Giving birth at Royal Columbian? Here’s what you should know
Will and I in hospital after Wesley's birth in 2007. Photo: Lorenn Klassen.
Of the five friends I have who delivered their babies at Royal Columbian Hospital, four of us had 30+ hour labours ending in emergency Cesarean sections. I have wondered how it could be that four out of five young, healthy women could all have so much trouble delivering our babies naturally that we would need our babies cut out of our bodies.
In the time following my own C-section I assumed it must be simply selection bias – we five weren’t necessarily representative of the general birthing population at Royal Columbian. Yet when I came across the Fraser Institute’s hospital report card, it resurrected the concern that too many births are ending with C-sections at RCH. According to previously private data the Fraser Institute unearthed through a Freedom of Information request, more than a third of mothers birthing at Royal Columbian delivered by Cesarean in 2007 and more than 80% of women who have had C-sections repeated the surgery to have their next babies. You can see that between 2001 and 2007 the rate of Cesareans at Royal Columbian has gone up to 32% from a low of 28%, and the VBAC rate (vaginal birth after Cesarean) has gone down from a high of 23% to only 18% .
This isn’t a problem only at RCH. About 30% of all births in B.C. were by C-section in 2007, and the VBAC rate was just 16.4%.
Baby Nora, after my 'triumphant VBAC' in 2009. Photo: Lorenn Klassen.
The World Health Organization says the C-section rate for any country need not be higher than 15%. Given that we have a publicly funded (and struggling) health system, the fact that we are seeing more than twice the recommended Cesarean rate is cause for economic as well as health concern. Among the long list of reasons to be concerned about the increase in C-sections on childbirth.org is this little factoid: “A cesarean costs nearly twice as much as a vaginal birth ($7,186 average vs. $4,334 average in 1989 in the US). It has been estimated that in Quebec, Canada, if the current rate of cesareans (18.8%) were reduced to that of Finland (11.9%), costs incurred by the provincial health care system could be reduced approximately $19 million per year.” Yowza.
In my first interview with the OB/GYN while I was pregnant, I asked all the questions recommended by my library of books: what is the C-section rate, what were their opinions on a variety of interventions, and other questions designed to get a sense of their level of support for a ‘natural’ birth. I had signed on with a team of six doctors, at my family doc’s behest, and each time I met a new one, I asked the same questions. Everyone responded that they would only use interventions and offer pain relief if ‘necessary.’ As I later discovered, ‘necessary’ is a matter of opinion.
Like many young women, I had assumed with my first pregnancy that I was at low risk for major complications. I had an easy pregnancy. I was only 25 and generally healthy. I had endured jokes about having “childbearing hips” more times than I could count. So I skipped the chapter on Cesareans in What to Expect When You’re Expecting. I spent the part of my birth preparation class that covered C-sections fantasizing about the relatively effortless and even pleasurable home births I had read about on the Internet. Labour was hard and long, but I had read almost every book for new mothers in the New Westminster Public Library (and a few more I ordered from Amazon), so I was expecting that. As my labour lengthened, I heard the empty ward begin to fill with other mothers’ cries followed by their babies’. My doctor kept going home. I laboured with little guidance from the nurses, grateful for my husband’s stalwart support.
My son was born after about 30 hours of labour followed by what I have learned is a textbook cascade of intervention: gas for the pain, doctor breaking the water to try to hurry the birth, followed by an epidural, hours of fruitless pushing and then an emergency C-section when we discovered the baby was poorly positioned. It’s possible that the outcome could have been the same had I been encouraged to labour in my own time with more support from my care provider. The experience of the birth of my daughter makes me wonder, however.
Those who follow me on Facebook or Twitter know that my second baby’s birth was ‘a triumphant VBAC’ (as my midwife Tracy Simpson described it on the Mama Love Midwifery Facebook page). It was a very short labour, also at Royal Columbian, and ended in the natural, medication-free birth I had so wanted with my first.
The midwife made all the difference. At least twice in my four hours labouring at the hospital, the OB on staff said he wanted to prep the OR for a repeat Caesarean. At one point the baby actually went back up the birth canal before the water broke, causing an increased risk of the umbilical cord wrapping around her neck. The OB wanted to send me for the C-section then, but the midwife recommended a controlled breaking of the waters, in which the OB carefully punctures the water sac and guides the baby down to ensure the cord doesn’t wrap around her neck. Then, towards the end, my baby’s heart rate dropped and although the OB would have recommended emergency surgery, my midwife wanted to give me the chance to push her out. With her support, I did, and my baby was born healthy and beautiful. I felt great. Tracey gave instructions at the hospital that I could leave after the required six hours of monitoring, as soon as I felt ready to go. Will and I brought baby Nora home in time for lunch!
In the end, neither birth was intervention-free. The difference was in how ‘necessary’ was defined, and how each care provider judged what level of intervention was required. With my first birth, I felt like everyone was just waiting to see how long it would take for me to give in. That’s probably not what they intended, but it is how I felt. The second time around I got scared, and my resolve began to waver. Instead of asking if I wanted drugs or taking my fear as a sign that I couldn’t do it, my midwife urged me to be strong and fight for the birth I wanted.
So, having now experienced both a Cesarean and a vaginal birth, an OB and a midwife, I have a few pieces of advice for expecting moms in New West:
- Seek out a midwife for the best chance at a low-intervention birth. Most doctors pop in and out for periodic checks until you’re ready to push or something goes wrong. Midwives will stay with you throughout your labour, lending support as necessary. Start looking as soon as you know you’re pregnant. Midwives are in such demand now that it can be difficult to find one who is accepting patients.
- If you’ve had a previous C-section, try a VBAC. The success rate is about 75%, so there are good odds that you will succeed. While the C-section itself is less painful than pushing out a baby, when the anesthetic wears off, the recovery is weeks-long instead of days. The postpartum experience is so different … I felt battered the first time, but euphoric after the VBAC. Also, with every repeat C-section, your risk of major complications with future pregnancies increases (important if you think you may want more kids).
- Throw out the birth plan. A piece of paper won’t matter during labour. You’ll have more success by putting your effort into choosing a care provider and support people who you can be sure will lend you the strength to have the best birth possible.
- Question your doctor. Don’t just ask if something is really necessary. Ask what will happen if it doesn’t get done, if you can try something less invasive or if you can delay just a little longer. Sometimes babies just need a little more time and we all should be a little more patient.
- If you do have a C-section, you are not alone. Once you start talking about it, you’ll probably discover a shocking number of others who have too. It’s also very common for women who have C-sections to feel sad or angry about the birth experience. It’s totally normal.
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Thanks for such a honest, open piece, Briana. I think I’m one of those four moms you talk about, as I too had a C-section at RCH. I had a midwife, but after 12 days overdue, an induction, a lengthy labour, and the entire cascade of intervention over the course of two days, even the midwife recommended the C-section because Kale was, as one nurse so nicely put it, “a star gazer” and was in the wrong position. But I never felt that it wasn’t my decision.
I absolutely agree with you about midwives; Linda Peters was my midwife. She is one of the very few New Westminster midwives, along with Tracey. I recommend her n(and other midwives) for her guidance and support, not just during labour, but through the whole pregnancy and even afterward for 6 weeks.
Briana this is great – we need a chorus of voices like yours, women demanding that their wishes be heard, and that concepts like “Risk” and “necessity” be appropriately understood.
I hope you are okay that I sent the link to all of my co-workers!
The only other suggestion I would make is for you to describe your decision-making process on how you arrived at a midwife the second time. As I recall, it wasn’t the first option and you did a lot of research and consideration to get to that point, with no small amount of opposition from medical people around you. Not to belabour the point – just to say for moms out there that you aren’t necessarily “born” a midwife patient, sometimes you evaluate your options and decide it’s the right choice for you. Also in your case you had difficulty finding a midwife, esp. in new west. Do you have any thoughts for New Westie moms who want to find a midwife? (other than to check the BC Association of Midwives website.)
My first labour and birth were at Royal Columbian, and my second was not. Which, I think, tells you what you need to know about my experience there. Although, in fairness, that had little to do with the birth and more to do with our experience in the Special Care Nursery.
My real point is that I completely agree with you about midwives. Both of my births were midwife-assisted, and I have not had a C-section. However, my first birth occurred unexpectedly at 34 weeks, so I was high-risk. I really believe that having a midwife present made all the difference in how that birth progressed. She absolutely intervened and advocated for me throughout the 9 hours I was there before my daughter arrived, and I was able to deliver almost exactly as I’d planned in spite of being preterm.
I would also like to add that many mothers find doulas to be very helpful. They are not medically-trained, and do not replace either a doctor or midwife. However, the support they provide in labour has been proven to be highly effective in reducing the rate of interventions, pain medication and C-section. My friends who used them rave about how great they are.
My labour was at a different hospital, in a different city and with different results- but I see the same themes running through what you are saying. I have also come to the same conclusion; when/if we have a second child getting a midwife will be first on my list.
My major issue with the care I received was, quite frankly, the amount of care I received. At the Foothills Hospital in Calgary, of my 12 hour labour, at least 4 hours was spent in the waiting room and less then one hour each was spent in the triage room and my labour room. Prior to going to the hospital I didn’t even know there was a ‘waiting room’; they must have missed that chapter in my pre-natal class. Given the amount of monitoring I had, we were very lucky that nothing went wrong. What I really needed was someone to be providing care for me through the whole labour.
To me it is all symptoms of the same problem- the hospitals are over crowded, the doctors (and nurses) are over worked and the nurses are being leaned on for parts of post-natal care that they really are not trained for. (I won’t go into the care I received post-delivery, suffice to say I wish I had had a midwife for that care too.) Was every person who provided my care in labour and deliver and post-natal care kind, caring and trying to to their best? Yes. Were they equipped with time and training to do their best? No.
I think it is this lack of time and people in our hospitals that have caused the c-section rate to be so high. It is more expensive, yes, but sometimes easier then really supporting a women through her labour. Midwife’s seem to be the best solution right now, but I think ultimately was need to start really talking as a country about the quality of health care we want to provide in our hospitals.
A must-read for anyone who’s expecting. Thanks for sharing your experience.
Great posting, Briana!
I do know that the cecarian rate in Australia is also quite high. Women there are encouraged to book the babies birthday to fit their schedules and that of their doctors. I was also prepped for a cesarean for my first birth. Thankfully things progress too far for that. The crazy thing is nurses in Australia are trained in a speciality of midwifery, yet cesarean rates continue to be high.
I do think it has something to do with timing,hospital efficiency, and the fear of liability. If only they were afraid of the liability for performing unnecessary surgeries!
I hope your post encourages women to seek out the help of a midwife and to speak up for themselves with their doctors!
Thanks everyone!
Jocelyn: I had always wanted a midwife, but honestly I was too lazy to do the legwork required to get one the first time around. When my family doc recommended the OB team at RCH I trusted that it would be fine to take the easy way and sign on with them. Stupid me. The second time around I wanted a VBAC and I didn’t trust that I would have a good chance with an OB, so I prioritized finding a midwife. My family doc didn’t think I’d be allowed to go with a midwife for a VBAC, and referred me to an OB to confirm that it was safe. Luckily the OB had worked a lot with midwives and he reassured me that it was safe, and even said that given my preferences it was probably a better choice than an OB! As for how I found the midwife … well we can’t all have sisters-in-law with connections to maternity care providers! I used you and Google, and discovered that it’s a lot harder to get in to a midwife than I thought. I was lucky to find an opening with Mama Love Midwifery (I just squeaked in).
Kathleen: Recent research suggests that midwife-assisted home birth is as safe as hospital birth for low-risk moms. If I wasn’t now considered higher risk due to the first Cesarean, I’d go that route. I am now convinced that many complications are due to hospital process disrupting a mother’s concentration, making her less relaxed. Nora was coming faster than we thought, and probably would have been born at home by accident if the midwife had been any later. When she went back up the birth canal, I think it was because we raced to the hospital and I was told not to push even though I felt the urge. I think we would have avoided that complication if we had just continued at home, and thus we would have avoided the other stuff too. In Wesley’s case, had I laboured at home, perhaps he might have righted himself before the water broke naturally. If not, if it would have been a C-section anyway, we would have had time to go to the hospital to get it done.
Buffy: it is definitely a fear of liability that fuels the rise in C-section rates. C sections are major surgery and as such there is a lot of post-op risk associated with it. But surgeons feel more comfortable with surgical risks than the random risks of natural childbirth. There’s also the fact that OBs are trained as surgeons. Natural childbirth is not really their area of expertise.
This is a really great post. Congratulations on your triumphant VBAC!
Both of my kids were born at BC Women’s – the first because we lived in Vancouver when I started my prenatal care and the second because the first had been. Comparing my experience to friends & acquaintances, I firmly believe that the key to a satisfying experience – whatever that means to you – is support. What your midwife did for you during labour with Nora was perfect – she knew what you wanted and she supported your choices and advocated for you.
Because I never have a family doctor I sought maternity care with both of my pregnancies. The first time I lucked out with the South Community Birthing Program, http://www.scbp.ca which is a fantastic mixed practice of midwives and doctors. It provides prenatal care in the form of a group prenatal class at the same time as the check-up; it provides support in the form of a group dynamic (you’re placed in a prenatal group with 10 other women who are due around the same time as you), plus a free doula, it was absolutely the best way to have a first baby. It’s only available to women in Vancouver but it is a model that I would so so so love to see done everywhere, all the time. My son ended up being delivered by a midwife – she was on call that day – and she fought her ass off for me every step of the way. She forced the OB to let me get out of bed and walk around instead of lying there with monitors on. She slowed everybody down, made them wait a few minutes to see what would happen instead of pushing the next intervention. I did end up delivering vaginally, with an epidural. It was the best possible outcome and I didn’t feel short changed in any way.
Of course, when I told my second maternity doctor this story, about having been induced because of low amniotic fluid, he told me that there’s research suggesting many low amniotic fluid situations are not as bad as they’re made out to be; if it’s a hot day and the mum isn’t drinking enough water, her fluid level will go down. He said had *he* been my doctor that he would have had me drink a litre of water and come back for another ultrasound, instead of admitting me and inducing me right away. So even at BC Women’s, there’s haste and unnecessary intervention; for many of the reasons your other commenters have outlined.
Yes, I completely agree. We had Linda as our midwife. I still remember her commenting that “I’ve never seen that doctor return a syringe that he’d prepared before” after I pointed out to him that my wife had said that she didn’t want those meds.
There are a lot of competing considerations for doctors, but ultimately they became doctors to practice medicine, and surgery is often regarded as the highest form of medicine.
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