Today NYC obstetricians Drs. Worth & Mussalli chat with Lisa to discuss all the ins and outs of gentle cesarean as well as the different medical indications for a c-section. They also compare and contrast planned cesareans to emergency cesareans to non-emergent cesareans. You’ll also hear them detail a new collaborative care model pathway in which pregnant folks in NYC can get prenatal care with them and then transfer their care for the big day to midwives at a local hospital. Grab a pen/device and take some notes to develop your belly birth plan, whether it’s being planned or just in case!
Resources:
The New Rule of Pregnancy by Dr. Jaqueline Worth et al*
Benefits of a Gentle Cesarean:
Improved newborn respiratory transition
Improved newborn thermoregulation
Better maternal-infant bonding
Improved successful breastfeeding
Less newborn crying with skin-to-skin
Increased newborn blood glucose levels
Stable newborn vitals: HR, RR, Temp
Emotionally better experience for mother, partner, and staff
Less maternal anxiety
Less postpartum blues
Elements of Gentle Cesarean (all optional; discuss with your care provider):
IV placed in non-dominant arm allowing the arm to bend without interrupting IV flow
Remove clothing from chest to allow immediate skin to skin
EKG electrode placed laterally or on back
Operating room temp set at 22 degrees celsius (instead of 18)
Doula present during epidural/spinal placement
Music selected by parent (if desired)
Pulse oximeter placed on ear lob or toe if desired (instead of finger) - anesthesiologist dependent
Light dimmed during delivery of head to reduce stress levels
Sounds are hushed - non nonessential conversation during the birth
Clear drape to observe delivery of head
Allow time for lung fluid to drain out of mouth and nostrils
Infant evaluated on maternal chest and immediate skin-to-skin bonding if resuscitation isn’t needed
Allow announcement of sex by a parent if desired
Partner cuts cord or performs second cut
Avoid exteriorizing the uterus
All newborn tests and procedures done on maternal chest; footprints, vitamin K injection, eye ointment
Sponsor links:
Free “Pack for Your Best Birth” Packing List (with free mini-course option)
East River Doula Collective (find a doula, attend our free “Meet the Doulas” event)
Birth Matters NYC Childbirth Education Classes (Astoria, Queens and virtual)
*Disclosure: Links on this page to products are affiliate links; I will receive a small commission on any products you purchase at no additional cost to you.
Episode Topics:
Introduction of the podcast and guests
Credentials and background of Drs. Worth and Mussalli
Importance of choosing the right care provider and their philosophy on birth
Discussion on gentle cesarean (belly birth) and its benefits
Reasons for cesarean sections – planned and emergency
Techniques and practices involved in gentle cesarean
VBAC (Vaginal Birth After Cesarean) and its considerations
Pathways and collaborative care options provided by Village Obstetrics
Historical and practical insights into cesarean delivery practices
Importance of birth planning and communication with healthcare providers
Importance of patient satisfaction and feedback in healthcare
Role of hospitals and individual providers in promoting gentle cesarean practices
Recommendations for improving the cesarean birth experience
Benefits of gentle cesarean on postoperative outcomes and overall maternal wellbeing
Interview Transcript
Lisa: Welcome to the Birth Matters Podcast. Today, I am thrilled to welcome two of the most respected obstetricians in the whole New York City area. Their names are Dr. Jacqueline Worth and Dr. George Mussalli and the name of their practice is Village Obstetrics. They are known for their respectful, patient centered, evidence based, low intervention care.
I don't know if that's how you would describe it. That's how I would describe it. They've always been so generous with their time to the New York birth worker community, as well as their patients. And for the birth worker community, they've regularly hosted gatherings and workshops at their office, which has been so wonderful to have some face time with OBs and to develop rapport.
And I also want to mention that Dr. Worth co-wrote a book, called The New Rules of Pregnancy: what to eat, do, think about, and let go of while your body is making a baby. And I really enjoyed reading that book when it came out. I wanted to have Drs. Worth and Mussalli on the show, both to more generally spread the good word about the great work that they do with folks planning and hoping for a physiologic birth, but also because they're expert at something called gentle cesarean techniques.
I thought it could be really helpful to have an episode on this podcast explaining straight from two respected doctors all about this great option for a scenario in which someone's going to have a cesarean, or might have a cesarean. This should help expectant parent listeners in case you want to ask more specific questions with your provider and express any preferences you might have for gentle cesarean techniques in the event that a cesarean is needed.
It's worth mentioning too, I just want to mention this real quick before I invite you to introduce yourselves more Drs Worth. and mussalli that you hold, I've shared this with you privately, but I want to share it more publicly. You hold a special place in my heart because you were the OBs for my very first doula client way back in 2010.
And it was at the now closed St. Vincent's Hospital, which actually closed shortly after I attended that birth. And your website says, working with you is joyful and unhurried. And that's exactly the vibe I got back in 2010 and have gotten from you ever since. Thank you for that. And just sending you a warm welcome to the show.
Welcome, would you please introduce yourselves, Dr. Worth and Mussalli after my very long casual introduction?
Introductions
Dr. Worth: Oh gosh. Thank you so much. It was a great honor to share that birth with you in 2010. And I remember St. Vincent's as the Garden of Eden of birth for us. It was a place where we started in a place that I think back to so joyfully. I'm Jacqueline Worth, I'm 1 of the 2 founders of Village Obstetrics. I'm a native New Yorker and a lifetime obstetrician and I trained here in New York and have always practiced here in New York and have a special love for the complexities of our city and the joy of our inhabitants.
And all the things that we want from our environment and from each other. And so I welcome you here to this talk about gentle C section, which we'll go on to define in more detail, but, I'll just say that it's my opinion that it's the way every C section should be. And I'm working to eliminate barriers so that, as long as there's not an urgent safety issue, every C section can be like this.
So thank you so much. Dr. Mussalli?
Dr. Mussalli: Thank you for having us. We love the work that we do. And so to talk about any of the different aspects is truly our joy. I'm Dr. George Mussalli, I have the privilege of sharing Village Obstetrics with the smartest doctor I know, Jacqueline Worth.
And it really is true. Together we have a really joyful practice and we love doing the work that we do. We only do obstetrics and so we get really experienced at this much smaller area. And I guess today we're talking about the surgical part. Which is, regardless of what's happening, always a possibility.
And so we were first learned about gentle cesarean actually from one of our patients. And I'm really proud that we are always listening. And I think some of the most important things that we have learned have been insights that have come to us from patients and their various experiences along the way.
And gentle cesarean is what we incorporated into our care, and, looking forward to discussing more of that together.
Pathway Options and Collaborative Care
Lisa: Thank you so much. And I'm hoping at the end of our discussion about gentle cesarean, we can also talk about a pathway for folks who are interested in working with you prenatally.
Before I mention this pathway, I just want to mention, clarify for me, correct me if I'm wrong, your practice, if someone wants to work with you for their whole pregnancy and you're delivering their baby, you're out of network currently, correct?
Dr. Worth: Because we're so small, yeah, we're out of network and we deliver exclusively at Mount Sinai Hospital on 98th and 5th.
Lisa: Great. Thank you.
Dr. Worth: For the practice with the two of us. Yes.
Lisa: Yeah. And that allows you to give that joyful unrushed care, because if you were in network, it would be very different, right?
Dr. Worth: It ends up being a little more hectic. Yeah, for sure.
Lisa: Yeah. Yeah, so this pathway you have come up with, I just really appreciate because it it's a model of care that is allowing maybe a little more accessibility, if I understand it correctly, to work with you prenatally and then to transfer the care on the big day to some wonderful midwives at a different hospital, at Metropolitan Hospital, correct?
Dr. Worth: That's exactly right. We created a collaborative practice where, Dr. Mussalli and I exclusively do the prenatal care, and then for delivery, the patients would transfer into Metropolitan Hospital and be cared for either by the wonderful team of midwives there, or if needed,or requested, by the wonderful physicians there.
So it's equally joyful, but collaborative practice that is still out of network because we're so small, the plans don't want us, but not expensive. And so that's what, sliding scale rates for patients, depending on their income, essentially.
Dr. Mussalli: And I would say that the Metropolitan team, the midwives and doctors have been working collaboratively for years.
And so what's really helpful is,when you start a pregnancy, everything might be uncomplicated; however, in an exclusively midwife practice, sometimes things come along and complications occur and somebody might risk out of a practice. And so I think that's one of the nice things that happens in our pathway is that, regardless of the complication, they remain, they belong, and they continue their delivery in a collaborative model of Metropolitan.
Lisa: Yeah. And now that I think of it, I'm really glad we're talking about the pathway at the front end of the episode, because some people might not be interested in learning about Cesarean stuff. And so it's probably a good idea for us to talk about this now. So that worked out well. And I want to add that just this past weekend in a birth class, a new client came in and we were all with eight couples talking about their care and their care provider and how comfortable are they with their care. And this one expectant mom pronounced to her class, she said, I'm so excited because I switched from my OB where I felt like a number, which was not you all, of course, to the midwives at Metropolitan. And she's like, it was like night and day. They gave me like four hours at my first appointment. Not everybody would want four hours, but she wanted four hours.
She felt so nurtured and so cared about. And she was like, this is what I needed. And that's what she deserves. People deserve to feel nurtured in this time in life. And so that just made my heart sing because it really drove home the power of finding a care provider that you feel so safe with and so respected by.
It's a collaboration. I love that word of the collaborative care. Yeah. So anything else you want to share about that pathway before we head on into Gentle Cesarean.
Dr. Worth: Sure. Anyone interested in that, either working with us towards Metropolitan or working with us at Sinai, just email me.
You can put in the email me or call the office and I'll call you right back.
Lisa: Yes. And I will absolutely link to your contact information, your website, in the show notes for today's episode.
Dr. Worth: Yeah. Thank you so much. Yeah.
Lisa: Great. Please check it out, listeners, if you are in New York and you are seeking really great care. All right.
Let's talk about gentle cesarean. I've already touched on, you're known in New York as a practice that has some of the lowest intervention rates, including C sections and the most satisfied clients on the other side of birth. Thank you for that again. That said, sometimes a surgical birth, what I like to call a belly birth, but also known as a cesarean or a C section is needed.
Reasons a C-Section Might be Deemed Necessary
Can you please go over some of the reasons that a C section might be necessary? Maybe some of the clear cut reasons and then maybe some of the less clearly indicated, just however, you want to take that question.
Dr. Worth: Absolutely. You know, there are not so many reasons for C section.
And so if you divide it into 2 categories to start with, there are the cesareans that are scheduled ahead of time, because of something going on with either the mother or the baby. And I can list those out in a second. And then there are the cesareans that happen when somebody's in labor.
And so to go first to the ones that happen when someone's in labor, there really are just two reasons for that. One is that the patient is in labor and the baby is not thriving in the labor. The baby is not tolerating the labor. And we doctors and nurses and midwives identify that by watching the baby's heart rate, and if you see that the baby isn't doing well with the labor, then you stop the labor and do a C section and that's called, usually, non reassuring fetal status. Or a C section is done because the reason is called arrest of labor, that the labor is not progressing at the appropriate rate. And that's something that, you know, that your doctor or midwife can go into in detail, but that it's no longer considered to be safe to let the labor continue because the labor isn't progressing.
And those are really the only 2 reasons that C sections happen in labor. There's some fine details, there might be bleeding, but it's basically, non reassuring fetal status or arrest of labor and then all of the others are done because they've been scheduled for some reason.
Either the mother has had a C section before and is requesting another one, that's called a repeat C section, or there's something about the pregnancy where it's not safe to deliver the baby vaginally, so the placenta is blocking the exit. That's called placenta previa or fibroids are blocking, or the baby's in a breech position, not head down, some reason why.
Or there's some other things about the placenta, there are a number of different names for it, but something is wrong there where it's not safe. It's known in advance that it's not safe to deliver, and so a C section is scheduled. Dr. Mussalli, is there anything I'm not thinking of? Those are the basics.
Dr. Mussalli: Yeah, I think those are the big ones. I think in addition, sometimes there are twins or higher order multiples and then, sometimes the size, estimated fetal weight is thought to be especially large or sometimes especially small and sometimes small babies that may have growth restriction don't tolerate a normal labor.
So those could be considerations that the doctor's suggesting a C section. And then some of the less common ones, if somebody has had a type of surgery where they've removed fibroids or other type of surgery where the incision has been made in the uterus in a certain area that might make labor unsafe. Or if somebody has had a repair for urinary incontinence, or for um, vaginal reconstruction, the process of going through childbirth might create a problem in that repair and repeat repairs, surgical repairs for those problems could be unsuccessful or especially difficult. So those would be other reasons why the doctor might suggest a cesarean.
Dr. Worth: Or a prior emergency in labor. Again, these all fall into the category of scheduled C sections where gentle C section is an important topic. But if someone's had a prior shoulder dystocia, meaning the baby got stuck on the way out, or a prior 4th degree laceration, meaning a tear into the rectum. So these are all, this is getting into the weeds, but all the different reasons why the doctor or midwife would identify that a scheduled C section should occur.
Dr. Mussalli: With the repeat C-section for prior section being a big one these days, many practices don't do vaginal birth after C-section or so-called VBACs, and in some cases, there may be a prior c section in another country where the surgical scar is unknown, because vertical scars on the uterus, vertical incisions are not safe for labor. And so sometimes a practice might be willing to do a trial of labor, after a prior c section, if they have the scar identified, but sometimes records can be difficult to get from a long time ago or from other countries.
Dr. Worth: So I also want to raise just on the topic of scheduled C section versus labor C section, some of the topics that Dr. Mussalli raised, like a baby that's very small that may not tolerate labor, some of these are judgment calls where a patient, one of the things that we're going to raise is that emergency C sections can be very scary and we'll talk about emergency C sections. And so it's not irrational to, if your doctor or midwife thinks there's a high likelihood of an emergency c section with your particular circumstances, it's not irrational to say, you know what, I don't want that. I would like to have a scheduled c section.
A little bit depends on some of your personal factors, family size, there are a whole lot of things that would go into that decision, but some of that is a little bit related to the topic today of gentle c section, because gentle c section is a more dignified and, meaningful and,emotionally protective way to have a C section than an emergency C section, which for almost everybody involved, partner, patient, doctors, nurses, midwives can be scary.
Lisa: Yeah. That's a great point. I was talking with a pregnant parent this past weekend in class, who's having twins and her doctor said there is a 78 percent chance you'll need a C section, like her whole pregnancy, the doctor had said this, and suddenly here in the third trimester, her doctor is saying, Oh, Baby A is head down, you can have a vaginal birth if you want to. And it really took her by surprise, and she was like, Oh, wait, I was in the headspace for a scheduled C section. Now, like I have an option and I don't know what to do with this. But her doctor did give her a huge list of the many risks of trying to do it vaginally.
So it seems clear that this doctor feels like she probably should do scheduled, but I was trying to just support her through that and say, What do you think you want to do, and I think what's important is for you to just really learn about all the benefits and risks on both sides, for you and for the babies and then make an informed decision that feels really, as good as possible for you.
And so that was one thing that came to mind as you all, you both were sharing those different indications. Another thing that came to mind was that some of these, you said this a little bit, but some of these are much more clear, yes, absolutely, this is absolutely medically necessary. There is no other viable option here. While other ones are more of a judgment call and like assessing the benefits and the risks, like with a large baby, there's a good chance that, many large babies could fit through the pelvis and through the vagina, and not get stuck, not have shoulder dystocia, but there is additional risk there.
And, with a placenta previa, I have so many clients sign up earlier in pregnancy for class and they say, oh, I may have to have a scheduled C section because the placenta previa, and I just try to encourage them that, for most of my clients, I see that as the uterus grows and the placenta moves some, most of the time it clears the cervix.
And that's almost always what happens with a lot of my, most of my clients. So that's another example of, I just wanted to mention that for listeners, because if you're being told really early in pregnancy that the placenta is covering the cervix, there's a good chance it could change. I don't know if you have statistics off the top of your head or just, even just anecdotally, what you see with placenta previa cases in terms of it clearing or not enough to have a vaginal birth or try for one?
Dr. Mussalli: I would say you're really correct. I think what isn't often described on the ultrasound reports is really the extent of the overlap over the cervix.
So if you have what we would call a central placenta previa where the middle of the placenta is really sitting over the exit. Those are much less likely to resolve over the weeks of pregnancy. But in most cases, it's really just the edge of the placenta that is covering the cervix. and as the uterus grows, that moves out of the way.
So words like central placenta previa, I think do mean something different.
Lisa: Thank you. I hadn't heard this term central. I had heard complete but not central. So thank you for adding to my vocabulary for that. That's great.
Labor Cesarean
And oh, one other thing I wanted to add and just comment on is, the terminology of a scheduled C section or a, I think Dr. Worth, you said, I don't think I'd heard this one, a labor cesarean, or something along those lines. Because you always hear emergency cesarean, and I feel like to my understanding, even when a cesarean happens in labor, it's usually not a super emergency, even though, even if it's perceived that way, because the baby, and can't remember if I heard this from you all, or another provider, but that the baby and the parents body, are telling us a story.
There's a narrative with the monitoring and observing the behavior and so many different kinds of things that we're monitoring. Just that there's this narrative and we usually have clues that something's not going well, if it's not going well, way before it becomes a true emergency. And I just always like to share that with people I work with, because I think that's reassuring to just understand that and to decrease people's anxiety to understand that a true true emergency where it's like, oh, we got to do something this very second is much less common than okay, we might need to start thinking about doing a C section here, because, the fetal heart tones are not reassuring and, too low, too high, whatever it might be.
Anything you would add to that or any comment on that?
Dr. Mussalli: I think that's also true. I would say that certainly the C sections that are done for what Dr Worth called an arrest where the cervix is not changing or the baby's not, coming down through the birth canal should not be urgent or emergency. It's really the fetal heart rate tracing ones that tend to cause an urgent delivery or not.
There are some components of the gentle C section, which can already be in place like where our IV has been placed and things like that, that can set us up for an improved surgical experience. And then even in the emergency situations, very often,once the baby is delivered and most of the time all is well, everyone can take a deep breath and a sigh of relief and then resume some of the things that are components of a gentle cesarean.
So even in an urgent cesarean, there are several things that can help restore some calm and tranquility. And so we'll touch on those I'm sure.
VBAC and C-Section Rates
Lisa: And one more thing I want to add before we move on is just a reflection on choice of care provider can make all the difference in the world in terms of how likely it is that, in the case of fetal distress or in the case of stalled labor and other things as well, VBAC, how likely it is that we could have the kind of birth we're hoping for, if someone's hoping for a physiologic or pelvic or vaginal birth.
What I'm trying to say here is that the two of you and some other care providers in our city and in our country and in our world, are slower to intervene unnecessarily. Really more conservative in terms of and really great outcomes, really safe, healthy outcomes. So that choice of care provider can make a big difference.
Example of that is, I believe you two, correct me if I'm wrong, I believe you are a generally VBAC supportive, practice. Is that right?
Dr. Worth: We do have a lot of patients coming to us for VBAC. And obviously we review carefully the reason for the prior C section and what might be different this time.
And I always do with every patient a VBAC calculator, which is not a perfect tool by any means, but gives an assessment based on some data of their likely success with some experts feeling that if the success rate is below 60, that you might be better off having a repeat C section and if it's above 60 to give vaginal birth a try.
I don't think there's a strict cutoff, but certainly if you maybe do the calculator and your likelihood of success is 18%, you'd be like, you know what, this is a bad idea, if that's what it shows, but I think it's important we just take the same approach, the same careful, safe approach to VBAC that we take to vaginal birth, just to watch the baby carefully, watch the mom carefully, be in the hospital and make sure that everybody's safe and give it time.
Lisa: Yeah. Yeah, I love that nuanced answer. There's so many providers who are very, like at the tiniest concern, seem to jump to a C section when someone's really hoping for a VBAC. And that's not to say that it's not sometimes necessary, but I feel like to find in that scenario, a VBAC supportive provider and who is expert in this and can go through what you were just describing and just assess and be sure that this person is like, with all of their medical nuances, history and everything, that they're a good candidate for that. Yeah, thank you.
All right. If someone were to ask, I always recommend that, people who are expecting a baby ask their provider as one of many touch points to ensure they've hired the best care provider for themselves, ask them what their C section rate is.
And so I am curious to just get your take on what do you think is an evidence based C section rate and reassuring that a provider is only doing a surgical birth when it's truly medically necessary?
Dr. Worth: You know, data is so complicated. And it's so difficult to assess, and in many different times over the years of this practice, I've gone through our patients and calculated different rates.
What I would say is that 1 thing that's really important to remember when you're asking, if you're trying to look at rates for things, is that to remember that obstetric care progresses over a long period of time, meaning it may not be just 8 hours or 12 hours. You might be in the hospital for 24 hours being cared for by 2 different doctors or 3 different midwives. And so when you ask what somebody's rate is, it's hard to have that be accurate because it's going to also be affected by the other people they're working with. And so I wouldn't over interpret or under interpret any set of numbers. I wouldn't, for example, look at the rates at different hospitals and think that's so incredibly meaningful.
Because it's really the people that you're with, not the hospital, that's doing the cesarean. I think that's really important to remember. And I wouldn't over interpret any individual's rate, because it may not really reflect what his or her work is. That being said, Dr. Mussalli can correct me with actual details, but I believe that generally a 3rd of the babies in this country are born by cesarean. And so it's a whole lot of them and there's a lot of focus right now, thankfully on reducing something called the NTSV rate, which is, the simple way to think about this is if you have somebody in labor, someone who's not having a scheduled C section, because those patients really shouldn't count in the C section rate, that's not really what you're asking. Yeah.
Really want to know, if somebody's in labor, what is the C section rate? And so one approximation of that is called NTSV, which is a new quality metric that's being published about different hospitals. It stands for nullip, which is first baby, term, meaning full term, singleton, meaning one baby, vertex meaning head down.
So if you have this, on paper, uncomplicated patient, what is the C section rate for that patient? And I believe at our hospital that they publish goals. I believe, is it 23 percent, the goal now for NTSV? Or 25 percent something like that? The hospitals are aiming to have that be the number and it isn't quite the number right now, but that's what a lot of effort in looking at labor curves and how to support patients in labor is to try to pull that number down.If you see somewhere that has an NTSV rate of 60%, that's too high. That means that everybody's getting a C section.
Dr. Mussalli: I agree with what Dr. Worth was saying. I think, unfortunately, just as statistics are starting to be published, doctor by doctor and hospital by hospital and group by group, it's become much more difficult to interpret what that means because practice is performed as much more of a group.
And just as a quick example, when I was working in a hospital in the Bronx, I used to cover the labor room on Fridays for the hospital and the doctor who worked on Thursday nights was famous for not wanting to be up at night at all. And so there would be, when I'd walk in on a Friday, there'd usually be three or four people who really needed a C section that should have been done overnight and it wasn't done.
And so if we're just looking at my C section rate, all of those C sections that might belong to somebody else were on my statistic, and vice versa, so I think when we talk--
Lisa: That sounds very unfair.
Dr. Mussalli: Well, I enjoy taking care of people, so we just do what needs to be done. But, I think it's hard to interpret what the C section means to me, as a mom, when there are so many different providers involved in the care.
And so I think it's hard to gauge what practice has probably a really good measure would be if they do VBACs in the practice, what their vaginal birth rate, in amongst the VBACs is because it really means that um, they're optimized all the things that they can optimize to try to have a vaginal birth.
And I think that's, maybe part of why our C section rates are low, both in general, and in moms who have had prior C sections, is that there's a process all through the pregnancy where you can try to improve the things that you can improve. Like having good nutrition and exercise to try to help the baby be optimally lined up.
And then in labor, of course, there's a bunch of things as well that try to set one up. So sets ourselves up for a vaginal birth as opposed to a C section. So I think it's hard for moms and partners to really figure that out, unfortunately, right now.
Lisa: I love that answer.
About asking a VBAC rate question as a way to assess. That's so creative and I love it. And I also love the nuance with which you both answered that question. Because everything in life is nuanced and, to get too over focused on numbers is just short sighted.It's only one piece of the puzzle.
And so when I'm teaching people in class, just questions to ask, one of the major things is open ended questions. Just get your provider talking to get a sense of their personality and their vibe to see how you feel, in their presence. And that's going to be much more helpful than asking, what is your rate of this or that, I think generally speaking. It might be worthwhile to ask some of that as well, but not to make that as your sole decision making number, or factor.
Dr. Mussalli: I think that's a terrific point. If people ask the doctor, what are the things that you do in the pregnancy and in the birth that help to decrease the chances of an unnecessary c section.
That might be a really interesting response to listen to.
Lisa: Yeah, absolutely.
What IS a Gentle C-Section?
All right. So to answer probably a burning question, if people are listening at this point, they're probably like, okay, get to the point. What's a gentle C section? Can you please tell us what is a gentle C section? And I know there are other terms as well, if you'd like to share some of those other terms. And then what is it, then maybe walk us through it.
Dr. Worth: I'll start with it. So you know, I met the gentle C section, at least 10 years ago now when a patient who needed to have a scheduled C section that she didn't want, maybe it was 15 years ago even, needed to have a scheduled C section that she didn't want, brought me a video from England who said, I really don't want this C section, Dr. Worth, but if I have to have one, I want you to do it like this. And she showed me this video, and I think it's still on the internet, maybe you can put the link, it's the one gentle C section with a J, and
Lisa: Have that one on my birth class list, yeah, I'll share it in the show notes.
Dr. Worth: And she said, I want all of these things and I looked at it and I'm like, wow, that's amazing.
But I can't do any of those things. I'm so sorry. And then what I'm so proud of is step by step, thing by thing, we've actually managed to do almost all of them, 99 percent, and so I'll just describe and then I'll tell you the thing we don't do from the gentle C section video.
But, what a gentle C section is, A C section where, to start off just to go in terms of, the nitty gritty of it, the mom is on the operating room table, but her arms are not tied down so that she can hold the baby when the baby's born. And the EKG leads are on her back so that she can do skin to skin in the, OR if it's appropriate and baby's not touching wires and the IV is ideally not in the crook of her arm.
So she can bend her arm. Maybe it's on her forearm. These are all things that need to be planned ahead of time. And her gown is prepared so that you can pull the gown down and do skin to skin after the baby's born. And then, the mood is, quiet and respectful, people on the team are not talking about what they had for lunch or what they're doing this weekend, they're, focused on the magic of the thing that's happening, which is that the baby is being brought into the world and maybe the mom and partner have music if they want. And then, the C section is done slowly and carefully without rushing and crazy pulling and tearing. Just take your time and cut the skin nicely.
And, you don't want to be slow because, but you want to do it at an appropriate pace. And then, most very important, there's a clear drape that can be used. So when you're having a C section, you're lying on the table with a drape covering you for sterility, and then something going up from where your shoulders are up to the, on a pole, not to the ceiling, but, three feet up so that there's, a barrier between, the patient and the surgical area.
And so that drape is usually cloth and you can't see through it, but in some of the open heart surgery cases, the anesthesiologists developed a clear drape so that they could actually see what was going on in the surgery. And for a cesarean, at the moment the baby's being born, you can take down the blue drape and have the clear drape be there.
And then the mom and partner can actually see the baby coming out of the incision, no gore, you just see the baby arriving and then you can hold the baby up and the mom and partner can touch the baby through the drape and do a minute of delayed cord clamping and actually see the baby and greet the baby.
And then, we cut the cord and then, ideally, the nurse or pediatrician quickly assesses the baby and then brings the baby right over to the mom to hold and do skin to skin and even possibly breastfeed during the rest of the C section. And if all those things can happen and the mom isn't sick or throwing up or dizzy and able to safely hold the baby, patients who've done it both ways with me, the old way and the new way, tell me that it's just transformative, that you completely forget for the rest of the case that you're being operated on, that you're mesmerized by the baby and just hold the baby, feed the baby and forget about everything else that's going on.
It's really quite wonderful. And then, we doctors finish the surgery and then you go back to your room. The thing in the gentle C section video that we don't do is I think they, in England, they pass the baby over the drape and they do their sterile technique differently.
So, instead of taking the baby out of the field and then back around to the mom, they actually pass the baby over the drape to the family and maybe even cut the cord. In our hospitals we were not allowed to do that. So we just have different rules when it comes to that. Dr. Mussalli, what would you add about my description?
Dr. Mussalli: I think it may be helpful to think of a little, there is a little bit of a disconnect between, doctors and patients. I think it's pretty normal for us as patients to think that the surgery is going to be safe and so I'm interested in having it be a better experience.
And from the doctor's point of view, even minor surgery, we worry about the things that can go wrong. And traditionally, everything in the operating room, including the cesarean delivery, has been optimized from the doctor's perspective. Bright lights and cool temperatures because when you're underneath all those surgical gowns, you get really hot.
And maximal monitoring, the monitors on the mother's chest and her finger for the oxygen saturation, all of those things are being done to maximize safety. Even the idea of tethering the arms, is so that if somebody's asleep or something happens to their level of consciousness, their arms aren't going to fall off and they get injured, et cetera.
So I think when the gentle cesarean came along, it was a great opportunity to describe to the doctors the perceptions of the mother and her partner in the standard way a C section was done and what areas were really concerning to them. And, similarly, I think it's helpful when it's explained to the moms the reason your arms are out to the sides have to do with monitoring your blood pressure and supporting your blood pressure with IV fluids. So that communication can be really helpful. And so when we talk to somebody about cesarean technique, we go through all of this stuff and there's a lot of those aha moments. And so gentle cesarean is really the happy medium of maximizing the safety, the surgical safety for the mom and the baby, but incorporating a lot of the things that can make it be a, much deeper, more tranquil, spiritual experience. And we've seen that.
I've seen nurses who have never seen a gentle cesarean technique applied, be moved to tears because they didn't realize that a surgical birth could actually be so meaningful. And so I think it's really appropriate for us as doctors to do everything we can to incorporate these measures into our operative deliveries, because it does make a difference to parents.
Dr. Worth: I want to give a shout out to Mount Sinai hospital. We've been at Mount Sinai since 2012 and a couple of years into it was when patients started asking for this. And I said, Oh, God, I can't do any of those things. And, the head nurse, who's now retired, listened to me, and she actually ordered the clear drapes.
I couldn't believe it. And then, when the patients loved it, and I would know where they were in the supply closet, and I would make sure that I got the clear drape, it was so complicated. And then eventually they just shifted to having the clear drape in every C section set so that any patient with any doctor, if they want to, can use the clear drape or not use it because some people think that's too gory and who wants to see all that.
But that is one of the cornerstones of the gentle C section is connecting with the baby by seeing the baby at the moment of birth. In addition to all the rest of it, that is really a cornerstone of it. And so I'm so grateful to Mount Sinai for being so open minded and just putting that on all the delivery trays.
Dr. Mussalli: And I think that the options moms and partners plan for vaginal birth, and, being able to plan for a cesarean birth, lots of data show that, having choices and being involved in those choices, is a big part of what makes the birth satisfying. And that in and of itself is an important reason to do a gentle approach.
Lisa: Yes. Agreed. Yeah. Yeah, I recommend to people who want to, that they come up with a, here's my ideal birth plan, which for most people is a physiologic birth, and then here is my C section plan and preferences. I prefer the word preferences than plan, since we all know things usually don't go 100 percent according to plan.
And then maybe an induction plan or preferences, because those are common as well. And that's going to look different in terms of earlier in labor, we're not going to be able to be at home, at least in New York City hospitals. And the way we do inductions. Yeah, so I love that.
What about, do you all turn the temperature a tiny bit less cold in the OR? Does your hospital do that or not?
I know it has to do with sterility and everything.
Dr. Mussalli: Ideally it's set for 75 degrees, it's a more comfortable temperature. And I think it's a little bit dependent on the team.
I do think that there are a lot of moving parts in the hospital. Not all members of the team have necessarily been fully indoctrinated and educated on the gentle cesarean approach. And it's one of the things that we would like to do is actually to create a gentle cesarean program, specifically training some of those things.
But I do think there is much more awareness than before, in terms of the room temperature.
Lisa: And then people can play their own music, right? In addition to the hospital staff being respectful about just that this is a really sacred event.
Dr. Mussalli: Sure. We've actually, it's interesting, I liked it better a few years ago when moms and dads used to, and partners used to select their music.
And we got to have a lot of interesting experiences because sometimes some of the quietest, calmest, couples that we knew played heavy metal and music that you just wouldn't expect was going to be coming out at the birth.
And sometimes they didn't know whether it was a boy or a girl, and they had a soundtrack for girls and different music for boys. And so it was really a lot of fun. But then along came the earbud, and so now a lot of couples are listening to the music in their own ears, and we don't get to hear that. Either one is acceptable, totally acceptable, and I encourage people to plan their music just as they would for a vaginal birth.
Lisa: I love it. And then what about, the light dimmed during the delivery of the baby's head. Is that something you all incorporate?
Dr. Mussalli: The surgical lamps are the things that are important, and that's the main lights that can be on, there can be lower level lights in the rest of the OR.
There needs to be enough light that the anesthesiologist can see what they're doing and nurses are not tripping on any equipment, et cetera. But it certainly can be done. And that's part of the plan. I think most vaginal births, moms like to have lower lighting, but not everyone.
I've definitely had people say, please, I want the lights all on, I'm nervous, I want to make sure everyone sees everything. So I think it's about discussing the different choices that somebody might want.
Lisa: Yes, that sounds great. And then what about the baby? Dr. Mussalli, when you taught a workshop on this, I really loved and appreciated your description.
And maybe you'll do a different description this time. And that's Totally fine. But the description of the birth of the baby and slowing that down to, my thinking, I think of it as trying to replicate the vaginal birth in the slow birth of the head and squeezing out amniotic fluid and so forth.
Anything you'd like to describe on that? There was a snake involved in a description of the uterus and how strong it is, I seem to recall. That's my little hint.
Dr. Mussalli: I had forgotten that, but now that you mentioned it, I recall. I think in countries where, like England, where the gentle cesarean technique has been around longer, I think you see a progression and an evolution of the different steps involved and a higher level of comfort with doing certain things like a more delayed delivery of the newborn. And obviously the circumstances of the c-section make a difference if an urgent section is being done because there's a concern about the heart rate, there may not be the luxury of time to do that slower delivery. But, an incision on the uterus, in the C section is a small opening, and the baby still has to squeeze through that opening in a similar way as squeezing through a vaginal birth canal. And if that can be done a little bit more slowly, some of the benefits of that sort of squeezing the fluid that's normally in the lungs and gets squeezed out in the process of birth, can be very helpful and can decrease the transition time in terms of, going from underwater environment to an air breathing environment. That's something that can be helpful. And then balance within reason because the uterus has a surgical incision and can be bleeding. And so there are some other factors that can alter the amount of time that you have to deliver.
Things You Can Ask For in Your C-Section
Dr. Worth: I want to add this to, to bring it back to the patient, that, I think it's definitely worth watching some of the gentle C section videos, particularly that one from England from 15 years ago, just to see what a c section can be like, and to recognize that there's not a wrong way to have a baby, and that if you are thinking that you may need a cesarean, and you're disappointed that you need a cesarean, just to re ground yourself that it doesn't have to be that there are many components to the cesarean that can be very fulfilling.
If not all of them. I'm not saying there's parts that aren't, but it's just to look at it and recognize that it can be this way, and to seek that out and talk with your doctor about what parts are most important to you, because even if he or she can't do them all the way I couldn't, they can at least refocus, you can almost always put the EKG leads on the patient's back and be able to hold the baby in the OR, and, almost always you can do that and not have the IV in the crook of your arm and have your gown so that you can pull it down. And besides the clear drape, those are the core components of the gentle C section, being able to hold the baby right away, assuming you're not ill from the anesthesia.
Lisa: Yeah. And one of the techniques I hadn't heard until I saw your list was also the pulse oximeter doesn't necessarily have to be on the finger, that it could be on the ear or the toe. Do your clients do that much?
Dr. Worth: It a little bit depends on your anesthesia team and their level of comfort and what their equipment is.
I sometimes ask for it to be on the ear and they're like, I can't do that right now. So I think it just, it a little bit depends because you do want to make sure you have a good pulse ox reading, but at least to not feel as if you're just completely, tethered at every extremity.
Dr. Mussalli: But I think interestingly, a lot of moms given the choice still ask for the finger. It's pretty unobtrusive right now, and it's not a big bulky thing that it used to be. And so it almost feels like having a bandaid on your fingertips.
So it's not so bad. And they might feel funnier with the clip on the ear. Yeah. So that's not so bad, but I think it's really about trying to optimize the skin to skin. And that's really the part that I think is transformative, to be undergoing an operation while you are holding your baby or maybe even breastfeeding your baby. Just, it's no other operation that anybody would have.
So it is, I think, a big part of what lowers the anxiety and improves the experience. But when Dr. Worth mentioned, as long as you're not feeling ill, that I did want to make sure to add that the nature of the anesthesia and the C section is such that, getting nauseous or vomiting, there is a high risk for that. And I think one of the things to be mindful of is, is speak to the anesthesiologist the instant that you might start to feel nauseous, even if you're, I always say to them, even if you're not sure if you're nauseous, If you're questioning it, bring that up because, by, supporting your blood pressure, they can really reverse that effect.
And sometimes if we, once we start to throw up, it's hard to break that cycle. And obviously that's going to interfere with the bonding and the skin to skin.
Lisa: Surgery, I would think too. Depending on where we are in it.
Dr. Mussalli: Yeah. Yeah. For sure. But, since we're focusing on mom's experiences today, I think it's really helpful and it's, you know, nobody likes to feel yucky, being sick.
Just let them know right away, rather than trying to tough it out and hoping it will pass, let the doctors know immediately so that they can help prevent that and make it a better experience.
Dr. Worth: And if your doctor says, I've never done a gentle C section. I can't do that. I would say that the things to ask for that they all probably will be able to help with will be to ask for the EKG leads on your back and to ask if you can hold the baby as soon as possible during the C section that, you, if possible, you'd like to delay the eye ointment and the vitamin K and the footprints and everything. Obviously put the band on the baby for safety, but, try to get the baby over to you as soon as possible and, advocate for yourself with the nursing team and just say, I would really love to be able to hold my baby as quickly as possible.
And those are the core components of the gentle C section. Just to not have the baby be over there in the warmer lying there by him or herself, but to have the baby in your arms as soon as possible. And almost any hospital and doctor will be able to do some of that. And do more as they gain comfort with it.
Stalled Labor to C-Section Preferences
Lisa: Yeah, absolutely. Thank you so much. So you said planned C sections, you can incorporate these things. In terms of unplanned C sections, obviously, an emergency one probably wouldn't be so possible to do a lot of these things, but with a say, it's a stalled labor, labor dystocia, I don't know if you call it that anymore.
You used a different term, but, could we incorporate some of these things in that kind of case where it's not an actual emergency, but we are moving in the process of spontaneous labor into, or an induction, into a C section?
Dr. Worth: Sure. If you think about the core components of the gentle C section being having the EKG leads on your back and holding the baby as soon as possible, those are things that can happen as long as the baby's not needing resuscitation.
And it's not such an emergency that anesthesia is hurrying and doesn't have a chance for you to ask to put them on your back or has never heard of that. Then, those are things that really you can ask for at any time, as you're going into the OR.
But I would say, write a birth plan and bring the birth plan to your doctor or midwife and just talk about, if there's a C section, what are the most important parts of that for you so that you could at least air out in advance, which parts of this might be possible.
Lisa: Sounds good. Thank you.
How to Encourage More Hospitals and Raise Awareness
And do you have any thoughts on, given the fact that most New York hospitals don't generally offer gentle cesarean techniques, any ideas, any theories on the barriers preventing that from being incorporated more readily?
Dr. Worth: Are you sure that they don't? Because you see the different hospitals. We don't go to any other hospitals. What are you seeing at the other hospitals?
Lisa: Yeah, NYU is one of the only hospitals as far as I have been able to tell based on the doulas who are in my collective and the doulas I know, as well as the many people I work with, with birth classes. When people go in and ask about whether or not gentle cesarean techniques can be incorporated, if a cesarean is necessary, it's usually just shut down.
And maybe the conversation, maybe it's just the term, maybe it's just unfamiliarity, maybe?
Dr. Worth: Yeah, I would say don't call it that. I would say, write a birth plan that says that if I have a cesarean, I'd like to hold my baby as soon as possible.
And, if possible, I'd like to ask to have the EKG leads on my back and to have a gown where I can maybe even do skin to skin if I'm feeling well enough. And nobody's going to say no to that.
Lisa: Yeah, I guess it's just the clear drape I know is not available at a lot of our hospitals.
And that's something that a lot of clients are like, I really wanted that.
Dr. Mussalli: I think we try to respond to the wishes of our clients. And so the more that clients they'll listen to this podcast learn some things and ask their doctors for it. And, the doctors want it to be a good experience.
And I think it's just raising awareness for everybody, especially the doctors. And as they start to look into, Can we do this? And how do we do this? I think we'll start to influence things because even at Mount Sinai, where it's available, there are many cesareans that happen without this technique.
So I think it's just a matter of the birth plan, if you will, birth preferences, and discussing that and seeing how we can do it. And I think it's been called a family centered cesarean, a gentle cesarean, a mother friendly, et cetera, but, even better, I think is what Dr. Worth suggested, which is, just, tell them the things that you're really interested in based on what you've learned about this approach and see which of those they can make possible.
Dr. Worth: I would also say, after you go to any hospital, certainly in New York City, I don't know about elsewhere, they're going to send you something called the Press Ganey survey, where they're going to survey how it went for you.
And I promise you this is a survey that the hospitals read very carefully. And in some cases, I think their payment is based on the Press Ganey ratings, and you can write on that survey. Let's say you have a birth at a hospital where they don't have the clear drape. I would say we always want to try to make things better for the people who come after us.
You can write on your survey, I loved my doctors. I loved my cesarean. Everything was safe, but, I wish that you'd had the clear drape because I would have liked to have seen my baby at the birth. And with time and with requests like that, probably some other hospitals will add the clear drape to their set.
It's not impossible.
Dr. Mussalli: And similarly, if you did have the clear drape, let them know that you really what did you like? You know, I'm so glad that you did this approach in my cesarean, that it made a huge difference to me.
Lisa: I love it. Yes. Everyone listen to Doctors Worth and Mussalli because I say something along these lines in birth class all the time.
The more you speak up, the more people speak up, the more we're going to see change toward having nitrous oxide available at more birth places and all these different things that people are like, I want that, but my hospital doesn't offer that. So thank you for echoing that idea of just, speak up and have your voice known on what you want.
And maybe they can honor it in real time, and, if not, then you could be helping people down the road who want similar things. Wonderful. Is there anything else that you haven't gotten to share about gentle cesarean techniques or anything else before we close it out?
Dr. Mussalli: I think it's just when you look at some of the studies on gentle cesarean approaches, it's remarkable some of the great benefits to both mother and baby, but things like reduced postoperative pain for the mother, improved breastfeeding outcomes, an increased sense of well being and less postpartum blues and depression.
Those are not small things. And these have all, I think, have come about through this approach, whether it's partaking in the decision making, having options, whatever it is, those are the outcomes. And it's worth exploring it and trying to have some of those methods incorporated.
Lisa: Well said. All right. Thank you again, Doctors Worth and Mussalli. It's been such a pleasure and an honor to get to chat with you and thank you just for spreading the good word and helping, people have, hopefully, a really beautiful sacred birth experience, including in a belly birth, in a cesarean.
And thank you for all the wonderful work you do.
Dr. Mussalli: Thanks for having us.
Dr. Worth: Yeah, thank you so much.
