Avoiding
Medical and Surgical Birth
by Karen Mykietka
My one-year-old toddles over and plops
herself in my lap as I sit on the floor with four other moms.
Preschoolers run around playing with toys, some babies' nurse,
others sleep. This is playgroup. Our snatches of conversation,
in between child interruptions and referee duty, jump from
topic to topic. As so often happens in a group of mothers,
the topic comes around to childbirth.
Jacqueline, who gave birth to her second
child less than two months ago, shares how her doula 1 came
over early in her labour. They went for a walk together then
ran some errands. Five hours later, they picked up Jacqueline's
husband and went to the hospital, but they did not check
in. They wandered in the hospital, Jacqueline stopping when
necessary to pant during contractions. When she did report
to labour and delivery, she was 8 centimetres dilated. She
birthed her baby a few hours later. Jacqueline's story illustrates
two things all women should do if they want to avoid unnecessary
interventions during labour.
TIP: Hire a doula
TIP: Stay home as long as possible
In the past, women birthed their babies
vaginally except in rare circumstances. Talk to a group of
mothers today and probably one-quarter of them had a surgical
birth. In all likelihood the majority of others had one or
more medical interventions such as induction, epidural anesthesia,
forceps, vacuum extraction, or electronic fetal monitoring.
More and more women are having an epidural for pain relief.
While women may be “choosing” this pain relief method, in
my opinion, it is likely many of them did not have a clear
understanding of benefits, risks and alternatives.
Medical interventions in childbirth can
be invaluable and life-saving; however, their use should
be evidence-based. Unfortunately, many of the decisions made
in obstetrics today are not based on scientific evidence.
They have more to do with “expert opinion,” doctors' preferences,
fear of being sued, and lack of appreciation for and skill
in natural childbirth. Furthermore, women are not given all
the information they need to make truly informed decisions
about their care.
TIP: Avoid an epidural (explore
other options of pain management)
Caesarean
The ever increasing use of Caesarean surgery
is a prime example of misuse of technology in childbirth.
The Caesarean rate in Canada hovered around 18-19% for 10
years; by 2000-01 it had reached 21.2% despite attempts to
lower it. According to the World Health Organization any
rate over 15% signals “inappropriate usage.” Now, whether
women should be able to choose Caesarean birth over vaginal
birth is being debated. Thankfully, in March 2004, the Society
of Obstetricians and Gynaecologists of Canada (SOGC) released
an advisory stating SOGC “does not promote Caesarean sections
on demand.”
Terms
• Caesarean (C-section) :
major abdominal surgery to remove a baby from the womb of
the mother.
• Emergency Caesarean : urgent surgery that takes place
immediately upon discovering the life of the mother or baby is at risk.
• Elective Caesarean : a non-urgent scheduled C-section.
The procedure may be medically necessary or chosen over vaginal birth because
of physician or patient preference.
• VBAC : Vaginal birth after Caesarean
SOGC states, “the decision to perform a
Caesarean section during labour and delivery should be based
on medical indications.” There are instances both urgent
and non-urgent when C-sections are absolutely necessary (e.g.
hemorrhage, placental abruption, eclampsia, placenta previa,
or cord prolapse). Many of the other clinical reasons given
for a Caesarean are not as clear-cut (pelvis too small, large
baby, fetal distress, twins, breech, previous Caesarean). 2
Connie Banack, Education Director of the
International Caesarean Awareness Network (ICAN) and mother
of four, says, “My three Caesareans were not necessary but
were caused by doctor impatience during long labours and
my fears based on ignorance in my first pregnancy and past
experience in my subsequent pregnancies.”
TIP: Don't rely on your doctor.
Do your own research.
Statistics indicate that non-medically
necessary C-sections are rampant. In northern and central
Alberta hospitals, the Caesarean rate varies between 4.9%
and 46.2%. So why do the rates differ so much from region
to region and hospital to hospital? Big city hospitals which
provide specialized services serve a higher-risk population
and would be expected to have somewhat higher surgery rates.
Yet the hospital with the highest rate is in Daysland, a
small community in east central Alberta. With only 52 births
in 2001, it had a whopping 46% C-section rate. This was an
85% increase from the hospital's 1999 C-section rate.
It is improbable the area was flooded with
high-risk women or that it has a higher incidence of obstetrical
emergencies than the rest of the province. The most likely
explanation for the high C-section rate is doctors' preferences.
Caregivers differ in the support they give labouring women
and the decisions they make about when to offer surgical
birth. Differences in regional policies and values also impact
intervention rates.
All consumers have a right to know their
doctor's and their hospital's track record in obstetrics.
Ideally, you would use this information to help you select
a caregiver, but in smaller communities there may be few
if any choices in care. Do not let anyone tell you statistics
are unavailable. Every doctor, hospital, and health region
receives a report with their perinatal statistics annually.
TIP: Find a doctor (and hospital)
with low rates of interventions
VBAC
One reason the Caesarean rate is increasing
is that once a woman has a Caesarean birth her subsequent
births are also likely to be by Caesarean. Only 15% of women
in Alberta even attempt a vaginal birth after Caesarean (VBAC).
Caesarean results in increased risks to mother and baby,
increased hospital stays and increased health costs; hence,
the Society of Obstetricians and Gynaecologists of Canada
states hospitals should promote VBACs. This, however, does
not happen. Hospitals often institute restrictive policies
on VBAC while many doctors do not promote VBAC but discourage
it.
TIP: Avoid induction
In fact, women who make informed decisions
about delivering their babies vaginally are often denied
this option. Penny Lindballe, who lives in Galahead, was
refused a vaginal birth after Caesarean by three different
doctors in her area. Not willing to compromise, she travelled
two hours to birth her baby with a midwife in a Red Deer
hospital. She says, “The most maddening part of the whole
scenario is that unnecessary surgery is permitted but support
for the other end of the spectrum (unmedicated natural physiologic
childbirth) is extremely lacking, not only philosophically
but monetarily as well.”
The SOGC clinical practice guidelines are
supportive of VBAC. Even women with twin pregnancies, breech
presentations, large babies, or more than one previous Caesarean
are acceptable for a VBAC. The guidelines state, “Every hospital
engaged in obstetrical care and capable of providing an emergency
Caesarean section should be able to offer care for a woman
undergoing labour after previous low segment Caesarean section.” 3 They
do not say VBAC is limited to hospitals where specialists
are immediately available (as the revised U.S. guidelines
state). The recommended “decision to incision” time in the
U.S. is 30 minutes (although a study showed that half of
emergency C-sections exceeded this time).
Despite SOGC endorsement of VBACs, many
hospitals across Alberta are reluctant to do them; some go
so far as to ban them. The risk of uterine rupture is often
used as an argument against VBAC but it is obstetrical practices
(like suturing in only one layer instead of multiple layers
and induction) that increase the risk of rupture. “Emergencies
are not isolated to VBAC women,” says Tonya Jamois, president
of the International Caesarean Awareness Network (ICAN). “If
a hospital is unable to provide emergency care for a VBAC
woman, then it is also unequipped to care for any labouring
woman who might experience complications.” The real reason
VBACs are not encouraged is because they are “inconvenient” for
the doctor. As one woman was told by a doctor, “I don't want
to waste my time babysitting a VBAC when you will end up
with a C-section anyway.”
Often there is no logical reason for banning
VBACs, yet it is done anyway. There are six hospital/health
centres in the Capital Health Region doing obstetrics. Fort
Saskatchewan does C-sections (scheduled and emergency), but
when asked about VBAC the comment was, “you may be more comfortable
in the city.” The midwives working in the Shared Care program
at the Westview Health Centre in Stony Plain were told by
Capital Health they could not take VBAC clients because they
do not have 24-hour emergency surgery available. Yet they
can have a woman in a city hospital operating room within
30 minutes, which is acceptable for other obstetrical emergencies.
So why isn't this acceptable for the remote possibility of
a VBAC emergency?
When researching your VBAC options, there
is more to consider than just whether or not a hospital will
allow a “trial of labour” as they call it. It is essential
that a woman trying a VBAC work through her fears before
labour. During labour, she must feel safe in her environment,
have a trusted support person and not feel rushed or on the
clock. In hospitals, women attempting VBAC are often forced
to have a “trial of labour” in an operating room (which already
assumes failure). Because hospitals do not meet women's needs
and many doctors decide to do a Caesarean at the slightest
hiccup, often women attempting VBAC are unsuccessful. As
with anything else in obstetrics there can be huge differences
in success rates from hospital to hospital and doctor to
doctor.
Your best chance of having a VBAC is with
a midwife at home or in hospital. Midwives have near a 100%
success rate. There is little difference between the Royal
Alex, Grey Nuns, and Misericordia Hospitals in Edmonton;
of the 42% women who attempt VBAC about three quarters are
successful. The Sturgeon Hospital in St. Albert has a better
success rate at 84%. Grande Prairie also has good success
with VBACs (79%), but only slightly over a quarter of women
attempt a VBAC. Fort McMurray and Red Deer have much lower
success rates (57%). From the statistics, the best place
in Northern or Central Alberta to try a VBAC is Wetaskiwin.
This hospital sees around 400 births a year, and of the 86%
of women who attempted VBACs, all were successful at having
a vaginal birth.
It is probably easier to find a doctor
willing to do a patient-choice Caesarean than a VBAC. Women's
choices with regards to VBAC are limited and getting worse.
The best choice (VBAC at home with a midwife) is not supported
by SOGC nor is it accessible by all women due to lack of
public funding and the small number of available midwives.
Funding midwifery could actually worsen the situation rather
than improve it. Since British Columbia funded midwifery,
VBAC is rarely attempted at home.
TIP: Know your rights. You have
the right to refuse any medical procedure.
Despite the fact that SOGC says it promotes
natural childbirth, if a woman wants a natural birth, she
will likely have to fight to have one. All women, even those
planning a natural birth, need to inform themselves on Caesarean
because there is a one in four chance their doctor will want
to do one. 4 Patients
have the legal right to make informed decisions; their decision
can be informed consent or informed refusal. Do not let anyone,
including doctors, intimidate or coerce you into having a
procedure you do not want.
The Society of Obstetricians and Gynaecologists
of Canada, Alberta Medical Association, Alberta Health, the
regional health authorities, and regional perinatal committees
are supposed to be promoting excellence, quality assurance,
evidence-based practice, and equitable access to services.
Personally, I am not impressed with their track record. Consumers
need to speak out: make complaints when necessary and demand
change.
1 A doula
is an experienced labour companion who provides physical
and emotional support before and during labour. (return)
2 Read Obstetric myths versus research
realities by Henci Goer for more on this topic. (return)
3 Low segment refers to the type of incision
which is the most commonly used incision today. The type of incision used
during Caesarean surgery affects whether a women can ever attempt a vaginal
birth. (return)
4 A great new resource is a booklet by Maternity
Wise called “What Every Pregnant Woman Needs to Know About Caesarean Section” available
on-line at www.maternitywise.org (return)
Labour and delivery interventions
Canada, 1991-1992 to 2000-2001
Intervention rates |
|
1991-1992 |
2000-2001 |
Induction |
|
16.5 |
22.0 |
Caesarean |
Overall 1 |
18.2 |
21.2 |
|
Primary 2 |
12.4 |
15.6 |
|
Repeat 3 |
73.2 |
70.1 4 |
Assisted vaginal delivery |
|
|
|
(forceps or vacuum extraction |
|
17.4 |
16.3 |
Episiotomy |
|
49.1 |
23.8 |
1 Percent of total births delivered
by Caesarean
2 Percent of Caesarean deliveries to women who
have not previously had a Caesarean delivery
3 Percent of Caesarean deliveries to women who have had a previous
Caesarean delivery
4 Repeat Caesarean rate dropped to 64.7 in 1995-96, and then rose
steadily
Article from Summer 2004 issue
of Birth Issues , published by ASAC in Edmonto
Return
to Articles
Previous Next
|
