Cesareans following shift toward patient-centered care



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.

Dr. Paola Aghajanian

Dr. Paola Aghajanian

“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.

Brigham and Women's Hospital uses clear surgical drapes as part of a gentle cesarean. Courtesy Brigham and Women's Hospital

Brigham and Women's Hospital uses clear surgical drapes as part of a gentle cesarean.

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.

Early skin-to-skin contact is typically encouraged as part of a gentle cesarean. Courtesy Brigham and Women's Hospital

Early skin-to-skin contact is typically encouraged as part of a gentle cesarean.

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.”

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