The Gentle Cesarean

 In graduate school for anesthesia, I did one of my large projects on the topic of the Gentle Cesarean. I presented the topic at multiple conferences to rooms of people who were a little confused about why this was an anesthesia topic. The truth is that every person in the room for a cesarean needs to be on board for an idea like this in order for it to work.  It can also be any member of the birth team that pitches this idea and gets buy in from the rest of the team. Often, the person pitching this idea will be the patient.  Below, I have included the major concepts for a Gentle Cesarean, why this method is important, and how you can talk to your provider about this birth option.  This is a pretty academic post since it is mostly made of a graduate paper. Feel free to leave any questions or check the references at the bottom for more information. 

What is a Gentle Cesarean?

Vaginal birth offers benefits to the mother and baby that cesarean births do not innately possess. The development of the “Gentle Cesarean” aims to bridge the gap between the two methods of delivery.  Implementation of certain procedures such as early skin-to-skin contact between the mother and baby, delayed cord clamping and autoresuscitation, parental participation in the birth, and vaginal colonization can give the benefits of a vaginal birth to a cesarean delivery.  

Why have a Gentle Cesarean?

When you do a quick internet search for "birth art" you find pictures like these:

These women are so strong, triumphant, free, happy. This baby is just gently floating into the world.  So peaceful.  This is how women create art about their births, this is the memory of that moment. Now when you search for cesarean art, you get these:

All autonomy is gone.  All triumph and power has vanished.  This is a woman who has been cut and doesn't feel her power in this birth.  Art is how we express our emotions.  The contrast between these methods of delivery can not only leave the mother with emotional scarring, there are significant physiological differences for mom and baby as well.

What are potential Cesarean Complications?

Mother

• Hemorrhage/Blood Loss
• Pain
• Infection
• Hypotension (Low blood pressure)
• Nausea
• Anxiety
• Decreased bonding
• Decreased rates of breastfeeding
• Increased pain scores
• Longer hospital stays

Newborn

• Temperature regulation (babies get cold easily which can cause a cascade of problems)
• Glucose control 
• Respiratory Distress- Transient Tachypnea of Newborn (TTNB)
• Intraventricular Hemorrhage (bleeding in the brain)

What are the facets of a Gentle Cesarean and how do they decrease complications?

Immediate Skin to Skin

This involves bringing baby directly to mom's chest after delivery without taking baby to the warmer or cleaning the baby (as long as baby looks healthy and their airway is secure). There are even clear plastic drapes that providers can pass baby through directly to the mother's chest. This also gives mom the benefit of seeing her baby born if she chooses. 

• Oxytocin release (decreases blood loss, increases bonding)

• Temperature regulation- Bringing the baby to mother’s chest immediately after birth is a common practice in vaginal deliveries.  Increasingly, parents are requesting to have baby placed on the mother’s chest after cesarean section.  Baby’s movement around the breast causes a release of oxytocin in the mother which increases milk production and breast heat.  This heat helps to warm the infant on the mother’s breast by relaxing him and causing further vasodilation and warming. (Beiranvand, Valizadeh, Hosseinabadi, & Pournia, 2014) Infants are not able to control their temperature through heat generation due to their inability to shiver.  They are susceptible to hypothermia in the immediate postpartum period. (Debra, Jolie, & Win, 2006))  Beirevand et al. relates the skin to skin contact immediately following Cesarean delivery to temperature regulation of the newborn and breastfeeding successfulness.  They were interested primarily in whether or not the skin to skin contact would affect hypothermia rates in the newborn. Beirevand et al. found that the temperature difference between the two groups was not statistically significant.  They concluded that skin-to-skin contact after a cesarean section is a safe option for the newborn with regard to temperature regulation.  The infant warming devices did the same job of warming the newborn as the mother’s skin.  

• Increased milk production- Early latching is crucial to breastfeeding success.  The baby naturally roots around looking for the breast after they are born.  This rooting stimulates oxytocin release which aids in milk production and prolactin secretion.  Prolactin is responsible for the “let-down” response in a breastfeeding woman.  It also aids in bonding.  Babies benefit from the colostrum that is secreted in the immediate postpartum period.  Large babies and those born to mothers with gestational diabetes are at increased risk for hypoglycemia. (Maayan-Metzger et al., 2014) This risk is decreased by immediate breastfeeding. Gregson et al. examined the breastfeeding success rates after skin to skin contact in the operating room.  They were interested particularly in whether or not the skin to skin contact affected breastfeeding rates in the immediate postpartum as well as a few months later. Gregson et. al found that the earlier exposure to breastfeeding and skin to skin was associated with a trend towards increasing breastfeeding rates six weeks later. This is referred to as a trend rather than an absolute increase due to the fact that the difference in breastfeeding rates at 48 hours and six weeks was increased but was not statistically increased in the experimental group.  However, there is a statistically significant correlation between the length of time spent performing skin to skin in the first 24 hours and the continuation of breastfeeding at 48 hours. 

• Glycemic control- early latching can provide the sugar necessary for baby to regulate her own sugars without the need for formula 

• Hemostasis- Oxytocin also helps the mother’s uterus contract.  Bleeding is the leading problem for surgeons and anesthesia providers in the immediate postpartum period.  By contracting the uterus, the risk for uncontrolled bleeding is reduced as well as the need for exogenous hormones to control bleeding. (El Behery et al. 2016)

• Decreased Oxidative Stress Markers- (Web MD has a good layman's explanation of what oxidative stress is here)  Yuksel et al. focused more on the effect of skin to skin and early breastfeeding in the operating room on the mother.  The specific factors they measured were maternal oxidative stress and post-operative pain.  Cesarean section is a procedure associated with a high amount of oxidative stress.  Breastmilk is known to decrease the amount of oxidative stress in the newborn following cesarean section. (Korchazhkina et al. 2006)  The researchers wanted to know if the breastfeeding also affected the mother’s oxidative stress by measuring total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress indices (OSI).  The researchers also measured oxytocin levels in the groups and analyzed how they correlated with stress markers and post-operative pain. Yuksel at al. found no statistical difference in the groups preoperatively.  Postoperatively, the group that received the intervention had statistically significant increased levels of TAS and statistically significant decreased levels of TOS and TOI compared to the control group.  They also found that postoperative oxytocin levels were significantly higher in the intervention group.  A negative correlation was discovered between postoperative oxytocin levels and pain scores.  It can therefore be inferred that early breastfeeding in the operating room after cesarean section can decrease pain in the mother as well as decrease oxidative stress for the mother.  Reactive oxidative species cause adhesions, impair wound healing, impair the contractile strength of the uterus, and increases the risk of peripartum cardiomyopathy. 

• Pain Control- see above

Physiologic Resuscitation aka "Walking Baby Out" 

• Vaginal birth squeezes baby- When a baby is delivered vaginally, it has time to be squeezed out of the canal and this compression has several important health benefits. 

• “Walking the baby out” in cesarean delivery- The surgeon can elect to “walk the baby out” during cesarean section by delivering the baby’s head slowly from the incision to mimic this compression received during a vaginal birth.
  
  
• Autoresuscitation- The surgeon is then “hands off” and the baby “autoresuscitates”, meaning the mouth is outside the body while the baby is still attached to the placental circulation.  The baby is breathing air and receiving a few extra minutes of time in utero. (Smith, 2012)  Pressure from the uterus and maternal soft tissue helps to expel liquid from the baby’s lungs much in the same way a vaginal delivery helps to clear the lungs. (Smith, 2012)  Once the baby cries, the shoulders and arms are delivered.

• Tamponade of surgical wound- The torso then acts as a tamponade of the surgical wound, decreasing bleeding.  (Smith, 2012) 
  

• Decreased incidence of transient tachypnea of the newborn- (good layman's explanation here) Babies born via cesarean section have a higher incidence of respiratory complications such as transient tachypnea of the newborn.  (Smith, 2012)  Retained lung liquid and lack of catecholamine and cortisol release, as occurs with vaginal birth, have both been implicated. (Hansen et al., 2007)  This process of slow delivery may decrease risk for respiratory complications. 

• Delayed cord clamping- A 2008 Cochrane review found that delaying cord clamping by at least 30 seconds is safe for the preterm newborn. (Rabe, Reynolds, & Diaz-Rossello, 2008)  These babies were also found to have higher circulating blood volume in the first 24 hours of life, less need for blood transfusion, and fewer incidence of intraventricular hemorrhage. (Rabe, Reynolds, & Diaz-Rossello, 2008)  
  

Vaginal Swabbing and the MicroBiome

• Vaginal birth: bifidobacteria- The newborn microbiome is a topic of recent interest to neonatal researchers.  After a vaginal birth, the newborn’s intestinal flora resembles that the mother’s vaginal canal and contains a significant amount of bifidobacteria , a genus of anaerobic bacteria that inhabit healthy mammalian mucosa  and is commonly used in probiotics.  

• Cesarean birth: hospital bacteria-  In contrast, after a cesarean section, the newborn’s intestinal flora resembles that of the mother’s skin and the operating room and has high levels of lactobacilli, a genus of anaerobic bacteria commonly found in the vagina.  (Pandey et al., 2012) 

• Stronger humeral response in cesarean babies- not a good thing- The cesarean infant is also shown to mount a stronger humeral immune response with higher levels of IgG, IgA, and IgM secreting cells. (Huurre et al., 2007)  This reflects excessive antigen response across the vulnerable gut barrier. (Huurre at al., 2007)   The method of delivery is therefore predictive of the immunological development of the child.  Bifidobacteria is crucial to the development of a diverse and robust microbiome in the gut.  When children are born via cesarean, they do not physically get access to these bacteria and establish a microbiome in their gut that initiates an immune response that is destructive to the gut and to overall immune health.  This heightened response also alters the establishment of a strong mucosal lining in the infant. (Huurre et al., 2007)  All of these factors may lead to problems with allergies, absorption, and even depression later in the life of the child.

• Vaginal swabbing to inoculate baby- A recent study published in Nature Medicine shows the effectiveness of swabbing the vaginal canal before the cesarean section and inoculating the baby with the swabs in the immediate postpartum period.  The study showed that through wiping the swabs on the baby’s skin and mouth after birth, the microbiome at 30 days postpartum resembled that of a child born vaginally.  (Dominiguez-Bello et al., 2016)  The study did not look at effects on the health of the child and this is a realm of research that is currently being pursued further.  This is also  sometimes called "vaginal seeding".

Setting the Mood

That was quite a bit of science and data.  We can also request a few things to just make it feel nicer.  

• Limit unnecessary conversation- I don't need to hear about the golf game or what you did last weekend.  This is my birth, I want to be addressed like a real person and I only want to hear conversations as they relate to my baby and the procedure. 

• Music- Most operating rooms have a great sound system.  Ask if you can play your own mix. 

• Dimming the lights- obviously I'm not talking about the lights the surgeon needs for the procedure, I'm referring to the rest of the harsh fluorescent lights in the room. These can usually be turned off without compromising any patient care.

• Have your hands free as much as possible- usually it isn't necessary to have your hands strapped to the table.  Ask to also have EKG stickers on your back instead of chest to make room for baby. Don't wear a bra, you want a nice clear chest for skin to skin. 

I have included all of my sources for my graduate project, much of it is cited in this post. Use these resources when pitching the idea to your provider, have evidence for your requests. If your provider is still resistant, it may be time to find a provider that will support your safer birth.  With birth plans, there is a misconception that mothers are fixated on their positive experience to the detriment of the baby.  The reality is that the parts of a birth plan that lead to the positive experience are almost always safer and more beneficial for mom and baby...they are also more work for the labor staff.  Resistance to these changes usually comes from an unwillingness to rock the boat and an "if it ain't broke, don't fix it" mentality.  Well, it is broken and we do need to fix it.  Your voice is the only thing that can do that.  Providers will continue to push the birth that is best for them unless patients demand a birth that is best for mom and baby. Here's a little Gentle Cesarean art to round this out.  A Cesarean can be a great birth. 

***The Gentle Cesarean is ideal for an uncomplicated cesarean with a healthy mom and baby. Demand a safe birth, even if that means you don't get a Gentle Cesarean.  Sometimes, safe is trusting your team. I am speaking specifically of complications such as hemorrhage, low apgar scores, and other emergency situations. Go in with this knowledge and your requests for this safe delivery but be willing to pivot and trust your team in the event of an emergency.***

Resources:

Beiranvand, S., Valizadeh, F., Hosseinabadi, R., & Pournia, Y. (2014). The Effects of Skin-to-Skin Contact on Temperature and Breastfeeding Successfulness in Full-Term Newborns after Cesarean Delivery. International Journal Of Pediatrics, 1-7. doi:10.1155/2014/846486  (Beiranvand et al., 2014)

Debra, L., Jolie, F. P., &Win, G., Thompsons Pediatric Nursing, 9th edition, 2006.

DiMatteo, M.R., Morton, S.C., Lepper, H.S., Damush, T.M., Carney, M.F., & Pearson, M., (1996). Cesarean childbirth and psychosocial outcomes: a meta-analysis. Health Psychol 1996;15:303–14 

Dominguez-Bello, M.,  De Jesus-Laboy, K., Shen, N., Cox, L., Amnon, A., Gonzalez, A., Bokulich, N., Song, S., Hoashi, M., Rivera-Vinas, J., Mendez, K., Knight, R., & Clemente, C., (2016) Partial restoration of the microbiota of cesarean-born infants via vaginal microbial transfer. Nature Medicine, 60(3), 23-28.

Elfil, H., Crowley, L., Segurado, R., & Spring, A., (2015) A randomised controlled trial of the effect of a head-elevation pillow on intrathecal local anaesthetic spread in caesarean section. International Journal of Obstetric Anesthesia, 24 (4), 303-307.

El Behery, M. M., El Sayed, G. A., El Hameed, A. A., Soliman, B. S., Abdelsalam, W. A., & Bahaa, A. (2016). Carbetocin versus oxytocin for prevention of postpartum hemorrhage in obese nulliparous women undergoing emergency cesarean delivery. Journal Of Maternal-Fetal & Neonatal Medicine, 29(8), 1257-1260. doi:10.3109/14767058.2015.1043882

Gouchon, S., Gregori, D., Picotto, A., Patrucco, G., Nangeroni, M., & Di Giulio, P. (2010). Skin-to-Skin Contact After Cesarean Delivery. Nursing Research, 59(2), 78-84.

Gregson S, Meadows J, Teakle P, Blacker J. Skin-to-skin contact after elective caesarean section: Investigating the effect on breastfeeding rates. British Journal Of Midwifery [serial online]. January 2016;24(1):18-25. Available from: Academic Search Complete, Ipswich, MA. Accessed August 23, 2016.

Hansen, A. K., Wisborg, K., Uldbjerg, N., & Henriksen, T. B. (2007). Elective caesarean section and respiratory morbidity in the term and near-term neonate. Acta Obstetricia Et Gynecologica Scandinavica, 86(4), 389-394. doi:10.1080/00016340601159256

Huurre, A., Kalliomaki, M., Rautava, S., Rinne, M., Salmenin, S., & Isolauri, E., (2007). Mode of delivery- effects on gut microbiota and humoral immunity. Neonatology, 93 (2),  236-240.

Korchazhkina O, Jones E, Czauderna M, Spencer SA. Effects of exclusive formula or breast milk feeding on oxidative stress in healthy preterm infants. Arch Dis Child 2006;91:327–9.

Kovacheva, V.P., Soens, M.A., & Tsen, L.C., (2016) Randomized, Double-blinded Trial of a "Rule of Threes" Algorithm Versus Continuous Infusion of Oxytocin During Elective Cesarean Delivery. Obstetric Anesthesia Digest. 36(2):61-63.

Lee, M., Kim, S., Hwang, B., Yoo, B., Koh, W., Jang, D., & Choi, W., (2016). The effects of prophylactic bolus phenylephrine on hypotension during low-dose spinal anesthesia for cesarean section. International Journal of Obstetric Anesthesia. 25, 17-22.

Maayan-Metzger, A., Schushan-Eisen, I., Lubin, D., Moran, O., Kuint, J., & Mazkereth, R. (2014). Delivery Room Breastfeeding for Prevention of Hypoglycaemia in Infants of Diabetic Mothers. Fetal & Pediatric Pathology, 33(1), 23-28. doi:10.3109/15513815.2013.842271

Martin, J. A., B. E. Hamilton, S. J. Ventura, M. J. K. Osterman, E. C. Wilson, & T. J. Matthews. (2012). National Vital Statistics Reports. Births: Final Data for 2010. Hyattsville, MN: National Center for Health Statistics

Ngan Kee, W.D., Lee, S.W.Y., Tan, P.E., & Khaw, K.S., (2015) Randomized Double-blinded Comparison of Norepinephrine and Phenylephrine for Maintenance of Blood Pressure During Spinal Anesthesia for Cesarean Delivery. Anesthesiology. 122, 736-745. 

Pandey, P., Verma, P., Kumar, H., Bavdekar, A., Patole, M., & Shouche, Y. (2012). Comparative analysis of fecal microflora of healthy full-term Indian infants born with different methods of delivery (vaginal vs cesarean): Acinetobacter sp . prevalence in vaginally born infants. Journal Of Biosciences, 37989-998. doi:10.1007/s12038-012-9268-5

Pivetti, V., Cavigioli, F., Lista, G., Napolitano, M., Rustico, M., Paganelli, A., & Ferrazzi, E. (2014). Cesarean section plus delayed cord clamping approach in the perinatal management of congenital high airway obstruction syndrome (CHAOS): A case report. Journal Of Neonatal -- Perinatal Medicine, 7(3), 237-239. doi:10.3233/NPM-14814006 

Rabe, H., Reynolds, G., & Diaz-Rossello, J. (2008). A Systematic Review and Meta-Analysis of a Brief Delay in Clamping the Umbilical Cord of Preterm Infants. Neonatology (16617800), 93(2), 138-144. doi:10.1159/000108764

Saravanakumar, K., Hendrie, M., Smith, K., & Danielian, P . (2015) Influence of reverse Trendelenburg position on aortocaval compression in obese pregnant women. International Journal of Obstetric Anesthesia, 26, 15-18.

Shah, N., (2016) A NICE Delivery-The Cross-Atlantic Divide Over Treatment Intensity in Childbirth. Obstetric Anesthesia Digest. 36(2):69.

Smith, J. (2012). The natural caesarean: a woman-centred technique. Journal Of Obstetrics & Gynaecology, 32(2), 204. doi:10.3109/01443615.2011.639179  

Stevens, J., Schmied, V., Burns, E., & Dahlen, H. (2014). Immediate or early skin-to-skin contact after a Caesarean section: a review of the literature. Maternal & Child Nutrition, 10(4), 456-473. doi:10.1111/mcn.12128  

The Natural Caesarean: A Woman-Centred Technique. You Tube. Accessed May 10, 2011. Available at: http://www.youtube.com/watch?feature=player_embedded&v=m5RIcaK98Yg.

Wrench, I.J., Allison, A., Galimberti, A., Radley, S., Wilson, M.J. (2016). UK Introduction of Enhanced Recovery for Elective Cesarean Section Enabling Next Day Discharge: A Tertiary Centre Experience. Obstetric Anesthesia Digest. 36(2):60-61.

Young, D. (2011, September). 'Gentle Cesareans': Better in Some Respects, But Fewer Cesareans Are Better Still. Birth: Issues in Perinatal Care. pp. 183-184. doi:10.1111/j.1523-536X.2011.00492.x.

Yuksel B, Ital I, Keskin N, et al. Immediate breastfeeding and skin-to-skin contact during cesarean section decreases maternal oxidative stress, a prospective randomized case-controlled study. Journal Of Maternal-Fetal & Neonatal Medicine [serial online]. August 15, 2016;29(16):2691-2696. Available from: Academic Search Complete, Ipswich, MA. Accessed August 23, 2016.