The
Art of Avoiding a Caesarean Birth -- the basics
by Claudia E. Villeneuve
 The
rate of Caesarean births has been steadily increasing for
the past 20 years. Statistics Canada reported a 17% Caesarean
rate in Alberta by December 2000, and Alberta Health estimates
suggest that the current rate might be closer to 25%. This
means that almost one in four women are now undergoing
major abdominal surgery in order to give birth. The World
Health Organization, the health agency for the United Nations,
recommends a Caesarean rate limit of about 10% because
of the increased risk to mother and baby without improvement
in birth outcomes.
Fortunately there are many things one can
do to avoid surgery. The two most common reasons for needing
a Caesarean are failure to progress (FTP or dystocia) and
cephalo-pelvic disproportion (CPD). FTP means that the contractions
are not effective in getting the cervix opened and the baby
born, and CPD means that the baby's head is considered too
big or the pelvis of the mother is considered too small to
allow the baby to be born. Both of these situations can be
prevented with careful preparation.
The first thing to remember is
that vaginal birth without drugs, commonly referred to as
natural childbirth, is a valid and safe option for most women.
The two concerns over natural childbirth are the fear over
labour pains, and the fear of not being able to birth the
baby safely without help. The pain is easily manageable if
you respect, according to Dr. Michel Odent, the five physiological
needs of the labouring woman: 1. quiet and peaceful surroundings,
2. soft lights or darkness, 3. the presence of a mothering
figure for security and protection, 4. privacy and not feeling
observed, and 5. the comfort given by a warm room or by immersion
in warm water. If these conditions are present, the woman
will “lose” herself in labour and achieve a natural state
of contemplation. Only then does the woman release all tension
and the labour can work unobstructed. The other concern is
the fear of not being able to birth the baby safely without
help. This is when a capable caregiver can assure the woman
that her body has carried the baby successfully for nine
months and that there is no reason to assume that she cannot
give birth to it. Boosting her confidence has the effect
of relaxing the woman, allowing the contractions to work,
again, unobstructed.
The second thing to remember in
labour is to allow the woman free mobility, and also give
her food and drink. A woman should be encouraged to move
freely and assume any position in labour that she prefers.
Standing, sitting, rocking, doing lunges, kneeling, crawling,
crouching, or just leaning forward, all improve the position
of the baby, of the pelvis and of the uterus. Optimal positioning
eases cervix dilation and aids in pushing. Labouring and
pushing while lying flat on a bed defy gravity and the physics
of birth. Pushing in this position is actually pushing the
baby upwards into the air, against gravity, and restricting
the pelvis from moving out of the way as the baby's head
passes through. Many Caesareans are called during the pushing
stage because the baby seems “stuck” when, actually, the
bed is holding the pelvis fixed. If you cannot move, then
lie sideways on the bed, allowing only a small side of the
pelvis to be fixed. Your partner or birthing doula could
hold your top leg up while you push.
When hungry, the woman should have unrestricted
access to food and water. We have to remember that labouring
is an extenuating physical activity requiring nourishment
for comfort and energy. The uterus is a muscle and muscles
need nourishment to perform. If this is not possible, then
eat properly at home before going to the hospital or birth
centre, and if you are having a homebirth, then happy eating.
The third thing to remember is
that if anywhere in labour, or before labour, you introduce
drugs, such as a drip for labour induction or an epidural
for pain relief, then you are experiencing a medical birth.
A medical birth, just like a natural birth, requires preparation.
A birth using drugs reduces the opportunities for the woman
to collaborate in her own labour. Furthermore, this type
of birth requires procedures such as IV (intravenous feed),
EFM (electronic fetal monitor) belt, and urinary catheter
(since the epidural dulls our bladder responses). Usually
a labour induction with the drip becomes very painful very
quickly, as opposed to a typical natural labour where pain
builds up gradually. This drives women to ask for an epidural,
an injection in the spine, to temporarily numb the abdomen
and the legs from pain. At this point, the progress of labour
depends mostly on the drip since the contractions she is
experiencing are not really her own. An epidural alone usually
slows down labour because the pain sensations signalling
to the brain that contractions are taking place disappear,
making it probably necessary to inject an induction drip
anyway to get contractions going at a steadily higher and
higher rate. In this state, drip and epidural, the woman
feels nothing, no pain and no contractions, but she is bedridden;
and she cannot help the progress of labour or position her
pelvis properly to birth the baby. This is how a failure
to progress or a CPD diagnosis can occur, leading to a now-necessary
Caesarean.
Even when accepting these interventions,
do try to be selective on when and how you receive them.
Timing and quantity are very important. For example, if you
need an induction drip you could request that it is postponed
as much as possible until you feel you want an epidural,
or ask that the induction is not continuous but intermittent
to allow your own body to catch up with the contractions
and with the pain. If you want an epidural, request that
it is postponed as much as possible, at least until after
5 cm of cervix dilation (full dilation is 10 cm) so that
you are sure that your body is in active labour and that
progress will not stop. You can also request a “walking epidural” meaning
that the dose is so low that you can still walk, get in the
shower, and even birth in any position you want.
The fourth and last thing to remember is
that the liberal use of the EFM, to measure baby's heartbeat
and the intensity of contractions, has been linked to the
increase of Caesarean births. This is because: (1) it may
give a false reading of fetal distress, requiring a Caesarean,
and (2) forces bed confinement, limiting the free movement
of the woman which is critical in allowing the baby, pelvis,
and uterus to fit together properly. Therefore be selective
on how long you stay on the EFM. You could request that the
staff monitor intermittently rather than continuously, allowing
you to get out of bed and walk around, or you could ask that
a handheld Doppler be used.
Following these suggestions, also found
in Caesarean avoidance books, have helped thousands of women
avoid a Caesarean. These women include those who have experienced
not just one, but two, three or more Caesareans in the past.
Avoiding surgery in the first place makes good sense because
a scarred uterus can compromise our future fertility, pregnancies
and labours. Women who seek a VBAC or vaginal birth after
Caesarean are under great pressure to “perform,” meaning
that their labours have to be near perfect to avoid a repeat
surgery, which is a lofty goal indeed for more reasons than
we could ever fit in this article. VBAC also stands for very
beautiful and courageous. Indeed.
Article from Summer 2004 Issue
of Birth Issues, published by ASAC in Edmonton.
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