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The two most common reasons women have a first caesarean section

 

Research in context

In Australia and many high-income countries, the rate of caesarean section (CS) is increasing. There is no evidence that higher rates of CS improve health outcomes, which raises concerns about overuse of the surgical procedure (ACOG et al., 2014).

In 2000, 1 in 5 Australian women had a caesarean section. That rate is now more than 1 in 3 (AIHW, 2018). For women having their first baby in Australia the risk of CS is 37% (AIHW, 2020). Once a woman has experienced a CS, future vaginal birth is much less likely. In Australia, 7 out of 8 women will have a repeat CS for their next baby (AIHW, 2020). Therefore, preventing the first caesarean section (called a “primary CS”) is paramount wherever safely possible (ACOG et al., 2014).

Some have attributed the significant rise in CS rates to the increase in older and more obese pregnant women (RANZCOGAIHW releases data on caesarean section in Australia). Indeed, age ≥35 years and obesity can increase the chances of health issues including high blood pressure, diabetes, and multiple pregnancies. Nevertheless, this change alone is unlikely to explain the magnitude of the rise in CS rates, nor the differences in CS rates in different settings (WHO, 2018).

What the research did 

New research led by PhD candidate Haylee Fox, supervised by TMCC Deputy-Director, Associate Professor Emily Callander, aimed to build our knowledge in this area: https://onlinelibrary.wiley.com/doi/full/10.1111/birt.12530

Fox et al. (2021) used routinely collected hospital data to analyse the main reasons recorded by clinicians for primary CS in Queensland Health hospitals. Nearly 100,000 women either having their first baby or having a subsequent baby after previous vaginal birth were included in the study. Women who had experienced a previous CS were excluded.

What the research found

The top two reasons women in Queensland public hospitals had a primary CS were: ‘abnormal fetal heart rate’ (23%) and ’primary inadequate contractions’ (23%). Medical interventions including artificial rupture of membranes (ARM), oxytocin augmentation or induction of labour, and epidural analgesia predicted CS for fetal heart rate concerns (as did obstructed labour). Where a primary CS was performed due to “inadequate” contractions, epidural analgesia, ARM, fetal stress, and oxytocin augmentation or induction were predictive factors.

So what does this mean?

Induction of labour and epidural analgesia predict the two most common reasons for primary CS.  Accurate, evidence-based information about the potential consequences of induction of labour or epidural should be provided to all women (Fox et al, 2021). Indeed, these results warrant professional reflection on the use of induction of labour and epidural analgesia, alongside critical review of relevant policies, given the clear link with primary CS.

An Australian study including 1.25 million reported women who accessed birth centre or homebirth had lower rates of oxytocin augmentation and epidural use. Maternal and perinatal outcomes by planned place of birth in Australia 2000 – 2012: a linked population data study | BMJ Open. The Cochrane systematic review found women receiving midwife-led care in a hospital setting were less likely to receive an epidural, although it appeared to make no difference to rates of induction of labour or oxytocin augmentation. Midwife-led continuity models of care compared with other models of care for women during pregnancy, birth and early parenting | Cochrane

Midwifery continuity of care models and out-of-hospital birth protect against overuse of medical interventions including CS. Universal access to continuity of midwifery care should be a national policy priority.

References

American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine, Caughey AB, Cahill AG, Guise JM, Rouse DJ. (2014). Safe prevention of the primary cesarean delivery. American Journal of Obstetrics and Gynecology, 210(3), 179-93. https://doi.10.1016/j.ajog.2014.01.026

Australian Institute of Health and Welfare. (2020). Australia’s Mothers and Babies 2018 – In Brief. AIHW.

Fox, H., Topp, S. M., Lindsay, D., & Callander, E. (2021). A cascade of interventions: A classification tree analysis of the determinants of primary cesareans in Australian public hospitals. Birth: Issues in Perinatal Care, 00, 1-12. https://doi.org/10.1111/birt.12530

Homer, C.S.E., Cheah, S.L., Rossiter, C. et al. (2019). Maternal and perinatal outcomes by planned place of birth in Australia 2000 – 2012: a linked population data study. BMJ Open, 9, e029192. https://doi.10.1136/bmjopen-2019-029192

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD004667. https://doi.10.1002/14651858.CD004667.pub5

World Health Organization. (2018). WHO Recommendations Non-Clinical Interventions to Reduce Unnecessary Caesarean Sections. WHO.

No Pain, No Gain? An opinion piece

During the final year of the Bachelor of Midwifery at Griffith University, midwifery students are asked to write an opinion piece focussed on normal birth that could be published. Dr Jyai Allen convenes this course and supported the students to complete this work. Several of these were of such good quality that we offered students the option of having them published here. This is the fourth articles in a series of five. This article was written by Monique Matthews.

No Pain, No Gain?

Many women express wanting a ‘drug free labour’ or a ‘natural/normal birth’. The International Confederation of Midwives (ICM) definition of normal birth, requires the process to occur without any surgical, medical, or pharmacological intervention.

Pharmacological pain relief are interventions that include, epidural, opioids (morphine) and nitrous oxide (happy gas). Women not using pharmacological pain relief have many options. These include heat, hydrotherapy/water immersion (shower/bath), acupressure and acupuncture, hypnosis, relaxation, breathing, massage, yoga, transcutaneous electrical nerve stimulation (TENS), aromatherapy, sterile water injections, and a birth ball. These techniques are termed non-pharmacological pain relief.

In 2018 in Australia, 21% of women exclusively used only non-pharmacological pain relief, whereas, 78% of women used pharmacological pain relief during labour. With a high rate of pharmacological pain relief and the known negative impacts of these techniques, the question needs to be asked: why have non-pharmacological techniques, that are less invasive and more natural, become the alternative rather than the standard option?

History

Techniques for pain relief in labour have changed throughout history, largely influenced by their availability and the values of practitioners. The earliest techniques were midwifery based, which facilitated the natural physiology of labour in the home with family support and only intervened in life threatening difficulties. Many of these non-pharmacological techniques are still used today.

In the early 1700s birth moved from midwifery to obstetrics as formal biomedical training started institutionalising birth in the hospital. Doctors perspectives became greatly influential. Doctor Joseph Lee likened women’s experience of childbirth to falling on a pitchfork and he wanted to rid childbirth of “unskilled” labour assistance. This enforced the idea that women were unable to cope with labour pain and they required professional help to survive. Pain became a target of medical intervention.

Pain relief techniques in labour through the 1800s and 1900s introduced pharmacological pain relief such as chloroform, nitrous oxide and a mixture of morphine (pain relief) and scolimeine (memory loss) coined ‘twilight sleep’. Women were barely conscious while giving birth, dehumanising the process and causing extensive trauma. In the 1960s, epidural pain relief gained popularity. An interest in returning to non-pharmacological birthing practices also emerged around this time, as the experience of pain was considered empowering for women. By 1990, women’s rights to pain relief were again promoted for a technological, pain free birth.

Today, the primary healthcare provider for a woman in labour in Australia can be a doctor or midwife. Women’s views on what techniques they will use during labour are diverse, as they are impacted by their social and cultural learning, the media, and the ongoing medicalisation of birth.

Biomedical Paradigm

While the ICM’s definition of normal birth excludes the use of pharmacological intervention, the Queensland Clinical Guidelines definition includes the use of nitrous oxide, normalising pharmacological pain relief. Within the guideline the term ‘non-pharmacological support’ is consistently used. This situates these techniques within a biomedical paradigm, with risk and pathology as the dominant discourse. This implies that these natural and traditional techniques are inferior, by stating that they are ‘other’ than the dominant pharmacological techniques.

This position is often supported in media representations where women are unrealistically shown lying on a bed, out of control, screaming for pain relief. Today, this is a more common source of information than having been present at an actual birth. The expectations women form, impact their experience of pain as it is a subjective experience, influenced by social and cultural learnings.

Physiological vs medical approaches to pain

When women experience uterine contractions, the pain is physiological rather than pathological. This pain is considered beneficial, as it emphasises the need for support, heightens elation and triggers hormones to support wellbeing. During labour, women naturally produce hormones (oxytocin and endorphins) that counter the intensity of the pain experienced. Stress hormones (catecholamines and cortisol) can override this natural pain relief when women experience fear or a lack of trust. If women and midwives understand these hormonal processes and use non-pharmacological techniques to enhance them, the fear cascade can be avoided.

If labour pain is a subjective experience, why is a medical approach, based on objective principles, used?

The biomedical paradigm views birth as a mechanical process requiring intervention for efficacy and safety. Using pharmacological pain relief changes labour from a physiological process to a medical procedure as side effects require management.

Nitrous oxide can cause nausea, vomiting, dizziness, and drowsiness. Morphine crosses the placenta lowering the baby’s breathing rate and alertness at birth. Women can also experience excessive sedation, a lowered breathing rate and nausea. Epidurals increase instrumental vaginal birth rates by 500% and can increase the use of synthetic oxytocin, length of labour, low blood pressure, and a less positive birth experience.

As non-pharmacological techniques have less side effects, why are they not better promoted? The answer may lie in the cost effectiveness of these techniques, which do not make manufacturers as much money, causing them to be understudied, which lessens practitioner’s confidence in the techniques. Sara Wickham articulates this point well when she said “Ethically, medical intervention has to prove itself against nature. Not the other way around”.

Power Play

Women can be empowered during their birth experience through woman-led, self-generating techniques that involve partners. However, pharmacological pain relief shifts power from the woman to the practitioner. This phenomenon occurs as standard monitoring is required to deem whether the situation is ‘safe’ to continue labour, creating parameters that may exclude women from decisions.

The power of suggestion can impact which techniques women use during labour. If midwives and practitioners are afraid of being with women in pain, they may offer increased pain relief when they feel the woman needs it, rather than upon request. Women have described feeling coerced and being presented with false dilemmas with limited choices. Consent is not valid in these situations if the risks of pharmacological pain relief are not fully disclosed, or the information is tailored by midwives. Research on epidurals, found they are sometimes used as a substitute for continuous support.

This raises the question: Is pain relief used more often for the convenience of practitioners, rather than to meet the needs of women?

Pain relief is a human right!

Access to pain relief is considered a human right. Some women accessing maternity care may state that they want an epidural immediately or make the decision to use pharmacological pain relief when they were not initially planning to. This is their right. However, pain perception is influenced by social and cultural learnings, medicalisation, and the media. This may not include evidence-based information on birth physiology and adequate support for non-pharmacological pain relief techniques.

A study on pain relief in labour found epidurals were considered the most effective pain relief, nonetheless, water birth was associated with higher levels of satisfaction than epidural use. Predictors for a positive birth experience include a positive attitude and support from midwives, ability to mobilise, confidence & autonomy, inclusion of partners and a safe birthing environment. Birth satisfaction does not solely depend on the level of pain experienced, but the care provided. Women’s autonomy is promoted when non-pharmacological techniques are appropriately explained and used.

Reframing non-pharmacological pain relief

Non-pharmacological pain relief needs to be reconceptualised. Labour is not a problem to be solved but an experience to be worked through. Non-pharmacological techniques enhance this experience and most are easily implemented, affordable, and effective in helping women and their partners actively engage in their care. Midwives, as the protectors of normal birth, should be confident to inform, promote and facilitate the use of non-pharmacological techniques during labour.

Pain relief techniques offered to women during labour are influenced by the opinions and values of their care provider. A mindset change in the way midwives and practitioners present choices to women could increase understanding of the benefits of non-pharmacological pain relief in labour. Discussing non-pharmacological pain relief options not defined by the medical paradigm, but rather, validated in their own right, could improve women’s confidence in their labour choices. Using words such as intuitive or natural techniques would be more appropriate.

Women’s decisions are influenced by social and cultural norms. Birthing choices can be positively influenced, by providing information around birthing techniques based on evidence, that focuses on women’s needs. Comprehensive discussion during antenatal care of physiology in labour and all of the pain relief techniques available, including the risks and benefits, would ensure women are adequately informed.

Current labour care is not always focused on women’s needs. Social and cultural learnings from media sources informed by a biomedical paradigm have influenced midwives and women to discount the benefits of non-pharmacological pain relief. Pharmacological pain relief techniques are being used in a majority of births without necessarily providing the best experiences. Non-pharmacological pain relief techniques, which have been effective since traditional midwifery care, enhance the physiological process, support women’s autonomy and can facilitate a positive birth.

So, I challenge you, instead of questioning whether non-pharmacological pain relief techniques are adequate labour care, question whether all pain relief techniques are being adequately facilitated and ask – who is benefiting from these choices?

References

Abdul-Sattar Khudhur Ali, S., & Mirkhan Ahmed, H. (2018, 2018/06/01/). Effect of change in position and back massage on pain perception during first stage of labor. Pain Management Nursing, 19(3), 288-294. https://doi.org/https://doi.org/10.1016/j.pmn.2018.01.006

Amiri, P., Mirghafourvand, M., Esmaeilpour, K., Kamalifard, M., & Ivanbagha, R. (2019). The effect of distraction techniques on pain and stress during labor: a randomized controlled clinical trial. BMC Pregnancy and Childbirth, 19(1), 1-9. https://doi.org/10.1186/s12884-019-2683-y

Aune, I., Brøtmet, S., Grytskog, K. H., & Sperstad, E. B. (2020). Epidurals during normal labour and birth — Midwives’ attitudes and experiences. Women and Birth, in press. https://doi.org/https://doi.org/10.1016/j.wombi.2020.08.001

Australian College of Midwives. (2016). Scope of Practice for Midwives in Australia. https://www.midwives.org.au/sites/default/files/uploaded-content/field_f_content_file/acm_scope_of_practice_for_midwives_in_australia_v2.1.pdf

Bonapace, J., Gagné, G.-P., Chaillet, N., Gagnon, R., Hébert, E., & Buckley, S. (2018). No. 355-Physiologic basis of pain in labour and delivery: An evidence-based approach to its management. Journal of Obstetrics and Gynaecology Canada, 40(2), 227-245. https://doi.org/10.1016/j.jogc.2017.08.003

Brennan, F., Carr, D., & Cousins, M. (2016). Access to pain management—Still very much a human right. Pain Medicine, 17(10), 1785-1789. https://doi.org/10.1093/pm/pnw222

Czech, I., Fuchs, P., Fuchs, A., Lorek, M., Tobolska-Lorek, D., Drosdzol-Cop, A., & Sikora, J. (2018). Pharmacological and non-pharmacological methods of labour pain relief—Establishment of effectiveness and comparison. International Journal of Environmental Research and Public Health, 15(12), 2792. https://doi.org/10.3390/ijerph15122792

Fockler, M. E., Ladhani, N. N. N., Watson, J., & Barrett, J. F. R. (2017, 2017/06/01/). Pregnancy subsequent to stillbirth: Medical and psychosocial aspects of care. Seminars in Fetal and Neonatal Medicine, 22(3), 186-192. https://doi.org/https://doi.org/10.1016/j.siny.2017.02.004

Gönenç, İ. M., & Dikmen, H. A. (2020, 2020/03/01/). Effects of dance and music on pain and fear during childbirth. Journal of Obstetric, Gynecologic & Neonatal Nursing, 49(2), 144-153. https://doi.org/https://doi.org/10.1016/j.jogn.2019.12.005

Happel-Parkins, A., & Azim, K. A. (2016). At pains to consent: A narrative inquiry into women’s attempts of natural childbirth. Women and Birth, 29(4), 310-320. https://doi.org/10.1016/j.wombi.2015.11.004

Health, A. I. o., & Welfare. (2020). Australia’s mothers and babies 2018—in brief. https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-and-babies-2018-in-brief

International Confederation of Midwives. (2014). Position Statement: Keeping Birth Normal. https://www.internationalmidwives.org/assets/files/statement-files/2018/04/keeping-birth-normal-eng.pdf

Keedle, H., Schmied, V., Burns, E., & Dahlen, H. G. (2019). A narrative analysis of women’s experiences of planning a vaginal birth after caesarean (VBAC) in Australia using critical feminist theory. BMC Pregnancy and Childbirth, 19(1), 142-115. https://doi.org/10.1186/s12884-019-2297-4

Luce, A., Cash, M., Hundley, V., Cheyne, H., van Teijlingen, E., & Angell, C. (2016, 2016/02/29). “Is it realistic?” the portrayal of pregnancy and childbirth in the media. BMC Pregnancy and Childbirth, 16(1), 40. https://doi.org/10.1186/s12884-016-0827-x

Lundgren, I., Healy, P., Carroll, M., Begley, C., Matterne, A., Gross, M. M., Grylka-Baeschlin, S., Nicoletti, J., Morano, S., Nilsson, C., Lalor, J., Sahlgrenska, a., Göteborgs, u., Gothenburg, U., Institutionen för vårdvetenskap och, h., Institute of, H., Care, S., & Sahlgrenska, A. (2016). Clinicians’ views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a study from countries with low VBAC rates. BMC Pregnancy and Childbirth, 16(1), 350. https://doi.org/10.1186/s12884-016-1144-0

MacIvor Thompson, L. (2019). The politics of female pain: women’s citizenship, twilight sleep and the early birth control movement. Medical Humanities, 45(1), 67. https://doi.org/10.1136/medhum-2017-011419

Mills, T. A., Ricklesford, C., Heazell, A. E. P., Cooke, A., & Lavender, T. (2016, 2016/05/06). Marvellous to mediocre: findings of national survey of UK practice and provision of care in pregnancies after stillbirth or neonatal death. BMC Pregnancy and Childbirth, 16(1), 101. https://doi.org/10.1186/s12884-016-0891-2

Nodine, P. M., Collins, M. R., Wood, C. L., Anderson, J. L., Orlando, B. S., McNair, B. K., Mayer, D. C., & Stein, D. J. (2020). Nitrous oxide use during labor: Satisfaction, adverse effects, and predictors of conversion to neuraxial analgesia. Journal of Midwifery & Women’s Health, 65(3), 335-341. https://doi.org/10.1111/jmwh.13124

Queensland Clinical Guidelines. (2017). Normal Birth. https://www.health.qld.gov.au/__data/assets/pdf_file/0014/142007/g-normalbirth.pdf

Sanders, R. (2015, 2015/09/01/). Functional discomfort and a shift in midwifery paradigm. Women and Birth, 28(3), e87-e91. https://doi.org/https://doi.org/10.1016/j.wombi.2015.03.001

Sanders, R. A., & Lamb, K. (2017). Non-pharmacological pain management strategies for labour: Maintaining a physiological outlook. British Journal of Midwifery, 25(2), 78-85. https://doi.org/10.12968/bjom.2017.25.2.78

Skowronski, G. A. (2015). Pain relief in childbirth: changing historical and feminist perspectives. Anaesthesia and Intensive Care, 43, 25-28. http://hy8fy9jj4b.search.serialssolutions.com/directLink?&atitle=Pain+relief+in+childbirth%3A+changing+historical+and+feminist+perspectives&author=Skowronski%2C+G+A&issn=0310057X&title=Anaesthesia+and+Intensive+Care&volume=43&issue=&date=2015-07-01&spage=25&id=doi:&sid=ProQ_ss&genre=article

Smith, L. A., Burns, E., & Cuthbert, A. (2018). Parenteral opioids for maternal pain management in labour. Cochrane Database of Systematic Reviews(6). https://doi.org/10.1002/14651858.CD007396.pub3

Spendlove, Z. (2018). Risk and boundary work in contemporary maternity care: tensions and consequences. Health, Risk & Society, 20(1/2), 63-80. https://doi.org/10.1080/13698575.2017.1398820

Thomson, G., Feeley, C., Moran, V. H., Downe, S., & Oladapo, O. T. (2019). Women’s experiences of pharmacological and non-pharmacological pain relief methods for labour and childbirth: a qualitative systematic review. Reproductive health, 16(1), 71-20. https://doi.org/10.1186/s12978-019-0735-4

Wickham, S. (2016). Whatever happened to the precautionary principle? https://www.sarawickham.com/articles-2/whatever-happened-to-the-precautionary-principle/

Wood, W. (2018). Shifting understandings of labour pain in Canadian medical history. Medical Humanities, 44(2), 82-88. https://doi.org/10.1136/medhum-2017-011417

World Health Organisation. (2015). WHO Statement on Caesarean Section Rates. https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf;jsessionid=9813B3D2910219254542B7A550D264B7?sequence=1

Epidural analgesia for labour: An update on labour, birth and perinatal outcomes

The use of epidural analgesia for labour is common, with just over 40% of Queensland women making use of it (Queensland Health, 2020). Epidural analgesia is widely considered to be a safe option. Transforming Maternity Care Collaborative researcher Dr Elizabeth Newnham led a team of researchers who recently examined outcomes for women who did, and did not, make use of epidural analgesia for labour (Newnham et al., 2020).

Data were collected as part of the Maternal health and Maternal Morbidity in Ireland (MAMMI) study which prospectively explored the health of women giving birth for the first time, between 2012 and 2017 in Ireland. Women who gave birth by caesarean section prior to the onset of labour were not included. Care was taken to statistically control for the effects of age, body mass index, and maternity care pathway (public or private care). Data from the birth through to three months postpartum were available for 1,221 women in total.

Women giving birth for the first time who used epidural analgesia were more likely to give birth with vacuum assistance (22.1% without epidural, 25.5% with epidural use) or forceps assistance (4.2% without epidural, 17.4% with epidural). This finding probably relates to the longer duration of the second stage of labour (average of 35 mins without epidural vs 213 mins with epidural). Caesarean section rates were much higher in women who used epidural analgesia (3.4% without epidural, 32.2% with epidural). Seventy percent of women who laboured without an epidural had a spontaneous vaginal birth, while only 24.9% of women with epidural analgesia did so.

Intravenous oxytocin and antibiotics were more commonly used in labour for women using epidural analgesia. The use of antibiotics possibly relates to the higher rate of fever during labour in women using epidural analgesia (0.8% without epidural analgesia, 9.1% with epidural analgesia). Rate of perineal trauma or postpartum haemorrhage were no different between the two groups.

No differences in Apgar scores (either at 1 min or 5 mins), or in the rate of admission to the neonatal intensive care nursery were found. Breastfeeding rates were lower at three months for women who has used epidural analgesia (63.1% without epidural analgesia, 47.5% with epidural analgesia).

The findings of this research reflect that found in previous research about epidural use. Given the nature of this type of research, it is not possible to claim that the outcomes seen were a direct consequence of epidural use. The information set out in the study  provides a useful starting point for obstetricians and midwives as they work with women to support them to make informed decisions about their care.

References

Newnham, E. C., Moran, P. S., Begley, C. M., Carroll, M., & Daly, D. (2020, Sep 11). Comparison of labour and birth outcomes between nulliparous women who used epidural analgesia in labour and those who did not: A prospective cohort study. Women Birth, in press. https://doi.org/10.1016/j.wombi.2020.09.001

Queensland Health. (2020). Queensland Perinatal Statistics 2019. Interim Report. https://www.health.qld.gov.au/hsu/peri/peri2019/queensland-perinatal-statistics-2019