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CE ONLINE Best Practices Regarding Gentle Caesarean Section An Online Continuing Education Activity Sponsored By Funding Provided By 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 and provide verification, if necessary, for 7 years. Requests for certificates must be submitted in writing by the learner. If you have any questions, please call: 720-748-6144. CONTACT INFORMATION: © 2016 All rights reserved 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 DISCLOSURE OF RELATIONSHIPS WITH COMMERCIAL ENTITIES FOR THOSE IN A POSITION TO CONTROL CONTENT FOR THIS ACTIVITY Pfiedler Enterprises has a policy in place for identifying and resolving conflicts of interest for individuals who control content for an educational activity. Information below is provided to the learner, so that a determination can be made if identified external interests or influences pose potential bias in content, recommendations or conclusions. The intent is full disclosure of those in a position to control content, with a goal of objectivity, balance and scientific rigor in the activity. For additional information regarding Pfiedler Enterprises’ disclosure process, visit our website at: http://www. pfiedlerenterprises.com/disclosure Disclosure includes relevant financial relationships with commercial interests related to the subject matter that may be presented in this continuing education activity. “Relevant financial relationships” are those in any amount, occurring within the past 12 months that create a conflict of interest. A commercial interest is any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients. 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 PRIVACY AND CONFIDENTIALITY POLICY Pfiedler Enterprises is committed to protecting your privacy and following industry best practices and regulations regarding continuing education. The information we collect is never shared for commercial purposes with any other organization. Our privacy and confidentiality policy is covered at our website, www.pfiedlerenterprises.com, and is effective on March 27, 2008. To directly access more information on our Privacy and Confidentiality Policy, type the following URL address into your browser: http://www.pfiedlerenterprises.com/privacy-policy In addition to this privacy statement, this Website is compliant with the guidelines for internet-based continuing education programs. The privacy policy of this website is strictly enforced. 5 CONTACT INFORMATION If site users have any questions or suggestions regarding our privacy policy, please contact us at: Phone: 720-748-6144 Email: [email protected] Postal Address: 2170 South Parker Road, Suite 125 Denver, CO 80231 Website URL: http://www.pfiedlerenterprises.com 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. 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