Rises in Rates of Cesarean Section Births Essay

In recent history, advancements in medical technology have resulted in an increase in labour and birth interventions. This has in turn, greatly increased caesarean section rates. Birth was once a natural, normal event in a woman’s life, however this has been replaced by a maternity system where intervention is routine and interferes with the normal physiological birth process, putting women and their babies at risk unnecessarily (Romano & Lothian, 2008). Normal birth is associated with the best emotional and physical outcomes for women and their babies (New Zealand College of Midwives, 2009). However women have lost confidence in their own ability to give birth without the assistance of technological interventions. Where midwives previously spent their time supporting and comforting labouring women they now spend their time managing technology (Romano & Lothian, 2008). This essay will discuss factors which promote or adversely affect the normal physiology of birth and how we can promote the normal physiology of birth within a public maternity hospital setting. Environmental factors which may negatively or positively affect the normal physiology of labour will also be explored.Rises in Rates of Cesarean Section Births Essay

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Normal physiological birth follows a natural sequence. Regular painful contractions of the uterus, stimulate and progress the cervix to efface and dilate along with foetal decent. This results in the spontaneous vaginal delivery of the baby and the placenta without complication to either mother or baby (Page & McCandlish, 2006).Rises in Rates of Cesarean Section Births Essay

It can be difficult to facilitate normal physiological birth within an environment dominated by a medical approach, where technology and medical expertise are highly valued. The midwife leaders need to show strong leadership to support all midwives. Midwives need to be well educated and competent in the facilitation of normal birth to increase the rate of normal physiological birth (Midwives experience of facilitating normal birth in an obstetric-led unit: a feminist perspective, 2009).Rises in Rates of Cesarean Section Births Essay

Many of the factors that promote normal physiology are environmental in nature. When women are in labour they are extremely sensitive to feeling observed, disrupted or disturbed, this disrupts the natural hormone responses and progress of labour. Women generally find a warm environment preferable so that they feel comfortable to take off their clothing if they wish to do so. When women labour in a calm and quiet environment they feel a change in consciousness to a more primitive brain where birth instincts take over. Privacy and a home like environment also help to facilitate normal birth (Sara Wickham – Midwifery: Best practice, volume 5, 2008). Migrant women have reported that privacy is of particular importance to them (Hennegan, Redshaw & Miller, 2014). Women benefit from freedom of movement during labour (Thies-Lagergren, Hildingsson, Christensson & Kvist, 2013) and if given the opportunity will instinctively choose a variety of movements to help them cope with labour including walking, swaying, standing, leaning and the hands and knees position. Allowing freedom of movement benefits the mother in a number of ways including comfort, shortening labour, increased uterine contractions and less need for pharmacologic pain relief. It can also correct poor progress, malposition and sometimes foetal heart rate anomalies (Romano & Lothian, 2008). When women push spontaneously without being coached they are less likely to require suturing from trauma and have less pelvic floor dysfunction than women who are coached to push (Romano & Lothian, 2008). The AWHONN (2013) recommends women should not push until they feel the urge to push and should do so spontaneously without direction. Women’s experiences of control during labour and birth are overwhelmingly associated with their involvement in the decision making process (Christiaens, 2010). The process of writing a birth plan also increases a woman’s feelings of control as it gives her the opportunity to think about possible scenario’s and plan her responses and choices (Kuo, Hsu, Yang, Chang, Tsao & Lin, 2010).Rises in Rates of Cesarean Section Births Essay Freedom to move around, scream out or make decisions about who enters the birthing space contributes further to the perception of control (Ford, 2009). Women also feel more in control if they have access to information during labour (Tiedje & Price, 2008). Health care providers can help to facilitate a woman’s access to information by answering any questions she may have allowing her to make informed choices. When women feel a sense of personal security, derived from feeling respected, trusted and supported by the health care provider who is looking after them, they will experience less fear and an increased feeling of control (Meyer, 2012). Continuous support for women in labour from a female with specialised training is thought to reduce anxiety and stress hormones known to cause vasoconstriction and lower uterine blood flow, which may slow down progress and potentially harm the foetus. Continuous support is said to increase the chance of a spontaneous vaginal birth, lower the use of analgesia, epidural, risk of caesarean and instrumental delivery (Sosa, Crozier & Robinson, 2012; Romano & Lothian, 2008). These are all important factors in the facilitation and promotion of normal birth and positively affect the woman’s labour and birth environment.Rises in Rates of Cesarean Section Births Essay

There are also many factors that adversely affect the normal physiology of birth, including induction of labour which increases a women’s need for analgesia or epidural and puts her baby at an increased risk of needing neonatal resuscitation. Induction of labour also increases a woman’s risk of caesarean section, instrumental birth, shoulder dystocia, intrapartum fever, low birthweight babies and admission to neonatal intensive care (Tracey et al, 2007). Augmentation of labour can be a tempting option to speed up labour, however amniotomy and oxytocin administration are not without risk. Options such as changing position and talking to women about their emotions, which are low or not risk options, can be as effective and more pleasant for labouring women (Romano & Lothian, 2008). Amniotomy can increase the risk of infection, may cause pressure injuries or ruptured placental veins or arteries resulting in significant foetal blood loss. It is also associated with cord prolapse (Cohain, 2013). If amniotomy is carried out early in pregnancy it can set off a cascade of intervention and increase the risk of caesarean section. If labour is still not progressing oxytocin is usually administered and makes contractions stronger and more difficult to cope with as it is exogenous and does not cross the blood-brain barrier, so endorphins are not released to decrease pain perception (Romano & Lothian, 2008). Oxytocin administration also puts women at risk of hyperstimulation (Selin, Almstrom, Wallin & Berg, 2009). Other interventions such as intravenous cannula and electronic foetal monitoring are also used in this intervention and there is an increase in other interventions such as epidurial which all have added risks.Rises in Rates of Cesarean Section Births Essay Amniotomy should only be used if progress is truly abnormal while oxytocin augmentation should only be used if labour is truly prolonged with sluggish uterine activity (Romano & Lothian, 2008). Epidural analgesia relaxes the pelvic floor muscles making foetal decent and rotation difficult (Al-Metwalli, Mostafa & Mousa, 2012). The absence of pain in labour can interfere with the natural oxytocin release. There is also a risk of hypotension so electronic foetal monitoring is used along with an intravenous cannula. Women who use this type of pain relief are less likely to have a vaginal birth and at a higher risk of instrumental delivery, prolonged labour and fever. Their babies are more likely to have infection (Romano & Lothian, 2008). All of these interventions carry risks to mother and baby and adversely impact upon the normal physiological birth process.Rises in Rates of Cesarean Section Births Essay

Some of the environmental factors that adversely affect the normal progress of labour include restriction of eating and drinking which began in the1940’s when general anaesthetic was commonly used in obstetrics to reduce the chance of aspiration. General anaesthetic is now rare in obstetrics as is aspiration due to the use of airway protection. Women prefer to have the choice to eat and drink during labour and there is no benefit in restricting them to do so (Singata, Tranmer & Gyte, 2013). When women are prevented from eating or drinking they are hydrated with iv fluids, this is also used to access a vein in case of an emergency. Although emergencies do happen there is no evidence to suggest iv access in low risk labouring women improves outcomes. Women with Intravenous lines are not free to move around, may have increased stress levels, may result in fluid overload in both mother and foetus and does not adequately hydrate or provide nutrients. Continuous foetal monitoring has been found to reduce neonatal seizures when babies have been exposed to high doses of oxytocin but has not been linked to positive long term outcomes. It does however increase the risk of caesarean section and instrumental delivery without a clear benefit to the baby and reduces the mother’s ability to mobilise (Alfirevic, Devane & Gyte, 2013). These environmental factors have a negative affect on a woman’s normal progress in labour and should be avoided if possible.Rises in Rates of Cesarean Section Births Essay

A midwife-led continuity of care model has been found to benefit women and their babies in a number of ways when compared with medical and shared models of care. Benefits include decreased use of epidural, less episiotomies and instrumental births and less preterm birth or loss of baby prior to 24 weeks gestation. Women also had more chance of having a spontaneous vaginal delivery. As a result a midwife-led continuity of care model gives women the best chance of having a normal physiological birth (Sandall, Soltani, Gates, Shennan & Devane, 2013).

For a midwife to promote the normal physiological birth process and give effective and appropriate care, she needs to establish a relationship with women antenatally. It is important for the midwife to get to know each woman and her wishes and dreams for her impending birth (New Zealand College of Midwives, 2009). This allows a partnership of trust and respect and helps to alleviate any fears or anxieties and share appropriate and correct information before the birth. When women talk about their fears with  the midwife, she will be better informed and able to provide woman centred care (Pairman, Tracy, Thorogood & Pincombe, 2010). Midwives need to use evidenced based practice staying within their scope of practice. Whenever a midwife interacts with a woman, she needs to support normal physiological birth and the natural cascade of normal labour. Rises in Rates of Cesarean Section Births Essay Every interaction she has with a woman affects this cascade either positively or negatively (New Zealand College of Midwives, 2009). When women are in labour midwives need to consider the woman’s birth plan while maintaining a private warm room. It is also important to encourage her to find a comfortable position with appropriate comforts such as pillows and beanbags. Encouraging partners to support women by providing drinks, cool washers, and other physical support is an important midwifery role (Pairman, Tracy, Thorogood & Pincombe, 2010). Midwives need to be unobtrusive and well prepared with safety equipment. When women are in the second stage of labour midwives need to encourage position changes to help decent where appropriate. Soothing hot compresses can be used on the perineum and vulva while the midwife gives clear and calm reassurance until the baby is born and given to the mother for skin to skin contact. These factors will help midwives to facilitate the normal physiological birth process (Pairman, Tracy, Thorogood & Pincombe, 2010). Midwives need to practice cultural safety by reflecting on their own cultural values and identity in an effort to recognise the impact their own culture has on their practice. It is important for midwives to understand their position of power within the healthcare system (Page & McCandlish, 2006).Rises in Rates of Cesarean Section Births Essay

It is in most women’s best interest to have a normal physiological labour and birth as it provides the best physical and emotional outcomes for both mothers and their babies. It is the midwife’s role to ensure birth proceeds as normally as possible and interventions are only used when absolutely necessary. To achieve this, midwives need to understand the factors that promote and adversely affect the normal physiological birth process and any environmental factors that may negatively or positively impact on a woman’s labour and birth. There are a number of different models of care available to pregnant women, however it has been found that a midwife-led continuity of care model gives the best possible chance for a normal physiological birth and labour. Midwives need to create a calm, quiet, culturally safe, supportive environment where women feel safe and secure to use their natural birthing instincts and encourage position changes where appropriate. The environment needs to be well equipped with comforts such as pillows and beanbags and any safety equipment that may be needed. Although it can be difficult to facilitate a normal physiological labour and birth within a medically dominated environment, if midwives have strong leadership and are well educated to facilitate normal physiological birth they are more likely to increase the rates of normal birth.Rises in Rates of Cesarean Section Births Essay

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Since 1985, the international healthcare community has considered the ideal rate for caesarean sections
to be between 10% and 15%. Since then, caesarean sections have become increasingly common in both
developed and developing countries. When medically justified, a caesarean section can effectively prevent
maternal and perinatal mortality and morbidity. However, there is no evidence showing the benefits of
caesarean delivery for women or infants who do not require the procedure. As with any surgery, caesarean
sections are associated with short and long term risk which can extend many years beyond the current
delivery and affect the health of the woman, her child, and future pregnancies. These risks are higher in
women with limited access to comprehensive obstetric care.
In recent years, governments and clinicians have expressed concern about the rise in the numbers of
caesarean section births and the potential negative consequences for maternal and infant health. In addition,
the international community has increasingly referenced the need to revisit the 1985 recommended rate.Rises in Rates of Cesarean Section Births Essay
Executive summary
Caesarean section rates
at the population level
WHO conducted two studies: a systematic review of
available studies that had sought to find the ideal
caesarean rate within a given country or population,
and a worldwide country-level analysis using the
latest available data. Based on this available data, and
using internationally accepted methods to assess
the evidence with the most appropriate analytical
techniques, WHO concludes:
1. Caesarean sections are effective in saving maternal
and infant lives, but only when they are required for
medically indicated reasons.
2. At population level, caesarean section rates higher
than 10% are not associated with reductions in
maternal and newborn mortality rates.
3. Caesarean sections can cause significant and
sometimes permanent complications, disability or
death particularly in settings that lack the facilities
and/or capacity to properly conduct safe surgery
and treat surgical complications. Caesarean sections
should ideally only be undertaken when medically
necessary.
4. Every effort should be made to provide caesarean
sections to women in need, rather than striving to
achieve a specific rate.
5. The effects of caesarean section rates on other
outcomes, such as maternal and perinatal morbidity,
paediatric outcomes, and psychological or social
well-being are still unclear. More research is needed
to understand the health effects of caesarean section
on immediate and future outcomes.Rises in Rates of Cesarean Section Births Essay
WHO Statement on Caesarean Section Rates
There is currently no internationally accepted
classification system for caesarean section that would
allow meaningful and relevant comparisons of CS rates
across different facilities, cities or regions. Among the
existing systems used to classify caesarean sections,
the 10-group classification (also known as the ‘Robson
classification’) has in recent years become widely
used in many countries. In 2014, WHO conducted a
systematic review of the experience of users with the
Robson classification to assess the pros and cons of its
adoption, implementation and interpretation, and to
identify barriers, facilitators and potential adaptations or
modifications.
WHO proposes the Robson classification system
as a global standard for assessing, monitoring and
comparing caesarean section rates within healthcare
facilities over time, and between facilities. In order
to assist healthcare facilities in adopting the Robson
classification, WHO will develop guidelines for its
use, implementation and interpretation, including
standardization of terms and definitions.
Caesarean section rates at the
hospital level and the need for a
universal classification system Rises in Rates of Cesarean Section Births Essay
2
Introduction
For nearly 30 years, the international healthcare
community has considered the ideal rate for
caesarean sections to be between 10% and 15%.
This was based on the following statement by a
panel of reproductive health experts at a meeting
organized by the World Health Organization (WHO)
in 1985 in Fortaleza, Brazil: “[T]here is no justification
for any region to have a rate higher than 10-15%”(1).
The panel’s conclusion was drawn from a review of
the limited data available at the time, mainly from
northern European countries that demonstrated
good maternal and perinatal outcomes with that rate
of caesarean sections.
Since then caesarean sections have become
increasingly common in both developed and
developing countries for a variety of reasons (2,
3). When medically justified, caesarean section
can effectively prevent maternal and perinatal
mortality and morbidity (4). However, there is no
evidence showing the benefits of caesarean delivery
for women or infants who do not require the
procedure. As with any surgery, caesarean sections
are associated with short and long term risk which
can extend many years beyond the current delivery
and affect the health of the woman, her child, and
future pregnancies. These risks are higher in women
with limited access to comprehensive obstetric
care (5, 6, 7).Rises in Rates of Cesarean Section Births Essay
The proportion of caesarean sections at the
population level is a measure of the level of access
to and use of this intervention. It can serve as a
guideline for policy-makers and governments in
assessing progress in maternal and infant health
and in monitoring emergency obstetric care and
resource use (8). Over the last few years, governments
and clinicians have expressed concern about the
rise in the numbers of caesarean section births and
the potential negative consequences for maternal
and infant health (9, 10, 11, 12). Cost is also a major
factor in improving equitable access to maternal
and newborn care, as caesarean sections represent
a significant expense for overloaded – and often
weakened – health systems (12, 13, 14).
Over the past three decades, as more evidence
on the benefits and risks of caesarean section has
accumulated, along with significant improvements
in clinical obstetric care and in the methodologies
to assess evidence and issue recommendations,
health care professionals, scientists, epidemiologists
and policy-makers have increasingly expressed the
need to revisit the 1985 recommended rate (9, 15).
However, determining the adequate caesarean
section rate at the population level – i.e. the
minimum rate for medically indicated caesarean
section, while avoiding medically unnecessary
operations – is a challenging task. To answer this
question, WHO conducted two studies: a systematic
review of available country-level studies that had
sought to find this rate, and a worldwide countrylevel analysis using the latest available data. The
process and the results are described in the first part
of this Statement.Rises in Rates of Cesarean Section Births Essay
At the heart of the challenge in defining the optimal
caesarean section rate at any level is the lack of a
reliable and internationally accepted classification
system to produce standardized data, enabling
comparisons across populations and providing a
tool to investigate drivers of the upward trend in
caesarean section.
Among the existing systems used to classify
caesarean sections, the 10-group classification (also
known as the ‘Robson classification’) has become
widely used in many countries in recent years (16, 17).
Proposed by Dr Michael Robson in 2001 (18), the
system stratifies women according to their obstetric
characteristics, thereby allowing a comparison of
caesarean section rates with fewer confounding
factors. WHO conducted two systematic reviews to
assess the value, benefits and potential drawbacks
of using this classification to better understand
caesarean section rates and trends worldwide. The
research process and conclusions are described in
detail in the second part of this Statement. Rises in Rates of Cesarean Section Births Essay