Labour and Birth Options

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Spontaneous Labour? Physiological Labour? Augmentation? Induction? Elective Cesarean? Emergency Cesarean?
 
What are they?

Spontaneous labour is labour that begins on its own, meaning that it is not started with induction drugs or a foley bulb/cooks catheter, it is the final culmination of your bodies hormones reaching a level that is individual to you combined with your baby signalling to your body by way of proteins that are released from his or her lungs that then travel to the placenta where they tell your uterus that baby is ready and your uterus then sends signals to your brain that tell your brain that it is time for labour to begin. Spontaneous labour can be augmented with syntocinon  (a labour inducing drug made from synthetic oxytocin which acts similar to but is not the same as the naturally occurring oxytocin in your body) and, in the case of premature labour, can sometimes be stopped with drugs that are designed to relax the uterine muscles and stop contractions (it does not always work however).

Physiological labour is spontaneous labour without any interventions (meaning no drugs, no augmentation, no induction etc and usually no internal examinations as they can sometimes disrupt the physiological process). With the way that our hospital based maternity system is designed this natural labour (it is a completely natural process) is usually only now occurring in rare scenarios – births before arrival (garage, side of the road, hospital car park or entrance way), in some birthing centre births (not all birthing centres are devoid of interventions though they do usually keep them to a minimum) and also in most planned homebirths.

Augmentation is usually used when a spontaneously started labour is going slower than a care provider would like it to go (as a doula and childbirth educator I will stress here that regardless of what a care provider prefers it is still your body and your baby and your birth and you can refuse augmentation if you wish to do so, it is always your choice). Syntocinon is used to make contractions stronger and closer together with the idea that it will speed up labour time (this may or may not be true, it is individual to everyone). There are risks involved with the use of syntocinon however so ask your care provider or doula to go through them with you so you can make an informed decision on if this is the right option for you. Augmentation can also be done when an induced labour, where syntocinon is not yet being used, is slowing down or stopping in order to get contractions going again.

Induction of labour is where labour is induced instead of allowing it to occur spontaneously. Induction usually follows the same general guidelines and which methods are used can depend on if there is any prior dilation of the cervix and what the hospital you are birthing at considers to be normal policy. In general if there is no prior dilation of the cervix a ripening agent will usually be used – like cervadil or misoprostal (both carry risks so please ask your care provider to talk through the benefits and risks of both of these drugs).

Cervical softening  could then be followed by either artificial rupture of the membranes (ARoM) or a foley bulb catheter/cooks catheter to increase dilation (which would then usually be followed by ARoM), this is then usually followed by syntocinon delivered at a steady but increasing rate via an IV drip. Syntocinon also has risks so please ensure that you ask your care provider to talk you through them.

When dilation has already begun prior to the induction ARoM is usually done followed by syntocinon.
Sometimes the cervical softening agents or the foley bulb/cooks catheter or ARoM are all that is needed to get labour going and in these instances syntocinon is not normally used unless labour starts to slow down and augmentation is needed.

Elective caesarean is a caesarean that is usually electively chosen and done before labour has even begun – sometimes labour will begin beforehand and in these circumstances it can be called an emergent elective caesarean (meaning it’s not an emergency, yet, but labour has already begun which means it is classed as an emergency – yes that doesn’t really make much sense but it is how it works in most hospitals). Most (meaning over half) elective caesareans are chosen without any complications indicating that a caesarean is needed and are purely the personal choice of the birthing person – this is perfectly OK, I want to make that very clear. While elective caesareans are considered to be safer than emergency ones they are still major surgery and major surgery carries risks. Prior to scheduling an elective caesarean your care provider should be talking through with you all of these potential risks – not just for the surgery itself but also for any future pregnancies too – so that you can make an informed decision about your mode of birth. If your care provider does not discuss this with you please make sure that they do – ask lots of questions, and ask to see the research.

Emergency caesarean carries many of the same risks as an elective one though usually has a few other risks related to the speed in which they can need to be done. Many emergency caesareans these days are done for reasons that aren’t a true emergency YET but could potentially become one quickly, some are also done solely because a care provider thinks that a birthing person has been in labour for “too long” (usually after 24 or more hours of labour which can be a very normal length of labour for some women) or a birthing person has not dilated beyond a certain point in 3 or more hours (from a physiological standpoint this is very normal and not an actual emergency situation, it just means that the fundus is doing some very hard work that doesn’t involve dilation and likely also indicates that the birthing person needs both food and sleep for energy before more dilation will occur).
 
 
Why should I think about them?

Thinking about your birthing options is important, it helps you to decide which option is the best one for you and your baby and can help you to learn more about what is involved. Getting you thinking before your birth is important, because during labour you may not be able to think clearly and having to make decisions while you are having contractions can potentially disrupt the labour process and make it harder for you to cope with labour.
When you know what you want ahead of time, and have already thought about all of your options and decided on both your main birthing plan and your backup birthing plans (the ones for if your circumstances change) then you don’t have to think as much during labour and there’s less interruptions – you can tell your care providers and partner to refer to your birthing plans first and then go on from there.
 
What if I need an emergency caesarean?

Hopefully you will have investigated this option prior to labour. Most first time mothers, and even many second, third, and so on, time mothers don’t actively think about this option until it comes up unless they have been exposed to the scenario before (either from their own previous birth or from friends, family and acquaintances who have been through it before.  I know for me as a first time mother an emergency caesarean was so far off my radar that I didn’t even look into it, or learn what was involved, and when it became the only option I was still refusing it and saying no while I was being wheeled into theatre because it wasn’t what I had wanted and I knew nothing about what was involved other than that I would be cut open and my baby pulled out of me.

Research!

Learning as much as you can about every option is one of the key’s to having a better birthing experience. You don’t have to know every single nitty gritty little detail about how it is done but knowing the basics can help you to feel more comfortable with what is happening. An emergency situation is almost always scary for the mother, her support people and even for her care providers, so being able to remain somewhat calm and knowing what will happen during the procedure can make it that little bit less scary for you.
 
What if an elective caesarean is offered to me?

This is your personal choice, always. You can consider an elective caesarean, and you can accept or refuse it at any time, and you can even change your mind at any time. You don’t have to make a decision right away and you can tell your care provider that you need time to think it over first.

Ask lots of questions – why is this being offered to me? What are the perceived benefits for me and my baby? What are the risks for me and my baby, not just during this surgery but also in future pregnancies? Are there any alternative options available to me? Do I need to make a decision right now (meaning is it actually an emergency or just a care provider preference?) or can I wait until I’m closer to my estimated due date before making a final decision? If I can’t wait longer before deciding, why? What if I change my mind later on and don’t want to go through with it? Will you support me in my choice if I do decide to not go through with it?

Regardless of what a care providers preference is in regards to your birth you are the one in charge, and you are the one who gets to decide how you birth, regardless of what is happening and what potential benefits or risks are involved.
 
Which option is, in the absence of any complications, safer for me?

From a physiological standpoint, and in the absence of any life threatening complications a spontaneous labour resulting in a vaginal birth is the overall safest option. In some situations an elective caesarean birth may be safer FOR your baby but would have additional risks for you that a vaginal birth does not have.

We need to remember that just a risk of something happening isn’t an immediate life threatening complication so it doesn’t count in this particular scenario (and should only be one minor consideration when making a decision about how you want to birth, combined with the benefits, other potential risks that might be involved, other options and their benefits and risks and your own personal wants, needs and choices) – risks have a place but they are generalised towards the entire population and not towards you as a unique person, and your own individual risk factors, which are separate from the general populations overall risk factors though they do make up one very small percentage of those general risks, often either aren’t taken into account or are considered to be far more important in the moment of making decisions than they actually are.

The risk of uterine rupture for a vbac is a good example of a risk being blown out of proportion, yes there is a risk (0.2% to 0.7% for vaginal births after up to 2 cesareans with an average risk of 0.5% - or 1 in 200, this risk applies to all of a pregnancy and not just to labour alone though it is often promoted as just a risk of labour itself) but the risk itself is quite small when compared to the risks for the mother, both during the surgery and later on in subsequent pregnancies, of a repeat caesarean, yet a repeat caesarean is often offered and even pushed on women who are thinking of having a vbac because of this one risk even though statistically a vbac is much safer for the mother and only slightly less safer (overall based on general risk factors, the vast majority of families who vbac have no problems at all despite not having had a repeat cesarean) for the baby than a repeat caesarean. This is why research, and choosing a supportive care provider are so important, so that you can know the risks, and the benefits, and make the right decision for you and your baby with the support of a care provider who will help you to achieve your goal and will only recommend a caesarean when it is really needed (*hint* most care providers don’t do this, but there are a few wonderful ones out there who do, finding these “unicorn” care providers is often the hardest part of the whole process of planning for a vaginal birth after a cesarean!)

Ask yourself – how do the benefits and risks of this particular option apply to me?
What other options are available to me?
What are their benefits and risks as well?
What do I want?
How does what I want apply to my options?
What could prevent me from birthing the way that I want?
And what can I do to minimise that thing that could prevent me so that I can increase my chances of birthing in the way that I want?
What are my care providers preferences and how do they apply to me?
Do my care providers preferences override my own wants, needs, wishes and rights?
How would my care provider react if I chose something that he/she did not approve of?
Am I comfortable with my care providers reaction?
Am I comfortable in only doing what my care provider says or do I prefer and/or feel more comfortable in doing my own thing?
Do I feel fear or worry or concern when I think about going against my care providers wishes or preferences?
If yes why - why are my care providers wishes and/or preferences more important to me than my own even when they aren’t what I want or what I feel comfortable with?

Regardless of how you choose to give birth make sure that you know what is involved and what your options are, because the more you know, the better prepared you will be, and the easier it will be for you to make informed decisions.
 
 

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