William Camann, MD Director, Obstetric Anesthesiology, Brigham and Women’s Hospital, Boston, Massachusetts
Robert L. Barbieri, MD Chair, Obstetrics and Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Boston, Massachusetts rbarbieri@frontlinemedcom.com
The authors report no financial relationships relevant to this article.
The clinical processes at cesarean delivery can be refocused to enhance early maternal–infant bonding and improve the mother’s experience of the surgery
Cesarean delivery is both a major surgical procedure and a momentous and miraculous event in the life of a family. Historically, the medical rituals and processes common to major surgical procedures have dominated the cesarean birth process. In most obstetric units, babies born by cesarean delivery are brought to a newborn resuscitation unit, examined, cleaned, banded, administered medications, weighed, and swaddled before being introduced to the mother. In cesarean deliveries early skin to skin (STS) contact and early initiation of breastfeeding are not common.1 In contrast, for vaginal delivery, many obstetric units have developed mother-, baby- and family-centered birth processes that emphasize immediate STS contact and the early initiation of breastfeeding.2,3
Research indicates that the traditional surgical rituals and processes of cesarean delivery prevent mothers from connecting to important physical and emotional aspects of the birth process.4 Practices that prevent early maternal-infant bonding and slow the initiation of breastfeeding may result in lower breastfeeding rates at 6 months of life and impact maternal behaviors.5,6
A new approach to cesarean delivery is the mother- and baby-centered cesarean delivery, also known as the “natural cesarean” delivery. In this approach, there is a reduced emphasis on traditional surgical rituals and an increased emphasis on facilitating the early interaction of the mother and family with their baby.7,8 The mother- and baby-centered cesarean celebrates the momentous birth event and encourages early mother–infant bonding.
Clinical processes that support a mother- and baby-centered approach to cesarean The mother- and baby-centered cesarean, with its focus on early STS contact and breastfeeding, is not recommended to be used routinely:
with preterm births
in emergency cesarean deliveries
in cases where the baby is at risk for a low Apgar score.
The mother- and baby-centered cesarean is an optimal approach:
when cesarean delivery is scheduled (such as in an uncomplicated repeat cesarean)
for a primary cesarean delivery following failure to progress in labor with a reassuring fetal heart-rate tracing.
Prepare with calming music and a video preview. Encourage the mother and family to select music to be played in the delivery room that they will find soothing.9,10 If the cesarean is a scheduled procedure, have the mother and her support partners view a video clip of a mother- and baby-centered cesarean delivery. A 12-minute video, “The Natural Caesarean: A Woman-Centred Technique” by the Jentle Childbirth Foundation is particularly well done.
Adjust anesthesia preparations to support STS contact and early breastfeeding. To accomplish this, free the mother’s dominant arm and chest for contact with the newborn by placing the oximeter, intravenous catheter, and the blood pressure cuff on the nondominant arm. Place the echocardiogram leads on the back or far laterally to facilitate early chest contact between mother and baby.
Recent evidence does not support maternal supplemental oxygen for routine uncomplicated cesarean delivery. Consider allowing the mother to breath room air without the bothersome mask.11,12
Use a gentle surgical technique that reduces the use of cutting, such as the Misgav Ladach cesarean technique.13,14
Offer the mother and her support partners the option to view the birth of their baby as active participants. If the mother desires to see the birth of her newborn, use clear drapes to permit the patient to view the birth of the head of the newborn (FIGURE), or drop the drapes prior to the birth of the head of the newborn.15 Raising the head of the table can facilitate the mother’s view of the birth of her baby.
Clear drapes facilitate the mother’s view of the birth during cesarean delivery. For mothers who have enlisted the support of a doula, consider welcoming the doula along with one other support person into the operating room for the birth.
Slow the delivery process. Gently deliver the head and leave the baby’s body in the uterus for a few moments. Some authorities believe that the contraction of the uterus around the body of the fetus, along with the initiation of breathing and crying will help clear the fetal respiratory system of fluid. Delay cord clamping to permit autotransfusion and improve neonatal iron stores.16
Plan for immediate STS contact. Immediately transfer the baby to the mother’s chest. Dropping the surgical drapes prior to delivery will help with this transfer. If the mother’s chest is not available or accessible for any reason, consider early STS contact with the father.17,18 Banding and vitamin K administration can be performed with the baby on the mother’s chest.
