How Richmond Hospital went from the highest rate of C-sections in B.C. to one of the lowest

When Dr. Brenda Wagner signed on as head of obstetrics at Richmond Hospital, the maternal team there had the highest rate of C-section births in B.C. A decade and a half later, it has one of the lowest.

There's no simple answer for how Wagner and her colleagues turned things around, but she said changing the culture of the maternity unit was key.

"There is a huge art to managing labour, and I think to some extent, we've lost some of it," Wagner told CBC News.

Numbers released this week show B.C. leads the country in delivery by caesarean. Last year, 35 per cent of births in this province were surgical, well above the national rate of 28 per cent.

Richmond's rate, on the other hand, was much closer to those in the rest of the country, coming in at 30 per cent.

Wagner, who sits on the steering committee for Perinatal Services B.C., said the single biggest factor in whether a woman will have a C-section is the location where she gives birth.

 "We [Richmond Hospital] didn't focus on changing our C-section rate. We just focused on providing really high quality evidence-based care," Wagner said.

That meant bringing all of the doctors, nurses, midwives and other health-care workers together to outline clear processes for dealing with women in labour.

Working as a team

One key step was recognizing that when women are admitted to hospital too early in their labour, they are more likely to undergo a C-section.

Everyone at the hospital needed to get on board with guidelines for sending expectant mothers home when they come in too early.

"Often, I see a woman who's in early labour, I feel like she's so distressed. I want to keep her in hospital. I'm feeling compassionate. I care for her, and the nurses are just like, 'Brenda, she needs to go home,'" Wagner said.

"That kind of teamwork facilitates me doing what I know is the right thing, but I sometimes find hard doing in practice."

The Richmond team also uses what it calls a multimodal approach to pain, where an epidural is the last resort. In the first stage, patients will be advised to have a bath, go for a walk or have a massage; next comes nitrous oxide and then an IV.

Saraswathi Vedam, a midwifery professor at the University of B.C., has another suggestion for bringing down caesarean rates.

She said the common practice of continuous fetal monitoring — watching the baby's heart rate throughout labour — can actually increase the likelihood a woman will have a C-section.

"The anxiety that is engendered by seeing these periodic changes [in heart rate] sometimes drives decisions toward intervention. Very rarely do they drive decisions in the opposite direction," Vedam said.

It's better to have someone check the heart rate periodically, according to Vedam. That means having a midwife, doula or one-to-one nurse on hand throughout the delivery.

"The evidence is clear that people with continuous labour support have improvements in progress and improvements in comfort," she said.

Clear benefits

The evidence is also clear on the benefits of vaginal birth, according to Wagner. Caesareans come with a high risk of infection, bleeding and scarring, and babies aren't exposed to the same healthy bacteria that will help babies breastfeed and digest their mother's milk.

Wagner said it's possible for any hospital to make the changes Richmond made.

"You have to have champions," she said. "Actually bring in people who understand high vaginal birth rates and understand how to promote normal labour and normal birth."

With files from Rachel Sanders