December 15, 2009

Medical Indications for Cesarean Sections, Fact vs Myth

Last Sunday I took a workshop with Jessie Levey, Certified Childbirth Educator (CCE) through the Childbirth Education Association of Metropolitan New York (CEA/MNY) on Cesarean Birth and Prevention. Workshops likes these always get me driven to share what I learn. I figure if some of these statistics are new and shocking to me, a gal very much in the childbirth education world, they are probably unfamiliar to the average pregnant mother and must be shared!

Currently, cesarean sections are accounting for the highest number of surgeries in hospitals in the US. The US is hovering around a 33% c-section rate, twice that recommended by the WHO (World Health Organization). This rate has gone up dramatically from 1970 when there was a 5.5% CS rate, and 205,000 surgeries performed that year. Twenty years later – in 1990 – there were 914,096 CS and a national rate of 22.7%. In 2006, 1,321,054 CS surgeries with a national rate of 31.1%. (Statistics from ACOG) In all fairness, I also want to present the infant mortality rates from the compared periods: in 1970, the US experienced 20.0 infant deaths per 1,000 live births; in 1990, 9.2 per 1,000 live births; and in 2006, 6.9 per 1,000 live births. (Stats from OECD- Organization for Economic Co-operation and Development) So from the data you can see that the US is up 400% in c-sections with a drop of infant mortality rate of 50%. However, to support the 400% of c-sections, we really should be seeing a 75% drop of infant mortality. The Office on Women’s Health at the U.S. Department of Health and Human Services has stated “Many experts think as many as half of all C-sections are unnecessary.” The good news is that cesarean sections are now much safer, and if there truly is a life threatening risk to mother and baby, we have the resources to save them.

If experts believe that half the C-sections performed are unnecessary, what medical indications are valid to justify this major abdominal surgery? The following list may be helpful in eliminating factors that may not be applicable to you, and may help you and your care provider decide if a cesarean birth is a medical necessity. If you feel pressured to accept a c-section by a care provider, take this list and review it with them. This way, you will feel more confident and empowered as you decide how to birth your baby.

Indications for Cesarean Sections, Fact vs. Myth

1. Fetal Distress.
Fetal distress is the #1 stated reason for c-sections. This means that the fetus is in distress during labor, usually referring to a lack of oxygen and a compromised fetal heart rate. There is no hard, solid definition of what “fetal distress” really means. I came across a very interesting article, “What Constitutes Fetal Distress?” by Jeffrey P. Phelan, MD, JD in which a seasoned group of OB/GYNs discuss their interpretation on fetal distress. Here are some of their thoughts:

David B. Owens, MD, Overland Park, Kan–A FHR (Fetal Heart Rate) with persistent, true, late decelerations accompanied by loss of beat-to-beat variability and no reactivity-unresponsive to O2, a change in maternal position, or correction of low blood pressure; or persistent severe variables with loss of beat-to-beat variability. Severe variables and loss of beat-to-beat variability should prompt a call from the L&D nurse.

Donald P. Ward, MD, Austin, Tex–Fetal distress is continually confused with fetal intolerance to labor. The former exists when the obstetrician has concluded with reasonable certainty that some degree of fetal hypoxia is present and that sustained exposure to this condition is likely to result in irreversible tissue damage. Thus, it may be more appropriately termed obstetrician’s distress over severely abnormal indicators.

Joseph H. Cutchin, Jr, MD, Salisbury, Md–To me, fetal distress is a term used by the legal profession after an obstetrician has a bad outcome. I have been practicing obstetrics for 30 years and I still do not know what fetal distress is, nor have I seen any studies that define it.

Ways to avoid fetal distress
*Avoid pitocin. (Pitocin is the synthetic form of oxytocin used to stimulate uterine contractions).
*Ask your care provider if you can do intermittent EFM (External Fetal Monitoring) instead of full-time monitoring.
*Change positions if the baby is not responding favorably to one position. Try multiple positions. While it is common to put a mom on her left side if the baby’s heart rate is decelerating, the cord may be on that side and laying on it will cause compression.

2. CPD (Cephalic Pelvic Disproportion)
Basically, this is the determination that the baby’s head is too big for the mother’s pelvis. True CPD is rare and often seen in cases where there is a maternal birth defect involving the pelvis, where the mother has experienced a major accident in which the pelvic was severely damaged, or when it is a teenage mother whose pelvis has not fully developed. Should your care provider mention that this is the case or a concern, make sure you are not birthing on your back. When reclining flat on the back, the sacrum is being pushed into the birth canal and the elasticized rectal space is being squished. Birthing on hands and knees or squatting allows maximum pelvic space.

3. Failure To Progress
This means that cervical dilation has reached a plateau. This could be the result of fetal position. If the baby is OP (occiput posterior) or in an asynclitic position – meaning that the baby’s head is tilted to the side – the speed and progress of dilation will be effected. Often this can be solved by changing position. I have used a “butt-up child’s pose” for 30-40 minutes to disengage the baby from the pelvis, allowing it to re-rotate into a more favorable, effective position.

Other reasons for “failure to progress” could be psychological: if the mother is feeling pressured, exposed or uncomfortable, for example. If there is someone in the room that is making the mother nervous or if she is fearful of what is going to happen once she progresses. Ina May Gaskin calls this the Sphincter Law. Our sphincters – including the cervix- can not open unless we feel comfortable and relaxed. It could be as simple as keeping the lights low and the door shut to help ensure privacy and create a cozy environment. Should this be the case, I recommend that the mother and partner (or whoever the mother choices to confide in) take a few minutes alone to talk about what might be the trouble.

4. Time Issue
The hospital or care provider may have a rule about how long you can spend in labor before a c-section is considered. Should this situation arise, consider the same factors as with a “failure to progress:” change position, look at the environment in the room, consider the language that the staff is using with you, and discuss potential fears. If the clock is ticking and the care provider has brought it to your attention that you only have a certain amount of time, ask: “if mother is ok, and baby is ok, can we have more time?” You can also ask, “what would happen if we did nothing and waited?”

5. Previous C-section.
Many doctors and hospitals are not performing VBACs (vaginal birth after cesarean), and some insurance companies will not cover VBACs. The main concern about the VBAC is uterine rupture. There is a .5-1% chance of uterine rupture (stat from ACOG). In the past few years, the protocol for those attempting a VBAC has changed. In the late 1990’s, women with one previous c-section were being induced with a prostaglandin called cytotec which resulted in a high rate of uterine rupture. Currently, those that do pursue a VBAC do so without the aid of prostaglandin induction. It’s important to note that there is still a greater risk to mother and baby with elective cesarean section then there is from a vaginal birth. The maternal death rate is twice as high for elective cesarean as it is for vaginal birth.

6. Placenta Previa
There is no getting around a cesarean birth if the mother has placenta previa. This is a situation where the placenta is completely covering the cervix. It would be life-threatening to both mother and baby to deliver this way.

7. Placenta Abruptio
Placenta apbruptio is a condition where the placenta has detached from the uterine wall. This is a serious situation and the results range from an automatic c-section to bedrest, depending on how far along the fetus is and if it is fully separated or partially separated. With a mild abruption, the care provider may opt for the woman to deliver vaginally if the baby is mature and there is little distress.

8. Umbilical Cord Prolapse
This is a condition in which the umbilical cord slips out the vagina after the amniotic sac has been broken. The compression of the cord cuts off the baby’s oxygen supply. This is a very rare occurrence and is seen in 0.6% of deliveries. Because of the high risk to the baby, this is resolved with a cesarean section.

9. Breech or Transverse Presentation
A breech baby has the buttocks, feet or knees presenting at the cervical opening instead of the head. Some doctors and midwives are still safely delivering breech babies. If your baby happens to be breech and you are still hoping for a vaginal birth, go to a doctor that is experienced with delivering a breech. Many doctors are uncomfortable with this and are no longer taught how to handle this fetal presentation.

If the baby is transverse, that means the baby is lying across mom’s belly and there is no presenting part. A transverse baby has to be born via cesarean section.

10. Twin Babies
The twin situation is much like the breech situation. There are care providers well-skilled at handling a twin birth, but since it is rarely taught to newer doctors, it may be difficult to find a care provider comfortable delivering twins vaginally. However, several seasoned doctors in NYC area are open to delivering twins vaginally if both babies, or at least baby A, is head-down. If both babies are head-up, the likelihood of a vaginal birth is low.

11. Previous Infant Death or Major Birth Injury
Remember that part of birthing is being able to let go and trust the body’s ability to give birth safely. If a mother has already experienced a previous infant death or major birth injury to a previous child, she may have lost that confidence and may feel safer with undergoing a scheduled c-section.

12. Sexual Abuse
In cases where the mother has been sexually abused, a vaginal birth may be too traumatizing, in which case, a cesarean birth may be the healthier option.

13. Active Herpes
If the mother is experiencing an active herpes breakout, it would be much safer for the baby to be born via cesarean section. A vaginal birth while the mother is has a lesion or prodromal symptoms can be extremely harmful to the baby. I have heard that women can suppress the herpes outbreak with medication, but as always, check with a care provider before taking any prescription drug during pregnancy.

14 Past Uterine Rupture or Scar Tissue
If the mother has already experienced a uterine rupture or has significant scar tissue on her uterus, a cesarean section is a safer method of birth.

15. Pre-eclampsia
Pre-eclampsia is a condition where there is protein in the urine and hypertension (high blood pressure). This is a serious situation that is best remedied by the birth of the baby. Depending on the severity of the case and gestation of the baby, some women are induced to deliver the baby while other women may require a cesarean birth.

16. Estimated Fetal Weight
I recently wrote a whole blog entry covering the issue of estimated fetal weight. Please read it for more information, especially if this is being presented to you as a reason to have a c-section.




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