- Kristin Eapen
Updated: Jan 10
The World Health Organization considers a C-section rate of 10 -15% to be ideal, stating;
“When the rate goes above 10 per cent, there is no evidence that mortality rates improve”
Yet, British Columbia has the highest rate of caesarean births in Canada at almost 37 per cent, compared to the national average of 28 per cent. In some areas like the Fraser Health Authority, nearly 42 per cent of babies are delivered via C-section. It had me thinking, why are these rates so high? Dr Sarah Munro, a postdoctoral fellow at the University of BC and researcher with the centre for Health Evaluation and Outcome Sciences said;
"the biggest contributing factor for the increase in c-sections [in Canada], is repeat c-sections."
Dr. Margaret Morris (president-designate of the Society of Obstetricians and Gynecologists of Canada) and Dr. George Carson (past president of the Society of Obstetricians and Gynaecologists of Canada) stated that;
'Across Canada, there are major differences in C-section rates among provinces, among hospitals in the same city, and even between individual obstetricians. We know from research that a major driver of this variation can simply be impatience. Deciding to do a C- section may often relate to providers’ and/or patients’ reluctance to wait for active labor'
As part of the Choosing Wisely Canada campaign, an organization dedicated to reducing unnecessary tests and treatments in health care, the SOGC released recommendations for all clinicians involved in birth, to reevaluate when cesareans are necessary.
No matter what the reason is behind the high cesarean rates, having an understanding of why a cesarean is being recommended and what your options, including the option for a VBAC (vaginal birth after cesarean) or TOLAC (trial of labour after cesarean) are so important.
So how can we be informed and prepared to understand the evidence and our options when it comes to Cesarean birth?
The first (and probably the most important) step is asking questions and choosing a care provider that aligns with your preferences and supports the physiological birth process.
Does your provider honour healthy birth practices such as avoiding interventions that are not medically necessary? Some care providers are trained to manage and prevent complications at all costs and don’t see birth as a natural, intuitive process.
If this is a pregnancy after cesarean, do they support VBAC and provide you with your options, including the option of TOLAC?
The next key piece in becoming prepared and informed is knowing where to get your information. Google is NOT an evidence based resource ;) Not every book or link is evidence based, so its important to know where to look. Hiring a doula can be just as helpful for a cesarean birth as a vaginal birth. Doulas can help you prepare for the big day, create a plan/list of preferences, get evidence based information, help you prepare questions to present to your care team, provide you with resources and help you manage fears.
Here are some great resources (evidence based!) when it comes to cesarean/VBAC;
What if I require a cesarean? How can I prepare? What options do I have?
Birth is a beautiful and sacred experience, no matter how baby enters the world. Yet, not a platitude in the world could or should change the feelings and emotions that surface when a new set of plans needs to be processed.
Whether you've planned a natural birth that required an induction, a home birth that transferred to the hospital or a vaginal birth that ended in cesarean, it’s normal to feel a range of emotions and even feel like a sense of control is taken away.
As humans we always want a reason why something happened. If our plans dont work out, we need to know the reason why. If my birth plan deviated, I must have failed to do all the right things. Maybe if I just did more pelvic floor physio or more position changes. But here's the thing about birth;
You can do all the right things and your birth still might not go as 'planned'
This is why it is so important to think through your options and be open and flexible to change. Planning for labour and birth is more about the process of understanding your options and clarifying your goals than it is the 'plan' itself.
So how can you take back control and own your experience?
Whether the need for cesarean arises before you go into labour or during the birthing process, its important to know your options and how to facilitate an informed decision making process so you can choose whats best for you and baby. There are no interventions that are inherently 'wrong' or 'bad', each serve a purpose when used appropriately. Cesarean has saved lives and there are many situations when cesarean is the best and safest option for either mom and baby.
Creating a plan and thinking through your options beforehand can help you feel empowered and reduce the possibility of trauma.
The Birth Trauma Association states;
'it is not always the sensational or dramatic events that trigger childbirth trauma but other factors such as loss of control, loss of dignity, the hostile attitudes of the people around them, feelings of not being heard or the absence of informed consent to medical procedures.'
Feeling empowered and heard in your experience is SO important! Every individual needs to know that they have the right to ask questions and the right to an informed decision making process, where they can choose what they feel is best for themselves and baby.
Despite a change in plans, you can still feel empowered and be given the tools to make an informed decision.
What questions can I ask?
The first thing you need to know is you can almost always ask for a few minutes to process or discuss this with your support team/partner.
You can say; "If possible, I would appreciate a few minutes to discuss this with my partner" (unless of course its a true emergency) If you are told during the labour process that cesarean is an option/recommended, ask questions;
Is my baby OK? Am I OK?
What would be the benefit to myself or baby to have a cesarean? Do I have other options? How does having a cesarean compare to X,Y,Z? What if I choose to wait? Is that an option? If so, what would be a reasonable time? What is my intuition telling me? (think 'BRAIN'- benefits, risks, alternatives, intuition, nothing/wait)
Creating a plan
Although every facility is different in terms of what family centred cesarean options they support, if you dont know what you can ask for, you don’t know you can ask.
Do your research and create a list of preferences that you can discuss with your care provider and bring with you to the hospital. Ask what family centred/gentle cesarean practices are supported. For example; 'I would like my partner to announce the gender' or 'I would like delayed cord clamping' or 'I am choosing to breastfeed and would like to know how I will be supported in this preference?'
What is a family centred/gentle cesarean?
Family centred cesarean provides options that create a more gentle, calm, natural experience that helps you feel more in control and promotes mother-baby bonding and breastfeeding (some options include; playing music during the procedure, taking photos/videos, announcing the gender, delayed cord clamping, ECG leads placed on back for accessible skin to skin, etc) Here is a link to family centred cesarean options; https://www.thevbaclink.com/family-centered-cesarean/
Keep in mind that each care facility and provider is different in terms of what gentle cesarean options are supported, but having the conversation and knowing what IS supported can help you plan and prepare.
Many institutions will only allow one support person in the OR, but that doesn’t mean you can’t request/advocate for your preferences if you would like a doula or other support person with you. Does it mean your request will be honoured? Not necessarily! But the saying goes; "If you don't ask, you don't get it."
Having two people in the OR means that your partner can go over to greet your baby at the warmer, and you will still have a support person next to you. If your baby needs to be transferred to the NICU or requires additional support, your partner can go with the baby without worrying about leaving you alone.
If you have a planned cesarean, ask your care provider if its safe based on your clinical situation to go into spontaneous labour before going in for the surgical procedure. There are many benefits to your body, your baby and future labors if you allow baby to initiate labor.
We talk about it a lot when it comes to planning a vaginal birth, but the same goes for cesarean birth…. replacing fearful thoughts with positive affirmations and mantras. Celebrate all that your body has done to nourish and grow your little one and the strength it takes to bring them into the world (whether that's vaginally or through abdominal birth)
“ I am ready to meet my baby.”
“ I welcome my baby with happiness, joy and love”
“Sometimes plans change, I am strong enough to adapt”
“My baby will be born surrounded by love”
“I am prepared to meet whatever turn my birthing takes”
“I get to meet my baby today/so soon/now”
Boundaries and support
Finally, its so important to protect your healing and bonding journey. This might be creating spaces where you can process your emotions, such as a therapist or trusted friend or creating circles of support in advance; physiotherapists, lactation supports, a postpartum doula, friends/famlily that can support you in the postpartum period. It might also look like creating firm boundaries so you can focus on whats really important; your mental health, your healing and bonding with your little one. No matter how you gave birth, its important to give yourself time and space to heal. Taking care of yourself and your mental health isn't selfish, it's necessary.
I'd love to hear your cesarean experience. What surprised you the most? What do you wish you knew about before having a cesarean?
Link to ICEA position paper on physiologic birth;
ACOG/Birth Matters; https://www.midwife.org/acnm/files/ccLibraryFiles/FILENAME/000000004448/HBI-BirthMatters-100314.pdf
My Next Birth
Sited article from Dr. Margaret Morris Dr. George Carson