Changing the Direction of the Current

Written by Melissa

Here is a little bit of the story of how I came to Mothers of Change.

My first pregnancy was in 2002/2003. This pregnancy was a surprise for us, so we had never considered trends in maternity care in Canada, nor challenging the status quo. We live in a developed country, with a national health care system, our society seems healthy and well functioning, what could be wrong with maternity care? I had considered that I would like to have a midwife way in the future when I decided to have babies, but when confronted with a surprise pregnancy, I didn’t have the mental energy to pursue it. I had heard that there was high demand for care and very few midwives, so it was difficult to find a midwife who was taking clients in our area. I didn’t have the energy to tackle that, so I went with what felt familiar; I went to my doctor.

I was pretty happy with my care. During prenatal appointments, my doctor took my blood pressure, listened to the baby’s heart rate by doppler, measured my uterus, and asked how I was doing. If I had questions, she answered them. If I had complaints, she listened to me. She has a very busy office so I routinely waited 30 to 40 minutes after my appointment time to see her, but this is fairly normal within our health care system, and not specific to maternity care. Because she has such a busy practice, I often felt bad for taking up her time. Appointments usually took about ten minutes.

I didn’t receive nutritional counseling beyond an admonition to “Watch your weight gain” when I hit 40 lbs gain at around 35 weeks. I felt short of breath and my heart raced during the second half of my pregnancy, and she said, “Well, you have a sensitive heart.” Which is true, I had heart surgery for a heart condition in my early twenties. I had painful Braxton Hicks and leg cramps and she said, “Those are common.” When I was 36 weeks I had some bleeding, so I went to the emergency department and the doctor who examined me there told me the blood was minimal and not to be concerned unless it continued or increased in volume, but that I had polyhydramnios and that my baby was breech. At my next prenatal appointment I told my doctor, and she ordered an ultrasound. Sure enough, he was in a position that looked much like this:

[image courtesy of Wikipedia]

Most babies are born head first, in a position that looks much like this:

[photo courtesy of www.spinningbabies.com]

At the time, the Society of Obstetricians and Gynecologists of Canada was recommending all breech babies be scheduled for birth by cesarean section. This was based on a large randomized controlled trial which was published in October of 2000, Planned cesarean section versus planned vaginal birth for breech presentation at term: a randomised mulitcentre trial.
So I was referred to an obstetrician, who was very nice and kind and a good surgeon, who delivered my son by cesarean section on May 8th, 2003. She quoted the above trial when she recommended a cesarean. After the surgery, she told me, “There is absolutely no reason why you cannot have a vaginal birth next time,” for which I am very grateful. I really wanted to give birth vaginally and was glad she encouraged me. I have since learned that this type of encouragement from an obstetrician is exceedingly rare.

In August of 2009, the Society of Obstetricians and Gynecologists of Canada retracted their previous recommendation regarding breech births. After nearly ten years of recommending the routine scheduling of planned cesareans for breech births, enough data was available to call into question the results of the 2000 study, which affected policies for birth all over the world. The new recommendation is based on a vast amount of data, and a close scrutiny of the 2000 trial, which revealed inconsistencies and weaknesses. The most up to date SOGC recommendation can be found here on their website, and includes critique of the 2000 study;

Published in 2000, the Term Breech Trial was a large, multicentre randomized controlled trial designed to determine the safest mode of delivery for a term breech fetus.9 In countries with a low perinatal mortality rate, the trial showed no difference in perinatal mortality between a
planned CS [cesarean section] and a TOL [trial of labour] but a striking difference in “serious” short-term neonatal morbidity: 0.4% versus 5.1%. No difference in maternal mortality or serious morbidity was measured, leading most experts to recommend planned CS for breech presentation at term.10,11 An abrupt shift in clinical practice ensued, and term breech CS rates increased around the world. The pool of expertise in vaginal breech birth has shrunk rapidly since, and many obstetrician-gynaecologists now graduate with little or no experience with vaginal breech delivery. In many regions of the world, women with a breech fetus no longer have the option of a medically attended vaginal breech birth.12,13 The TBT [Term Breech Trial] is the largest randomized clinical trial ever undertaken on term breech mode of delivery, and it has provided a wealth of information about breech birth. Despite its strengths, however, a number of weaknesses have been identified since its publication.14–20 Based on the information available at the time, its findings may have been misinterpreted and may have led to premature changes in clinical practice. A comprehensive analysis is beyond the scope of this guideline; however, an examination of the TBT’s major limitations is critical to estimating the true risk of labour to a
breech fetus. They can be grouped as follows:
(1) inadequate case selection and intrapartum management;
(2) maternity units with markedly different skill levels
grouped together; and
(3) short-term morbidity used as a
surrogate marker for long-term neurological impairment.

It wasn’t until six years after my cesarean that I realized I had had an unnecessary cesarean. The current recommendation from SOGC is that women whose babies are breech be presented with the option to give birth vaginally. [SOGC]

Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus. (I)
With careful case selection and labour management, perinatal mortality occurs in approximately 2 per 1000 births and serious short-term neonatal morbidity in approximately 2% of breech infants. Many recent retrospective and prospective reports of vaginal breech delivery that follow specific protocols have noted excellent neonatal outcomes. (II-1) Long-term neurological infant outcomes do not differ by planned mode of delivery even in the presence of serious short-term neonatal morbidity. (I)

…………………

In light of recent publications that further clarify the lack of long-term newborn risk of vaginal breech delivery and the many cohort reports noting excellent neonatal outcomes in settings with specific protocols, it is acceptable for hospitals to offer vaginal breech delivery. Hospitals offering vaginal breech birth should have a written protocol for eligibility and intrapartum management, including notification of the most responsible health care provider upon admission in labour.Faced with a parturient requesting a TOL, the health care provider must evaluate his or her own system of breech selection, intrapartum management, delivery technique, and clinical experience. Women should be informed that the risk of short-term neonatal morbidity maybe higher for a planned vaginal delivery than for a planned CS but that long-term infant neurological outcome is not different. In the low-perinatal-mortality-country arm of the TBT and the PREMODA study, perinatal mortality was not different between the planned vaginal delivery and planned CS groups.

After my son Ayden was born, I developed a rare complication of spinal anasthesia called a Spinal Headache. Every time I was upright, I had a crushing headache for approximately two weeks. I had residual vertigo [dizziness] for four months. I eventually recovered.

For our next baby, for reasons unrelated to our previous birth, we chose adoption. We travelled overseas to adopt a little boy from a foster home in North Central Thailand. Matthew is a bright, energetic addition to our family whom we cherish every day and are very grateful for! We like to say Matthew was ‘born twice,’ once a natural physiological birth in a hospital, and the second time in an airport when we met each other, and our home grew by two more feet.

Four years later, when Ayden was five and Matthew was four, I gave birth to our third boy. When I became pregnant this time, I was determined to have a VBAC [vaginal birth after cesarean], and experience the natural process I had missed out on the first time around. I did some research and discovered that midwives had a reputation for lower cesarean rates than doctors in Canada. Since I wanted to maximize my chances of a successful VBAC, I chose a midwife for my maternity care provider. The supply and demand for midwives had become more equalized, so it was not difficult for me to find a midwife who was accepting patients.

The two midwives I found who practiced together were wonderful! They were almost always on time, and appointments were booked for forty-five minutes, and they often allowed me a full hour if we were discussing something emotional or important and were not finished in forty-five minutes. I received plenty of nutritional counseling. When my shortness of breath and rapid heart rate returned they checked my iron stores and found them low, and resolved those symptoms with iron supplements. When I developed painful Braxton Hicks and leg cramps in later pregnancy, they advised calcium and magnesium supplements with Vitamin D, and my symptoms resolved. I had a surprising number of deep questions, emotions, and issues to discuss with forty-five minute appointments!

And in the end, I had a beautiful, empowering, drug free VBAC in hospital, attended by both of these lovely midwives. I was not subjected to external fetal monitoring, IV for fluids, restrictions during labour, drugs, arbitrary time limits for stages of labour, induction, augmentation, nor instrumental delivery, all of which can be common with physician assisted births for VBACs. I had a physiological labour and delivery, a healthy baby, an intact uterus, and an overwhelming sense of empowerment and accomplishment. I also had home visits postpartum, and all my postpartum follow up care was performed by my midwives, for eight weeks after the birth. I was so inspired by the experience of watching my son be born, that I decided shortly after his birth that I wanted to go back to school and become a midwife myself, so I could be a part of such positive experiences on a regular basis.

When I was pregnant, I read voraciously regarding natural childbirth, and learned some surprising things. Canadian maternity care is not amongst the highest rated in the world, despite our developed nation status and universal health care. Our infant mortality rate recently fell from 6th in the world to 24th [Globe and Mail article]. Our cesarean rate is a full 11% higher than the highest possible recommended cesarean rate according to the World Health Organization, which recommends a cesarean rate no higher than 10-15%. The U.S. cesarean rate is a full 17% higher than the WHO recommendation of 15%. Women in our country are routinely submitted to continuous external fetal monitoring, which has been proven to increase intervention and cesarean rates without improving fetal outcomes. World Health Organization

Directly quoted from the article: “Compared to intermittent auscultation, continuous cardiotocography showed no significant difference in overall perinatal death rate.”

Women in Canada are also routinely restricted from food and drink during labour, encouraged to remain in bed in a reclined or semi reclined position, push while holding their breath instead of following their natural urges to push, push on their backs, and accept interventions without full disclosure of risks and benefits thereof, including induction, continuous external fetal monitoring, internal fetal monitoring, augmentation, instrumental delivery, analgesia and epidural drugs, episiotomy, active management of third stage labour, pitocin/oxytocin administration after delivery, and cesarean section.

What are the recommendations for a safe and healthy labour and delivery for mother and baby?
The Society of Obstetricians and Gynecologists of Canada recommend the following:

The SOGC and its partners providing maternity health care recommend:
1. The development of national practice guidelines on normal childbirth that address philosophy and practice expectations to provide a framework for all professional associations providing maternity health care and that include the following components:
• Spontaneous onset of labour
• Freedom of movement throughout labour
• Continuous labour support
• No routine interventions
• Spontaneous pushing in the woman’s preferred
position
• Use of fetal surveillance by intermittent auscultation
• Institutions offering options for pharmacologic and
non-pharmacologic approaches to pain relief (such
as tubs/showers, access to natural light,
environmental designs/adaptations, quiet area)
2. The development of interdisciplinary committees to implement standardized unit policies on normal childbirth and all aspects of maternity care with membership from all contributing disciplines.
3. Promotion among childbirth educators and maternity care providers of knowledge about and experience with the birth process and evidence-based practices so that women and families can be informed about normal birth; antenatal preparation requires a positive focus on practical
skills for coping with labour and birth pain.
4. The provision of information and opportunities for discussion about natural childbirth to all pregnant women at low risk. This should include the information that unnecessary interventions increase risks to mother and baby.
5. Promotion of expert knowledge and skills in normal childbirth among health care practitioners/professionals providing intrapartum care.
6. The creation of collaborative education opportunities on normal childbirth for maternity care providers. The aim of education and training programs is to build the confidence to support women who wish to give birth without technological interventions.
[SOGC]

Lamaze International recommends:

• Let Labor Begin on Its Own
• Walk, Move Around, and Change Positions Throughout Labor
• Bring a Loved One, Friend, or Doula for Continuous Support
• Avoid Interventions That Are Not Medically Necessary
• Avoid Giving Birth on Your Back, and Follow Your Body’s Urges to Push
• Keep Mother and Baby Together – It’s Best for Mother, Baby, and Breastfeeding [Lamaze]

The more I learned, the more convinced I became that current maternity practices in Canada were not moving in the direction of what was best for women and babies during pregnancy, birth, and post partum. Most women, expecting the latest evidence based practices to be incorporated into their care, are receiving less than they deserve. Less than they expect. Less than the research says we can achieve as far as outcomes, morbidity, mortality, and satisfaction with our experiences. So when a friend approached me with the idea of Mothers of Change, I was ecstatic!

Women pushing for change in our mothers’ generation is what made maternity caregivers change their practices and allow fathers in delivery rooms, discontinue routine shaving, anasthetic wash, enema administration, episiotomy use, and move towards natural, normal birth. Our generation of birthing women would be appalled if their husband was banned from the delivery room, or if she were shaved and given an enema before birth. If we band together, perhaps the next generation of birthing women will be appalled at the thought of pushing on her back, continuous fetal monitoring, and a cesarean rate above 10-15% [or even lower!]. I believe strongly in the safety and normalcy of physiological birth, and hope to see change in maternity care practices in the very near future!