One of the most important lessons from last week’s NIH meeting on VBAC is that, if we reduce the primary cesarean surgery rate, fewer women and babies will be at increased risk in future pregnancies because of a uterine scar. So, what can we, as childbirth educators, do to bring down our sky-rocketing cesarean rate? Ideally, we can reach expectant parents in early pregnancy and help them to plan for a healthy pregnancy and birth. If your students are primarily planning to birth at home or in birth centers, you will not have to spend much time on avoiding unnecessary cesareans. However, if like many of us, you teach in a hospital and meet your students in traditional, third-trimester childbirth classes, encourage them to do the following (printable pdf):
1. Let labor begin on its own. Medical studies have clearly shown that induction almost doubles the likelihood of cesarean surgery for a first-time mom.
2. Hire a doula or arrange for a woman experienced with childbirth to stay with you and your partner throughout labor. A good doula will not interfere in the relationship between you and your partner. Instead, she will provide reassuring support for both of you and recommend comfort measures.
3. Stay at home in early labor. Labor takes much longer than most people think. Recent studies suggest that the average labor for a first birth is somewhere between 12 and 17 hours. At home, you can move around freely, take a walk in a nearby park, relax in your tub, and eat lightly according to your appetite. Once you get to the hospital, there may be a focus on getting birth “done” in a certain time period.
4. Ask that your baby be monitored intermittently (at regular intervals) rather than continuously. The American Congress of Obstetricians and Gynecologists (ACOG) states that intermittent monitoring is just as safe for low-risk women as continuous monitoring and that continuous monitoring is associated with an increased risk for cesarean surgery.
5. And ask for a “hep lock” or “saline lock” rather than IV fluids. Being “hooked up” to an IV restricts your ability to move freely and to use comfort measures such as the bath and shower. ACOG says that it is safe for women with uncomplicated labors to drink clear fluids during labor.
6.Move around! Bring your birth ball and use it. Ask for a room with a rocking chair. Staying upright, walking, and changing positions frequently may shorten your labor by about an hour. When labor progresses at a good pace, it is less likely that your health care provider will recommend a cesarean for “failure to progress.”
7. Try natural methods of pain relief to delay/avoid epidural analgesia. Although it is controversial as to whether epidurals increase the risk for cesarean surgery, there is no question that the interventions required when you have an epidural (for sure, continuous monitoring and IV fluids; and often, medications to speed up labor, a catheter in your bladder, and a forceps or vacuum delivery) change the ways in which you labor. Many women find that a warm bath substantially reduces the pain of labor. A shower, walking or slow dancing, bouncing or swaying on a birth ball, massage, and reassurance from your partner, your doula, and your health care team all will help you to cope with contractions. Remember that the hardest part of labor is also the shortest part.
8. Ask for more time. As long as you and your baby are doing well, it is okay for labor to last a long time. If the average labor for a first-time mom is 12 to 17 hours, then some “normal” labors will take much longer than that. Plateaus, when labor slows or even stops for a while, are also considered normal.
9.Do not begin pushing until you feel the urge to do so. Some health care providers want your baby to be born within a specified time limit after you begin pushing. Whether you have an epidural or not, waiting to push until you feel the urge to will decrease the time you spend pushing. Pushing in response to your body’s urges, rather than being “coached” to push, is safer for you and for your baby.
10. Believe in birth and in yourself. Most women (at least 85 to 90% according to the World Health Organization) can and should give birth naturally (vaginally). Do all that you can to make birth as safe as possible for you and for your baby.
In addition to encouraging the ten strategies listed above, you also may want to distribute in your classes the new handout by the Coalition for Improving Maternity Services (CIMS), The Risks of Cesarean Surgery. The six healthy birth practices identified by Lamaze International promote safe and healthy birth. Visit the Lamaze website at www.lamaze.org to download free video clips and pamphlets for each healthy birth practice. In our handbook, Prepared Childbirth – The Family Way, we discuss strategies to reduce unnecessary cesareans on page 53, “Are All Cesareans Necessary?”
As of April 1, the Joint Commission has identified the “low-risk cesarean rate” as one of the new Perinatal Quality Measures. In addition to promoting cesarean-reducing strategies in your classes, work within your hospital to develop protocols and policies that promote natural, safe, and healthy birth.The time has come for all of us: childbirth educators, nurses, providers, and administrators (as well as legislators, insurers, attorneys) to work together to decrease our alarming and dangerous cesarean rate.
If you’d like the references to any of the “Top Ten” points, please email me at amis@thefamilyway.com.