Updated: Oct 28, 2020
Alright, folks. Let's talk about cesarean birth in BC. Last year our province had 35% of births being surgically performed, with rates for Fraser Health being closer to 40%. The World Health Organization says an ideal c-section rate is about 10-15%. Some communities, like Ina May Gaskin's Farm, have had cesarean rates as low as 2%! Surely we can do better here.
Again this week I saw a birth announcement on social media from an acquaintance, with photos of the exhausted new parents each holding their baby, the dad still wearing his scrubs from the OR. They had a long labour, were in the hospital for most of it, and ended up with an emergency cesarean. This kind of story is so common.
We all know that a surgical birth is the best choice in some cases. Perhaps it's for a medical reason: high maternal blood pressure, issues with the placenta, and babies in distress are some examples. Also, sometimes people may choose to have a cesarean birth for non-medical reasons. Everyone has the right to choose how they will give birth, and their reasons are their own. We are grateful that we have OBs in our hospitals who are skilled at performing this surgery, for those who need or want it.
Now, let's talk about those other cases, like the one mentioned above. Let's talk about the people who plan to have an intervention-free vaginal birth, but somehow end up in the operating room to meet their baby. They learn what they think they need to know, and they trust their medical team to support them along the way. They go to the hospital once they are in labour, looking for the support they need. Often labour slows down or is taking longer than they expected, and after a while they get tired or anxious and end up agreeing to interventions they hadn't planned on. This results in a cascade of interventions that leads to an unplanned "emergency" c-section. Sound familiar?
If you look at the Society of Obstetricians and Gynaecologists of Canada's info leaflet about c-sections, you'll notice that they cite things like "the birth process is slow", and "labour is too long" as reasons to perform a c-section. This is one part of the problem that we have the power to change. This is where families in BC can be better supported to allow their birth process to unfold in its own unique and unpredictable time. A long labour is not an emergency. Birth taking a long time is normal and good. Babies need time to find their way through the pelvis, time for their little heads to turn and mould as they slowly descend. Birthing people's bodies need time to gently soften and open and allow the baby to pass through. There is no magical formula of dilation per hour which holds true for every body, or every birth. (Evidence Based Birth has a great article about this).
So, how can families be better prepared for and supported during their birth process? How can we avoid these diagnoses of labour being "too long" or "too slow", or, perhaps the worst one of all, "failure to progress", that lead to unplanned c-sections?
First of all, the choice of medical care provider and place of birth is a really big deal. Our society has become used to the relatively new idea that giving birth is a medical event, requiring the care of doctors in hospitals. This isn't necessarily true. As we said earlier, it's wonderful that we have OBs who can take care of the people who have complications in pregnancy and birth. Obstetricians are highly trained surgical specialists who can safely help babies be born in a hurry when needed. However, more often than not, this kind of specialized help is not needed. What's needed is patience, a warm and dimly lit space where the birthing person feels safe, and people who believe in them and in the birth process.
Birth is a normal physiological process, and when someone is healthy and has an uncomplicated pregnancy, it can be safely experienced in the comfort of their own home, with the people of their choosing. We are so lucky in BC to have midwifery care available (and covered by MSP), making home birth with trained medical care an option. Dr. Rosenthal, an obstetrician, said that "the first intervention in birth that a healthy woman takes is when she walks out the front door of her home in labour". For anyone having a low-risk pregnancy and wanting an intervention-free birth, learning about home birth and deciding if it feels right for you is a great idea. We, like other mammals, instinctively prefer to be in our own little dens to have our babies. This is where we feel safe and comfortable, and our hormonal orchestra best plays out to keep birth moving along. (If you want to learn more about the role of hormones in birth, check this out.) When we leave our 'den', we interrupt the hormonal flow. If you do some research on home birth and decide not to have your baby in your home, it's still a good idea to stay at home until you're well into active labour before going to the hospital.
Another way for an expecting family to best set themselves up for an intervention-free birth is to have someone there whose entire focus is on the birthing person's (and their partner's) emotional and physical needs. Someone who will spend time with them during pregnancy, give them information about the realities of birth, and help them to create strategies for coping at each stage. Someone who will show up at their house when they are in labour and feel like they want some support. Someone who will be that continuous calm presence, making sure that everyone is drinking, eating, and resting as needed. Someone who knows when to step in with hands-on comfort, and when to sit back and let them be in it together. Someone who can show the partner how to help the birthing person deal with the strong sensations of birth. Someone who whispers words of encouragement when it's exactly what they need to hear. Someone who will be there as soon as they want support, and will stay until after the baby is born, to be sure that they are all settled in as a new family.
Having the support of a doula increases the likelihood for someone to have a spontaneous vaginal birth. People with doulas are also less likely to have any pain medication, epidurals, negative feelings about childbirth, vacuum or forceps-assisted births, and cesareans. (You can read more about the evidence on doula support here.)
Long and slow labours can be so difficult to go through, especially if there are long stretches with no measurable 'progress' being made. It can be even more difficult when people are charting, timing, monitoring, and expecting things of you that you can't seem to achieve. Our recommendation is to avoid (or at least delay) entering the place where birth is measured, monitored, and managed. Stay for as long as you can in your cozy den, with your chosen few who will support and witness you as you do this amazing thing.
So, what BC families need to do in order to lower their chances of having an unplanned cesarean birth is to carefully choose the place where they will have their baby, and the people who will support them through it. We can do this. One family at a time.