considering the cesarean section

The rates of cesarean births are increasing alarmingly each year, with over one in every three births ending in major abdominal surgery. When a cesarean is necessary, it can be a life saving technique for both mother and baby. With countless documented medical risks to the mother's health, including infections, hemorrhage, transfusion, injury to other organs, anesthesia complications, psychological complications, and a maternal mortality two to four times greater than that for a vaginal birth, it is hard to understand why cesarean births are becoming the new norm. Even the World Health Organization states that no region in the world is justified in having a cesarean rate greater than 10 to 15 percent. If we hope to do anything meaningful to decrease the rate of cesarean births, we need real culture change. However, change can only begin with understanding the barriers. This post highlights the common reasons cesarean sections are performed.

Placenta Previa This occurs when the placenta lies low in the uterus and partially or completely covers the cervix. One in every 200 pregnant women will experience placenta previa during their third trimester. The treatment involves bed rest and frequent monitoring. If a complete or partial placenta previa has been diagnosed, a cesarean is usually necessary. If a marginal placenta previa has been diagnosed, a vaginal delivery may be an option.

Since placenta previa involves pre-term bleeding, it can be a very traumatic experience for pregnant women, especially as some women believe they are miscarrying. The diagnosis can help medical practitioners rectify the problem, but the baby is usually delivered by cesarean. In this case, is definitely safer to have it by cesarean than to try to push a baby over a placenta, especially when it can detach during the birthing process. There is truly a difference between placenta previa and a low lying placenta, though in the case of true placenta previa, cesarean births are definitely worth the risk.

Placental Abruption This complication occurs when the placenta separates from the uterine lining before the baby is born. Approximately 1% of all pregnant women will experience placental abruption during the third trimester. The mother will experience bleeding from the site of the separation and pain in the uterus. This separation can interfere with oxygen getting to the baby and, depending on the severity, an emergency cesarean may be performed. There are two types of placental abruption, partial placental abruption and complete placental abruption. In the case of a partial separation, a cesarean is not necessary if the bleeding stops and the baby is not in distress. A complete separation, however, is a true medical emergency requiring immediate cesarean.

Uterine rupture In approximately 1 in every 1,500 births, the uterus tears, or ruptures, during pregnancy or labor, leading to hemorrhaging in the mother and interfering with the baby's oxygen supply. Uterine rupture is a reason for immediate cesarean as it can lead to a hysterectomy and death if it is not repaired right away. While uterine rupture can occur during any form of birth, the risk is higher for women who have had a previous cesarean birth, which in itself increases the rate of repeat cesarean birth.

Breech Position When dealing with a breech baby, a cesarean delivery is often considered by obstetricians to be the only option, especially due to the increased chances of cord prolapse and fetal distress. Even if the baby is in a breech position before the pregnancy is full-term, a cesarean may be preformed pre-term, resulting in premature delivery. Since medical schools no longer teach obstetricians how to deliver breech babies, cesareans are considered the 'safer' option for the baby. However, breech babies are commonly and safely born vaginally every year. In Canada, for instance, cesarean birth is no longer routinely performed for breech babies. Birthing position (such as squatting or hands and knees) is the key factor in order for a woman to successfully birth a breech baby vaginally. Breech birth is only a variation of normal childbirth, not necessarily something that is completely abnormal and to be feared.

Cord prolapse This situation does not occur often, but when it does, an emergency cesarean is performed. A cord prolapse is when the umbilical cord slips through the cervix and protrudes from the vagina before the baby is born (occurring, for instance, when the water breaks and there is too much space between the baby’s head and the cervix). As the uterus contracts, pressure is placed on the umbilical cord which diminishes the blood flow to the baby. Increased risk for cord prolapse occurs when the water is artificially broken. In the case of a cord prolapse, the baby must be delivered immediately, often by cesarean, so his oxygen levels do not decrease; if oxygen is cut off for too long, death or mental retardation may result.

Fetal distress The most common cause of fetal distress is lack of oxygen to the baby. If fetal monitoring detects a problem with the amount of oxygen that the baby is receiving, then an emergency cesarean may be performed. When this is correctly diagnosed, a cesarean is the best option. Unfortunately, fetal distress is often misdiagnosed in order to move labor along and get a woman to deliver faster. However, numerous tests are available to make sure the baby is not actually in fetal distress. It is common for a baby's heart rat to slow during contractions; a change of position may show that the baby is not in distress at all. If there is true fetal distress, however, changing positions will not help, and if a woman is not far enough along in her labor to speed a vaginal delivery, a cesarean may be imperative. 

Failure to progress Once a woman is in labor, a failure to progress can occur when the cervix has not dilated completely, labor has slowed down or stopped, or the baby is not in an optimal delivery position. Since the first phase of labor (0-4 centimeters dilation) is almost always slow, failure to progress is diagnosed correctly only when the women is in the second phase (beyond 5 centimeters dilation). Once a woman reaches active labor (more than 4 centimeters dilation), it is commonly thought that dilation should proceed by once centimeter every hour. However, as labor is drastically different for many women, some women will open faster, some much slower.

Unless there is an actual medical emergency that requires the baby to be delivered immediately, failure to progress is not a good reason for a default cesarean, even though many medical professionals believe that some women's bodies just cannot handle labor and cannot give birth. In its natural course, labor naturally speeds up and slows down and plateaus and then speeds up again. Sometimes a laboring body needs time to rest and gain strength for the next leg of the race. If labor 'stalls,' a woman can change positions, walk around, and be active in order to get things moving again.

Repeat cesarean A cesarean section is major abdominal surgery. While the first cesarean is not necessarily considered a big deal, subsequent cesareans are particularly dangerous. Any number of complications can arise, including placenta previa, placenta accreta (abnormally deep attachment of the placenta into the middle layer of the uterine wall), uterine rupture, injury to internal organs during surgery, excessive blood loss, need for hysterectomy, and maternal death. These risks rise with each subsequent repeat cesarean delivery. However, nearly 90% of woman who have already had a cesarean birth are candidates for a vaginal birth after cesarean (VBAC) for their next birth. The biggest risk factor involved in a VBAC is uterine rupture, which is common in 0.2-1.5% VBACs. There is certain criteria a mother must meet in order to be eligible for a VBAC; women should consult their care providers in order to understand their options. The U.S. has such a low VBAC and high cesarean rate because obstetricians deliver most of our babies, and obstetricians are not primary care clinicians. In his article VBAC rates are low, but are obstetricians to blame?, Kenneth Lin, MD, explains that labor managed by family physicians and professional midwives is considerably more likely to result in a vaginal birth than labor managed by an obstetrician, especially when considering VBACs. As with labor in general, there are risks in VBAC, but the risks are far greater with a repeat cesarean.

Cephalopelvic Disproportion (CPD) A true diagnosis of CPD occurs when a baby’s head is too large or a mother pelvis is too small to allow the baby to pass through. Like failure to progress, most cases of CPD are misdiagnosed (based upon the belief that the baby is too big for the mother to sufficiently dilate in a timely, scheduled manner), especially as pelvic measurements are based upon estimations. If a woman has rickets or something else has altered her pelvic bones, CPD can be legitimately diagnosed. But for the most part, a woman's body naturally will not make a baby bigger than she can push out, especially not the 30% of women in the US who give birth via cesarean. Remaining active and maintaining mobility helps a baby to position itself for vaginal delivery and helps a mothers cervix to dilate.

Active genital herpes: If the mother has an active outbreak of genital herpes at the end of her pregnancy (diagnosed by a positive culture or actual lesions), a cesarean may be scheduled. A cesarean is necessary in this case in order to prevent the baby from being exposed to the virus while passing through the birth canal. However, if the mother does not have an active outbreak, she is perfectly able to have a vaginal delivery safely without exposing the baby to the disease. 

Diabetes If a mother develops gestational diabetes during her pregnancy or is otherwise diabetic, her likelihood for having a baby larger than normal increases, as does the likelihood for other complications to arise. If the case of diabetes is uncontrolled or undiagnosed, the baby may grow too large for the mother to push out. However, diet goes a long way in controlling diabetes and baby growth; by discussing options with her care provider, a mother can control the diabetes to prevent excessive growth in the baby and successfully have a vaginal birth. 

Preeclampsia Preeclampsia is a condition of high blood pressure during pregnancy, which prevents the placenta from getting the proper amount of blood and decreases oxygen flow to the baby. This condition is very severe, and, once diagnosed, a mother is closely monitored. Delivery is sometimes recommended as treatment for this condition, and most women are able to deliver vaginally, but there are rare, extremely severe cases of preeclampsia where an emergency cesarean is necessary in order to save the mother and baby. 

Birth defects If a baby has been diagnosed with a birth defect, a cesarean may be performed in order to reduce the risk of any further complications during delivery. In some instances, a vaginal delivery will only complicate a particular birth defect, especially when the baby rotates and shifts during the birth process. Since this shift does not occur during cesarean birth, a cesarean is the lesser of two evils. 

Multiple births As multiple births are labeled as 'high risk,' these babies are usually delivered via cesarean. However, vaginal delivery is a safe option for many multiple births given that the babies are in a favorable position (any position other than transverse). If she is pregnant with multiple babies and hopes to deliver vaginally, she should find a supportive care provider who is confident in the female body's ability to naturally birth multiples, who believes twins do not require additional interventions, and who is knowledgeable about positions that are favorable for delivering multiples.

preparing for natural childbirth

One of the most important choices a pregnant woman will make is how she will give birth. While it is common for many birthing women to choose medications and synthetic drugs to manage pain during labor, choosing to do so brings on a greatly increased risk of birth complications and further labor intervention procedures. While childbirth may be painful, in a healthy pregnancy, a natural, drug-free childbirth is by far the best option for having a healthy delivery. A woman who trusts in her body's natural ability to labor and birth will have the most rewarding, emotional and powerful birth experience.

There are many steps you can take during your pregnancy in order to prepare for a natural birth. Make sure you keep a healthy lifestyle during your pregnancy, eating primarily nutritious, whole foods and getting plenty of easy exercise by walking, doing stretches, and yoga.

Once you decide you are serious about having a natural childbirth, hire attendants who are more likely to support your decision to birth naturally. Consider hiring a midwife rather than an OB. Midwives are autonomous practitioners and are the primary carer for the vast majority of women in both the developed and undeveloped worlds during their pregnancy. Provided a pregnancy is progressing normally, a woman need never see a doctor. According to Catherine Taylor in her book Giving Birth: A Journey into the World of Mothers and Midwives, midwives have a 19% lower rate of infant deaths and a 33% lower rate of neonatal mortality (infant death in the first month) than doctors attending comparable births, and midwives who attend hospital births have a cesarean rate that is half the national average. Additionally, midwives tend to be more open to different methods of childbirth. And, if complications do arise, midwives are assuredly knowledgeable and capable.

Whether you choose to hire a midwife or not, you may also consider hiring a doula. Essentially, a doula is a natural-childbirth coach and advocate for the birthing mother and her family. If you have a doula present at your birth, she will be able to remind you of the reasons you chose to birth naturally and gently push you to continue as you had planned when you are in the throws of labor. She will also be able to assist you with relaxation, breathing and pain-relieving techniques and help labor move along as smoothly as possible. In addition to providing emotional and physical labor support, she will advocate your wishes and can assist in communication with medical staff in a hospital setting, as well as obtain information for you to better be able to make informed decisions in regards to procedures and possible interventions.

Perhaps the most important step to preparing yourself for a natural childbirth is to educate yourself about every aspect of the birth experience. You have nine months to learn all you can about labor options, birth attendants, common procedures, possible necessary and unnecessary interventions, and the common and unique qualities of other successful natural childbirths. With the internet, there are literally countless resources at your fingertips. There are also many books that focus objectively on natural birthing options, including my favorites, Birthing from Within: An Extra-Ordinary Guide to Childbirth Preparation by Pam England and Rob Horowitz and The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions by Penny Simkin. When browsing birth-education reading material, be sure to choose books and sources that positively support your decision to have a healthy, aware, and natural childbirth.

Another step you can take to prepare yourself for a natural birth is to participate in childbirth education classes. While many hospitals offer basic classes for pregnant couples, there are many alternative options that actually focus on natural labor techniques. Lamaze is the most discussed method of birth education and natural pain management, teaching techniques for focused breathing. Lamaze will help you focus on making it through each contraction, though it does not necessarily prepare women for what to expect in regards to the intense pain involved in labor. Becoming increasingly popular, however, are comprehensive natural childbirth classes such as Hypnobabies, The Pink Kit, and Birth Outside the Box. These well-rounded, objective courses are comparably priced and available to you in the comfort of your own home or in small group settings, and they will provide you with options for natural pain-relief and a solid foundation on which to build your natural birth experience.

Lastly, be confident about your decision to have a natural childbirth and your body's ability to birth. For most women who choose natural childbirth, their main goal is to be lucid and alert after the delivery of their baby, to be able to immediately and peacefully see, hold and bond with their baby. Visualize this positive outcome throughout your pregnancy and be confident that this is what your want. If you expect horrible labor pain, you are more likely to actually be in pain. Confidence is actually a big step in making the labor process more bearable.

Once you educate yourself about your options and decide on birth attendants who support your decision to birth naturally, you will be able to develop a clear picture of your own expectations for a emotionally fulfilling positive birth experience. If you begin feeling discouraged at any point during your pregnancy or labor, remember this one simple thing: You were made for this.

modern midwifery

In the United States, less than 1% of births take place at home. It is difficult for the other 99% of Americans to make the transition from believing that technology is the benchmark for establishing worldwide leadership to the understanding that, in reality, the human body is designed to give birth. Our bodies are generous and amazing in their abilities to give birth naturally.

The rates of surgical birth and birth intervention in the US have soared beyond those of other developed countries around the world. The rate of maternal and infant mortality is not only significantly higher in the US than that of other developed nations, but also has not improved in nearly thirty years. Despite a significant improvement in the US maternal mortality ratio since the early 1900s, it still represents a substantial and frustrating burden, particularly given the fact that essentially no progress has been made in most of the US since 1982. Additionally, the Centers for Disease Control and Prevention has stated that most cases of maternal mortality are probably preventable. Among the causal deaths that could be prevented were those that involve both underlying health issues such as poor nutrition and high blood pressure as well as those that are physician-caused, including infection and hemorrhage.

There are many preventable risks of placing birth in a hospital environment. To begin with, bacteria can be introduced, first by the mother arriving in an environment where diseases are being treated, as well as from
infiltrating the natural barriers we have against infection through vaginal exams and, of course, surgical delivery. Additionally, there are higher incidences of hemorrhage from forced delivery of the placenta (when a care provider intentionally pulls on an umbilical cord). Furthermore, injuries and deaths related to the physician’s care range from the off-label use of medicine for the induction of labor as well as the sanctified use of surgical delivery, which is one of the leading causes of maternal mortality and a risk directly associated with cesareans and hospital births.

It is important to remember that pregnancy is a normal, low-risk, significant time in a woman's life. With knowledge of her body, a woman can interpret her body’s signals and maintain her own health. She can educate herself about care options and make good choices based on impartial and complete information because she knows her own body. Modern midwifery care is based on many concepts which are proven to reduce maternal and infant mortality rates and increase a mother’s joy in her birth experience.

Pregnancy effects and is effected by all aspects of a woman’s life: social, economic, professional, familial. A woman who knows about her body and how she gives birth is less likely to need medical interventions. An experienced midwife spends time with her clients. She gets to know them, teaches them and helps them think through their options to make reasoned decisions. She spends time with the client’s partner, observing the dynamics and providing holistic support. She helps identify how best to prepare the chosen space for labor and birth. Under a midwife's care, a typical prenatal visit lasts 30-60 minutes, labor accompaniment is consistent through the active labor and birth, and postnatal care includes several follow-up visits. It is estimated that midwives spend 10-15 times as many hours with a client as doctors spend--at about half the price! Midwives still do 70% of the births in the world and are experts not only at “normal” birth but at keeping infants normal around the birthing process. Midwifery care makes sense for normal pregnancies because midwives are skilled at keeping the pregnancy normal.

Women deserve knowledge to care for themselves before conceiving and during pregnancy and birth. Women gain the best birth knowledge from other women who have chosen natural childbirth with supportive birth care. Women are naturally intuitive and need not accept the negative images of labor that the media portrays. Women, their partners and their advocates can differentiate between normal birth and situations that may require medical guidance. Women want to choose important aspects of their birth experience based on credible information, not fear of litigation. The most favorable physical, mental and emotional birth outcomes for mothers and their babies are best supported by midwifery care.

Women have the right to choose a care provider and with whom and where to give birth. Every woman, and her family, must be recognized as being an individual with her own unique expectations for hers and her baby’s birth. It is a myth that women who seek a homebirth are willfully putting themselves at risk. Women are fully capable of considering their options and choosing how to care for themselves.  It is not rational to say homebirth is never safe; saying so is the product of hysteria. All birth information providers must create a more personable environment for the woman to learn about birth, her body and her birth options.  Protecting choice, not limiting choice, is good, no, GREAT health care.

Artwork: Music by Katie M. Berggren