twin's difficult birth put a project designed to reduce c-sections to the test - whiteboard

The little hand and forearm slipped out too early.
Babies don't give birth first. Dr.
Terri Marino is an obstetrician in the Boston area who specializes in high school
Venture the delivery and put it back into the boy's mother.
"He tried to shake my hand, and I thought, 'I don't have this --
Put your hands back there, "Marino will later say, after all, the 5 pounds-pound baby lies crying under the heating light.
This is a story about how that baby Bryce McDougall tested the best efforts of a dozen medical staff at Weymouth South Bank Hospital, Massachusetts.
One day last summer
Bryce's birth also tested a new method of reducing C-section in Dr.
Ariadne Labs at Atul Gawande is the "Joint Center for Health System Innovation" at Brigham Women's Hospital and Harvard University T"H.
School of Public Health in Boston.
The story begins before Bryce was born, and on the last day of August, around 9: 30 a. m.
Melissa McDougall has just entered the South Bank after a routine ultrasound.
She was pregnant for 36 weeks with twin boys.
The doctor warned Melissa that her placenta would not exist for a long time.
She was lying in bed with blonde hair pulled into a neat bun and the makeup was still fresh and she ordered a sandwich when her regular obstetrician arrived. "How are you? " asks Dr.
Ruth levisk swept into the room and clapped his hand.
"You're having a baby today!
Are you excited?
The first of the twinsBrady —is head-
Prepare for normal vaginal delivery.
But his brother Bryce is horizontal at the top of Melissa's uterus.
This is one of the reasons why Melisa became a candidate for C-section.
The baby will not come out sideways.
In Melissa's case, most doctors will never consider another reason for vaginal delivery, Levesque said.
Four years ago, she gave birth to her twin sister by Caesarean section. "[Melisa]
Levesque explained: "There are scars on her uterus, so the risk of a rupture of the uterus is --
It's very rare, but it's always possible.
"It's probably more likely for Melissa because she's 37 and has a pair of twins.
But the McDougall couple want both boys to have vaginal delivery.
"I just think it's better for the kids --
"It's better for babies," Melissa said . ".
How Team birth projects avoid C-
Chapters are also better for many mothers.
For cesareans, the recovery period is longer and the risk of infection is greater, associated with injury and death.
Most of them are medically unnecessary, doctors say.
Neel Shah directs delivery decision-making initiatives at Ariadne Labs.
"We are fairly confident that when you look at diversity across the country --
If not most peopleof C-
"Parts may be avoided," said Shah . ".
C that can be avoided
Part of it is the focus of the team fertility program designed by Shah, from the input of about 50 doctors, nurses, midwives, Duras, public health experts and consumer advocates who focus on delivery.
Southbank Hospital is one of the pilot sites of the project.
In describing the cooperation, Shah first acknowledged that delivery is complex.
You have two patients.
Mom and baby-
A team that is temporary and constantly changing, at least mom, nurse and doctor.
"So you have three people who have to come together and be a very tall person --
"In a very short period of time, in one of the most important moments of a person's life, the performance team," Shah said . ".
The team must perform best in an unpredictable event: Labor.
Doctors and nurses usually agree on three things, Shah said: When mothers give birth actively;
When the mother can definitely try vaginal delivery;
When she has to have C-section.
"There is a huge gray area," Shah said . "
"In fact, everything about the team Birth Project is to solve the gray problem.
Avoid unnecessary C
When it was not clear what to do, the hospital, along with the Ariadne program, changed the way labor and childbirth were handled from start to finish.
First of all, women will not be admitted until active delivery.
Secondly, mom's preferences
For example, if she wants epidural anesthesia and if she wants "skin"to-
Skin contact with baby immediately after birth
Help guide members of the Labor team.
Team members draw delivery plans-
Including Mom's preferences and guidance from the medical team-
On the whiteboard, like the one in Melissa's room.
For the birth of Bryce and Brady McDougall, the white erasable planning committee was heavily used.
Under "team"
Levsk and registered nurse Patty newbit wrote their names.
Melissa and Sean McDougall are also listed as equal partners.
The names of other family members or nurses may be added and removed as delivery progresses.
Shah's idea is that the team will "squeeze" together on a regular basis throughout the delivery process to discuss the evolving birth plan.
The delivery plan itself is divided into three separate elements on the board of directors: maternity (the mom), fetal (the baby)and progress (
In terms of how labor is progressing).
Mothers with high blood pressure may need special attention
This will be noted by the board
But she still has normal delivery and vaginal delivery.
Good communication is the key.
Kim Dever hosting OB
The GYN department on the South Bank highlighted a section on the whiteboard called the "next assessment ".
Dever said, "this category is included in the board because one of the things I often hear from patients is that they don't know what's going to happen next. Now they know.
Ask mom-
The couple
Levesque says their preference for delivery is also crucial.
"It forced us to stop and think about everything with the patient," she explained . ".
"It allows us to express our thinking process, which I think is very good.
"Sean McDougall went through the room and looked at the whiteboard carefully.
"To be honest, this seems to be common sense," he said . "
"I always think nurses will have something like this, but where mom and dad can see it --
I think it's cool.
"With Melissa McDougall's plan in place, everyone settled down and waited.
About four hours later, Melissa had not yet felt contractions.
Levesque broke the water sac around Brady.
"It looks beautiful and clear," Levesque reported . ".
"Hey bud, come on, go out with us," she said to the baby, scratching his head.
"So, you will continue to leak the liquid before you leak the baby," the doctor explained to Melissa . ".
"Whenever you start to feel uncomfortable, we will give you an epidural anesthesia at that time.
Levesque moved to the board and added updates: Melisa expanded 4 cm;
Her water was broken at 13: 26.
The next assessment will be after she has undergone epidural anesthesia.
The medical team insisted in advance that if Melissa wanted to send Bryce, she agreed to be numb below the waist
The second twin. vaginally. Melissa agreed.
The obstetrician may need to spin the baby in her womb, find 1 feet and pull Bryce out, causing pain that most women can't stand.
One of the doctorsMarino —
Looking into the room, it was rough.
"I just came to say hello," said Marino . " He has more experience in giving birth to babies like Bryce than most obstetricians.
Marina, along with levisk, often visits Melissa in the office.
Sean McDougall asked the doctor if they would take a photo with his wife.
"Can we make funny expressions? Ask Levesque for a general introduction.
"I want you to do that," Sean said . "
"You are like her favorite person on this planet.
"Shifts have changed over time, and registered nurse Barbara Fatemi has joined the McDougall team.
She regularly examined Melissa's pain levels to determine when she was ready for epidural anesthesia.
Melissa said she didn't feel very good, but added that she had a high tolerance for pain.
Sean told Fatemi that he saw the tension on his wife's face.
Fatemi took action on Sean's assessment and called the anesthetist to prepare him for epidural anesthesia, which, after Sean, reinforced his feeling of being a team for them
Levesque soon arrived at the "next assessment" promised ".
"Melissa has now expanded 10 centimeters to prepare for delivery --
But she had to hold on until the nurse sent her into the operating room.
She explained that Levesque would still try vaginal delivery of two babies, but in the operating room, Melissa would be in the right position if Bryce did not change his position in the womb, the doctor needs to do the last-Minute Caesarean section
"I'll see you in a few minutes.
No push without me, okay?
"When she went to the operating room to prepare, Levesque said.
Melissa said weakly, "I'll try it . "
A minute later, the nurse followed levisk and rolled her into the hall.
About five years ago, two women who were pushed into the hospital operating room at the time of delivery died after receiving a caesarean section. sections.
Although national investigators did not find evidence of unqualified care, Dever said the hospital had examined everything carefully.
"When you have something similar happening, it will accelerate your efforts," she said . ". "Exponentially.
"Now, Dever says, she sees an opportunity to model changes that can help women fly away through the team Birth program.
"I want women from all over the world to come in and have a safe born and healthy child," she said . ".
"That's why I did it.
"They didn't flinch," Dever is about to see her pilot study of the team Birth Project pushed to new limits by little Bryce McDougall.
First of all, though, Melissa had to send Bryce's brother Brady to the hospital.
Even his birth is easier than expected and more difficult than expected.
Her face was almost half bent, with red beets, five push Melissa varieties.
She vomited and then began to work again.
Suddenly, he came.
"Oh my God, Brady, Brady," sighed Sean.
He held his son in a heater with a nurse.
Marion replaces Sean's position next to levisk, who has arrived inside Melissa to get the next twin.
Levesque's mission is to grab Bryce's foot and guide him out.
But everything is like a finger, not a toe.
"It was a hand," she whispered.
"This is also a hand.
"Marina did an ultrasound on Melissa's stomach, hoping the scan would show 1 feet.
But Bryce's feet can't see or reach.
Mariano has more experience than most obstetricians with lateral infants, a procedure called hip removal;
She asked for a try.
When Levesque moves to the right side of the Melisa, she stretches into the uterus of the Melisa, moves Bryce with her forearm and pushes it down.
Director of obstetrics Dever has walked into the room and took over the ultrasound.
Melissa has a tight face with at least six doctors and nurses around her. Shaun frowns. "Babe, you OK? " he asks. Melisa nods.
Bryce's heart rate is stable.
But there is still no sign of 1 feet.
A small hand slipped out and Marino pushed it back.
"Open the table," said Marino . " Her voice was a little nervous.
Her colleague said it was open and ready, referring to a series of sterile surgical instruments that Mariano might need soon, to start C-section.
This room with a dozen adults has become unusually quiet in 36 seconds.
Everyone is looking at Marino twisting his arms like this and is determined to find Bryce's foot.
Levisk leaned hard in Melissa's stomach.
Sean bit his lips.
And then what's Marino doing?
Wearing gloves, her blood-covered hand appeared, holding Bryce tightly on his two legs.
"Oh baby, here he is, here he is --Woo! Sean screamed.
Sean was excited again.
Melissa was exhausted with a smile.
Baby Bryce asked everyone to wait a few more seconds before howling.
Levisk began to sew a small tear for Melissa, and Marino came over to congratulate the new mother.
"He's fighting you, right?
Melissa said with a smile.
Outside the operating room, levesk and Marina looked relaxed and pleasant.
Both agreed that most doctors would pass C-section.
But on the South Bank, A McDougall hospital found a challenge asking itself to reduce C-
Experienced doctors in these unusual deliveries
People who understand and respect their parents' preferences.
"They especially want to have both children delivered in the vagina," said Marano . "
It was in her mind during the hard times.
Bryce is fine, says Marino, so her decision is that Sean and Melissa are not panicking.
They're not holding back-
"They are like 'keep going, '" Marano recalls '. ".
"Sometimes the patient says 'stop' and then you have to stop.
"The baby's father said that at the last minute before Bryce was born, he almost asked to do so.
The part of the arm
"This is very positive," Sean said . ".
But he added that at that moment he felt a little different from Melissa being part of the team.
"It makes us more comfortable and that comfort translates into trust," Sean said . ".
"We believe in the decisions they make.
Melissa said she was grateful for vaginal delivery.
"I don't want to give birth and C-section naturally.
Part, "she said.
"It will be a brutal recovery.
"Instead, 30 minutes after Marina pulled Bryce out of her, Melissa was nursing Brady and talking to her family through FaceTime.
The next assessment of team Birth Project Southbank began using the team birth method in April.
The other three hospitals are also pilot areas: St. Francis in orclattulsa. ;
EvergreenHealth, Wash, Kirkland. ;
Over Lake Redmond.
The test cycle is two years.
In the first four months of the South Bank, the hospital's mainrisk C-
Down from 31% to 27%-
Four less C-
Monthly segmentation.
Experts who contribute to the development of the team fertility program are eager to see if other hospitals can reduce C-
Lock them up.
"Once you have surpassed the early adopters, how do you show the benefits to those who are not willing to change?
Asked Gene Declercq, professor of community health science at Boston University School of Public Health.
Declercq pointed out that some insurance companies began to force this issue and refused to raise C-
High rates for partial rates or other unnecessary (if not harmful) care.
Declercq said that it makes sense for the project to focus on communication in the delivery room, as many doctors decide when to have a caesarean section based on clinical habits or hospital culture.
"If you can influence this decision --
"During the production process, you may change the culture that may lead to unnecessary cesareans," Declercq said . ".
The federal government has set a target rate for hospitals: no more than 23.
The first 9%time, low-
Risk mothers should pass C-section. The U. S.
The average for 2016 was 25. 7 percent.
Because research has shown that if a woman's first delivery is a caesarean section, the goal is established.
In part, her subsequent delivery is likely to be C-sections, too —raising her (and her baby's)
The risk of complications and even death.
The story is part of NPR's collaboration with WBUR and Kaiser Health News.