Episode 41 (Epilogue): Gentle Cesarean Sections

Tonight we discussed the innovative and quickly growing technique of Gentle Cesarean Sections. Our guests were Dr. George Kovacevic and Nurse Manager Nancy Travis of Lee Memorial Health System, as well as mothers who delivered by Gentle Cesarean, Melissa Murray and Angie Ahmed. Both Dr. George and Nancy referred to Memorial Hospital in Rhode Island as their inspiration for innovating the program here in Florida. 

The practice has been in place in the United Kingdom for several years. The following video is sort of the gold standard for explaining this kind of delivery.

As we spoke to Dr. Kovacevic, we asked the tough question: is the idea of "Gentle Cesarean" in fact a wolf in sheep's clothing? Will this promote elective surgery? He said absolutely not. This is still a major abdominal surgery. And overwhelmingly the contact and feedback from our listeners has reinforced this belief. Every mother we spoke with that has experienced this method of delivery was planning a vaginal birth, had to change course for medically necessary reasons, and was extremely grateful for the opportunity to hold their baby immediately after the surgery. Dr. George said that in EVERY elective or scheduled cesarean delivery, gentle cesarean practices are possible. When asked how we can overall lower our cesarean section rates, Dr. George advised eliminating unnecessary labor inductions.

Next we spoke with Nurse Manager Nancy Travis, who facilitated the program for Lee Memorial Health System. She described the major differences between a routine cesarean and a gentle cesarean--the crux of which is the focus on immediate bonding between mother and baby. It was very refreshing to hear that the staff at Cape Coral Hospital was willing and excited by this concept and moved forward without insurmountable obstacles of paperwork. "We don't really have a policy for a mother to hold their babies. It just makes sense," said Travis.

We then spoke with mothers Melissa Murray and Angie Ahmed, who each found themselves at the right place at the right time when faced with changing their birth plans from natural delivery to cesarean birth. Dr. George delivered both women's babies and neither of them knew that the option existed for them to hold their babies immediately after delivery. Each mother felt surprised, empowered and grateful for the ability to bond and nurse their babies. Their pain levels were lower and their recovery times shorter than they had expected. Both mothers are successfully breastfeeding and neither is suffering from postpartum depression.

If you are a pregnant mother who is on the road toward a cesarean delivery (or should you find yourself changing course during your labor), you have rights as a pregnant patient to completely informed consent. You can create a birth plan, just as you would when planning a vaginal delivery. Here are some things you might consider including in your birth plan:

• I would like my arms unrestrained so that I may touch my baby
• I would like the screen lowered once my baby’s head is out so that I can see his/her birth
• I would like the baby to be placed immediately on my chest
• I would like to nurse the baby immediately
• I would like dad to hold baby
• I would like baby to stay with my partner and I (no nursery unless medically necessary)
• I would like my doula and my partner with me during the surgery

Finally, here are some ideas for the "Best Cesarean Possible" by Penny Simkin, a physical therapist who has specialized in childbirth education and labor support since 1968.

If you have learned that you must have a cesarean (a “planned cesarean”) for your safety or the baby’s, you may feel disappointed that you cannot have the birth you had hoped and planned for. Here are some ideas for tailoring the cesarean birth of your baby to make it very special and personally satisfying for you, your partner, and your baby.  

Before the Surgery: 

• Be sure you understand and agree with the reasons for the cesarean (i.e., malposition of the baby, a medical problem for you or the baby). Learn about the procedure. Read about it in Pregnancy, Childbirth and the Newborn or the Birth Partner and discuss it with your caregiver.
• Learn about your anesthesia choices and how each is administered. General information is available in the books mentioned above. If possible, however, meet and discuss medications with an anesthesiologist along with any concerns you have. A spinal or epidural block is the most common type of anesthesia when a cesarean is planned in advance, but there are other possibilities.
• Learn the layout of the operating room, particularly where the baby will be taken for initial care. Will she be in the same room or an adjacent room? Will you be able to see her? Can your partner move back and forth between your side and your baby’s?
• Discuss the possibility of waiting until you go into labor and then going to the hospital to have the cesarean. The advantage is that the timing for birth is more likely to be optimal for the baby. The disadvantages are that you might not know the doctor on call who will do the surgery, and that you cannot plan ahead (which is the same as with most vaginal births).  
• If you do not decide to await the onset of labor, make your appointment for the surgery. If there is a choice of times, you may want to consider having the first appointment of the day for two reasons: there is less likely to be a delay (from earlier surgeries taking longer than expected); and you will not be as hungry if you do not have to wait all day. You will probably have to avoid eating from the night before.

During the surgery and repair:

• For your personal comfort, consider these ideas: Have your partner put some pleasant-scented (lavender and bergamot are popular) lotion, massage oil, or cologne on your cheeks. He can also put it on his wrist for you to sniff. This is soothing and may counteract the “hospital smells.” Because some staff members may be allergic to some scents, you’d better ask if this is okay. 
• Ask if at least one arm can be left unrestrained. 
• Bring your own CD or tape of music to be played during the surgery. Music that is familiar and that you love improves the ambience. Many operating rooms have CD players.
• Plan to use relaxation techniques and slow breathing (like sighing) during the surgery. Hold your partner’s hand.
• Ask that they lower the screen when the baby is lifted from your body so that you can see the birth.
• During the repair procedure, there is one technique that some doctors do, while others believe it is unnecessary and possibly problematic. This is to lift the uterus out of the abdomen to inspect it and then replace it. This procedure may cause considerable nausea while it is being done, and later gas pains. You might wish to discuss this with your doctor beforehand. If he customarily does it, ask for the advantages.
• Ask about picture taking during the surgery or afterwards. There sometimes are policies restricting picture taking.  A digital camera has the advantage of allowing pictures of the baby to be shown to you within seconds. If your baby is out of your sight, it may be possible for your partner (or a nurse) to take a picture and show it to you.
• Once your baby is born, your partner might go to the baby and talk or sing to him. A familiar voice often calms the baby at this time, and seeing the baby’s response is a poignant moment for the partner. Some couples have sung a special song (i.e., “You Are My Sunshine”) aloud to the baby frequently before birth. The baby seems to be soothed when hearing that song.  
• The partner may be able to bring the wrapped baby back to you for your first contact. You can nuzzle, kiss and talk to your baby, but it is unlikely you will be able to hold her or breastfeed until you leave the operating room, because the operating table is narrow and you may feel quite weak.
• Spinal or epidural anesthesia and other medication issues: The spinal block has many advantages for a planned cesarean, which make it the usual choice. It is quick to administer and to take effect. It usually involves only a single injection, and does not require a catheter in your back. It causes numbness that lasts a few hours. You remain awake and aware. It hardly affects your baby. The injection may also contain some long-acting narcotic such as morphine that provides good postpartum pain relief without grogginess for up to 24 hours after the surgery. 
• An epidural is very similar and has these advantages, but is more complex to administer and takes longer to provide adequate pain relief. There are, however, some concerns about spinal and epidural blocks that might be frightening: It is not uncommon to have a period during which you feel breathless or as if you cannot breathe. It can be scary. It happens because the anesthetic may numb the nerves that let you feel your breathing, while the nerves to the muscles that make you breathe are not blocked. In other words, you are breathing, but cannot feel it. What to do: Say that you cannot breathe. The anesthesiologist, who is at your head, will check and reassure you. Your partner should coach you with every breath, watching closely and saying, “Take a long breath in -- yes you are doing it, and now breathe out. Good.” He might hold your hand in front of your mouth so you can feel your breath, and reassure you, “You are breathing, even though you can’t feel it.” This feeling does not last for the entire surgery.
• On very rare occasions, the level of anesthesia rises high enough to involve the muscles of breathing, so that you really are not breathing.You cannot talk either. The anesthesiologist, who is watching the monitors closely, discovers this and takes measures to assist your breathing. You and your partner should also have a signal. If you can’t breathe and can’t talk, blink your eyes many times. That means, “I can’t breathe!” Your partner should be watching you, and if you blink in that way, says, “I think she can’t breathe!” This may alert the anesthesiologist a few seconds before he would pick up the problem.
• On other, even more rare occasions, the anesthesia is not adequate, and you feel the surgery. This is very scary. The doctors will probably want to make sure your reaction is not an anxiety reaction to the surgery, and may seem not to believe you at first. If you are feeling the surgery, tell them to stop. Your partner must help you with this. Make them give you better anesthesia before proceeding. This might mean repeating your block or giving you a general anesthetic. 
• During the repair, you may feel nauseated and shaky for a period of time. These are normal reactions to major surgery and vary from feelings of queasiness to vomiting and from trembling to shaking and teeth chattering. There are medications to ease these symptoms. They are often put into your IV without you knowing, which may be okay with you. They may, however, cause amnesia (e.g., Versed), or make you very sleepy. They can keep you from being able to nurse your baby (or to remember that you did), and to remember the first hours of your baby’s life. If you want to stay awake for this time, discuss this with your anesthesiologist ahead of time. You might ask the anesthesiologist not to give you anything for nausea or trembling unless you ask. You may very well be able to tolerate the symptoms, but if you find you cannot, then you can ask for the medication.
• Post-operative pain medications are available to help you during the days and weeks after the birth. Some women try to avoid using them due to worries about possible effects on the baby. However, since very small amounts reach the baby, the effects to be minimal. The baby nurses and remains awake and alert for periods of time. The downside of avoiding pain medications is extreme pain, which greatly reduces your ability to move about and to care for, nurse, and enjoy your baby. With adequate pain relief, you can have more normal interactions with your baby.

The first few days:

• Most hospitals have a bed available for the partner so he or she can remain in the hospital with you. This is lovely for many reasons. You are together as a family. Your partner can share in baby care. If your partner is there, your baby can probably room in with you the entire time. If he or she is not there, you will need help from the nurse to change the baby’s diapers, move him from one breast to the other, and carrying him, even for short distances. In some hospitals, the baby spends more time in the nursery if the partner is not there.
• Breastfeeding is definitely possible, but presents some challengs after a cesarean. Nursing positions such as sidelying, and the “football” or clutch hold avoid painful pressure on your incision. Using a pillow over the incision also reduces pain while holding your baby on your lap. Ask for help from the hospital’s lactation consultant in getting started with nursing.
• Rolling over in bed can be very painful, if you don’t know how to do it. The least painful way uses “bridging.” To roll from back to side, first draw up your legs, one at a time so that your feet are flat on the bed. Then “bridge,” that is, lift your hips off the bed, by pressing your feet into the bed. While your hips are raised, turn hips, legs, and shoulders over to one side. This avoids strain on your incision.
• Help at home is essential to a rapid recovery. If possible, someone in addition to your partner should help keep the household running smoothly. If that person knows about newborn care and feeding, all the better. All three (or more) of you need nurturing and help during the first days and weeks to ease and speed your recovery and help you establish yourselves as a happy family.