The Gentle Cesarean

The Gentle Cesarean is a cesarean birth where the baby is placed skin-to-skin with their mother immediately after birth.  This is something we have offered at my hospital since 2012.  We often get asked about it and there are a lot of places around the United States who still do not offer Gentle Cesareans.  I believe that this should be the standard of care for cesarean births for healthy mothers and healthy babies.    

Why is this important?  For starters, after a mother has gone through her whole pregnancy, the first thing she wants is to hold her baby.  Listening to mothers talk about their births, especially mothers who have had a cesarean, and if the baby was taken away from them to another room for "procedures", they often feel like they "missed something".  We had heard this for many years.  When we found out about the Gentle Cesarean, we wanted to offer it at our hospital for this reason.  

So, how do you do it?   We were pretty great at getting babies skin-to-skin with their mothers after vaginal deliveries.  We found out about the Gentle Cesareans from Memorial Hospital of Rhode Island and at the time, I had a pretty amazing OB Department Chair, Dr. George Kovacevic.  I shared the information with Dr. George and it was all he needed to hear and we were on our way.  We tried it out with our first mother who was a nurse and she knew she was going to be the first one.  We did pretty good with her Gentle Cesarean but we needed to practice some more!  So that is what we did.  Our staff took turns going back to the OB Operating Room and actually one would pretend to be the patient, the other would pretend to be the baby nurse and another would pretend to be the circulating nurse.  We looked at where we could place the drapes, how we could lower them down beneath the level of the breasts so that we could have room for placing the baby skin-to-skin.   We practiced where to put the leads for the cardiac monitor so we knew exactly where to place them to get a good heart reading and also have them out of the way of the baby.  We practiced where to put the baby and how to place the baby for mom's comfort and for baby's safety.  We practiced placing a mirror near the warmer so that if the baby needed to go to the warmer, the mother would still be able to see her baby while she was having her surgery.  Lots of practice makes perfect!

We kept reading everything we could about Gentle Cesareans and we found a hospital in Boston had started using clear drapes!  So, we found out where to get them and we started offering them to our patients.

We had it perfect!  Mothers were happy and babies were thriving in our Operating Room!  Babies even started to self-attach to the breast in the Operating Room!  This is just amazing to watch!

A lot of people have asked me for a policy of how we do it, but we have chosen not to have a policy for a mother to hold her own baby.  I have however, made a Basic Steps for a Gentle Cesarean Birth.   In addition, I have included a link to our famous mother of triplets who had the first Gentle Cesarean of Triplets in the United States.  

Basic Steps for a Gentle Cesarean

Scheduled Cases/Non-Urgent Cases

·       Explain Skin-to-Skin procedure to all mothers on admission.  This is routine care for all deliveries.

·       Determine mother’s preferences

o   Does she want a clear drape?

o   Does she want pictures?

o   Who will be her support person?

In the OR

·       Inform the anesthesiologist that the mother would like a gentle cesarean

·       Leads to be placed to the sides

·       Drape to be placed under the breast level (IV poles work great with clips)

·       Arms are to be left free, not tied down

·       Gown is to be unsnapped and loosened to receive infant

Preparing for the Baby

·       A mirror positioned by the warmer angled down on the warming bed so that the mother can see the baby in case the infant has to be taken to the warmer.  Check with mother to make sure she can see the warmer

·       Have warmed bath blanket ready

·       Have sterile warmed baby blankets ready to receive the baby from the obstetrician

·       Prepare safety equipment in warmer, suction, oxygen, etc. as usual

·       Inform the Respiratory Therapist that the mother would like a Gentle Cesarean

Receive the Vigorous Baby

·       Nurse receiving baby is in sterile gown and gloves

·       Baby is received into a warmed, sterile baby blanket

·       Is the baby crying and vigorous?   YES?   Continue on with steps below

·       Dry the baby as much as possible with warmed baby blanket

·       Place the baby Skin-to-Skin with mother

·       Remove wet, baby blanket

·       Cover baby and mother with a warmed bath blanket

·       Observe baby.  Often secretions will drain easily with prone positioning of the baby on the mother’s chest 

·       Observe the mother

·       Assist mother and partner with positioning of the baby as needed as the surgery is completed

·       Take photographs for the family as requested

·       Baby may self-attach to the nipple.  Support breastfeeding as needed

Receiving the Baby Who Needs a Bit of Help/Not Sure

·       Baby is received by the nurse and is taken to the warmer

·       Baby is dried and stimulated

·       Is the baby crying and vigorous?  YES?  Begin Skin-to-Skin.  Continue with steps for receiving Vigorous Baby

·       NO?   Continue with observation and treatment until baby is stable

     Surgery is completed

·       Baby is given to support person until mother is transferred from the delivery table to bed/stretcher

·       Mother and Baby go to the PACU together to continue with recovery process All newborn procedures and vitals are possible to do on the mother’s chest

·       Measurements can wait until after first feed.  

·       Bath should be delayed (Wait for Eight!) Document Skin-to-Skin in Medical Record Document first feed in Medical Record

Video of the Triplet Mom who was first in the United States to have a Gentle Cesarean

http://youtu.be/nwP_JXfbKm0

As you can see, our team has worked hard to skillfully perfect the process and it is now routine care for every cesarean birth for healthy mothers and healthy babies.  It has made the world of difference for families receiving care in our facility.   This can be done for cesarean births for healthy mothers and babies.  I feel it should become the standard of care for all cesarean births around the United States.

Don't Be Afraid

In the last 10 years or so of my nursing career, people have asked me to come and speak in front of groups.  A lot of my speaking engagements come from various AWHONN friends.  I think one of the best ones I have ever been asked to do was one by the Massachusetts AWHONN section to speak on Family Centered Maternity Care.  The best part of this one was that it was going to be held at my old school of nursing, Lawrence Memorial Hospital School of Nursing (now Regis College).    What was cool about this is that I was able to bring my mother and my sister with me to hear me talk.   I remember that I was nervous about speaking.  This is where my nursing career began.  My mother would be watching.   I kept looking over my shoulder as I spoke and was waiting to hear the voice of one of my original nursing instructors saying "Wait a minute, you shouldn't be up there speaking!"  But, I was there, I spoke and it was fun!  What my mother said to me after I finished was, "Wow, how can you do that?  Aren't you afraid to get up in front of all those people?"  I knew however, that she was very proud of me that day!

Since then I have had a few more speaking engagements, at AWHONN National Convention, at AWHONN Section Conferences and at local AWHONN Chapter Meetings, where I get to speak about my team and the wonderful work they do!  I think a lot of times about what my mother said to me that day and I realize that nurses should never be afraid to speak up and tell the stories of the great work that their teams do every day.  We should always share our stories with others.  It is important to share the good things happening on your units.   Never pass up the chance to speak and tell others what you do.   

Tonight I just finished speaking to another AWHONN Chapter on the east coast of Florida.  I shared the speaking duties with another colleague from my facility.  People come up and thank you for telling your story.  In the end, sharing stories helps others make changes in their practice and it helps mothers and newborns even further than your reach.   

So, don't be afraid.  Speak Up!  Tell your story.  Tell about the good things happening in your team!  It is through sharing that we all become great and the care for all mothers and newborns improves!

Using Nitrous Oxide for Labor

A little over a year ago, we began using Nitrous Oxide on our unit for analgesia for laboring women.  I had heard about Nitrous while at an AWHONN meeting several years earlier.  At that time, I brought information back and discussed it with our head of Anesthesia who said it really wasn't a great idea and so I let it drop.   In the spring of 2015 one of our obstetricians became interested in using Nitrous for his laboring patients and we decided to form a task force of all of the Ob Directors in our System, our OB Educators, Anesthesia, and OB Physician champions.  We pride ourselves on being cutting edge with offering new things and a free-standing birthing center in our area was already offering Nitrous.  We had had some requests for Nitrous on our social media page.  In our discussion we wanted to be able to provide an alternative analgesia for patients who wanted it and to also use it as a bridge for patients before they receive an epidural.  

Our Perinatal Practice Nurse investigated the evidence for us.   We found the following:

›Minimal Risk- No Complications

›Maternal

›No impact on cardio-respiratory functioning

›No impact on labor progress or post partum bleeding

›Minimal/possible side effects: nausea, vomiting, drowsiness

›Fetus

›No change in FHTs

›No impact on Agpar Scores or resuscitation

›No impact on cord pH

›No known effects on breastfeeding

›Efficacy

›Pain relief- satisfactory

›Anxiety- favorable

›Satisfaction- favorable

The next steps were to discuss scope of service and ownership of the Nitrous program.  For us, we decided to make this a provider order with our physicians and midwives.  The financial decisions had to be made as to what equipment we would purchase and how we would pay for it.  Because we do not have Nitrous in our medical gases in the L&D rooms we went with the portable Nitrous units.  In addition, we had to decide how we were going to charge for the Nitrous and how we would be reimbursed for it.  For us, we decided to just charge for the disposable circuits.  We had to develop a policy and we decided to reach out to other organizations who were using Nitrous.  They were very helpful for us with our own policy development.  We had to consider how we would maintain safety and security of the Nitrous and we worked that into our policy.  We decided to utilize a written consent for use of the Nitrous.  Our consent also included a screening checklist.

There are some contraindications to using Nitrous and they are listed below:

  ›    Cannot hold their own face mask/ mouth piece
›Impairment of consciousness, or intoxicated with drugs and/or alcohol
›Documented vitamin B12 deficiency and are receiving vitamin B 12 supplementation
›Have impaired oxygenation (O2 sat consistently less than 95% on Room Air)
›Previous adverse reaction to nitrous oxide
›Category III fetal heart rate tracing
›IV opioids within the last 2 hours
›Received Methadone, Subutex, or Suboxone in the last 5 days
›Hemodynamic instability as defined by a Systolic Blood Pressure < 100.
›Decreased cobalamin function (e.g. Crohn’s disease, Celiac disease, gluten intolerance, pernicious anemia, strict vegan diet).
›Pneumothorax, bowel obstruction, increased intra-ocular pressure or recent eye/ear surgery in previous 3 months. 

Before implementation we had to consider the safety of our pregnant staff members and allowed them to opt out of caring for women using Nitrous.  We had to prepare brochures that could be used in our childbirth education classes and birth center tours.  We worked with our Marketing Department to get some press on the start up.  We made some adaptations to our Electronic Health Record so we would be ready to document the Nitrous use.   We were almost ready to start!  

Training of the team came next!  The training was multimodal.  We used a knowledge-based training that was completed by staff on-line first.  The company we purchased the Nitrous machines came in and went over the equipment with the staff and finally, the staff signed an attestation that they would use the equipment safely according to the policy.  AND WE WERE OFF!!  Ready to go!

The feedback from the patients the first year have been good.  We have had an occasional disappointment with Nitrous, "I didn't like how it made me feel".  It has offered us an additional option for pain management during labor and immediately after delivery (i.e. for repairs).  It has been an effective bridge for some women prior to them receiving their epidural.  Other women have used Nitrous throughout their labors successfully.  We feel like it has decreased our use of IV pain medication.  We have noted that if the Nitrous is brought into the woman and explained to her prior to labor being very advanced that it works better.  It does seem to have a direct impact on reducing the patient's anxiety.

So after one year, what is my advice to others considering this for their own Obstetrical Units?  Just do it!  Nitrous has been a win-win for us.  It is low cost.  It is a patient satisfier.  It is patient centered, safe and effective.  

We would be willing to share our Policy and Procedure as well as our Patient Information Sheet and Consent if you contact me.

Breastfeeding, Baby Friendly and Other Fun Stuff

Our hospital is on the journey to Baby-Friendly.  We have been on the journey for the last 4 or so years.  Actually, we have probably been on this journey for longer than that because when I first joined this team as their director, I had a pediatrician who was very excited about  becoming a Baby Friendly Hospital.  We have worked steadily along the way making improvements for mothers and babies.  Our hospital is unique. In fact, it opened it's obstetrical services in the late 80's and was set up as a LDRP unit without a well baby nursery!  Babies and mothers have always roomed-in together!  Pediatricians have always examined babies in the rooms with their mothers.   Unique.  They do not know how unique they are!  Nurses took care of both mothers and babies AND labored mothers too!  All right from the start!

When I first arrived my job was to assist the staff in getting to a place where we were all trained to recover mothers and babies together after cesarean sections.  We had a PACU (Recovery Room) but it was mostly used for a classroom.  Mothers went to the main Recovery Room after cesareans and babies went back to the LDRP room with their dads.  We had the pediatrician who was passionate about Baby Friendly come talk to the staff about how important it was to keep mothers and babies together after cesareans and it was all the staff need to hear.  We were all trained and began to recover moms and babies together.  A few years after that, we did a pilot study called NIMS  (Nursing Intervention to Minimize Maternal and Infant Separation).  We keep mothers and infants visually no more than 10 feet apart after cesareans and we thought we were being progressive because we did cheek to cheek with mothers and babies in the Operating Room and then did skin to skin care in the Recovery Room.  That study was published in JOGNN and we did have some great outcomes!  From there, we learned about the Gentle Cesarean program at Memorial Hospital of Rhode Island and we implemented that at our hospital.  Babies went skin to skin with their mothers in the Operating Room and began to nurse on the Operating Room table very often!  We became known for it in the community!  A good problem to have!  We even were the first hospital in the United States to put triplets skin to skin in the Operating Room and all three of them got a chance to nurse in the OR too!

The Florida Breastfeeding Coalition started their Florida Quest for Quality Maternity Care Award several years ago.  We decided to apply for this award and became the first hospital in the state to achieve the one star award, and then the first in the state to achieve the two star award, and then the first in the state to achieve the three star award and then the first in the state to achieve the four star award.  The fifth star comes when your hospital achieves Baby-Friendly Hospital designation.  (We don't have that one yet, but we will!) Along this pathway, we developed our infant feeding policy, we banned the bags, delayed bathing for newborns, implemented the Golden Hour, Quiet Time, and we continued to work on breastfeeding.  We decided to get all of our nursing staff certified as Breastfeeding Counselors to be able to have a breastfeeding expert at the mother's bedside 24 hours a day, 7 days a week.  This is in addition to our IBCLC who work with our patients.

Last year, we learned about a program called the EMPower Breastfeeding program.  EMPower Breastfeeding: Enhancing Maternity Practices (EMPower) is a hospital-based quality improvement initiative focusing on maternity practices leading to Baby-Friendly designation based on the Ten Steps to Successful Breastfeeding, as defined by the World Health Organization (WHO) and UNICEF. The initiative is funded by the Centers for Disease Control and Prevention’s (CDC) Division of Nutrition, Physical Activity, and Obesity (DNPAO) and is implemented in partnership with the Carolina Global Breastfeeding Institute (CGBI) and Population Health Improvement Partners (PHIP).  We applied to the program and were accepted as one of the 90+ hospitals.  This program allowed us to enter the Baby Friendly USA's 4-D Pathway!  We were so excited!!    So, we continue to learn, grow, change!   It has been great working with the team from EMPower Breastfeeding with our coaches.  We continued on the journey, becoming a Breast Milk Depot for the Mother's Milk Bank of Florida.  We stopped providing pacifiers.  We got rid of all formula company marketing materials.  We talked about safe infant feeding practices to parents.  We started a breastfeeding support group for mothers, partnered with our local WIC office and had peer counselors at our hospital.  We even partnered with our La Leche League group and offered our facility to them to hold meetings!  We also opened a Baby Weigh Station for parents to bring their babies back when ever they wanted to check their baby's weight!

It is hard work but it is the right thing to do for healthy mothers and healthy babies!  It is after all, supporting an Optimal Healing Environment, right from the start of life!

#AWHONN 2016:  Day 4

The convention is coming to an end today.  What a great convention it has been!  

The first session I attended today was Improving Interprofessional Collaboration:  Best Practice Guidelines for Transfer from Planned Home Birth to Hospital Care.  This was a great session.   It highlighted the importance of collaboration between the home birth midwives and the hospital providers.  The speakers talked about development of a policy that is made in collaboration with all parties involved.  The speakers shared an important website that may be helpful for facilities developing a policy or interested in setting up a formal collaborative practice.  Here is a link to the website:  http://www.homebirthsummit.org/best-practice-transfer-guidelines/   There was also discussion about how out of hospital birth parents should let their local EMS know that they are planning a home birth and their actual due dates, etc. so they can be prepared in case of emergency. I really liked that they had a "birth plan" that would include all of the emergency activities to include where the parents would want to be transferred to in case it was needed.  Win Win for all parties involved.

The next session I attended was Oral Presentations on Postpartum Topics.  The first part of this was about Postpartum Education:  Are We Meeting Mothers' Needs and Expectations.   It seems like everyone is having the same issues, there is so much to teach new mothers about their newborns and so little time to do it.   New mothers want their visitors, their babies, and their sleep!   Hard to get it all done with all those priorities.  There was discussion on group classes vs individual teaching and it seems like most are doing individual teaching.  The last half of the session was spent on discussing Indicators for Postpartum Depression Risk.  There was discussion about the movie "Dark Side of the Full Moon" that we had seen on Day 3 as well as tools that could be used for evaluation of depression risk.  My take on this is that I am going to be more aware of mothers who have a previous history of depression and to listen more carefully to mothers postpartum.  We also have to look for resources in our community and make sure we have them in our bag of tricks to help new mothers.

The LAST session was The Power of Resilience:  Game On!  I got a whole lot out of this session.  I want to share some of the slides that spoke to me in this talk!

It was then time to do look at all the fun we will have next year in New Orleans!!  

And hug friends until next time!

#AWHONN2016  Day 3

The day started out with a great panel discussion about Nurses Leading Change and Improving Outcomes.  All nurses lead change efforts and are responsible for improving outcomes in their practice.  We can not stay stagnant in our practice as things are changing every day as new evidence comes into play, we must be the ones to help implement this evidence into our daily practice!

The next session I attended was about Second Stage Labor Management and Promoting the Safety of the Mother and the Fetus.  Great information about what to look for in the second stage with the mother as she is pushing to assist her to birthing her baby and what to look for on the Electronic Fetal Monitor during this important time.

Rocky Mountain High:  Weeding through the Issues of Marijuana Legalization was a great session by colleagues from Colorado.  They gave us many insights into what the birthing hospitals are dealing with in regards to mothers who use marijuana (legal to do so) and the birth of their babies (who may now be positive for marijuana upon their birth).  Are they reported to Child Protective Services?  How are they dealt with?  Important ethical issues to know about.

I had seen my friends Catherine Ruhl (New Mexico) and Paris Maloof-Bury (California) earlier in the day.  We had been talking about the importance of labor support and discussing how we wished there was a way to show nurses how important they are to mothers in providing labor support.  This is a big deal as it also could potentially decrease the need for a cesarean birth.  We know it is important to help women have an empowered birth.  We decided to meet up after lunch and discuss the possibility of submitting a proposal to speak at the AWHONN Convention in 2017. You see, when you go to the AWHONN Convention, you are so inspired to do more.  So the three of us sat and brainstormed ideas!!  So many stopped by the table and cheered us on as we were brainstorming!  Dodi Gauthier, Cathy Ivory, Clinton Kenon, Robyn D'Oria, Mimi Pomperleau and others!  In the end, we had the draft of what we will send into AWHONN for a possible session in New Orleans!  We will work together over the next few months on this submission!

My next session was Implementation of the 4 Ps (Patience and Positioning for Physiologic Progress) for safe Second Stage Labor Care.  Another excellent session!   What I took away from this one is that we should reconsider the use of the indwelling Foley catheter for all patients laboring with an epidural.  That is something I am definitely going to bring back to my team.  Decreasing CAUTI (Catheter Associated Urinary Tract Infections) is a big deal for hospitals, and this is one reason to do this, but also the fact that it can actually interfere with second stage.  Patience.... Knowing the importance of it and when to give the woman time to birth her baby.  

There was a movie time for the last session.  Dark Side of the Full Moon was the movie. This movie was excellent. It highlights the issue of postpartum depressive disorders. I want to get my hands on the DVD so I can share it with our team.  It was powerful!  http://www.darksideofthefullmoon.com/the-film-1/

#AWHONN2016

 Day 2

I went to a terrific talk about using Glucose Gel for neonates with Hypoglycemia today.  Why is this important?  It can prevent babies having to go to the Special Care Nursery/Neonatal Intensive Care Nursery to get IVs!  It can help a mother to keep her baby in her room and continue to successfully breastfeed without her baby having artificial milk/nipples.  Breastfeeding is a very important thing to me and keeping mothers with their babies is my goal!  This one will definitely be coming back to my hospital with me.

Another session I went to was about how breastfeeding impacts mothers and nurses during the night shift.  I got some interesting ideas in this session too!  Resting during the day can impact the night time breastfeeding success especially on the second night...What one hospital did was change the name from Quiet Time to Family Bonding Time.  As always skin to skin was brought up as very important for baby and mothers.

I went to a session on Infant Metabolic Screens and learned from people at State Laboratories how they are improving the turn around time from collection sample through delivery at the state lab to getting the results out to parents to babies getting into treatment.  HUGE impact on babies lives.

So, this is what I learned on day two!  BUT, there was also fun!   President's Party was a lot of dancing fun!!

BUT the coolest thing was being able to see a photograph from MY HOSPITAL on the cover of an AWHONN publication!  Here is a picture of me with my friend Shirley Piccard from Rhode Island.  I chose this picture because you see, it was Shirley who sent me a copy of a video from her facility and it started the whole Gentle Cesarean movement at Cape Coral which made it possible for us to put the triplets skin to skin in the Operating Room!  I am so proud of my team!  Thank you Shirley and Memorial Hospital of Rhode Island for sharing with us!  

To My Team:  I also found some really cool drapes that I am bringing home to my team to look at and we may be able to make Skin to Skin in the OR even better for our mothers and families!