One Twin’s Difficult Birth Puts a Project Designed to Reduce C-Sections to the Test

Doctors step beyond routine procedure and show natural childbirth possible
By Martha Bebinger, Kaiser Health News
January 13, 2019 Updated: January 13, 2019

The tiny hand and forearm slipped out too early. Babies are not delivered shoulder first. Dr. Terri Marino, an obstetrician in the Boston area who specializes in high-risk deliveries, tucked it back inside the boy’s mother.

“He was trying to shake my hand and I was like, ‘I’m not having this—put your hand back in there,’” Marino would say later, after all 5 pounds, 1 ounce of the baby lay wailing under a heating lamp.

That baby, Bryce McDougall, tested the efforts of more than a dozen medical staffers at South Shore Hospital in Weymouth, Massachusetts, that day last summer.

Bryce’s birth put to the test a new method of reducing cesarean sections developed at Dr. Atul Gawande’s Ariadne Labs, a “joint center for health systems innovation” at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health in Boston.

Melisa McDougall checked into South Shore Hospital at 9:30 a.m. on Aug 31, after a routine ultrasound. She was in her 36th week, pregnant with twin boys. The doctors had warned Melisa that her placenta won’t hold out much longer. She was propped up in bed, blond hair pulled into a neat bun, makeup still fresh, ordering a sandwich when her regular obstetrician arrived.

“How are you?” asked Dr. Ruth Levesque, sweeping into the room and clapping her hands. “You’re going to have some babies today! Are you excited?”

The first of the twins—Brady—was head-down, ready for a normal vaginal delivery. But brother Bryce was horizontal at the top of Melisa’s uterus.

That was one reason why Melisa was a candidate for a C-section. Babies do not come out sideways. And there was another reason most doctors would not consider a vaginal delivery in Melisa’s case, Levesque said. Four years ago, she delivered the twins’ sister by cesarean.

“[Melisa] has a scar on her uterus,” Levesque explains, “so there’s a risk of uterine rupture—very rare, but there’s always a possibility.”

And that possibility was likely greater for Melisa because she was 37 and having twins. But the McDougalls hoped to have vaginal deliveries for both boys.

“I just feel like it’s better for the kids—better for the babies,” Melisa said.

The ‘Team Birth Project’

Avoiding C-sections is better for many moms. With cesareans, there’s a longer recovery period, a greater risk of infection and an association with injury and death. And most C-sections are not medically necessary, said Dr. Neel Shah, who directs the Delivery Decisions Initiative at Ariadne Labs.

“We’re fairly confident that, when you look nationally, the plurality—if not the majority—of C-sections are probably avoidable,” said Shah.

Those avoidable C-sections are the focus of the Team Birth Project, designed by Shah with input from roughly 50 doctors, nurses, midwives, doulas, public health specialists, and consumer advocates who focus on childbirth. South Shore Hospital is one of the pilot sites for the project.

Childbirth is complicated, Shah said. You’ve got two patients—the mother and the baby—and an ad hoc, often shifting team that at a minimum includes the mom, a nurse, and a doctor.

“So you’ve got three people who have to come together and become a very high-performing team in a really short period of time, for one of the most important moments in a person’s life,” Shah said.

And this team has to perform at its best during an unpredictable event: labor.

Shah said doctors and nurses generally agree about three things: when a mom is in active labor; when a mom can definitely try for a vaginal delivery; and when she must have a C-section.

“And then there’s this huge gray zone,” Shah said. “And actually, everything about the Team Birth Project is about solving for the gray.”

To avoid unnecessary C-sections when what to do isn’t clear, this hospital, in conjunction with Ariadne Labs, has changed the way labor and delivery is handled from start to finish.

First, women aren’t admitted until they are in active labor. Secondly, the mom’s preferences—such as whether she’d like an epidural or not, whether she wants to have “skin-to-skin contact” with the baby immediately after birth—help guide the labor team. The team maps the delivery plan—including mom’s preferences and the medical team’s guidance—on a whiteboard, like the one in Melisa’s room.

For the births of Bryce and Brady, the white erasable planning board got a lot of use.

Under “Team,” Levesque and registered nurse Patty Newbitt wrote their names. Melisa and Shaun McDougall were listed as equal partners. The names of other family members or nurses may be added and erased as labor progresses. Shah’s idea is that this team will “huddle” regularly throughout the labor to discuss the evolving birth plan.

The birth plan itself is divided into three separate elements on the board: Maternal (the mom), Fetal (the baby) and Progress (in terms of how the labor is progressing). A mom with high blood pressure, for instance, may need special attention—and that would be noted on the board—but she could still have a normal labor and vaginal delivery.

The whiteboard in Melisa’s hospital room detailed the birth plan, including her preferences and the medical team’s guidance.

Good Communication Is Key

Dr. Kimberly Dever, who chairs the OB-GYN department at South Shore Hospital, highlighted a section of the whiteboard called “Next Assessment.”

That category is included on the board, Dever said, “because one of the things I often heard from patients is that they didn’t know what was going to happen next. Now they know.”

Asking the mom—and the couple—about their preferences for the delivery is crucial, too, Levesque said.

“It forces us to stop and to think about everything with the patient,” she explained. “It makes us verbalize our thought process, which I think is good.”

Shaun walks across the room to get a closer look at the whiteboard.

“Honestly, it seems like common sense,” he said. “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’s plan in place, everyone settled in, to wait. About four hours later, Melisa wasn’t feeling contractions. Levesque broke the water sac around Brady.

“Looks nice and clear,” Levesque reports. “Hey bud, come on and hang out with us,” she said to the baby.

“So, you’re going to keep leaking fluid until you leak babies,” the doctor explained to Melisa. “Whenever you start getting uncomfortable, we’ll get you an epidural at that point.”

Levesque added to the board: 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.

As the hours ticked by, there was a shift change, and registered nurse Barbara Fatemi joined the McDougall team. She checked Melisa’s pain level regularly to determine when she’s ready for the epidural.

Melisa told Fatemi she wasn’t feeling much but added that she has a high tolerance for pain. Shaun said he saw the strain on his wife’s face. Fatemi acted on Shaun’s assessment and called an anesthesiologist to prepare the epidural, something Shaun later said reinforced his feeling that they were a team.

Levesque soon arrived for the promised “next assessment.” Melisa was 10 centimeters dilated and ready to deliver—but she had to hold on until nurses could get her into an operating room.

The operating room would be the right place if the second baby, Bryce, didn’t shift his position and the doctor needed to do a last-minute cesarean.

“I’ll see you in a few minutes. No pushing without me, OK?” Levesque said over her shoulder as she headed to the operating room to prep.

“I’ll try,” Melisa said, weakly. In a minute, nurses were 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 exponentially,” she said.

Now, Dever 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.”

‘They Did Not Flinch’

Dever was about to see her pilot study of the Team Birth Project pushed to new limits by little Bryce. But first, Melisa must deliver Bryce’s twin brother, Brady. Even his birth, the one that was expected to be easier, was more difficult than anticipated.

Bent nearly in half, her face beet red, Melisa strained for five pushes. She threw up, then got back to laboring. And suddenly, there he was.

“Oh my goodness Brady, oh Brady,” Shaun wailed. He followed a nurse holding his son over to a warmer.

Marino took Shaun’s place next to Levesque, who reached inside Melisa to get the next twin. Levesque’s mission was to grab Bryce’s feet and guide him out. But everything felt like fingers, not toes.

“That’s a hand,” she murmured. “That’s a hand, too.”

Marino rolled an ultrasound across Melisa’s belly, hoping the scan would show a foot. But Bryce’s feet were out of sight and out of reach.

Marino had more experience than most obstetricians with transverse babies and this procedure, known as a breech extraction; she asked to try. She reached into Melisa’s uterus while Levesque moved to Melisa’s right side and used her forearm to shift Bryce and push him down. Dever came into the room and took over the ultrasound. At least six doctors and nurses encircled Melisa, whose face was taut.

“Babe, you OK?” Shaun asked.

Melisa nodded. Bryce’s heart rate was steady. But there was still no sign of a foot. One little hand slipped out and Marino nudged it back in.

“Open the table,” said Marino, her voice strained.

It was open and ready, her colleagues told her, referring to the array of sterile surgical instruments that Marino may need, to begin a C-section.

For 36 seconds, the room grew oddly quiet. Everyone was watching Marino twist her arm this way and that, determined to find Bryce’s feet. Levesque leaned hard into Melisa’s belly. Shaun bit his lip. Then Marino yanked 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 was overcome with emotion again. Melisa managed an exhausted giggle. Baby Bryce kept everyone waiting a few more seconds and then howled.

Outside the operating room, Levesque and Marino looked 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 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 said—and that was on her mind during the difficult moments.

Bryce was fine, said 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.”

Shaun said 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 said.

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,” said Shaun, and that comfort translated to trust. “We trusted the decisions they were making.”

Melisa was grateful for the vaginal delivery.

“I did not want to have a natural birth and a C-section,” she said. “That would be a brutal recovery.”

Instead, 30 minutes after Bryce’s birth, Melisa was nursing Brady and talking with family members on FaceTime.

Next Steps for Team Birth Project

South Shore began using the Team Birth approach in April. Three other hospitals are also pilot sites: Saint Francis in Tulsa, Oklahoma; Evergreen Health in Kirkland, Washington; and Overlake in Redmond, Washington. 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 hospitals that have high C-section rates in their networks, 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 have deliveries 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.

Martha Bebinger covers health care and other topics at WBUR, the NPR affiliate in Boston. This story is part of a reporting partnership with WBUR, NPR, and Kaiser Health News, where this article was originally published.

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