On January 10, 2006, after twenty-six hours of labour, I gave birth to my first son. I was so exhausted, but so happy! What a beautiful baby boy, chubby, healthy, breathing. We gazed at each other as he lay naked covered in white vernix on my bare chest, although I was so tired I could barely keep my eyes focused.
Where do you picture this birth happening? What is the first image that comes to your mind?
If you pictured the hospital, you are right. Most women in Canada give birth in the hospital, with a doctor there for the actual delivery and nurses to monitor the mother and baby during labour.
What kind of maternity care are women in Canada receiving? We often think that because the government is providing maternity care, that the maternity care we are receiving is the best possible. But is this true? What makes good maternity care? What makes the best maternity care?
There are other details to my story.
I had heard good reports about my local hospital: they had one private room for each woman, and you laboured, birthed, and roomed with your baby there. There was a private bathroom in each room, and women could use the shower to help with natural pain management. Birthing balls (exercise balls) were available, and walking was allowed.
I was a bit worried about who my doctor would be, as I had two doctors, and they were on call on different weeks. I felt comfortable with Dr. Williams and that she understood my requests to decrease the use of technology that had little or no research on safety and benefits behind it, such as routine ultrasounds and use of the Doppler to listen to the baby’s heart rate, while Dr. Ikeji didn’t.
But I had a birth plan, all written out and shared with my doctors, and I was confident that I could have the birth I wanted and that was best for the health of my baby, without pain medication and a vaginal delivery, in the hospital.
When you pictured the birth of my son, how did you imagine that he was born? Were we in the operating room, and he had just been delivered by cesarean section? Or were we in my hospital room and he was born vaginally?
I went into labour on the evening of January 8. I laboured at my house for a few hours, using a birthing ball and breathing through contractions, and then went into the hospital at 3 am because I wanted someone to reassure me and give me guidance on my labour. In retrospect, I wish I had a doula. A doula’s job is to support the mother, usually starting at the mother’s home, and to reassure her about her progress, help with natural pain management, provide emotional support to the mother and her partner, and help the mother advocate for herself with hospital staff. A doula would have provided the reassurance I needed so I didn’t feel the need to go to the hospital so early. Doula services have been shown to reduce the length of labours, reduce the need for pain medications, and reduce interventions.1
The hospital nurse checked my dilation and encouraged me to go back home, as I wasn’t very dilated. I went home, and laboured there until about 3 pm, when I went back to the hospital. My water had not broken. The car ride was very painful.
I was disappointed to find out that Dr. Ikeji was the doctor on call. She came in to check on me and told me I wasn’t in serious labour as I was still in the smiling stage. I felt bothered by this. I felt she was invalidating my experience.
A few hours later she came back and suggested an amniotomy (breaking my water), which she said would help speed up labour. I had read in Having a Baby, Naturally that breaking the water is not generally a good idea, but Dr. Ikeji assured me it would be fine. I consented. I found out later that research has shown that amniotomies do not speed up labour.2
Before the amniotomy, Dr. Ikeji offered me drugs. I had clearly told her that I wanted a natural birth without pain medication, and drugs had not even crossed my mind while I was in labour. I refused the drugs, but told her that if I felt like I couldn’t cope later on then I knew I had the option. At the time I wasn’t bothered that she offered me drugs, but now I am. I’m quite angry, actually. Pain medication in labour has risks for both the mother and the baby, which should not be taken lightly. There is no reason to offer a mother drugs if she is coping well using natural methods. I wonder if she would have gone over the risks with me if I had decided to take drugs. Research has shown that babies that are exposed to opiates (like morphine) during labour, are at a much higher risk of drug addiction later in life.3 Research has also shown that babies have more difficulty breastfeeding after medications like morphine or an epidural, they cry more, and their heart rate can be altered unfavourably, along with risks to the mother.4, 5
After the amniotomy my labour became more intense. I went into the shower, moving my hips and swaying, which helped. I started to feel the urge to push, just a little bit. The hospital staff wanted to check me to make sure I was ready to push, and apparently there was a bit of a lip on my cervix still. I really, really had to push. But Dr. Ikeji told me to lie on my side and NOT PUSH. This was incredibly, incredibly hard. My husband says I was speaking gibberish, and I remember him counting through the contractions with me, and my mom doing blowing breathing with me so that I wouldn’t push. I don’t remember how long this went on, but finally I was given approval to push. I found out later that spontaneous pushing can actually help to dilate the cervix, and there is no risk of the cervix swelling if the woman is not being directed to push but pushing how she wants with her own urges.6
The back of the bed was propped up so it was like a couch, and I squatted facing the back of the bed and pushed. This felt agonizing and great at the same time. Dr. Ikeji thought I would have the baby soon, and asked me to turn from squatting into semi-sitting. When I was semi-sitting she and the nurse instructed me on how to push: hold your breath and give a big push, three times for each contraction. I obeyed. I knew from my reading that directed pushing wasn’t necessary and following my body’s instincts was better, but they seemed so confident that this was the right way. I found out later there is no evidence that directed pushing shortens the length of labour, that it can lead to a decrease in the baby’s heart rate, and that there is a greater risk of perineal tears.7 I also knew that squatting and allowing gravity to help would make labour more effective. Dr. Ikeji wanted to make sure that she had a good view when the baby was born, so she wanted me to stay in a semi-sitting position, but finally she ‘allowed’ me to squat for a few contractions. There was a bar that could be positioned over the bed and used for holding onto while squatting, which I tried and which was very exhausting. I thought maybe the floor would be more conducive, but then I had to get up and down off the bed. I was literally doing gymnastics in labour. My original position facing the back of the bed had been much better for me, but no one suggested I return to it.
It’s no wonder I was getting very tired and my contractions were getting weaker. Dr. Ikeji suggested we augment my labour with pitocin, a hormone that imitates the oxytocin the body makes naturally to contract the uterus. I had a sense from my reading that augmentation wasn’t a good idea, as it was interfering with the body’s natural processes, but she and the nurse assured me they would give me the lowest dose and it would just help my contractions be a bit stronger to make all the work I was doing more effective. I consented. The nurse had trouble putting in the IV, and I bled a lot. I felt stressed. There is not enough information about what effects augmentation during pushing has on the labour process or on the baby. I don’t know how the augmentation affected my baby, and I still don’t know how he is affected to this day.
Finally, finally! my baby’s head was crowning, after two and a half hours of pushing. Dr. Ikeji asked for the bright spotlights to be on so she could see everything clearly. I had wanted my baby to be born in a dim atmosphere, to make his adjustment into the outside world as gentle as possible. But I consented to the lights. I asked Dr. Ikeji how my perineum looked, as I didn’t want to tear. She said it looked fine. My baby’s head was out, and Dr. Ikeji told me to give one big push, so I did and he was born. He was placed on my chest, and I found out he was a boy!
A few minutes later I found out that I had a severe perineal tear, from my vagina to my anus (3rd degree). I discovered almost a year later when I talked to a midwife that this was most likely because of Dr. Ikeji’s directions to give one big push at the end. Going as slowly as possible right at the end is important to prevent tears. I required a lot of stitches, and I was told by the nurse that Dr. Ikeji was the best doctor at repairing tears because she used to be a plastic surgeon. Sitting was painful for a long time, and made it more difficult to care for my baby.
My birth plan had made it clear that I wanted my baby to stay on my chest for at least one hour after the birth, as I knew from my reading that this gives the baby a chance to start breastfeeding on his own and is important for bonding.8, 9 I was quite tired and I started shaking, and perhaps the nurse thought I shouldn’t have to hold the baby, because she took him off my chest to be weighed and measured about half an hour after he was born, as I was being stitched up. I was so tired that I wasn’t thinking about what I had read or what I had wanted. A doula would have been very handy at this moment to help me advocate for what I wanted, along with quite a few other moments during the birth. I could have kept holding my baby, especially with my husband there to help me, even if I was shaking and tired.
My son did not start breastfeeding until three days after he was born, and it was a very difficult time for all of us. The nurses kept trying to help, but they would push his head onto my breast and that was not okay with him. I also worried about him having the perfect latch, which detracted from our attempts to breastfeed. Finally my husband suggested I lie down in bed and put my son close to my breast but not on it. My son made his way to my breast, latched on, and breastfed for forty-five minutes. I had blisters, but at least we had started the breastfeeding relationship. I found out later when I attended a lactation management course about the breast crawl, and later about biological nurturing, methods that use the baby’s natural instinct to crawl to the breast, bob their head, and latch on effectively. The mother should be lying down, semi-sitting or sitting, with the baby held upright between her breasts or on her abdomen, with her hand supporting the baby’s neck if needed, but not pushing or guiding.10
I had what many would call a ‘good’ birth. I was not induced. I had no drugs. I used natural pain management techniques. I moved around during my labour. I had a vaginal birth without use of forceps or vacuum. I did not have a cesarean section. My baby eventually started breastfeeding, and breastfed until he was almost three years old. But…I still experienced a multitude of practices and attitudes that were not evidence based and not what I wanted.
I feel I was fortunate to escape my hospital experience without any of these major interventions and complications. Many women in Canada are not so lucky.
Twenty-five percent of all births in Canada are by cesarean section. That’s a lot of major abdominal surgery with high risks, and far above the World Health Organization’s recommended 5%-10% cesarean sections for optimal health of both mothers and babies. At least 15% of cesarean sections in Canada are ‘unnecessarians’—unnecessary major abdominal surgery that has risks for both the mother and baby. The current attitude of many doctors in Canada and the hospital environment creates the atmosphere that leads to this unnecessary surgery.
And what about the other births, the vaginal births? How many of these are full of unnecessary interventions leading to other complications and long term health problems? And even if complications are few, how many women are treated by doctors in a condescending manner, or with an attitude and a perspective that does not support the woman listening to her own body and doing what is best for herself and her baby? How many women are subjected to practices that have no evidence of any benefits to the mother and baby, and in fact can cause harm?
And this is one of the keys to defining the best maternity care. The best maternity care uses practices that research shows has clear benefits, with full disclosure of risks and involvement of mothers in weighing the risks, and does not use practices that have no evidence or that research shows has little benefit and/or can cause harm.
Canada’s maternity care system does not meet these criteria. We do not have the best possible maternity care. Harm is being done to mothers and babies every single day.
Women deserve the best maternity care. Babies deserve the best maternity care. We have enough of both scientific research and birth stories to know the best care is care that provides true and detailed information to the mother about risks and benefits of any practice, preferably before labour, and supports her and her baby’s health by creating optimal environments for physiological birth. We know that the birth process is a physiological process that when left alone and supported emotionally unfolds perfectly without any help ninety percent of the time.
The evidence is clear. Our maternity care needs to change. Who will create that change?
We will. We are mothers. We create babies in the center of our being, with our strength and our resources and our love. We will create change from the center of our being, for the sake of our babies yet unborn, for our sisters yet to birth, and for our daughters and our grandchildren. We know that birth can empower women, can teach us to trust our feminine wisdom and our vital choices. We know that birth carries immense significance for lifelong health and well being of children, both physically and emotionally. And we know that we can be the mothers of change, even if that process is painful, or long, or met with resistance. We are birthing better maternity care. We are becoming mothers of change.
1. Birth Doulas Make A Difference. DONA International. http://www.dona.org/resources/research.php
2. Smyth, R.M.D, S.K. Alldred, and C. Markham. 2007. Amniotomy for Shortening Spontaneous Labour. Cochrane Database of Systematic Reviews. Issue 4. Art. No. CD006167. http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD006167/frame.html (accessed May 15, 2010).
3. Nyberg, K., S.L. Buka, and L.P. Lipsitt. 2000. Perinatal Medication as a Potential Risk Factor for Adult Drug Abuse in a North American Cohort. Epidemiology 11(6): 715-16. http://journals.lww.com/epidem/pages/articleviewer.aspx?year=2000&issue=11000&article=00018&type=abstract (abstract accessed May 15, 2010).
4. Ransjo-Arvidson, A.B., A.S. Matthiesen, G. Lilja, E. Nissen, A.M. Widstrom, and K. Uvnas-Moberg. 2001. Maternal Analgesia During Labour Disturbs Newborn Behaviour: Effects on Breastfeeding, Temperature, and Crying. Birth 28(1):5-12. http://www3.interscience.wiley.com/journal/119023270/abstract (abstract accessed May 15, 2010).
5. Lieberman, E., and C. O’Donoghue. 2002. Unintended Effects of Epidural Analgesia During Labour: A Systematic Review. American Journal of Obstetrics and Gynecology 186(5):S31-S68. http://www.ajog.org/article/S0002-9378%2802%2970181-6/abstract (abstract accessed May 15, 2010).
6. Avoid Giving Birth on Your Back and Follow Your Body’s Urges to Push. Birth Sense Blog, April 7, 2010. http://www.themidwifenextdoor.com/?p=765 (accessed May 15, 2010).
7. Bosomworth, A., and J. Bettany-Soltikov. 2006. Just Take A Deep Breath: A Review to Compare the Effects of Spontaneous versus Directed Valsalva Pushing in the Second Stage of Labour on Maternal and Fetal Wellbeing. MIDIRS Midwifery Digest 16:157-66. http://www.childbirthconnection.org/pdfs/jognn2007janfeb.pdf (summary accessed May 15, 2010).
8. Forster, D.A., and H. L. McLachlan. 2007. Breastfeeding Initiation and Birth Setting Practices: A Review of the Literature. Journal of Midwifery and Women’s Health 52(3):273-80. http://www.jmwh.com/article/S1526-9523%2806%2900669-6/abstract (abstract accessed May 15, 2010).
9. Moore, E.R., G.C. Anderson, and N. Bergman. 2007. Early Skin-to-Skin Contact for Mothers and Their Healthy Newborn Infants. Cochrane Database of Systematic Reviews. Issue 3. Art. No.: CD003519. http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003519/frame.html (abstract accessed May 15, 2010).
10. Biological Nurturing Website. http://www.biologicalnurturing.com (accessed May 15, 2010).