4:38
- ABC News
- November 27, 2018
Birth puts plan to reduce C-sections to the test
Avoidable C-sections are the focus of the Team Birth Project.
4:38
Shaun McDougall walks across the room to get a closer look at the whiteboard.
“Honestly, it seems like common sense,” he says. “I would always think the nurses would have something like this, but to have it out where mom and dad can see it — I think it’s pretty cool.”
With Melisa McDougall’s plan in place, everyone settles in, to wait. About four hours later, Melisa isn’t yet feeling contractions. Levesque breaks the water sac around Brady.
“Looks nice and clear,” Levesque reports. “Hey bud, come on and hang out with us,” she says to the baby.
“So, you’re going to keep leaking fluid until you leak babies,” the doctor explains to Melisa. “Whenever you start getting uncomfortable, we’ll get you an epidural at that point.”
Levesque moves to the board and adds updates: Melisa is 4 centimeters dilated; her waters broke at 13:26; the next assessment will be after she gets an epidural.
The medical team insisted ahead of time that Melisa agree to be numbed from the waist down if she wants to deliver Bryce — the second twin — vaginally. Melisa agreed. The obstetricians may need to rotate the baby in her uterus, find a foot and pull Bryce out, causing pain most women would not tolerate.
One of those doctors — Marino — peeks into the room and waves.
“Just came to say hi,” says Marino, who has more experience than most obstetricians in delivering babies positioned like Bryce. Along with Levesque, Marino has been seeing Melisa regularly through office visits.
Shaun McDougall asks the physicians if they’ll pose for a picture with his wife.
“Can we make funny faces?” asks Levesque.
“I want you to,” says Shaun. “You guys are like her favorite people on the planet.”
As the hours tick by, there’s a shift change, and registered nurse Barbara Fatemi joins the McDougall team. She checks Melisa’s pain level regularly to determine when she’s ready for the epidural.
Melisa says she isn’t feeling much, but adds that she has a high tolerance for pain. Shaun tells Fatemi he sees the strain on his wife’s face. Fatemi acts on Shaun’s assessment, and calls an anesthesiologist to prepare the epidural, something Shaun later says reinforces his feeling that they’re a team.
Levesque soon arrives for the promised “next assessment.” Melisa is now 10 centimeters dilated and ready to deliver — but she must hold on until nurses can get her into an operating room.
The OR will be the right place if the second baby, Bryce, doesn’t shift his position, and the doctor needs to do a last-minute cesarean.
“I’ll see you in a few minutes. No pushing without me, OK?” Levesque says over her shoulder as she heads to the OR to prep.
“I’ll try,” Melisa says, weakly. In a minute, nurses are rolling her down the hall, following Levesque.
Almost five years ago, two women who were wheeled into this hospital’s operating rooms during childbirth died after undergoing C-sections. Though state investigators found no evidence of substandard care, Dever, the head of obstetrics, said the hospital scrutinized everything.
“When you have something like that happen, that expedites your efforts,” she said. “Exponentially.”
Now, Dever said, she sees an opportunity, through the Team Birth Project, to model changes that could help women far and wide.
“I would love women everywhere to be able to come in and have a safe birth and healthy baby,” she said. “That’s why I’m doing it.”
Dever is about to see her pilot study of the Team Birth Project pushed to new limits by little Bryce McDougall. First, though, Melisa must deliver Bryce’s twin brother, Brady. Even his birth, the one that was expected to be easier, is more difficult than anticipated.
Bent nearly in half, her face beet red, Melisa strains for five pushes. She throws up, then gets back to laboring. And suddenly, there he is.
![\"PHOTO:](\"http://a.abcnews.com/images/Health/c-section-03-khn-jc-181127_hpEmbed_3x2_384.jpg\")
“Oh my goodness Brady, oh Brady,” wails Shaun. He follows a nurse holding his son over to a warmer.
Marino takes Shaun’s place next to Levesque, who has reached inside Melisa to get the next twin. Levesque’s mission is to grab Bryce’s feet and guide him out. But everything feels like fingers, not toes.
“That’s a hand,” she murmurs. “That’s a hand, too.”
Marino rolls an ultrasound across Melisa’s belly, hoping the scan will show a foot. But Bryce’s feet are out of sight and out of reach.
Marino has had more experience than most obstetricians with transverse babies and this procedure, known as a breech extraction; she asks to try. She reaches into Melisa’s uterus while Levesque moves to Melisa’s right side and uses her forearm to shift Bryce and push him down. Dever has come into the room, and takes over the ultrasound. At least six doctors and nurses encircle Melisa, whose face is taut. Shaun frowns.
“Babe, you OK?” he asks.
Melisa nods. Bryce’s heart rate is steady. But there’s still no sign of a foot. One little hand slips out and Marino nudges it back in.
“Open the table,” says Marino, her voice strained.
It’s open and ready, her colleagues say, referring to the array of sterile surgical instruments that Marino may soon need, to begin a C-section.
For 36 seconds, this room with more than a dozen adults grows oddly quiet. Everyone is watching Marino twist her arm this way and that, determined to find Bryce’s feet. Levesque leans hard into Melisa’s belly. Shaun bites his lip. Then Marino yanks at something — and her gloved hand emerges, clenching baby Bryce by his two teeny legs.
“Oh babe, here he comes, here he comes — Woo!” squeals Shaun.
Shaun is overcome with emotion again. Melisa manages an exhausted giggle. Baby Bryce keeps everyone waiting a few more seconds and then howls.
Levesque tends to Melisa, and Marino comes around to congratulate the new mom.
“He was fighting you, huh?” Melisa says, and laughs.
“I think I found at least five hands,” says Levesque.
Outside the OR, Levesque and Marino look relieved and elated. Both agree that most doctors would have delivered Bryce by C-section. But at South Shore, the McDougalls found a hospital that has challenged itself to perform fewer C-sections, and a doctor with experience in these unusual deliveries — one who knew and respected the parents’ preference.
“They specifically wanted to have a vaginal delivery of both babies,” Marino says — and that was on her mind during the difficult moments.
Bryce was fine, says Marino, so the deciding factor for her was that Shaun and Melisa did not panic.
“They did not flinch — they were like, ‘Keep going,'” Marino recalls. “Sometimes the patient will say ‘stop,’ and then you have to stop.”
The babies’ father says he came close to requesting that, in the very last minute before Bryce was born.
“That part with the arm — it was pretty aggressive,” Shaun says.
But in that moment, he adds, the feeling that he and Melisa were part of the team made a difference.
“It made us more comfortable,” Shaun says, and that comfort translated to trust. “We trusted the decisions they were making.”
Melisa says she’s grateful for the vaginal delivery.
“I did not want to have a natural birth and a C-section,” she says. “That would be a brutal recovery.”
Instead, 30 minutes after Bryce’s birth, Melisa is nursing Brady and talking with family members on FaceTime.
South Shore began using the Team Birth approach in April. Three other hospitals are also pilot sites: Saint Francis in Tulsa, Okla.; EvergreenHealth in Kirkland, Wash.; and Overlake in Redmond, Wash. The test period runs for two years. In the first four months at South Shore, the hospital’s primary, low-risk C-section rate dropped from 31 percent to 27 percent — about four fewer C-sections each month.
Experts who contributed to the development of the Team Birth Project are eager to see whether other hospitals can lower their rates of C-section and keep them down.
“Once you get past the early adopters, how do you demonstrate the benefits for others that aren’t willing to change?” asked Gene Declercq, a professor of community health sciences at Boston University School of Public Health.
Declercq noted that a few insurers are beginning to force that question, refusing to include in their networks hospitals that have high C-section rates, or high rates of other unnecessary, if not harmful, care.
The federal government has set a target rate for hospitals: No more than 23.9 percent of first-time, low-risk mothers should be delivered by C-section. The U.S. average in 2016 was 25.7 percent.
The target was put in place because research has shown that if a woman’s first delivery is a C-section, her subsequent deliveries are highly likely to be C-sections, too — raising her (and her baby’s) risk for complications and even death.
Declercq said the project’s focus on communication in the labor and delivery room makes sense because many physicians decide when to perform a cesarean based on clinical habit or the culture of their hospital.
“If you can impact that decision-making process, you can perhaps change the culture that might lead to unnecessary cesareans,” said Declercq.
This story is part of a reporting partnership with WBUR, NPR and Kaiser Health News.
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
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