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By Georgia Smith, Charlotte Harford, and Maggie Arlidge
Gloucestershire NHS Foundation Trust
Maternity services have been evolving over the last 20 years, leading to the provision of more patient-focused care. The Department of Health’s publication ‘Changing Childbirth’ was one of the first publications to recognise the need for maternity services to be woman-centred. This was followed by ‘First Class Delivery,’ which highlighted that women wanted more and better-quality information about services and options for their care.
In 2016, the National Maternity Review report confirmed there were increasing numbers of births in addition to increasing complexity of obstetric cases. There were, however, opportunities to make maternity care more personalised and family friendly. This led to the concept of “Better Births,” which is part of the NHS Five Year Forward View and highlights key priorities in improving maternity care. Personalisation of care is one of these priorities, with the underpinning principle that ‘every woman should develop a personalised care plan’. Community midwives caring for pregnant women in the UK, routinely discuss a birth plan for women who aim for vaginal births. However, personalising a birth for women undergoing a caesarean is something which is not routinely offered in the UK, contrary to NICE Guidance.
Usually, when a woman undergoes an elective caesarean, the theatre environment, operative technique and processes once the baby has been born remain the same for each woman, with no personalisation of the experience by the woman. This generic “conveyor-belt” approach can lead to many consequences, including an increased length of time before the first breastfeed in comparison to vaginal birth, with a reduced incidence of exclusive breastfeeding. In addition, birth by caesarean has shown to be an overall less satisfactory experience, culminating in lack of bonding and consequential higher rates of postnatal depression.
We propose an initiative designed to improve the birth experience for all women and their families undergoing a caesarean, without compromising the safety of the surgical procedure itself.
We initially carried out a preliminary survey of women’s wishes to provide further credibility to the vision of improving women’s birth experience at elective caesarean. We surveyed 20 women who were booked for an elective caesarean at Gloucester Royal Hospital, asking them whether, if such a service existed, they would like to be offered choice regarding certain aspects of their birth. Every woman responded that they wished that this service already existed, which inspired us to continue our endeavour.
We subsequently performed an evaluation of the current system in place for elective caesareans. We used a standard proforma to ask 20 women about their birth experience after electively undergoing a caesarean. Women were asked (1) “When you were booked for your elective caesarean, how much choice for the birth did you feel that you received?” and (2) “Were you made aware of any options available to you for your birth?” They were also invited to write any further comments about their experience. We found that no women were offered choice regarding their birth and no options were discussed with women for their birth. Comments included a desire for a more personalised approach to their care.
We implemented #mycaesarean in December 2020 at Gloucester Royal Hospital.
#mycaesarean is a bespoke service designed to provide women who are already booked for an elective caesarean the option to shape their birth experience. Upon booking their caesarean in antenatal clinic, they are provided with a leaflet regarding the service and a checklist. The checklist is designed to allow women to choose certain aspects to be included in their birth. They are offered low lighting around the theatre, LED candles throughout, their own music playlist via Bluetooth speaker, aromatherapy, lowering of the surgical drapes (either for the whole procedure or just the delivery), time allowed for the baby to be born, delayed clamping of the cord and immediate skin-to-skin. There is also space for the woman to document any other requests they may have with the option of discussing them on the day of their surgery with the operating team.
Regarding the technical aspects of birth, in 2008, Smith et al. proposed the art of natural caesarean, which includes the woman and birth partner being invited to watch the birth, engaging them in the delivery itself and mimicking the scenario of a vaginal birth. The surgical procedure is a “hands-off” approach, allowing time for the baby to spontaneously emerge where possible. As soon as the baby’s head has been born, the process of ‘fetal autoresuscitation’ occurs, whereby the uterine contraction stimulates the baby’s lungs. We fully endorse this approach and feel that this process is improved even further when the woman’s upper body is assisted upwards slightly, which subsequently increases the intra-abdominal pressure and often helps the spontaneous birth of the baby. We find that in this more upright position, the mother is able to witness the birth more easily and to be ready to receive her newborn baby with open arms. At the time of birth, our midwife is usually scrubbed in order to facilitate the transfer of the baby to the mother’s arms or chest, so as not to de-sterilise the surgeon.
Another way in which we preserve the surgical field is by using an additional 70 x 70cm surgical drape which is placed over the standard surgical drapes on the mum’s chest. After delayed cord clamping, the birth partner or mother herself are invited to cut the cord, and following this we peel back the original drapes, leaving behind the additional drape so that the sterility of the surgical field is maintained. The midwife present at the birth is then able to assist the baby to have immediate skin-to-skin, which is facilitated further by having the woman’s gown untied at the back, with lines and monitoring away from the maternal chest.
Subsequently, the caesarean continues in a standard surgical fashion, whilst the midwife can support skin-to-skin and help to initiate the first feed. If the couple wish, the baby can be weighed in theatre in full view of the mother and birth partner, with the weighing scales brought next to the operating table.
It was essential to provide thorough training for all staff involved with booking and performing caesareans due to there being many changes to normal procedures. This training was performed prior to the formal launch date and included run-through demonstrations with mannequins and a training video with live examples. In addition, we had some women who directly asked for a ‘natural caesarean’ and so during these patient-led cases, we were able to demonstrate the #mycaesarean approach to the team prior to the implementation date, leading to a gentle introduction for which we were all well prepared. #mycaesarean requires excellent team-work in order to succeed in making the woman’s birth experience as special as possible.
Importantly, all women and their families are counselled prior to the operation to explain that if a surgical complication occurs, it may be necessary to curtail the options put in place to ensure that the safety of both mother and baby is prioritised.
After implementing #mycaesarean, we surveyed 20 women about their experiences. Every woman felt that they had been given options for their birth experience and choice to personalise their birth. We were overwhelmed with the free-text comments received from our mothers and their families, thanking us for providing ‘an incredible experience which they will never forget.’
A woman who was undergoing her second caesarean explained the importance of immediate skin-to-skin contact with her newborn. Immediate skin-to-skin is in-keeping with the WHO/UNICEF Baby Friendly Health Initiative, with this early mother-newborn contact being critical in promoting successful bonding and the best chance of successful breastfeeding. This comment was particularly poignant as the woman compared her birth to her previous one, where her baby was taken to the resuscitaire, weighed out of sight, and then wrapped up immediately without direct contact even being offered, all as standard practice. She described her birth experience this time as ‘an absolute dream,’ all because she had been directly involved in shaping her care.
We were humbled to receive feedback from the theatre staff themselves, describing how special each individual birth was and how they now are able to feel part of the woman’s experience and make a difference to their care.
We are very proud that our novel #mycaesarean approach has now become the “new normal” at Gloucester Royal Hospital and we want to thank all of the obstetricians, midwives, anaesthetists and theatre staff for their ongoing support in this endeavour. We believe that #mycaesarean is an initiative which can be adopted by all maternity units the UK, as we propose, within the realms of safe practice, that the woman’s choice should be integral for all types of births.
Author Bio: Dr Georgia Smith
Georgia is a Senior Registrar in Obstetrics & Gynaecology, working at Gloucestershire NHS Foundation Trust. Georgia is a huge advocate for patient choice and improving the birth experience at caesarean section without compromising patient safety. Georgia leads on the development and teaching of the #mycaesarean pathway and was the main author of the article. Please direct any correspondence to firstname.lastname@example.org
Author Bio: Charlotte Harford
Charlotte is a Senior Midwife who works as a Delivery Suite Co-ordinator at Gloucester Royal Hospital. She is primarily the patient and birth partner’s advocate and will do her utmost for the patient to receive the best possible care from herself and her team. Charlotte has registered the #mycaesarean pathway as a Quality Improvement Project within our trust and has received incredible feedback for the project.
Author Bio: Dr Maggie Arlidge
Maggie is a Consultant Obstetrician with interests in Fetal Medicine and Perinatal Mental Health, working at Gloucestershire NHS Foundation Trust. She is passionate about empowering patients with choice and even incorporates this in her care of high-risk pregnant women. Maggie is the Consultant Supervisor of the #mycaesarean endeavour.
 Department of Health, London (1993), ‘Changing Childbirth. Part 1: Report of the Expert Maternity Group.’
 Drife J (1997), ‘Maternity services: The Audit Commission reports. Listen to women, especially after delivery,’ BMJ 314 (7084): 844.
 NHS England (2016), ‘National Maternity Review: Better Births: Improving outcomes of maternity services in England. A Five Year Forward View for maternity care’: https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf.
 NICE (National Institute for Health and Care Excellence) (2017), ‘Intrapartum care for healthy women and babies. NICE clinical guideline 190.’ London: NICE; 2014 (update 2017). Available at: www.nice.org.uk/guidance/cg190.
 Stevens J et al. (2014), ‘Immediate or early skin‐to‐skin contact after a caesarean section: A review of the literature,’ Maternal & child nutrition, 10(4): 456–73.
 Smith J et al. (2008), ‘The natural caesarean: A woman‐centred technique,’ BJOG: An International Journal of Obstetrics & Gynaecology 115(8): 1037–42.
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all.
The AIMS Journal spearheads discussions about change and development in the maternity services. From the beginning of 2018, the journal has been published online and is freely available to anyone with an interest in pregnancy and birth issues. Membership of AIMS continues to support and fund our ability to create the online journal, as well as supporting our other work, including campaigning and our Helpline. To contact the editors, please email: email@example.com
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