Prevention of the Primary Cesarean Section:
Facts, Myths and Tips
by Vijaya Krishnan

[Editor’s note: This article first appeared in Midwifery Today, Issue 118, Summer 2016.]

Not long ago, when a woman conceived and had a healthy pregnancy, she took it for granted that she would give birth naturally, the way nature intended. However, we have come to such a tipping point now that when women give birth naturally at our birth center, relatives and friends are surprised that she had a normal delivery. “Wow,” they say. “It is a miracle that you had a normal delivery!” In India, simply by walking into a hospital during labor and birth, a woman stands a significant chance of having a cesarean. Cesarean rates vary across the country, but recent articles report an unchecked increase in cesarean rates in India. In many private urban hospitals in cities across India, cesarean rates are above 75% (LiveMint.com 2016; Rao 2015). That means two out of three women give birth via major abdominal surgery. What has changed? Is this really necessary? How can we prevent that first (primary) cesarean? What do you as a parent need to be aware of?

I passionately believe that mothers and fathers deserve accurate information to make good decisions. The latest findings regarding the effects of cesareans come from a mammoth study including two million full-term births over a 35-year period in Denmark, showing that children born by cesarean had a “significantly increased risk” of developing certain chronic disorders (Ringgaard 2014). They showed a 20% greater chance of asthma, a 10% greater chance of juvenile rheumatoid arthritis, a 17% greater chance of leukemia and an over 40% greater chance of developing immune deficiencies, as well as higher chances of systemic connective tissue disorders and inflammatory bowel disease.

Adverse neonatal outcomes have not been associated with the duration of the second stage of labor (pushing stage). … My Tip: Asking your doctor to wait until you feel the urge to bear down, and then giving you at least three hours, and using upright positions like squatting, can prevent unnecessary interventions including a cesarean.

All too often, mothers are given only one side of the picture: cesarean is better because it is less risky. Less risky for what or for whom? As the study mentioned above rightly points out, it is important for the public to understand that cesarean rates have risen for decades without lowering the mortality rate for babies; without lowering the mortality rate for mothers (it has actually risen dramatically); and in the absence of research on the long-term risks of cesarean birth (Ringgaard 2014).

Cesarean section can be a life-saving surgery, but it is being remarkably overdone for reasons that defy evidence-based practice.

With the tremendous increase in cesarean rates over the last few years, the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine issued a joint Obstetric Care Consensus statement on the Safe Prevention of the Primary Cesarean Section (ACOG Consensus 2014). This statement provides fantastic guidelines in the way maternity care should be delivered and in the way hospitals and doctors should look at progression of labor, electronic fetal monitoring, breech presentations and twin pregnancies. All of this is done in an effort to reduce that primary cesarean!

The Consensus Statement first establishes that vaginal birth in most cases is less risky and more beneficial for most mothers and their babies.

Childbirth by its very nature carries potential risks for the woman and her baby, regardless of the route of delivery. The National Institutes of Health has commissioned evidence-based reports over recent years to examine the risks and benefits of cesarean and vaginal delivery. For certain clinical conditions––such as placenta previa or uterine rupture––cesarean delivery is firmly established as the safest route of delivery. However, for most pregnancies, which are low-risk, cesarean delivery appears to pose greater risk of maternal morbidity and mortality than vaginal delivery. (ACOG Consensus 2014)

So, what are some of the recommendations for prevention of the primary cesarean section?

1) Slow, but progressive labor in the first stage of labor should not be an indication for a cesarean. As long as mother and baby are doing well, cervical dilation of 6 cm should be the threshold for active phase of labor.

My Tip: Asking your doctor to wait for some more time, as long as you and baby are doing well, may dramatically reduce your chance of having a cesarean.

2) Adverse neonatal outcomes have not been associated with the duration of the second stage of labor (pushing stage). Therefore, giving three hours of pushing time to a first-time mother, and a minimum of two hours of pushing to a woman with previous children, is recommended. The Cochrane database considers spontaneous bearing down as the beginning of second stage of labor. So using just complete dilation as the start of second stage is not recommended, and this itself can lead to decreased cesarean for non-progression of second stage of labor.

My Tip: Asking your doctor to wait until you feel the urge to bear down, and then giving you at least three hours, and using upright positions like squatting, can prevent unnecessary interventions including a cesarean.

3) Instrument delivery can reduce the need for a cesarean section. The authors note with concern that many obstetricians do not feel competent using forceps for delivery.

My Tip: Ask your doctor if they are able to assist the birthing mother with vacuum or forceps. While routine epidurals and directed pushing increase the need for forceps and vacuum, when a woman has not had any intervention and is unable to push beyond a certain point, having the care provider skilled in assisting with instrumental delivery can mean the difference between a normal delivery and a cesarean.

4) Recurrent variable decelerations appear to be a physiologic response to repetitive compressions of the umbilical cord and are not pathologic. The guideline goes on to have some good in-depth discussion about how to monitor fetal heart rate patterns and presents some of the other solutions available, other than jumping into a cesarean for variable decelerations. This in turn has the potential to remarkably reduce cesarean rates.

My Tip: While you may not be able to argue with your doctor on the merits and demerits of taking you in for a cesarean based on heartbeat patterns, it would be wise for you to decline continuous electronic fetal monitoring (EFM). Continuous EFM is known to increase cesarean rates without improving maternal-fetal outcomes (Alfirevic, Devane and Gyte 2013). Unless you are in the high-risk category, intermittent EFM is much better able to monitor baby, while allowing you freedom of movement in labor.

5) Induction of labor can increase the risk of a cesarean. Induction is not recommended prior to 41 completed weeks, unless there are compelling maternal/fetal indications. Cervical ripening with induction can reduce the need for a cesarean. Only after 24 hours of induction with Pitocin/Syntocinon and ruptured membranes can induction be considered as a failure. Obviously, this gives much more time to the laboring mother.

My Tip: Research shows that your baby’s brain, lungs and liver continue to develop in the womb in the last few weeks. Near term, babies who are born between 37 to 39 weeks with induction have greater chances of respiratory distress, infections and feeding problems; further, studies are now showing decreased math skills at later age (Kugelman and Colin 2013). It is best to let baby choose her own birthday. ACOG recommends consideration of induction only after 41 completed weeks, should the need arise, and definitely recommends induction after 42 completed weeks (ACOG Bulletin 2014). If you do need to be induced, ask for at least 24 hours after start of induction before going in for a cesarean.

6) Neither chorioamnionitis (infection of the maternal/fetal membranes) nor its duration should be an absolute indication for a cesarean. In other words, as long as mother and baby are well and are being monitored, and other interventions as needed are being provided, a cesarean can and should be the last option.

7) Rupture of membranes in itself should not be a reason for cesarean. In approximately 8% of pregnancies at term the fetal membranes rupture before labor begins; 60% of these women will labor spontaneously within 24 hours and over 91% within 48 hours. Only 6% remain pregnant beyond 96 hours. A meta-analysis study of 12 studies in which early induction of labor (immediately or up to 12 hours after presentation with term PROM) was compared with expectant management (for variably between 24 and 96 hours before induction) showed no difference in rates of cesarean and operative births, and secondary analysis showed lower rates of neonatal infection in the early induction group. Early intervention was associated with fewer maternal infections and with fewer neonatal care unit admissions. (Royal Cornwall Hopsitals 2014)

As a secondary point, just seeing meconium in the fluid should also not be an absolute indication for a cesarean; 15–20% of babies are born with meconium-stained fluid. Of these, 2–5% will develop meconium aspiration syndrome (MAS), which needs vigorous treatment. Just meconium-stained fluid does not mean that the baby will have MAS. (Reed 2015)

My Tip: Based on the weight of the evidence, you can ask your care provider to wait at least 24 hours for labor to start on its own after your bag of waters releases. If your care provider is willing to wait, and if you and baby are monitored and are doing well, it may be appropriate to wait even much longer, as long as good transparent information is given to you. After 24 hours, it may be appropriate to induce depending on doctor/hospital practices. As long as mother and baby are well, direct cesareans should be seldom needed just because the bag of waters is broken, even if it is meconium stained.

8) Late pregnancy ultrasounds are associated with an increase in cesareans with no evidence of neonatal benefit. Macrosomia (a big baby) is not an indication for a cesarean. More than 70% of babies that are called “big” on ultrasound are average size babies at birth. Large randomized clinical trial results have not shown the clinical effectiveness of prophylactic cesarean delivery when any specific estimated fetal weight is unknown. Results from large cohort and case-control studies reveal that it is safe to allow a trial of labor for estimated fetal weight of more than 4000 g. Nonetheless, the results of these reports, along with published cost-effectiveness data, do not support prophylactic cesarean delivery for suspected fetal macrosomia (Chatfield 2001).

My Tip: Avoid late-term ultrasounds if you can. If need be, discuss with your doctor about evidence-based practice recommending trial of labor, even with a suspected big baby.

9) Low fluid levels should not be an absolute indication for a cesarean. In data from the multicentre clinical trial of routine antenatal diagnostic imaging with ultrasound (RADIUS), in which 15,151 low-risk pregnant women were randomly assigned to the ultrasound screening group or the control group, oligohydramnios (amniotic fluid index < or = 5 cm) was diagnosed in 1.5% of women with ultrasound screening compared with 0.8% among the controls. Fetal weight percentiles in isolated oligohydramnios cases did not change significantly from diagnosis until delivery. Pregnancies with isolated oligohydramnios had perinatal outcomes similar to pregnancies with a normal amniotic fluid index. The study concluded that isolated oligohydramnios is not associated with impaired fetal growth or an increased risk of adverse perinatal outcomes (ACOG Bulletin 2014). Another study showed that out of 92 women who were scanned at term, 22 (24%) women had isolated oligohydramnios. A greater tendency to intervene in such cases was noted with 10 (45%) women having labor induced, while one (4.5%) had an elective cesarean section. Emergency cesarean section rates were also higher in the oligohydramnios group (13.5%) than in a low-risk group (6%). There was no increased perinatal morbidity when compared with pregnancies managed expectantly. (Elsandabesee, Majumdar and Sinha 2007)

My Tip: Ultrasound measurement is a poor predictor of actual amniotic fluid volume. Avoid late pregnancy ultrasounds if you can. If your care provider insists on an ultrasound, measuring amniotic fluid by the single deepest pocket method is more accurate. The main risk of low amniotic fluid at term in a healthy pregnancy is induction (and cesarean delivery as a result of the induction). Current evidence does not support induction for isolated oligohydramnios at term, nor does it support direct cesarean. Talk to your care provider about evidence-based practice.

10) Cord around the neck is never an indication for an immediate cesarean when seen on an antenatal ultrasound.

My Tip: Since 1 out of 3 babies is born with a cord around the neck, it is something that seldom causes problems. The cord’s vessels are protected by a jelly-like substance and it is stretchy, allowing for the baby to be born, after which the care provider can unravel the cord and help the baby onto mother’s belly. In the very rare case of a tight cord, intermittent monitoring during labor might show some non-reassuring fetal heart rate patterns, or even more rarely it can prevent descent of the baby beyond a certain point. If any of these scenarios arises, then a cesarean may be appropriate. But, to say that you need a cesarean simply because a cord has been seen near or around the neck in an antenatal ultrasound makes no sense.

11) External cephalic version for breech presentation can lower the cesarean rate. The recommendation for breech vaginal birth is that the parents should be told of the risks involved (perinatal/neonatal morbidity/mortality) but should be given a choice to birth their baby vaginally with a good informed consent being provided for the procedure.

12) Outcomes for twin gestations, especially when the first twin is cephalic (head down) are not improved by a cesarean delivery.

My Tip: Ask for a trial of labor if you are a mom in this circumstance.

13) Continuous labor support is one of the most effective ways to reduce cesarean rates (Hodnett et al. 2013). The authors note that this resource is probably underused.

My Tip: Bring a doula with you to your birth. If a professional doula is not available, ensure that either your partner or someone who can encourage you and be an advocate for you is present 24/7 with you during your labor. If you have a trained midwife or a midwife-led practice in your area, explore that option for a gentler, safer birth.

As Judith Lothian points out in her article on this topic (2014):

The new ACOG guidelines offer great promise in lowering the cesarean rate and making labor and birth safer for mothers and babies. They also suggest an emerging respect for and understanding of women’s ability to give birth and a more hands off approach to the management of labor. Women will be allowed to have longer labors. Obstetricians will need to be patient as nature guides the process of birth. Hospitals will have to plan for longer stays in labor and delivery. And women will need to have more confidence in their ability to give birth. Childbirth educators can play a key role here. The prize will be safer birth and healthier mothers and babies.

All of the above is no surprise to me as a midwife. When mothers are provided with a safe space to birth their babies, when they are supported and monitored in labor, when they have been given adequate antenatal support, advice and preparation, nature has its way of guiding the process of birth. Midwives around the world have low interventions and cesarean rates since they respect the woman’s body and the innate intricacy of maternal/fetal hormones that drive labor and birth. It is satisfying to see that these recommendations from ACOG are slowly aligning with good birth practices.

So, how does your hospital and care provider measure up when it comes to using evidence-based practices in pregnancy, labor and birth? It may be good for you to invest time and energy to find out, so that you can have a safe, healthy and optimal birthing experience.

With more recent evidence emerging that the place where you give birth may be the single most important factor in determining whether you have a normal delivery or a cesarean (Haelle 2016), here is a potential list of questions that may help you decide in choosing your care provider/hospital:

  • What is your standard practice for women who go “past due?”
  • What is your rate of induction? What is the most common reason for induction?
  • How many of your patients have a natural, spontaneous childbirth?
  • What is your after-hours procedure? Who takes calls, who makes decisions during my labor if you are not on call or are unavailable?
  • What percentage of your patients’ births do you attend?
  • How many partners are in your practice?
  • How many patients have a cesarean in your practice? How many patients have instrumental deliveries?
  • How many of your patients have episiotomies? What is your suture rate? How do you help women avoid tearing?
  • What is the most common choice of pain relief among your patients? How many of your patients are given epidural analgesia?
  • How quickly do you clamp and cut the cord after birth? How do you feel about delayed cord clamping? How much time is allowed for natural delivery of the placenta? What do you do if this limit has expired?
  • Will I be given immediate and uninterrupted skin-to-skin contact with my new baby after birth?

Empower yourself to have a healthy and safe pregnancy, labor and birth.

References:

Vijaya Krishnan is a certified professional midwife and co-founder/director of Healthy Mother Wellness & Care. She believes that through education, advocacy and practice, we can bring sustainable positive change to current birth practices in India, while using the midwifery model of care.


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