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.
This is the story of how that baby, Bryce McDougall, tested the best efforts of more than a dozen medical staffers at South Shore Hospital in Weymouth, Mass., that day last summer.
Bryce's birth also 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.
The story starts before Bryce's birth, on the last day of August at about 9:30 in the morning.
Melisa McDougall has just checked into South Shore, after a routine ultrasound. She's in her 36th week, pregnant with twin boys. The doctors have warned Melisa that her placenta won't hold out much longer. She's propped up in bed, blond hair pulled into a neat bun, makeup still fresh, ordering a sandwich, when her regular obstetrician arrives.
"How are you?" asks 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 -- is head-down, ready for a normal vaginal delivery. But brother Bryce is horizontal at the top of Melisa's uterus.
That's one reason Melisa is a candidate for a C-section. Babies do not come out sideways. And there's another reason most doctors would not consider a vaginal delivery in Melisa's case, Levesque says. 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 may be greater for Melisa because she's 37 and having twins. But the McDougalls hope to have vaginal deliveries for both boys.
"I just feel like it's better for the kids -- better for the babies," Melisa says.
How The 'Team Birth Project' Came To Be
Avoiding C-sections is also 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.
In describing the collaboration, Shah begins with an acknowledgment: Childbirth is complicated. 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 says 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, 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 members of the labor team. The team members map 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 McDougall, the white erasable planning board gets a lot of use.
Under "Team," Levesque and registered nurse Patty Newbitt write their names. Melisa and Shaun McDougall are also 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.
Good Communication Throughout Labor And Delivery Is Key
Dr. Kimberly Dever, who chairs the OB-GYN department at South Shore, highlights 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 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."
'They Did Not Flinch'
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.
"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.
Next Assessment For The Team Birth Project
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.