Iatrogenic Distress

Welcome to our series on cesarean birth!  You can read our post, Who Needs Cesareans? to get a deeper sense of our take on this topic.  We in Canada are fortunate to have access to good quality emergency care when needed.

Sometimes, cesareans are necessary.  The natural rates of true obstetrical emergencies are quite low; considering the complex hormonal, neurological, and structural changes that happen during the birth process, it is remarkable how infrequent these situations are.   Prolapsed cord occurs in between 0.14 and 0.62% of births (PubMed via UpToDate).  Placenta previa occurs in approximately 0.003% of singleton births (SOGC).  HIV rates and active herpes outbreak rates are minimal.  Persistent transverse presentation of the baby occurs in between 0.15 and 0.29% of pregnancies (SOGC).  Fetal distress is a difficult one to quantify but is low in unmedicated, spontaneous, well supported labours~much like one would find at Ina May Gaskin’s Farm, and described in her book, Ina May’s Guide to Childbirth.

The difficulty with the above list of situations necessitating cesarean surgery for safe delivery is that how a woman is treated during pregnancy, labour, and birth can affect the rates at which women and babies experience these situations.  For example, prolapsed cord is a rare obstetrical emergency but the incidence increases with artificial rupture of the membranes (AROM), particularly if the head is not well engaged.  Placenta previa is a very rare condition but the incidence increases with prior cesarean surgery.  Fetal distress rates increase with AROM, inductions, pitocin augmentation, pain relief medication, confining women to bed, routine external fetal monitor (EFM) use, increased maternal fear or tension, and directed pushing.  When a negative outcome (fetal distress or prolapsed cord, for example) occurs as a result of caregiver action, it is considered an iatrogenic outcome.  The decision to intervene or act on the part of the physician, nurse, or midwife, caused the distress which necessitated the surgery. 

Another frequent reason cited for cesarean surgery is failure to progress in labour.  This occurs in a small percentage of labours, and generally is the result of some problem such as an occiput posterior (sunny side up) fetus, a nuchal arm, or a large baby.  Often, with patience and skill, these problems can be resolved or overcome without resorting to surgery.  This is the type of situation where an epidural can mean the difference between a vaginal birth and a cesarean birth.  Or, if the mother is handling a long labour well, plenty of movement, vocalization, changing positions, walking up and down stairs, meditation, water immersion, and labouring on hands and knees can resolve an OP baby or allow the woman’s body the time it needs to labour down a big baby or one in a superman’s pose with his hand above his head. 
Impatience on the part of the caregiver, however well intended, can produce an iatrogenic outcome for these women. 

While we acknowledge that cesareans are sometimes necessary, it is important to also acknowledge that they don’t need to be necessary quite so often as they are in our current maternity care system.  A supportive and physiological approach to labour and birth, with a focus on emotional support, non medical pain relief techniques, movement in labour, allowing labour to begin on its own, and allowance for the wide variety of normal when it comes to birth, and a hands-off caregiver approach can avoid iatrogenic distress, and therefore avoid surgery.  Making this a more universal approach to childbirth will surely lower our cesarean rate from 26% to a more reasonable and healthy percentage.

Here are the Lamaze Six Healthy Birth Practices:

Let labour begin on its own
Walk, move around, and change positions throughout labour
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