Lots of women go into the hospital to have their baby without thinking that they will end up needing a cesarean section to birth their baby. In America, this happen a whopping 1/3 of the time. The World Health Organization (WHO) recommends a 10-15% rate for c-sections. So why is the USA doing more than double that at 33%? There are all sorts of things that can lead to a c-section. Some of it out of anyone’s control and some times we do things without knowing it can increase our risk for a surgical birth. Sadly, sometimes things are done to women by their care providers that puts them on the fast track to the OR. Just for the convenience of the care provider. But I’m not going to talk about that part today.
Let’s talk about things that would indicate a need for a c-section.
Placenta Previa: This is where the placenta is covering the cervix, either partially or completely. Often times it is noticed around 20 weeks when most women have their anatomy scan. If it is only partially covering the cervix there is a good chance that as the uterus grows the placenta will move away from the cervix, making it possible to have a vaginal birth. Usually by 36 weeks the care providers check the placement of the placenta again before recommending a scheduled cesarean birth. The risk of placenta previa is that as labor progresses and the cervix dilates it is pulling away from the placenta and reduces blood flow and oxygen to baby, putting baby in distress and putting mom at risk for excess bleeding. A c-section is the much safer option for mom and baby in this case. There is nothing you can do about placenta previa, it just happens.
Fetal Distress: This can mean lots of things, baby is compressing it’s own cord during contractions which is causing the slow of blood and oxygen, there could be a knot in the cord that is causing the distress, baby may just not be tolerating labor. Often times changing mom’s position can be what is needed to shift things so baby gets the blood and oxygen needs. Sometimes the nurse will give mom an oxygen mask and instruct her to take deep breaths while they watch the fetal heart rate on the monitor. Depending on your care provider and how far along you are in labor will be factors on whether or not you need to deliver baby via c-section. If you’re pushing already, your care provider may suggest assisting with vacuum or forceps to help get baby out while encouraging you to push with all your strength. If you’re still in the early stages of labor and baby seems to be in distress ask your nurse or care provider to please explain what they are seeing on the monitor and what they would like to be seeing instead and how you can help it. If baby’s heart rate drops too much for too long they will likely suggest a c-section for the safety of your baby. There is some controversy over the fetal monitoring though. Some say this is why our cesarean rate is so high, that not all babies are actually in distress- that the machine is not working properly or not picking up the heart rate well. In most hospitals you can request intermittent monitoring so you can be free from the machine and walk and move freely while they put you on it for so many minutes every so often or they will check on baby with a hand held doppler. But in the event of an induction or augmentation of labor with pitocin, or after you’ve received pain medication or an epidural you will be required to have continuous fetal monitoring to make sure baby is ok with these interventions.
Cephalopelvic Disproportion or CPD: This is when the baby’s head or body is too large to fit through mom’s pelvis. It can be hard to determine if it is a true case of CPD because often times when a woman is labeled ‘failure to progress’ they say it is CPD. When an accurate diagnoses of CPD has been made, then a cesarean delivery is safest. But according to the American College of Nurse Midwives, CPD occurs 1 in 250 pregnancies. According to a study published by the American Journal of Public Health more than 65% of women that were diagnosed with CPD went on to deliver subsequent babies vaginally. If you truly have a small or misshapen pelvis there is nothing you can do about that but to try positions in labor to help open the pelvis, like being in a squatting position on a ball or using a squat bar to push. But if you are able to do these things and baby does fit, then it wasn’t a true case of CPD. There is no way to tell by x-ray or ultrasound how much your pelvis will or wont open up during labor, you just have to wait and see what happens when the time comes.
Transverse or Breech presentation: This is when baby is not in the head down position when labor starts. Only about 4% of babies are in the breech position at time of birth. Babies being in the transverse (laying sideways in utero) only occurs about 1 in 2,500 births. Breech babies can be born vaginally, you need to have a care provider who is skilled in breech vaginal births and be comfortable with this. Back in 2001 a study determined that a c-section was the safer mode of delivery for breech babies. So they stopped training new OBs how to do breech vaginal births. Since then more studies have come out showing that a breech vaginal delivery is a safe and reasonable option for most women. If you would like to have a breech vaginal delivery you may need to switch providers to find one who is skilled in that. Transverse babies cannot come down the birth canal without flipping to a breech or head down position first. Some doctors will suggest trying to manually move baby, usually done in the hospital with monitoring to watch for distress and with ultrasound right there to confirm success. You can do things yourself to try to encourage baby, http://www.spinningbabies.com is a great place to start for suggestions. Sometimes the force of contractions can move a baby from the transverse position making a vaginal birth possible. But if baby refuses to budge, then a c-section is the best and really only option.
Placental Abruption: This is when the placenta starts to pull away from the uterine wall before baby has been born. Sometimes it happens before labor has even begun. Other times it occurs during labor. When the placenta starts to pull away from the uterus the blood flow is compromised and deprives baby of oxygen and nutrients. Some women feel pain from it while others do not. Usually it is accompanied with excessive vaginal bleeding and fetal distress. It is considered to be rare, happening in less than 200,000 pregnancies in the US per year. Depending on the severity of the abruption and the gestation of the pregnancy will decide the course of action. Sometimes it’s just bed rest and other times it is an emergency cesarean section. Women that are more than 40 years old or have high blood pressure are at an increased risk of placental abruption. This is one those things that you cannot prevent.
Cord Prolapse: This happens when the umbilical cord passes through the cervix before the baby does. This can make it easy for the baby’s head to trap the cord and compress it resulting in fetal distress. When this happens it is a quick run to the OR while usually there is someone(a nurse or dr.) with their hand in the woman’s vagina holding the baby’s head off of the cord to reduce the compression and keeping oxygen flowing to baby until they can get baby out safely via c-section. The most common cause of cord prolapse is the rupturing of membranes prematurely, before baby has gotten nice and engaged into the pelvis. Other risk factors include premature delivery of baby, multiples pregnancy (twins, triplets), excessive amniotic fluid, breech delivery, and a longer than usual cord. A good way to reduce your risk of cord prolapse is to wait for your amniotic sac to rupture on it’s own.
Failed Induction/Failure to progress: This is when your cervix does not dilate and bring baby down to be born vaginally. Sometimes this happens because baby is malpositioned, sometimes it is because your baby and body were not ready for labor. Different doctors and hospitals will all have varying determining factors for what they consider to be a failed induction/FTP before decided that a c-section is needed. Labor is not an exact science and you cannot assume that because someone else (your mom,aunt, cousin,friend, neighbor, lady behind you in the grocery store check out lane) had a failed induction(s) that you will too. There is also no way to tell before hand how quickly or slowly your labor will progress. Some women take 3 days of labor to get to 10cm while others take 3 hours. There is no magic one size fits all. The best way to avoid a failed induction is to not be induced. If you do decide to be induced or have a medical need for an induction discuss with your Dr. all the options you have and ask about your Bishop score. If you are in labor (induced or not) and you start to stall(cervix stays the same for several hours) and there is talk of being failure to progress change what you are doing,if you are sitting on a ball get up and go walk instead, if you are walking, try taking a slight break and resting and gathering energy. Talk to your nurse and Dr about what you can try to help make progress, there are always alternatives to try. If you have a doula, she will usually have a whole list of things to do and try to help encourage labor to move along. The majority of the time, the only thing the mother and cervix needs is time. Your cervix doesn’t care about the clock and as long as mom and baby are healthy and safe during the labor you shouldn’t care about the clock either.
Preeclampsia: This is when the mother’s blood pressure is high and usually have high levels of protein in their urine along with quite a bit of swelling in their hands/legs/feet. Pre-e can range from mild to severe. You could have several signs of pre-e(including blurred vision, quick onset of swelling and weight gain, headaches, etc) or have none. The exact cause of pre-e is unknown but we do know that it has to do with the placenta not functioning correctly.
While it is defined as occurring in women have never had high blood pressure before, other risk factors include:
- A history of high blood pressure prior to pregnancy
- A history of preeclampsia
- Having a mother or sister who had preeclampsia
- A history of obesity
- Carrying more than one baby
- History of diabetes, kidney disease, lupus, or rheumatoid arthritis
Often times it is when the mom’s blood pressure starts to get too high it becomes dangerous to remain pregnant and an induction or cesarean is planned. Usually an induction is what is scheduled where mom and baby are monitored closely. If baby does not tolerate the induction a cesarean is needed to ensure everyone’s safety. If mom’s blood pressure becomes dangerous or she starts to experience seizures then an emergency cesarean is needed. Since the exact cause of pre-e is unknown at this time it is really hard to say what may or may not help keep it away. There are lots of theories out there of special diets and tips and tricks to help, so it may be worth it for you to look into some of those suggestions. Depending on the severity of your preeclampsia and the gestation of your pregnancy you may need to be on medication to help keep your blood pressure under control until you reach a point where it is safe for baby to be born.
Planned Cesarean: Sometimes a mom decides she would just prefer a c-section to birth her baby. Your Dr may ask for your reasoning for coming to that decision but your doula never will.
Of course there are all sorts of circumstances that can require a cesarean birth for your baby and there is no way to know what those would be ahead of time. Every mom should do her best to be prepared for the birth of her baby and be supported every step of the way. Trinity Doula Services is committed to making sure our clients get all the information they need and are supported 100% in their choices.