Avoiding a Cesarean

Most of us of childbearing age have heard somewhere that the cesarean rate is on the rise.  In 1998, the rate of cesarean deliveries performed in the United States has increased every year and gone from 21% to 35%.  In New Jersey, our rate is one of the highest in the country.  Most census data actually have New Jersey at the highest rate, around 40%.  This rate of cesarean delivery is even higher if you are a first time mom.

For first time mothers in New Jersey, your chance of a cesarean delivery can be as high as 60%, and even higher depending on which OB practice you use.  You can see the trend here.  At one point in 1997, the US had a rate of cesarean delivery around 21% and it has only grown since then.

In March of 2014, the Society for Maternal – Fetal Medicine and the American College of Obstetricians and Gynecologists released a joint statement in which they said;

“The rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortally raises a significant concern that cesarean delivery is overused.” 

Basically, what they are saying is that we are having a huge increase in C/S birth without gaining better outcomes for moms or babies.

There are several indications for when a cesarean delivery is completely warranted; such as, placenta previa (when the placenta blocks the head from passing through the vaginal canal), cord prolapse (when the umbilical cord comes before the head), an active herpes lesion (HSV) at time of birth, and situations in which the mother and/or the baby’s life is at risk.   These indications are indisputable and obstetricians, midwives, perinatologists, and family physicians all agree.  Yet, the majority of cesarean deliveries are not happening for these reasons alone.

Cesarean deliveries do save lives, but when performed unnecessarily can pose risks to both the mother and the baby

In 2007, a large Canadian study looked at the risks of having a cesarean delivery vs a vaginal delivery. The risks they looked at included: bleeding that required a hysterectomy (removal of the uterus) or blood transfusion, uterine rupture, anesthesia complications, shock, heart attack, kidney failure, blood clot, and infection.   What they found was that, while low, these risks are associated the 3 fold increase for a cesarean delivery vs a vaginal delivery (2.7% vs 0.9%).   Cesarean delivery can also affect future pregnancies as it creates scar tissue on the uterine wall and will increase a woman’s chance of a placenta accreta or placenta previa.

What accounts for the disparity in high and low rates across the US?  How can NJ have an overall rate as high as 40% while states like Utah, New Mexico and Alaska have rates around 22%.  The answer is that more than half of all cesarean deliveries are performed for either labor dystocia (a slowed or stopped labor) or fetal heart rate readings.  The other most common indications for a cesarean delivery include poor positioning of the baby, twins or triplets, or a suspected big baby.

It may seem like what is a girl to do?  How can you set yourself up to have the best chance of a vaginal delivery vs a cesarean delivery. Here we’ve outlined the top 5 best ways to reduce your risk from 50% in New Jersey to 10%.

#1 Choose the right provider

There has been a lot of press about choosing the right hospital to avoid a cesarean delivery. Publications like leapfrog and the Bergen Record publish hospital data, but the walls don’t perform cesarean deliveries.  It’s your provider who will ultimately make the decision about whether or not you need a cesarean delivery, whether you are at home or in the largest hospital in the state.  Choose a provider who supports vaginal birth and has the patience to wait for labor to progress.   

It is also important to work with someone who can offer a multitude of strategies or skills to encourage your body to do what it is meant to do.

Certified nurse midwives typically have very low cesarean delivery rates without compromising on maternal or fetal well-being.  They often work with women throughout their pregnancy to encourage ways to prepare the body for an optimal birth.  They typically have more patience than their MD counterparts and spend 80% more time at the bedside, working with women and their babies to rotate and dilate in labor.  Patience can sometimes be all that is needed to avoid a cesarean delivery as the most common indication for a c/s is a slow or stopped labor.  Midwives typically offer more remedies and solutions in addition to or in lieu of a medical augmentation of labor.

Working with a certified nurse midwife who is in collaboration with an excellent physician is often seen as the best of both worlds. With a practice like this, you are able to tap into the resources from both fields of medicine

The third most common reason for a cesarean is the baby’s position.  Choosing someone who is skilled in optimizing the baby’s positioning and assisting you in rotating the baby into the correct position can be paramount.  You can talk to your provider about how they handle this situation if and when it arises.

#2 Keep your modifiable risk factors low.

There are certain things that you can do to keep your risk lower for a cesarean birth. We know that excessive weight gain can increase your chance of a cesarean delivery.  For women who are of normal weight when they get pregnancy, you should gain no more than 35 pounds in pregnancy and 25-30 is usually preferable.   Keeping a diary of your food intake, exercise , and an overall healthy diet can help to keep your weight down.

Exercise can also be an excellent tool in overall health in pregnancy increasing your change of spontaneously labor near your due date and helping you avoid excessive weight gain. Exercise is usually encouraged from most pregnnat women, but needs to be ok’ed by your OB or Midwife. 

#3 Get a second opinion

The 5th most common reason for a cesarean delivery is suspected macrosmia (big babay).  It can be common for a OB provider to recommend a cesarean delivery because they suspect that the baby is large.  This is when getting a second opinion from a provider with a low caesarean delivery rate can help you feel confident that a cesarean is the best option for you. In addition, consider an induction of labor vs an automatic cesarean delivery if your OB is saying the baby is too big for a vaginal delivery.  Most women with a suspected big baby are excellent candidates for a trial of labor and are happily suprised to find a vaginal delivery ensues.

#4 Know your provider’s rate

While you may love your OB and think the world of them, it’s important to know his/her vaginal delivery rates.  You may be surprised to find some amazing and wonderfully skilled OBs practice more like surgeons and have rates as high as 80% or even 90%.  This type of OB may be a great gynecologist or even friend, but might not be the one you want in the delivery room with you.  Talk to your provider about their practice and their rates.  Also, know who works with your OB.  If your particular doctor isn’t guaranteed to be on call when you go into labor, find out what their partners’’ rate is and go with something you are comfortable with.  Many midwives will have rates between 10%-20% and it should be relatively easy to find several choices of MDs with a 20-30% rate. 

When choosing a midwife, it is important to know exactly who their collaborating doctor is and what that collaborating doctor’s rate is.   In the state of New Jersey, all certified nurse midwives have collaborating agreements with a board certified physician.  This is a physician who assists them in the case of the need for surgical intervention.  And while many certified nurse midwives perform cesarean deliveries with their MD collaborators, it is important to know exactly who their MD partners are.

#5 Consider an operative vaginal delivery over a cesarean delivery.

An operative vaginal delivery is a vacuum or forceps delivery.  Unfortunately, the number of physicians who are trained in the use of forceps and vacuum is declining,  but in New Jersey you can still find several doctors who use them when appropriate.   A vacuum delivery is the use of a small suction cup placed on the baby’s head to assist the mother in the second stage or pushing state of labor.  It is a safe alternative and can sometimes make the difference between a cesarean delivery and a vaginal delivery.  

Forcpes are blades or “hands” that are used to assist when a vacuum is not adequate. Forceps have been around since the 1500’s and were a proprietary family secret of the Chamberlain family for over 150 years.  The man who invented them was midwife-surgeon to the King of England and princess of France in the 1570’s.  While back then, a cesarean delivery was not an option; the use of forceps became, at times, a lifesaving maneuver for both the baby and the other, and this skill was born. 

Today, forceps are not used nearly as aggressively as they were 400 years ago, but this technique has been perfected and modified for a modern obstetrical environment.   

 Talk to your provider about these options and see if this is something that they are comfortable using appropriately.  If you are using a certified nurse midwife, be sure their collaborating physician is adequately trained in the use of forceps and vacuum deliveries. This way whether you use it or not, this option is available to you at the time of delivery. 

This article was written by Kristin Mallon, CNM, MS, RNC-OB, a certified nurse midwife and founder of Mindful Midwifery in Hoboken and Hackensack New Jersey.  For more information about Kristin and her practice, see her website at www.njmidwifery.com

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