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Best Practices
Regarding Gentle
Caesarean Section
An Online Continuing Education Activity
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Welcome to
Best Practices Regarding
Gentle Caesarean Section
(An Online Continuing Education Activity)
CONTINUING EDUCATION INSTRUCTIONS
This educational activity is being offered online and may be completed at any time.
Steps for Successful Course Completion
To earn continuing education credit, the participant must complete the following steps:
1. Read the overview and objectives to ensure consistency with your own learning
needs and objectives. At the end of the activity, you will be assessed on the
attainment of each objective.
2. Review the content of the activity, paying particular attention to those areas that
reflect the objectives.
3. Complete the Test Questions. Missed questions will offer the opportunity to reread the question and answer choices. You may also revisit relevant content.
4. For additional information on an issue or topic, consult the references.
5. To receive credit for this activity complete the evaluation and registration form.
6. A certificate of completion will be available for you to print at the conclusion.
Pfiedler Enterprises will maintain a record of your continuing education credits
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If you have any questions, please call: 720-748-6144.
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Pfiedler Enterprises, 2170 South Parker Road, Suite 125, Denver, CO 80231
www.pfiedlerenterprises.com Phone: 720-748-6144 Fax: 720-748-6196
Overview
Pregnancy is one of the most profound events for a woman and is laden with physical
and emotional experiences. It is generally a time of joyfulness and well-being, however, it
can become overwhelming when complications occur that place the mother and unborn
child at risk. These complications may result from medical conditions that prevent the
mother from having a vaginal birth and leave her with the only other option--a Caesarean
Section (C-Section) birth. Some women find traditional C-Sections distressing due to
the surgical nature of the procedure and the initial separation from the baby immediately
after birth when a physical and psychological connection between mother and baby is
especially significant. Over the past few years a new trend has emerged for mothers who
want more of the feeling and environment of a vaginal birth, during a C-Section. This
patient-focused modification of the traditional Caesarean process has been introduced
as a “Gentle Caesarean Section” birth. The goal of the Gentle C-Section is to provide a
more patient- and family-centered experience without compromising safety and sterility
and make the delivery as natural as possible. The purpose of this activity is to provide
nurses and other healthcare professionals (HCP) with a general understanding of the
fundamentals of Gentle Caesareans, the benefits to both the mother and child, and how
to implement some of the practices found during and after vaginal deliveries into the
operating room.
Objectives
After completing this continuing education activity, the participant should be able to:
• Define a Gentle Caesarean procedure
• Describe the elements of a Gentle Caesarean procedure
• Discuss clinical and logistical aspects of implementing a Gentle Caesarean
program
• Describe the short- and long-term physiological and psychological benefits to the
mother and child
• Identify the teaching topics that are relevant to patients who want to experience a
Gentle Caesarean
Intended Audience
This activity is designed to provide nurses and other healthcare providers with
information about Gentle Caesareans and the knowledge and tools to educate pregnant
mothers of this patient- and family-centered surgical birth option.
3
CREDIT/CREDIT INFORMATION
State Board Approval for Nurses
Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing,
Provider Number CEP14944, for 2.0 contact hour(s).
Obtaining full credit for this offering depends upon completion, regardless of circumstances,
from beginning to end. Licensees must provide their license numbers for record keeping
purposes.
The certificate of course completion issued at the conclusion of this course must be retained
in the participant’s records for at least four (4) years as proof of attendance.
RELEASE AND EXPIRATION DATE
This continuing education activity was planned and provided in accordance with accreditation
criteria. This material was originally produced in August 2016 and can no longer be used
after August 2018 without being updated; therefore, this continuing education activity expires
August 2018.
DISCLAIMER
Pfiedler Enterprises does not endorse or promote any commercial product that may be
discussed in this activity.
SUPPORT
Funds to support this activity have been provided by Ecolab.
AUTHORS/PLANNING COMMITTEE/REVIEWER
Julia A. Kneedler, RN, MS, EdD
Program Manager/Reviewer
Pfiedler Enterprises
Denver, CO
Judith I. Pfister, RN, BSN, MBA
Program Manager/Planner
Pfiedler Enterprises
Denver, CO
Dondra Tolerson, BA, MS
Academic, Medical & Technical Writer/Author
Woodstock, GA
Melinda T. Whalen, BSN, RN, CEN
Program Manager/Reviewer
Pfiedler Enterprises
Denver, CO
4
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visit our website at: http://www. pfiedlerenterprises.com/disclosure
Disclosure includes relevant financial relationships with commercial interests related to
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Activity Planning Committee/Authors/Reviewers:
Julia A. Kneedler, RN, MS, EdD
No conflict of interest.
Judith I. Pfister, RN, BSN, MBA
No conflict of interest.
Dondra Tolerson, BA, MS
No conflict of interest
Melinda T. Whalen, BSN, RN, CEN
No conflict of interest
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5
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6
INTRODUCTION
Expecting a child is a joyous experience for parents and families. Over 85% of all women
will experience pregnancy sometime in their lives, and its influence on a woman’s health
and well-being in particular can be profound.1 Many women create a birth plan, which
informs their clinical care team of how they would like the environment and labor to be
managed. Certainly some aspects of the experience will not go as planned, and in those
instances both the care team and woman need to be flexible. This is especially true when
situations occur that have the potential of placing the woman and/or her unborn child at
risk, creating the need to deviate from the plan of having a vaginal delivery, and opting for
a Caesarean section instead.
The Caesarean Section is one of the most common operating room (O.R.) procedures2.
Over 30% of the estimated 4 million babies born in the United States (U.S.) annually are
born via C-Section.3 This is a dramatic increase from 5% of births occurring via Caesarean
delivery reported back in 1970.4 Though percentage rates of women having C-Sections
have fluctuated over the last 3 decades, the fact is that Caesarean deliveries in the U.S.
are now commonplace.
Among women who have a Caesarean delivery, more than 90% will deliver their
subsequent pregnancies by Caesarean as well.1 Some women work with their obstetrician
to pre-plan a C-Section due to health reasons5, 6 while other women intend to deliver
vaginally but will require a Caesarean delivery when unexpected problems occur.
Numerous medical studies have pointed to the benefits of the natural aspects of childbirth
commonly seen in vaginal deliveries such as immediate skin-to-skin contact,7, 8, 9 early
breastfeeding initiation,10, 11 and a focus on a serene environment, where mother and
baby can begin their bonding experience. Caesarean delivery practices however, can
create uneasy experiences that do not facilitate this immediate mother-baby contact. In
most instances when a newborn is delivered via C-Section, they are quickly taken to a
resuscitation unit to be examined, cleaned, banded, weighed, administered medications
and swaddled before being given to their mother. It is widely known that mothers often feel
disheartened by this process and disappointed that they had to have a Caesarean birth
without the normal bonding experience with their newborn.12
EVOLUTION OF A C-SECTION
Though the practices involved in a C-Section have not drastically changed over the last
few decades, some measures to improve the mother’s comfort level have been put in
place. Active patient warming is one example of this. Comfort and infection control are
some reasons why the temperature of the mother is critically important during surgery.13
In some situations, a surgeon may request a lower room temperature than recommended
for his/her personal comfort while clothed in layers of surgical attire.14 However, lowering
the room temperature compounded with the physiological effects of anesthesia are
common risk factors of inadvertent perioperative hypothermia,15 which can increase blood
loss, recovery time, rates of wound infection, length of hospital stay and negative health
outcomes,16 and continue to be an issue of clinical concern.
7
To help control maternal temperature and maintain perioperative normothermia,
intravenous fluid warming, warm irrigation fluid, and body warming devices can be
used during a C-Section.17 A systematic review of 12 studies substantiated that IV fluid
warming and preoperative body warming devices were effective at maintaining maternal
temperatures, and reducing shivering, for mothers.17 Forced air pre-warming also
results in higher core temperatures in Caesarean mothers and their infants, as well as
significantly greater umbilical vein pH values in newborns.18
Another change that has evolved in Caesarean practices to improve the mother’s
comfort level and enhance the overall birthing experience is the introduction of the
Gentle Caesarean procedure. The Gentle C-Section is built on the idea of incorporating
elements that women who deliver vaginally get to experience, into the operating room. In
the past few years Gentle Caesarean births have been increasingly discussed in clinical
circles and implemented in hospitals throughout the world. Benefits from this procedure
add value to the mother’s birthing experience and may provide clinical advantages and
improved outcomes for both the mother and child. Complication rates among Gentle
C-Sections are comparable to or lower than those for traditional Caesarean births,
and Gentle Caesarean deliveries are steadily replacing the traditional practices as the
standard of care at some institutions.12
WHAT IS A GENTLE CAESAREAN?
A Caesarean can be more than a surgery. Hospitals and birthing centers that adopt a
Gentle Caesarean model can transfer elements of a traditional birth experience, seen as
a rite of passage by many women, to the operating room. In the U.S., Gentle C-Sections
are a relatively new idea that allow for more active participation in the family’s first moments together. Unfortunately, many doctors, nurses and other healthcare professionals
are not aware or do not have experience with this option creating a disconnect between
the evidence and practice.19 Gentle Caesareans include several elements of a natural
delivery in order to create a peaceful, calm atmosphere that resembles what occurs during and immediately following vaginal childbirth. Hospitals and birthing centers may incorporate different elements in their model; however, the central feature is giving parents the
following options:19, 20
• Seeing their baby as he or she is being delivered
• Experiencing cutting the umbilical cord
• Receiving and bonding with their baby immediately after delivery
• Breastfeeding the baby while in the O.R.
• Enjoying environmental accommodations for a more tranquil experience
Research reveals that the processes of traditional Caesareans frequently prevent
mothers from connecting to important physical and emotional aspects of the birthing
process.21 Caesarean mothers report more negative perceptions about their birth
experiences, themselves and their babies. Some data suggests that they display poorer
8
maternal-child interaction and may be at higher risk for postpartum mood disorders.22, 23 It
has been argued that a great number of mothers choose not to conceive again after having
a traditional Caesarean due to some of the negative experiences.24, 25
Marrying the aspects from a vaginal delivery to those in a C-Section, still include the clinical,
safe, and sterile practices that take place inside an O.R., but with some slight process
changes.
Newborn Visibility
Transparent drapes enable a cesarean One aspect of a Gentle C-Section that
can
be pivotal
to the parents’ experience
Newborn
Visibility
procedure to be a safe and familyof the birthing process is watching the
centered birth experience.
birth
their of
child.
There
are a variety
of be
One of
aspect
a Gentle
C-Section
that can
pivotal totechniques
the parent’s
experience
of thetobirthing
draping
that
can be used
process this,
is watching
thethe
birth
of of
their
child.
achieve
including
use
a solid
There that
are amay
variety
of draping
drape
include
a cleartechniques
viewing that
can be used
to achieve
this, including
window,
or using
a one-piece
drape the use
of
a
solid
drape
that
may
include
a clear
featuring both an opaque and clear
viewing window, or using a one-piece drape
drape. After the uterine incision is made
that features both an opaque and clear drape.
the
opaque
drapeincision
is dropped
permitting
After
the uterine
is made,
the opaque
the
mother
to
watch
through
the
clear and her
drape is dropped permitting the mother
drape,
window,
as her
partnerortoclear
watchviewing
the delivery
through
the clear
baby
delivered.
In many
caseswhile
the
drape,is or
clear viewing
window,
surgeon
conduct
delivery
withthe
maintaining sterility. In many cases, the surgeon can conduct
a slow can
delivery
with atheslow
intent
to imitate
26 the nurse or anesthesiologist can
26 Following
birth ofdelivery.
the baby,
“vaginal
of a vaginal
delivery.squeeze”
thesqueeze”
intent to imitate
the “vaginal
of the
a vaginal
Following the birth of the
lift thebaby,
opaque
the viewing window
to obstruct
parent’s
viewthe
during
the remainder
thedrape
nurseororclose
anesthesiologist
can lift the
opaquethe
drape
or close
viewing
window toof the
surgery.
Offering
drapingview
technique
a clearofwindow
and an Offering
opaque screen
gives
both the
obstruct
the aparents’
duringwith
the both
remainder
the surgery.
a draping
technique
parents
and
surgical
staff
the
opportunity
and
flexibility
during
the
procedure
regarding
whether
to view the
with both a clear window and an opaque screen gives both the parents and surgical staff
birth. the
Foropportunity
example, if and
complications
from
the
surgery
arise
which
would
alarm
the
patient,
the
window
flexibility to change their minds during the procedure about whether to in the
drape does not need to be opened. The only modification to the traditional process of using one single,
view the birth. For example, if complications from the surgery arise which would alarm the
solid drape is the surgical staff’s responsibility to open and close the viewing window at appropriate times
the window in the drape does not need to be opened. The only modification to the
duringpatient,
the procedure.
traditional process of using one single, solid drape is the surgical staff’s responsibility to
and close the the
viewing
window
at appropriate times during the procedure.
Cordopen
Clamping/Cutting
Umbilical
Cord
The umbilical
cord is a part of the
support system
Cord Clamping/Cutting
thelifeUmbilical
Cord of a baby that is still needed in the moments after the
infantThe
is born.
In
the
1950’s
it
was
believed
that
early system
cord clamping
reduced
of postpartum
umbilical cord is a part of the life support
of a baby
that isinstances
still needed
in the
maternal hemorrhage and early cord clamping became a standard practice for many years.27 With early
moments after the infant is born. Unfortunately, in the 1960’s it was believed that early
cord clamping, the physician, midwife, or nurse would clamp the cord and pass the baby off as quickly as
cord clamping reduced instances of postpartum maternalearly
hemorrhage
and early cord
possible. Decades of research have revealed that immediate or
cord clamping does not reduce
27
clamping
became
a
standard
practice
for
many
years.
In
this
scenario
the physician,
hemorrhaging or offer any clear benefits in an uncomplicated birth; rather, it disrupts
normal physiology,
midwife
or nurse
would clamp
theitcord
andthe
pass
thefrom
baby
as quickly as placenta
possible.and halts the
anatomy
and the
birth process
because
severs
baby
theoffstill-functioning
Decades
of research
have
revealed
that immediate
or early
cord clamping
does not
circulation
of blood
to the baby
from
the placenta.
Furthermore,
immediate
cord clamping
canreduce
result in
offer
anybaby
clearforbenefits
an uncomplicated
birth;
rather,
it disrupts
normal
lowerhemorrhaging
blood levels ofor
iron
in the
up to 6 in
months
after birth. Early
cord
clamping
can cause
complications
for anatomy
the motherand
as the
evidence
shows that
it increases
the risk
of post-partum
hemorrhage and
physiology,
birth process
because
it severs
the baby
from the stillretained
placentaplacenta
in the mother
by engorging
the placenta
withThis
the baby’s
blood
it harder
for the
functioning
and halts
the circulation
of blood.
can result
in making
lower blood
levels
27
uterusoftoiron
contract
and
expel
the
placenta.
in the baby for up to 6 months after birth. It can cause complications for the mother
A growing number of parents are opting for delayed cord clamping for their baby which is a birth practice
where the umbilical cord is not clamped or cut until after pulsation has stopped, or until after the placenta is
9
delivered. The delay in clamping the cord is an opportunity
for the mother’s spouse or birth partner to
too, as evidence shows that early clamping increases the risk of post-partum hemorrhage
and retained placenta in the mother by engorging the placenta with the baby’s blood. This
makes it harder for the uterus to contract and expel the placenta.27
A growing number of parents are opting for delayed cord clamping for their baby which
is a birth practice where the umbilical cord is not clamped or cut until after pulsation has
stopped, or until after the placenta is delivered. The delay in clamping the cord is an
opportunity for the mother’s spouse or birth partner to prepare to cut the umbilical cord.
In some cases the partner may opt out; however, in other cases it is an anticipated,
rewarding and memorable experience for them.
Delay in clamping the cord is appealing because studies have shown that the timing of
clamping the umbilical cord has a sizeable impact on health outcomes for the mother and
newborn. When delayed cord clamping is offered to families, it provides the baby with
normal and healthy blood volume, placental transfusion and ensures safe oxygen levels
for the transition to life outside the womb. One-third of a preterm or full term baby’s total
blood volume dwells in the placenta, which is the equivalent to the volume of blood needed
to fully perfuse their lungs, kidney and liver at birth. Secondly, the concentration of red
blood cells, stem cells and immune cells in fetal blood is higher than any other time of life.
These cells play a vital role in the development of the immune, respiratory, cardiovascular,
central nervous systems and many other functions. A third benefit of delayed clamping is
that it keeps the maternal-child unit intact and can prevent complications with delivering
the placenta.28, 29, 30
Based on a number of systematic reviews, it is recommended that there should be at least
a 30 to 60 second delay before clamping the umbilical cord for all births.27 In fact, aside
from some infants in the delayed cord clamping category requiring phototherapy for mild
jaundice in the initial postpartum days, studies support that in full term infants, umbilical
cord clamping between 30 and 180 seconds after birth results in higher concentrations of
hemoglobin and hematocrit during the neonatal period. Increased serum ferritin levels and
lower incidences of iron-deficiency anemia31 at 4–6 months of age are also reported. These
benefits are especially important for children in low and middle income countries where
iron-deficiency anemia is highly prevalent.32, 33 It is important to note that at least 10% of
10
the general U.S. population, ages 1 to 3 years old, is iron deficient and the frequency of
iron deficiency is rising in certain ethnic and socioeconomic populations. With delayed cord
clamping providing as much as a 4 to 6 months supply of iron, it can prevent newborns
from starting out low and facing the challenge of trying to catch up their iron levels.28, 29, 30
In preterm infants, delaying cord clamping for at least 30 seconds increases the
concentrations of hemoglobin and hematocrit, improves mean systemic blood pressure,
urine output and cardiac function, and decreases the need for vasopressors and blood
transfusions during the neonatal period. It also decreases the prevalence of necrotizing
enterocolitis, sepsis, and intraventricular hemorrhage.32 That said, for just three additional
minutes of time, considerable benefits can be offered to both the mother and her baby.
There is some concern that universally adopting delayed umbilical cord clamping may
jeopardize timely resuscitation in infants27; however, several sources34, 35, 36 indicate that
resuscitation is less likely if there is a delay. In fact, many practitioners are looking for ways
to resuscitate with the cord intact,37 while others have already developed a method of
resuscitation of the neonate at caesarean section with the cord intact.33
Immediate Skin-to-Skin Bonding
Separating mothers and newborns at birth has been a standard clinical practice following
Caesarean delivery for decades. Growing evidence of the positive effects of keeping
mothers and newborns together dates back to the early 1970’s. Winifred Gallagher38
suggested that infants experience a psychological and physical withdrawal when they
are separated from their mothers. Numerous studies from the 70’s and 80’s revealed that
mothers who had brief early skin-to-skin contact with their babies were more confident and
comfortable interacting with their babies than mothers who did not have early contact and
were only reunited every few hours for breastfeeding.39 A Cochrane Review on the subject
indicates that mothers who hold their newborns skin-to-skin immediately following delivery
have a strong desire to do it again for subsequent deliveries.40 More recent studies found
that mothers who experienced immediate skin-to-skin bonding following their surgery
reported less post-operative pain and anxiety than mothers who were separated from their
infants. Furthermore, pre-term infants who experienced skin-to-skin bonding had higher
APGAR scores, thus superior stabilization than neonates who did not.40 Researchers
found that infants held with skin-to-skin contact also cried for a shorter length of time, were
more likely to breastfeed successfully and for a longer duration during their first feeding,
and made more mouthing movements than newborns who were swaddled in blankets.41
Skin-to-skin bonding is another aspect typical of a vaginal birth that benefits both the
mother and the baby, and can be duplicated in the O.R. Not only is it a nice experience
for the mother, but it also initiates biochemical circuitry in the brain that activates
attachment and maternal caregiving behaviors.39 This interaction helps babies transition
from the womb to the world by regulating their temperature, blood pressure and heart
rate.7, 12 Studies show that it reduces infant crying and leads to more successful rates of
breastfeeding.39, 40 Skin-to-skin bonding also activates the emotional learning portions of
the newborn’s brain, the amygdala, contributing to the maturation of the brain structure.39, 42
11
During a Gentle Caesarean, only
one of the mother’s arms should
be strapped to an arm board,
leaving her other arm free to hold
her baby immediately after the
birth. The EKG leads are also
placed on her back or sides rather
than her chest, to create enough
space for the baby to rest and not
infringe the mother’s ability to see,
hold, or breastfeed her baby in
the moments following the birth.12
Once the umbilical cord is cut,
the pediatric team performs initial
stimulation and resuscitation. If there are no medical concerns involving the mother and
baby, a sterile-dressed surgical staff member may receive and place the baby on the
mother’s chest right away for skin-to-skin bonding.19
Some concern has been expressed amongst certain neonatal caregivers that infants
exposed to the cool temperature in the operating room may experience newborn
hypothermia. The physician who receives the newborn immediately after delivery can
determine appropriateness of skin-to-skin placement based on the clinical assessment of
the baby’s vigorousness--a heart rate greater than 100 beats per minute (bpm), normal
tone and respirations.43 Skin-to-skin contact involves placing the naked infant prone
on the mother’s bare chest with its head and back draped with a warm blanket or the
mother’s robe.40 Through thermal synchrony, skin-to-skin contact allows the temperature
of the mother’s chest to warm the infant’s cool, wet body.39
The baby may remain with the mother and continue skin-to-skin bonding while they are
being transported into the recovery or postpartum room. The spouse or partner of the
mother can engage, hold, and bond with the baby during this time as well.19 The spouse
or partner should be given an equal opportunity to be a caregiver from birth, especially
under circumstances in which the mother is not conscious or is unable to hold the baby,
or when there are medical complications with the mother.39
Breastfeeding in the OR
Mothers who have a desire to breastfeed do so for a variety of reasons including
convenience, health benefits, closeness with their infant, being ‘natural’ and the
emotional rewards.44 Unfortunately in traditional Caesarean scenarios, mothers are not
always permitted to breastfeed soon after delivering their newborn. In some cases, the
baby is given a bottle of sugar water or formula before being introduced to the breast.45
This causes some mothers to feel denied of initial bonding moments. Furthermore, it
has been shown that supplemental bottle feedings may also interfere with the baby’s
appetite for nursing, which can lead to diminished milk production for the mother.45, 46
As previously stated, during a traditional C-Section, mothers usually have both arms
secured to an arm board and EKG leads affixed to their chest preventing bonding and
breastfeeding within the first hour of the baby’s life. Missing this opportunity can lead to
12
breast-feeding positioning difficulties and infrequent feeding events following the surgery.
For these reasons, breastfeeding outcomes are often lower after surgical deliveries when
compared to vaginal births.45, 47
Caesareans do not necessarily need to be associated with poorer breastfeeding outcomes.
Ideally it should be a priority to offer support for breastfeeding immediately after the baby
is lifted from the womb.44 In fact, the World Health Organization (WHO) recommends that
infants solely breastfeed from the first hour of birth through six months of age, and to
continue to include breastfeeding as an important part of their diet through the age of two.48
These recommendations are derived from the extensive evidence of the short- to long-term
benefits of breastfeeding, such as:44
• Enhanced health for infants and mothers
• Heightened cognitive and behavioral development for infants
• Family satisfaction
• Economic factors
Gentle Caesarean models accommodate breastfeeding as soon as possible while the
mother and baby are still in the operating room to take advantage of the baby’s first alert
periods.40 Milk production is usually signaled once the placenta separates from the uterus,
so mothers are often able to breastfeed while the surgical team is closing the surgical site.
Evidence-based analysis indicates that all forms
of additional support increase the duration of both
partial and exclusive breastfeeding.17
Breast milk contains antibodies that help the infant fight off viruses and bacteria; it also
lowers the baby’s risk of having asthma and allergies. Infants who are breastfed have
lower mortality rates and are less likely to be hospitalized with a preventable disease or
suffer from childhood diabetes and obesity. Breastfeeding also has a positive impact on
IQ and educational or behavioral outcomes for the child.48 Furthermore, studies show that
breastfeeding as soon as possible increases the effectiveness of breastfeeding, minimizes
breast engorgement, and decreases the mother’s risk of breast cancer. In terms of socioeconomic impact, breastfeeding often increases spacing between subsequent pregnancies.
In recent years there has been a substantial decrease in breastfeeding. In fact, data from
the U.S. Infant Feeding Practices Study II conducted by the Food and Drug Administration
from 2005 to 2007 revealed that 83% of mothers initiated breastfeeding, but less than 50%
exclusively breastfed through the end of their hospital stay. This disconnect is attributed to
unsupportive post-partum hospital routines. As such, nurses should provide encouragement
for breastfeeding through reassurance, information and addressing the mother’s questions
and concerns during the post-op period.44, 49 While educating pregnant women on the
elements of a Gentle Caesarean, it is important to underscore that it is not uncommon for
13
breastfeeding to be exhausting, uncomfortable or even painful for the mother. These
feelings are not the direct effect of having a C-Section instead of a vaginal birth.45
Environmental Accommodations
An additional element of a Gentle Caesarean to consider is to minimize extraneous noise
in the operating room because the presence of loud equipment and conversations by the
clinical team can contribute to unharmonious ambient noise. The surgical team may be
asked to keep voices low and conversations to a minimum.
To mask the inherent equipment noise, soothing sounds and images provided by the
hospital or mother can be used to create a peaceful environment, reduce the mother’s
anxiety and distract her from uncomfortable stimuli in the O.R.50 Evidence-based
research proposes that judiciously-selected audiovisual media used during surgery can
produce an anxiolytic effect in patients by suppressing the sympathetic nervous system,
leading to decreased activity in the nervous system and decreased neuromuscular
arousal.50, 51, 52
IMPLEMENTING A GENTLE CAESAREAN PROGRAM
The Gentle Caesarean is a way for the entire perioperative team to utilize a holistic
approach steeped in the evidence of the physiological and psychological benefits for the
mother and child. There is an absence of evidence that precludes Gentle C-Sections
from being the standard practice for surgical births. In fact, the most universal barrier
to adopting this patient-centered procedure is reluctance to change rather than
philosophical differences.
The main consideration for starting and implementing Gentle Caesareans at a healthcare
facility is having a cooperative and collaborative O.B. surgeon, nurses and surgical team
members26, 53 who assist the mother in experiencing the patient- and family-centered
elements of the Gentle Caesarean. The process begins with addressing clinical team and
stakeholder concerns (surgeons, nurses, technicians, patient/family representative) and
providing training for relevant clinical staff members to clarify the rationale and explain
the benefits.
In many cases, there is minimal change in clinical workflow or operating room
environment between traditional and Gentle Caesarean deliveries. According to
organizations that have implemented this type of Caesarean delivery the logistical and
training considerations shown in table 1 were necessary:12
14
Table 1.
Equipment
Considerations
Personnel
Considerations
 Workflow Considerations
 Mother’s birth plan reviewed
before surgery
 Placement of anesthesia
equipment and I.V. poles to
accommodate space for the
mother's support person and
clinical personnel during skin to
skin assessment
 Audio/visual device
for enhanced
environmental
accommodations
Prep Work
 Drape with clear
piece or viewing
window
Not applicable
 Materials checklist
and corresponding
materials requested
by the neonatal
provider
Newborn
Visibility
Cord Clamping /
Cutting
Umbilical Cord
 Relocation of blood pressure cuff,
O2 saturation monitor, and I.V.
catheters from the antecubital
fossa to a more convenient place
on the mother's non dominant
arm
 EKG leads placed on mother's
side or back, to leave her chest
free
 Drape with clear
piece or viewing
window
Not applicable
 2nd pair of sterile
scissors
 Nurse dressed
in sterile
manner, may be
part of the
pediatric team
 Raising and lowering opaque
drape or viewing window at
appropriate times
 Physician may leave cord extralong, clamping at umbilicus and
again 6-8 inches from the infant
 Sterile nurse carries infant and
2nd pair of scissors to partner so
as to imitate cord cutting
 Physician determines if infant is
suitable for skin to skin placement
Skin to Skin
Contact
 Blanket to cover
infant and mother
 Nurse dressed
in sterile
manner, may be
part of the
pediatric team
 Nurse moves infant from sterile
field to mother's/partner’s chest
and covers child with blanket
 Clinician will examine baby in
prone position
 Nurse moves infant across
mother's chest in a chest-to-chest
manner, allowing mother to use
free arm to cuddle and hold baby
Breastfeeding
Not applicable
Not applicable
 Nurse assists in placement of
baby's mouth to mother's breast
to allow for latch to occur and
remains nearby and attentive for
additional support.
Some hospitals may also choose to include additional staff such as a dedicated neonatal
nurse to be present for the entire birth. The neonatal nurse may require equipment or 9
supplies that the O.R. nurse and perioperative staff may not normally have available
during a standard Caesarean preparation. Creating and implementing a materials
checklist ensures that the operating room is properly equipped. A hospital may also
require both a doctor and nurse to remain in the O.R. until the mother and baby are
moved to a post-partum room to ensure that they are never left unattended should
one of the team members need to leave the O.R. for any reason.12 Variations in Gentle
15
Caesarean processes and clinical staffing are unique to each facility and will be heavily
influenced by individual budgets and available resources.
Another potential deviation from traditional practice may include the mother’s request for a
doula to be present during her Gentle Caesarean. Doulas are non-medical personnel with
whom the mother has an established relationship, who are trained to provide labor support
during the birth process and can communicate updates to the mother during surgery
while the surgeon, nurses and other members of the team concentrate on the surgical
procedure.12
An important factor to consider when transitioning to a Gentle Caesarean is that these
small adjustments can be incorporated with ease and without compromising medical care.
The elements of a Gentle C-Section are simply refinements to the previous standard
practice that will make more of a significant impact on how mothers, fathers, partners and
family members remember the birthing experience.19
PATIENT EDUCATION12, 19, 39
Gentle Caesareans are not replacements for
vaginal births and when a woman requires
a C-Section it is important to educate her
and her birth partner on the procedure,
aspects and risks of the surgery and tailor
that education to her comfort level. During
a consultation with the OB/GYN or surgical
care team member prior to the Caesarean,
the mother can be provided a birth plan
questionnaire that includes the aspects of a
Gentle C-Section. This will allow time to educate the mother about the Gentle Caesarean
concept, answer questions and ensure understanding and a high degree of comfort prior
to surgery. For example, some women may be uncomfortable with seeing any part of
the surgical procedure, but she or her partner may still desire skin-to-skin contact after
delivery. In other instances the mother may want to view the birth, but not engage in the
other elements of a Gentle C-Section. The birth plan questionnaire allows the mother and
spouse or partner to choose only the aspects of the Gentle C-Section with which they are
comfortable.
There may also be a few circumstances when the visibility of the baby during birth is not
recommended and they should be considered and discussed in depth with the mother and
family.
a. Surgical complications. In some instances, complications with surgery may make it
more appropriate to keep the opaque portion of the drape in place, especially if it is
a circumstance where it is challenging for the surgeon to explain what is going on
while trying to concentrate on the surgery.
b. Newborn health. The health of the baby may be a concern, so the mother may wish
to observe the delivery, but the baby may need attention from the pediatric team for
an extended period of time before initiating skin-to-skin bonding.
16
c. Heavy anesthesia. Under general anesthesia or additional sedation, the mother
may feel too groggy to safely to hold her newborn directly following the birth;
however, in this scenario the mother’s birth partner may be able to hold the
newborn immediately.
For some partners, cutting the cord is a wonderful way to participate in the birth. While
explaining the compelling evidence of the benefits of delayed cord clamping, the mother
should be given the opportunity to discuss her wishes for having her partner participate in
cutting the umbilical cord. The birth partner’s expectations should be set by making them
aware that the umbilical cord is thick and spongy, and the cut can be slightly messy and
is not made with a quick snip. Allowing time to discuss this in advance of the procedure
can prevent disappointment or confusion of the physician cutting the cord.
Gentle Caesareans are a win-win option in which families get the experience that they
expected without compromising medical care. Based on the information that the mother
is provided with regard to benefits, risks, and evidence-based short- and long-term value,
she can identify which elements of the experience are most important and resonate
with her. Gentle Caesareans can ensure that mothers will not miss out on watching their
babies emerge, cuddling with them chest-to-chest and soothing their first cries.54, 55
SUMMARY
During pregnancy many mothers dream about the moment when their baby is delivered
and they get to hold him or her for the first time. Any opportunity available for the surgeon
and nurse to make the childbirth experience more serene for mothers and their partners
should be considered. Unfortunately, the surgical nature of a traditional Caesarean can
distract from valuable elements of the birth. The prospect of more patient-centered, kind,
and gentle Caesarean care for parents and their babies is exciting.
Gentle Caesareans incorporate several elements that distinguish them from traditional
Caesarean deliveries. By making minor changes to a traditional Caesarean the mother
can witness her child being ushered into the world, experience skin-to-skin placement
and bonding with her baby in the O.R., and begin breastfeeding in the O.R. in a better,
more relaxed environment. Both mother and baby can also be spared the disruption
of the normal birth process with delayed cord clamping which promotes healthy
cardiopulmonary transition, prevents iron deficiency during a critical time of brain
development, provides a rich supply of stem cells and helps sick newborns achieve
better clinical outcomes.
Gentle C-Sections have been shown to improve breastfeeding rates, help mother and
baby bond quicker, improve the regulation of the baby’s temperature and heart rate and
reduce stress for both the mother and infant. This family-centered model also positively
influences the mother’s mood and improves her expectations about childbirth.
Advocating for Gentle Caesareans should not be confused with promoting elective
Caesarean births. Vaginal births are the safest method of delivery in general; however,
when surgical delivery is medically necessary, a Gentle Caesarean provides parents and
the baby with a positive birthing experience rather than a standard, impersonal surgery. It
17
is a way to use innovation to optimize the birth experience. Nurses play an integral role in
educating women in the prenatal and perinatal periods and can communicate the options
available to make a Caesarean birth more like the vaginal birth the mother may have
envisioned.
18
GLOSSARY
AnxiolyticA medication or other intervention that inhibits
anxiety.
APGAR Score Acronym for Appearance, Pulse, Grimace,
Activity, and Respiration. A measure obtained
by adding points for a newborn’s heart rate,
respiratory effort, muscle tone, response to
stimulation and skin coloration; a score of ten
represents the best possible condition.
Caesarean Section Delivery A surgical operation for delivering a child by
cutting through the wall of the mother’s abdomen.
Doula
A trained and experienced professional who
provides continuous physical, emotional and
informational support to the mother before, during
and just after birth.
General Anesthesia
The use of drugs that produce a sleep-like state
to prevent pain during surgery.
Hypothermia
The condition of having an abnormally or
dangerously low body temperature.
Intravenous Line
A short catheter (a few centimeters long) inserted
through the skin into a peripheral vein and allows
liquid medicines, fluids and nourishment to flow
into the body.
Maternal WarmingRaising the patient’s core temperature externally
by the use of warming blankets or other external
warming devices or internally through the
administration of warmed intravenous fluid and/or
irrigation fluid to prevent unintended hypothermia.
Normothermia The condition of having a normal body
temperature.
Postoperative (Post-op) During, relating to, or denoting the period
following a surgical operation.
Skin-to-skin Contact
Holding a newborn or baby chest to chest to help
him or her adjust to the outside world.
19
Umbilical CordA cord-like structure containing blood vessels that
connects the fetus to the placenta.
Uterus
A muscular organ located in the female pelvis
that contains and nourishes the developing fetus
during pregnancy.
Vigorousness (infant) Strong respiratory effort, good muscle tone, a
heart rate greater than 100 beats per minute and
no evidence that tracheal suctioning is necessary.
20
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Post-Test and Evaluation
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