1. Tillett, Jackie ND, CNM, FACNM
  2. Clinical Professor

Article Content

The proportion of births by cesarean delivery in the United States has risen steadily in the last 20 years.1 In some institutions, nearly a third of infants are born by cesarean delivery. Advantages of vaginal birth are many, and some of these advantages such as the "vaginal squeeze" and the exposure of the infant to the mother's vaginal flora cannot be duplicated in a cesarean delivery. However, the initiation of early skin-to-skin contact (SSC) of newborns with their mother has clear benefits for the mother and the infant and can commence in the operating room with some modifications of the procedure and with communication and teamwork. Other options available for a vaginal birth can also be offered to women needing a cesarean delivery, both planned and urgent, such as maintaining an ambient setting and family presence at the birth.


Various terms have been used for these adjustments of policy surrounding cesarean delivery, including "gentle cesarean," "natural cesarean," and "family-centered cesarean."2 The term "gentle cesarean" has been used in this column.


Institutions have developed and offer differing components of the gentle cesarean delivery. All protocols involve early or immediate SSC of the infant and the mother. Some protocols for gentle cesarean delivery may include lighting adaptations, music, better sight lines for the mother to see the infant, delayed cord clamping, and more liberal policies regarding family presence in the operating room, among others.3


Early literature from the United Kingdom described physiologic autoresuscitation of the newborn.4 This technique attempts to emulate as closely as possible the vaginal processes for lung clearance and first breaths and has been described as "walking the baby out."4 There is little in the American literature describing the use of this technique. This several minutes' delay in delivering the trunk of the infant may be a difficult maneuver for the obstetrical team to feel comfortable with during the operation.


Why is there a growing interest in gentle cesarean delivery at this time? The reasons are 2-fold. As the cesarean delivery rate rises in the United States, more attention is being paid not only to infant outcomes such as Apgar scores and neonatal intensive care unit admissions but also to the psychological aftermath for the mother following cesarean delivery. With a third of all births in the United States performed by cesarean delivery, the sheer number of women with this birth experience is huge. Mothers who have given birth by cesarean delivery have reported a sense of loss of the experience of giving birth, feelings of detachment from the infant, lack of involvement in decision making about the birth, and feeling a lack of support by the labor and delivery staff.5 These feelings may persist long after the birth. The gentle cesarean protocols give the woman more control over her experience and allow her the benefit of family support both for the scheduled cesarean delivery and the urgent cesarean delivery. Templates for birth plans for gentle cesarean can be found online, facilitating discussion between the pregnant woman, her family, and care provider before the birth.6


The second motivation for hospitals to explore gentle cesarean protocol shifts is the emphasis on early SSC and the beneficial effects of SSC on breast-feeding. Breast-feeding rates for individual hospitals are being examined in the quality assessments of hospitals. To receive the "baby-friendly" designation, a majority of infants and mothers must have SSC within an hour after the birth.7 Gouchon et al8 randomized women with planned cesarean delivery to an early SSC group or a routine cesarean care group. The average time for the infant to attach to the mother's breast was 22 +/- 8 minutes in the SSC group and 43 +/- 67 minutes in the control group. After implementing a gentle cesarean delivery protocol, Brady et al9 found that the rate of exclusive breast-feeding among women having experienced a gentle cesarean delivery was double that of women who experienced traditional cesarean delivery care.


Magee et al2 point out that while practices surrounding vaginal birth have changed quite a bit in the last 30 years, cesarean delivery practices have remained static. The major changes in cesarean delivery include the increased use of regional anesthesia and the dominance of the low transverse incision. Both of these practices are conducive to gentle cesarean delivery.


There are issues to be considered in the implementation of a gentle cesarean protocol. While the benefits of SSC for thermoregulation of the newborn following vaginal birth are well known, there is concern that infants born by cesarean delivery could suffer from hypothermia. The operating room is generally kept cooler than the birthing room for a vaginal birth. Gouchon et al8 compared infants given early SSC after cesarean delivery with infants given routine care after a cesarean delivery. The mean temperature of both groups was almost identical at 30 minutes of life and again at 120 minutes of life. Infection can be another concern because the infant is placed directly on the mother's skin. A large clinical trial in the Netherlands found no differences in maternal infections.9 Infants born by gentle cesarean delivery were less frequently admitted to the neonatal intensive care unit and treatment of neonatal infection was less frequent than for those infants born by conventional cesarean delivery.9


Challenges to developing and establishing a protocol for gentle cesarean delivery are described in the literature by some of the programs that piloted and implemented new policies. Concerns were voiced by all members of the team, including nursing, obstetrics, anesthesia, and pediatrics. Added staffing is needed for the gentle cesarean delivery because an infant nurse must be added to the team. Some changes were as simple as moving the intravenous poles back toward the head of the patient and repositioning the electrocardiographic leads. Routine practices such as securing the mother's arm to a board need to be changed to allow the mother to hold her infant. One program showed a surprising finding that there was little resistance from the anesthesia providers but that the lactation consultants had concerns about the space needed at the mother's head and the support of the mother and the infant during SSC.10 The left tilt used routinely during cesarean delivery needs to be adjusted after the birth of the infant.


Some institutions allow for all nonemergent cesarean deliveries to use the gentle cesarean delivery protocol, whereas other institutions limit the use of the protocol for scheduled uncomplicated repeat cesarean deliveries. Almost all institutions limit the use of the gentle cesarean delivery procedures to term "vertex fetuses," whereas at least 1 hospital in the literature extends the use of the protocols to those fetuses in breech presentation. Protocols and policies are developed to meet the needs and experiences of the patients and the staff. Some protocols call for the use of a clear drape at the head of the bed, some call for raising the head of the table to allow the mother to watch the birth, some policies call for immediate SSC, and some maternity care teams place the infant in the warmer for staff observation for 5 minutes after the birth. Those staff members who place the infant in SSC immediately described the challenges of assessing the infant while the infant is in a prone position.


There are several descriptions in the literature describing the journey of the labor and delivery unit to the practice of gentle cesarean delivery.2,4,9,11 All of these experiences stress the need for an interdisciplinary team to explore the challenges of change, the rituals surrounding cesarean delivery, and the need for champions, especially among the nursing staff.


As a caveat, there is concern that attempting to "normalize" cesarean delivery makes the surgery more attractive and acceptable to both women and obstetrical providers. There is an uneasiness in some of the literature and the responses to the literature that the cesarean delivery rate will continue to rise and that the trial of labor after cesarean rate may decrease with the implementation of a gentle cesarean delivery protocol. It should be noted and remembered that cesarean birth is still major surgery and that vaginal birth is usually the safest mode of delivery. Vaginal birth should be promoted, but meanwhile the provision of a gentle cesarean birth enables earlier bonding, increased breast-feeding starts and duration, and more patient satisfaction than traditional cesarean birth.


-Jackie Tillett, ND, CNM, FACNM


Clinical Professor


Department of Obstetrics and Gynecology


University of Wisconsin School of Medicine and Public Health


Madison, Wisconsin




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