivery into a mother, baby and family-centered experience? For many cesarean delivery procedures the answer is a resounding “Yes”. Refocusing the clinical processes that surround the cesarean delivery requires the commitment and cooperation of many disciplines. Obstetricians, anesthesiologists, pediatricians, and maternity nurses are the leaders who must work together to facilitate this important practice change.
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