The On-line Journal of Mary Esther Malloy

A birth by cesarean can be life saving. We are fortunate to live at a time when this technology is as widely available as it is. And yet, many expectant parents tell me that a cesarean is their top fear.

Expectant parents are alarmed because cesareans are an overused technology. One in three babies is born by cesarean in the U.S., well in excess of the 10 to 15 percent recommended by the World Health Organization (WHO).  In New York City, where I attend births, a number of our hospitals have rates as high as 40 percent and if you venture to certain New York Metro area hospitals, cesarean rates approach and even exceed 50 percent.

The Numbers from the CDC

•  The overall cesarean delivery rate in the United States increased 60% from 1996 through 2009, from 20.7% to 32.9%.
• Nearly one-third of births continue to be delivered by cesarean every year.
• 1,291,071 babies were born by cesarean in the U.S. in 2013.” (i)

Doctors want to lower the Cesarean Rate

Increasingly, obstetricians are also concerned. The near-steady rise in cesareans in recent decades has not improved outcomes for U.S. mothers and babies. In fact, data show that high cesarean rates may do more harm than good. A WHO News Release says,“New studies reveal that when caesarean section rates rise towards 10% across a population, the number of maternal and newborn deaths decreases. But when the rate goes above 10%, there is no evidence that mortality rates improve…caesarean sections can cause significant complications.”(ii) Globally, the U.S. now ranks an abysmal 61st in maternal health, worse than any developed country, according to Save the Children’s State of the World’s Mothers 2015 report.(iii) Newborn outcomes don’t fare much better, with the U.S. ranking 41 out of 45 industrialized nations. Many consider our high intervention birth culture among the reasons for these poor standings.  At last, a national push is underway to reduce the number of cesareans.  In 2014, a report entitled “Safe Prevention of the Primary Cesarean,” was released by the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM).(iv) The groundbreaking guidelines found in this report encourage doctors to make many changes in how maternity care is offered.

What can expectant parents do to minimize the likelihood of an unnecessary cesarean?

These ideas may help:

1. Location location location!
2. Labor might be long!
3. Learn about the new guidelines!

Location Location Location

Choose carefully where you give birth and with whom.

It is well within your rights (and some would say it is your responsibility) as a parent to ask your doctors about how they practice.  If you feel your providers’ beliefs about birth are not a good match with yours, don’t hesitate to switch practices.  A small headache now (switching practices) may save you a big headache later. If my doula clients are particularly concerned about an unnecessary cesarean, I suggest they consider midwifery care, since midwives often have cesarean rates closer to the 10 to 15 percent WHO recommendations.

What is predictive of your likelihood of a cesarean is less your age or health status than your providers’ cesarean rate. Henci Goer, author of The Thinking Woman’s Guide to a Better Birth, writes,

“Studies show that whether you have a cesarean depends on such factors as what part of the country you live in (the South is the worst, the West is the best); whether the hospital is for-profit; the hospital culture and policies; which nurse you get; whether you have an obstetrician, family practitioner, or midwife: whether you plan to have your baby in a hospital, in a freestanding birth center, or at home; and most especially, you particular caregiver’s cesarean rate. This last, in turn, depends on your caregiver’s beliefs about birth.”(v) 

Labor might be long

It might not be long, but research shows that labors often take longer than doctors had previously thought.  In fact, ACOG and SMFM report that the number one reason for primary cesareans in the U.S. is labors that are thought to progress too slowly.  In the past, the active labor “clock” would start ticking once a woman reached 4 cm dilation.  After that point, a labor would be considered stalled if it didn’t progress at an expected rate.  Medication or a cesarean would often follow. The new ACOG/SMFM guidelines point to research that indicates that labor shouldn’t be considered active until 6 cm dilation, since dilation from 4 to 6 cm takes longer than older data show.

If you have a long labor, or even a normal-long labor, keep these ideas in mind.

• -Get out of bed! Movement helps labor progress. Alternate periods of activity such as a long walk, or climbing stairs, with periods of rest.
• -Stay hydrated and nourished. Prepare sipping broths in advance of labor for a warm, drinkable source of sustenance. The Mindful Cesarean Toolkit for a Healthy Birth has a recipe for my cesarean recovery sipping broth. It is excellent for labor as well!.
• -Limit vaginal exams or ask not to be told the dilation. This can help women cope well when labor is slow.

Learn about the new guidelines

ACOG and SMFM are recommending many changes in maternity care that research shows can safely lower the national cesarean rate. Learn about these guidelines and discuss them with your careprovider.

• The new guidelines encourage doctors to avoid inducing labor unless medically necessary.
• They suggest possible alternatives to a cesarean if a baby experiences Category II fetal heart rate deceleration.
• They recommend that doctors attempt to manually turn breech babies, given the high success rate of this procedure.
• Planned cesareans are no longer recommended for suspected large babies, unless the baby is thought to be 11 lbs or greater, and doctors are encouraged to counsel women that late term ultrasound is not an accurate measure of fetal weight.
• If a woman is having twins and the presenting baby is head down, a vaginal birth is to be considered.
• Most centrally, these new guidelines urge doctors to base their judgments on contemporary data showing that labor takes longer than we had thought.

Of course each situation is unique, but what does your doctor think about the new ACOG/SMFM guidelines? You will want to know before labor begins.

Choose your birth location carefully, remember that long labors can be normal, and learn about the new ACOG/ SMFM guidelines.

Labor Support Matters

There is one more idea to mention. The AGOG/SMFM guidelines also state that continuous labor support, such as care provided by a doula, is one of the most effective ways to decrease the likelihood of a cesarean.  Research shows that the presence of doula can reduce the chance of a cesarean by 28%.(vi) That’s a lot! Consider inviting a doula to your birth team.

How does including a non-clinical care provider on your team improve clinical outcomes?  In labor, women need the free flow of the hormone oxytocin. Darkness, silence, a feeling of privacy and a feeling safety all aid the release of this important labor hormone.  A doula can help you create the conditions that help oxytocin flow. As Dr. Nils Bergman says, “You invite a midwife to your birth so you are safe. You invite a doula so you feel safe.”(vii) Feeling safe matters!

Cesareans are an overused technology. Be a wise consumer and choose carefully where and with whom you will birth your baby. If labor is long, have good support in place and strategies to help you cope well. And, if a birth by cesarean is ultimately the best and safest way for your baby to be born, embrace your child’s birth as a real birth. Breathe together with your partner and welcome your baby, even as you navigate the emotional tacking that often accompanies a birth by cesarean.  There are no second class births.

By Mary Esther Malloy, MA,  from themindfulcesarean.com

References:

(i) Osterman, M.H.S, Martin, J. “Trends in low-risk cesarean delivery in the united states, 2009 -2013” National Vital Statics Reports, 63(6)(2014) Retrieved from

http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_06.pdf,  Nov 5, 2014

(ii) “Caesarean sections should only be performed when medically necessary” World Health Organization (2015) Retrieved from http://www.who.int/mediacentre/news/releases/2015/caesarean-sections/en/, January, 2016

(iii) “The urban disadvantage. Save the Children State of the World’s Mothers 2015 report.” (2015) Retrieved from http://www.savethechildren.org/site/c.8rKLIXMGIpI4E/b.8585863/k.9F31/State_of_the_Worlds_Mothers.htm#download-the-report, Feb 2016.

(iv) “Preventing first cesareans: recently released guidelines that you can discuss with your doctor or midwife,” (2014). Choices in Childbirth. Retrieved from

http://choicesinchildbirth.org/wp-content/uploads/2014/08/Preventing-First-Cesareans-Consumer-Stmt-4-29-14.pdf , Apr 2014

(v) Henci Goer, The Thinking Woman’s Guide to a Better Birth, TarcherPerigee 1999

(vi) Hodnett, E.D., Gates, S., et al., (2012) “Continuous support for women during childbirth. Cochrane database of systematic reviews.” Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21328263, Mar 2014

(vii) Personal communication, Oct 2016