Almost 1 in 3 babies born in North Carolina and around the world is delivered via C-section, a procedure that can save lives but also poses serious risks to both mother and infant.

Among them: infection, hemorrhage, injuries to nearby organs, breathing problems for baby, delayed bonding and even death. And once a mother delivers via C-section, her chances for a future vaginal birth plummet.

That’s why Novant Health nurses and midwives are taking steps — from hydrotherapy to peanut balls and nontraditional positions — to help more women deliver vaginally.

The strategies dovetail with a national push by the federal government to reduce the rate of C-sections in first-time moms (also known as primary C- sections) to 23.5% by December 2021. Overall, Novant Health has averaged 22.3% since late last year.

Leading the charge is Novant Health Forsyth Medical Center in Winston-Salem, which has surpassed the goal month after month — paring its primary C-section rate to between 12% and 13% last summer, typically the maternity department’s busiest time of year.

“We're extremely proud of the results we've seen,” said Danielle Liddle, a labor and delivery nurse at Forsyth. “Just looking at the numbers is a true testament of the hard work everyone has done. There's nothing better than to be able to be with the mother in one of the ultimate moments of her life.”

Danielle Liddle nurse
Nurse Danielle Liddle

She credits the teamwork of doctors, midwives, nurses and support staff for making such a difference in the life of patients.

"We are certainly not trying to reduce any C-section number that would present the best outcome for a mom and fetus," said Liddle. "What we want to reduce is that C-section that is preventable."

As part of the effort, nurses and midwives get ongoing training in techniques to promote more efficient labor. And Novant Health’s labor rooms have been redesigned to create an aura of comfort and calm, with soothing art and soft colors, as well as room to roam.

That extra space has value beyond sheer aesthetics. Women who haven’t had an epidural are encouraged to get out of bed and walk, squat or bounce on yoga balls, all of which help foster vaginal delivery. They can also retreat to newly expanded showers and tubs, where warm water helps relieve pain and tension that can slow progress. There’s even room for a spouse or birthing coach to hop into the water and offer an assist.

Women who do receive an epidural have to stay in bed — but that doesn’t mean staying still. Novant Health has adopted an approach called Spinning Babies that helps nudge the fetus into position and make room for its trip through the birth canal. The offbeat labor positions call to mind the pretzel twists of a contortionist.

"Oftentimes, patients have their elbows on the floor and we have their knees up on the bed and we’re supporting their hips and keeping them there for a few contractions," Liddle said. "Women will say, 'Are you sure? This sounds crazy.' But it works on the physiologic aspects of the pelvis and the maternal body to get that fetus where it needs to be."

A large peanut-shaped cushion that fits snugly between the thighs can also help open the birth canal and move things along.

Leigh Anne Smith Nurse
Nurse midwife Leigh Anne Smith

Lead midwife Leigh Anne Smith, who has worked in labor and delivery for a decade, said nurses have told her about patients who "absolutely five years ago would have had a C-section" but were able to deliver vaginally, thanks to the maneuvers and added support during labor.

"They were stuck at a certain dilation and with the maneuvers they did, they were able to achieve a vaginal delivery, and I really do think it was because of that," Smith said, adding that "the numbers speak for themselves."

Giving first-time moms the gift of time has also helped Novant Health keep primary C-section numbers lower.

That means waiting to see if women whose water breaks or whose pregnancy has continued past 39 weeks will go into labor on their own, Smith said. And once labor begins, it may be allowed to continue longer than in the past, so long as neither mother nor fetus is in distress. Sometimes, of course, a C-section is needed to achieve the goal of a healthy mom and baby.

Whenever possible, though, the benefits of delivering vaginally are significant for both mother and newborn, according to Smith and Liddle.

For mom, there’s less risk of bleeding, blood clots, infection and injuries to bladder, intestine and other organs. Importantly, there’s no scar inside the abdomen to boost the future risk for premature separation of the placenta — a significant cause of death for mothers and babies.

Meanwhile, babies born vaginally acquire beneficial microbes from their mothers that newborns delivered by cesarean miss, studies have found.

The trip through the birth canal also gives baby’s lungs a beneficial squeeze that helps head off respiratory distress. Babies born via C-section must often be rushed to the neonatal intensive care unit for respiratory support. That and other post-surgical checks after a cesarean can even delay the first step in bonding between mother and baby — skin-to-skin contact — as well as breastfeeding, Liddle said.

Learning new ways to help more women have a vaginal birth has been eye-opening, she said.

"It just requires education, knowledge, time and effort," Liddle said. "It’s been so exciting and fun to … watch the culture be transformed."

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