7 Steps toward Cesarean Prevention
by Judy Edmunds, CPM

[Editor’s note: This article first appeared in Midwifery Today Issue 57, Spring 2001.]

For over 20 years, I have been an independent homebirth midwife with an active, solo practice, averaging two births per month. My overall cesarean rate is about 3 percent, comprised mostly of repeat cesareans, early in my career, on women who had their initial birth/surgery experiences with other care providers. Only one woman for whom I provided start-to-finish care needed a cesarean to have her first baby, (scheduled for a footling breech with borderline oligohydramnios). Three other women, who transferred late into my care, required primary cesareans for malpresentation or cephalopelvic disproportion (CPD), for a career total of four primary cesareans (two primips, two multips). While an element of client self-selection certainly figures into these statistics, it cannot account for everything, as I rarely turn anyone away and attend women from all walks of life, ethnic origins, socioeconomic situations, ages and parity. Some planned a homebirth from the start. Others were belatedly steered my way by friends or relatives, financial deficits, doctor-patient conflict or fear of the hospital. I share these statistics at the outset to provide a basis for comparative reflection on practice styles and outcomes, and for preliminary evaluation of the effectiveness of steps outlined in this article.

I am so grateful for access to skilled surgeons and the amazing body of knowledge used to successfully perform cesareans. I feel confident that at least most of the cesareans I have been associated with were actually necessary, many even life-saving. Yet looking back over my practice, I can easily pick out scores of women who surely would have had cesareans had they chosen care elsewhere. With the corresponding U.S. rate averaging around 23–24 percent during much of my career, each woman I transferred for surgery would need to drag along seven companions before we matched the “norm.” I would begrudge those additional cesareans, despising the lingering pain they caused, feeling they were unnecessary, needlessly disempowering each of those women, putting them at risk. While I feel that carefully selected, truly indicated cesareans are a gift and blessing, general over-reliance on them has become a bonafide curse.

There is no simple solution, as so many things would have to change before the statistics could reflect only truly unavoidable surgeries. Since correcting those things on a grand scale is beyond my reach, I do what I can at the grassroots level, one woman at a time. Like others in my stead, I’ve challenged the status quo, grown opinionated and passionate about my findings and forged methods I know won’t work for everyone. Still, if even small changes are adopted and bring some improvement, maybe a few, or gradually many more, surgeries could be averted.

Step 1. Understand Why

In trying to better understand why so many cesareans are performed in North America, I reviewed the literature and talked with many women who themselves, or their friends and family members, have had cesareans. I spoke with physicians who perform cesareans, and considered my own observations. A number of physical reasons, psychological issues, and cultural cues or expectations emerged as common factors.

For example, from a physical standpoint many women are growing particularly large babies, which prove difficult to push out. Other babies, adversely affected by poor maternal diet, smoking, substance abuse or various disease processes, are frail and falter as labor intensifies, requiring surgical rescue. Cesareans are also used to rescue babies from potential infection, either bacterial (strep) or viral (HIV). Widespread infection also means increasing numbers of women have undergone cervical treatments, such as conization or laser ablation, often for conditions associated with human papillomavirus (HPV), and the residual scar tissue dramatically interferes with dilation. Many babies begin labor in posterior or other sub-optimal presentations. These births often end in cesarean. Along with this, as vaginal delivery skills decline and malpractice fears increase, cesareans are touted as the safest route for breech deliveries. A similar policy prevails for multiple gestations. Endocrine disruption, from chemicals in plastics and pesticides, as well as widespread use of medications that inhibit prostaglandin synthesis, leads to postdate pregnancies. Failed inductions frequently lead to cesareans. Modern labor practices, such as epidurals and supine maternal positioning, reduce the body’s ability to push out a baby effectively, while restricting food and drink exacerbates maternal exhaustion. Finally, cesareans are self-perpetuating: for example, concern with scar integrity leads to scheduled repeats, as does the increased incidence of placenta previa in post-cesarean pregnancies.

Psychologically, many women are terrified of giving birth. They lack confidence in their bodies to accomplish the task, and fear for the safety of their babies and themselves. They have been conditioned to view birth as a medical procedure requiring close clinical supervision, management and technological intervention. Paired with this belief is the perception of pain as something to be avoided at all cost, and this fear of pain drives much of the decisionmaking surrounding birth choices. Additionally, previous sexual abuse and varying degrees of sexual inhibition or dysfunction can spawn a myriad of labor problems. This complex amalgamation of intense anxiety, poor self-image, dependence and pain aversion sharply reduces the prospects of a straightforward, satisfying vaginal birth. It also severely diminishes maternal motivation to objectively explore the alternatives sufficiently to make a truly informed choice.

Culturally, cesareans are seen more as an inevitable occurrence or procedural birth variation than as major abdominal surgery with serious potential complications. The routine nature of the surgery is reinforced when a woman considers the birth experiences of her friends and family: nearly one in four will have had a cesarean. If a woman voices regret or raises questions about the necessity of her surgery, the event is quickly framed as an unavoidable intervention she should be grateful for, and doubts are often brushed aside with encouragement to focus on the health of her new baby. Ostensibly to spare her feelings, she is reminded that many women need cesareans these days, and it’s nothing to feel bad about. Besides, thanks in part to the proliferation of HMOs and capitation, there’s just no time to contemplate such complex issues. The waiting room is full. With reflective thought discouraged, an important opportunity for change is lost.

The expectation of a cesarean is increased by articles in popular childbirth magazines with titles such as “Help is Standing By” emblazoned above a photo of gowned and masked medical staff, directly followed by the even more overt “You’re Going to Need a Cesarean.” Anticipation may be inadvertently heightened by routine inclusion of cesarean preparation segments in childbirth classes, by the media’s insistence on portraying birth as an emergency, and by our societal expectation of being in control. We want to have it our way, to know what’s going to happen how and when. Partner this with protocols and policies that create pressure to take action when labor goes on longer than expected, the water is broken for some time, when pushing doesn’t produce a baby quickly enough or when everyone is just plain tired out, and the cycle continues.

So, it’s complicated: Babies either get too big, take too long, lodge in bad positions, are small and sickly or they’re too early or overdue. Birth hurts and it’s scary. There’s chaos, blood, sweat and pain. And the pain, stretching and burning—maybe even tearing—involves private, sensitive, sexually important areas. Hence many reason along these lines: “My best friend, who’s bigger and braver than I am, couldn’t do it,” and so conclude, “neither can I.” Many give up without even trying.

Clearly, prevention efforts must address these issues in a creative, individualized, multifaceted, and tenacious manner.

Step 2. Realize the Danger

To avoid scaring pregnant women, the risks of cesareans are often downplayed or sugarcoated. But then where’s the motivation to avoid something that doesn’t seem all that bad? To facilitate informed decisions, it’s only fair that women receive full, frank and clear information. Even if it’s disturbing, or perhaps especially so, women deserve to know the whole truth about cesareans. For example:

  • maternal mortality is four to eight times higher than in vaginal births
  • postpartum hemorrhage, gallbladder disease, genitourinary problems and appendicitis are common associated complications
  • pelvic injuries are twice as common compared to vaginal births
  • uterine infection is twice as likely (one out of every four or five)
  • cardiopulmonary complications occur twice as often
  • thromboembolic complications are also twice as likely
  • there will be a large, permanent maternal scar in 100 percent of the cases
  • many women experience pulling or puckering around the scar site
  • 2–6 percent of babies will also be accidentally cut during the surgery
  • more babies require diagnostic work-ups (including lumbar puncture)

Step 3. Consider the Cost

Each cesarean immediately costs thousands of dollars more, often twice as much, as a vaginal birth. No matter how you figure it, this results in billions of wasted healthcare dollars each year. When you consider that the mother is incapacitated for some time following the surgery, and then add the cost incurred by others attending to her needs during her prolonged recovery, the costs escalate further. If you begin to look at the auxiliary costs associated with very common complications such as infection or hemorrhage, or the uncommon complications such as death, the cost of unnecessary cesareans is simply unacceptable.

Step 4. Acknowledge the Aftermath

Following a cesarean a significant number of women will require re-hospitalization for associated complications. Many will find their fertility has decreased, and they face an increased risk of ectopic pregnancy, placenta previa, uterine rupture or placental abruption in subsequent pregnancies. Many women report that an entire year passed before they regained their pre-surgery energy level. Some experience a sense of loss and lingering regret. In any case, each woman joins the ranks of nearly a quarter of childbearing women in the United States who bear a large, permanent scar across their lower belly.

Step 5. Educate Others

Once a birth care provider examines factors underlying the growing number of cesareans and honestly considers the associated danger, cost and aftermath, s/he is obligated to find ways to communicate this information to clients and develop individualized strategies. Thus one may engage the woman and her family to share in earnest and meaningful prevention efforts.

Step 6. Take Action

Promote reasonably sized babies by discouraging excessive intake of animal proteins, dairy products and sweets. Eat organic when possible, to avoid growth hormones. Don’t be passive about prolonged gestations. Be thorough in determining accurate “due dates” early on and proactive about facilitating labor before the baby gets too big or the head grows too hard. Inadequate diets must be identified early so counseling and follow-up can be employed to correct deficiencies or bad habits. I like to encourage a predominantly vegetable-based diet, adding grains and proteins in moderate quantities, plus a modest amount of fruit. Discuss specific examples of substitutions or improvements tailored to individual tastes and habits.

Smoking should, of course, be discouraged, but it will take more than just lip service or patient education handouts. If quitting immediately seems out of reach for a client, work toward harm reduction by suggesting that she delay her response to smoking urges, limit the daily use of cigarettes to a predetermined and, ideally, decreasing number, and smoke only a small part of each one before extinguishing it and walking away. Schedule a family meeting and enlist the help and support of family members. Share detailed information about the risks to the baby from smoking, such as the greater incidence of asthma and Sudden Infant Death Syndrome (SIDS), and insist that any smoking be permanently moved outside. Anticipate and forgive relapses. Strategize and support—don’t shame. Ameliorate the physical effects by increasing oral intake of vitamin C, bioflavonoids and other antioxidants. High intake of B vitamins may help reduce cravings, and other creative approaches such as acupuncture or support groups may be tried. Some of the same strategies apply to substance abuse, although particularly problematic situations may preclude homebirth. Again, your willingness to try to understand and offer help, rather than pass judgement, is imperative.

Diseases, conditions, and syndromes (i.e. hepatitis, toxemia, HELLP, etc.) each have unique etiologies and interventions, all beyond the scope of this article. Suffice it to say that the more you have to offer by way of alternative therapies and skill in facilitating a multidisciplinary approach, the more likely it will be that you can turn a situation around and avoid surgical intervention. Heavy colonization with beta strep, HIV infection or HPV requiring treatment (conization, cryotherapy or laser therapy) are problems where education and prevention would have been your best bet. When it’s too late for that, a key principle I already advocate in most births, but strictly adhere to in every case involving infection, is: minimize vaginal exams and never, ever perform an amniotomy! This reckless, irrevocable intervention exponentially multiplies the chances of increasing the infection and starts the cesarean clock countdown. Remember: one of the biggest determinants in vertical infection (mother to baby) is length of time the membranes are ruptured. Plus, should you have to perform lengthy manual reduction of cervical adhesions from HPV treatments, the lack of barrier into the intrauterine environment further predisposes to infection, and the baby’s bare scalp is exposed to friction from your gloves, so abrasions and infection are even more likely. Don’t do it!

Malpositioning is another area where prevention is key. Early detection and correction of persistent posterior or breech presentations requires visual scrutiny of the fundal profile, attention to maternal reports regarding the location of the most prominent fetal movement, competent and thorough palpation, and verification of suspected position via location of heart tones, occasionally supplemented by a vaginal exam if you are not absolutely certain. Ultrasounds are rarely necessary, if you are willing to take the time to understand what your hands are feeling. While determining position can be tricky, it’s worth your effort as correction is usually possible if you start early enough. Posteriors can be turned by spending time daily in a hands-and-knees position and by performing pelvic rock exercises. Breeches may be turned with the aid of tilt exercises, moxa, homeopathy, visualization or via external cephalic version—or at least you can work to optimize the conditions for a vaginal breech delivery. Missing a malposition can happen to anyone, but hopefully it’s a very rare or singular event. Determination to prevent this occurrence may be strengthened by considering the adage: Fool me once, shame on you. Fool me twice, shame on me.

When the going gets tough, and everyone thinks they just can’t take it anymore, a cesarean may seem like the easy way out. Women and midwives should weigh their choices carefully. Plead your case with conviction: Why exchange a few hours of pain now for weeks or months of pain later? It’s just not a good trade. If the baby is OK and the mom is OK (even if she’s really, really tired), the labor is probably OK, too. Take a break; walk outside; suggest a change in position, music, temperature, or lighting; encourage napping in between contractions; call in fresh attendants; offer refreshment; redirect your efforts. Pray fervently for wisdom and help. And know this: pushing longer than two hours is not a crime, but it may mean the midwife needs to provide more specific direction or hands-on assistance such as pushing back a recalcitrant slip of cervix or dragging down rigid vaginal muscles. You may need to work harder than you ever imagined. It’s worth it!

Step 7. Provide Leadership

Some cesareans may be prevented by simply refusing to go along with the dominant paradigm characterized by surgical deliveries of multiple gestations and breeches, eroding support for VBACs, routine inductions, ubiquitous epidurals, supine positioning, restricted movement, electronic fetal monitoring and nothing-by-mouth (NPO) policies. Just as protesters chain themselves to old growth trees to prevent them from being cut down, we must attach ourselves to women to prevent them from being cut up. Think of it as maternity civil disobedience. Attachment midwifery. We must all work hard to transform terror into trust, build self-confidence and courage, prevent and heal the wounds of sexual abuse, and strengthen family bonds and community health. By counteracting negative media with stories of wonderful births and viable alternatives, we must all boldly educate and inform.

When parents and midwives really comprehend the full seriousness of major abdominal surgery, they will be more inclined to reserve it as a genuine last resort: when the mom or baby’s life or health is in dire jeopardy—not when the midwife is tired, the mom is fed up, the dad feels helpless and the in-laws are calling every half hour. Prior to labor the mom must have built up her health and endurance, developed a trust in birth and tolerance for the unexpected, and formed a loving, protective attitude toward her belly. If she has, she won’t be so quick to acquiesce to letting someone slice into it. May we as her friends, supporters, and caregivers provide inspiring companionship and strong leadership to help her accomplish those tasks.

Judy Edmunds, CPM, is also an Oregon licensed midwife, chartered herbalist, registered nutritional consultant, licensed massage practitioner and contributing editor at Midwifery Today.

References

  1. Delivery Method Drives Rehospitalization Rates. American Journal of Nursing 100 (8): p. 20. (August 2000). News item reprint from Lydon-Rochell M., et al. JAMA 2000; 283 (18): 2411–16.
  2. Wagner, M. (1994). Pursuing the Birth Machine: The Search for Appropriate Birth Technology. Sydney and London: ACE Graphics.
  3. Wagner, M. (2000). Risks of cesarean section. Handout, global birthing class. Midwifery Today New York City International Conference.

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