Take Action – Preventing a Preventable Cesarean
There’s been a lot of talk lately about unnecessary cesareans. Cesarean surgery has become common practice in the United States. Despite the fact that our cesarean rate—nearly one in three—is higher than it’s ever been in history, there have been no recent improvements in outcomes for women or babies, and we are beginning to see alarming increases in serious health problems that result from cesarean surgery. Most of the countries with the best health outcomes for mothers and babies have cesarean rates well below the U.S. rate. In this country, it’s clear that more cesareans take place than are necessary.
Talk with almost any woman who has had a cesarean and she’ll say her surgery was necessary. Indeed, by the time many cesareans take place, the surgery has become necessary—either because the baby is signaling distress or labor is not progressing. But if you take a closer look, you’ll see that these problems often occurred as side effects of the way labor was managed. Some cesareans can be prevented with care that supports—rather than interferes with—the normal processes of labor and birth. By talking about “preventable cesareans,” instead of “unnecessary cesareans,” we can point to specific choices and care practices that might change the course of labor.
Research reveals that interfering in the natural processes of labor and birth can create problems that, in turn, must be managed with more interventions. Lamaze International has identified healthy birth practices, adapted from the World Health Organization, that help keep birth natural and improve birth outcomes. Together, these practices go a long way toward preventing preventable cesareans.
- Let labor begin on its own
- Walk, move around and change positions throughout labor
- Bring a loved one, friend or doula for continuous support
- Avoid interventions that are not medically necessary
- Avoid giving birth on back and follow the body’s urges to push
- Keep mother and baby together – it’s best for mother, baby and breastfeeding
Other things you can do to avoid a preventable cesarean surgery include:
- Select a care provider and birth site with low cesarean surgery rates. Research suggests that this may be one of the most important things you can do to lower your chance of having a preventable cesarean. Some states make this information available from the Department of Public Health or another agency. You may also ask your provider his or her rate, which should be around 15 percent or lower.
- Download and read the free booklet What Every Pregnant Woman Needs to Know About Cesarean Section .
- Plan for excellent labor support. Consider hiring a doula.
- Let your labor start and progress on its own unless there are clear, compelling health reasons to induce or speed up labor.
- Move and change positions often during labor.
- Labor at home for as long as possible.
- Keep up your energy by eating if you are hungry and drinking when you are thirsty in labor.
- Insist on intermittent auscultation (listening to the baby’s heart periodically with a handheld Doppler instead of continuously monitoring the heartbeat with a machine) if you are healthy and you do not have complications in your pregnancy, such as high blood pressure.
- Try lots of non-drug comfort measures before considering an epidural.
- If your baby is breech and other measures have not worked to help the baby turn, plan to have an external cephalic version (manually turning your baby head-down). External cephalic version is generally safe and is effective at turning babies.
Adapted from The Official Lamaze Guide: Giving Birth with Confidence.
ASK AN EXPERT
Question:
“I’m scheduled for a hospital tour next week. I’m looking forward to seeing the place where I’ll give birth. But I have to admit, I’m not sure what I really should be looking for! What kinds of things should I be paying attention to during the tour?”
Response from Carol Penn, DO, MA, RYT, LCCE, FACCE:
Somewhere near the beginning of every childbirth education series that I teach, I ask the class participants to jot down what they really would like to get out of class, what are they sitting in their seats really hoping to do, really listening for? The pieces of paper come back to me and often, the new mothers- or fathers-to-be are very interested in going on the “tour” of labor and delivery.
I give them what I call the “natural birth tour.” I utilize each of the healthy birth practices, in turn, holding them up as the gold standard for helping them model their own questions. I want my students to understand that, as consumers, they have influence and choice. The class tour is another opportunity full of teachable moments where previous class learning can be reinforced and students also can learn what they can do to shape the hospital environment.
Let’s take a look at each practice.
#1. Let labor begin on its own. For most expectant parents, labor will begin at home, away from the hospital. However, as we are walking around the hospital labor and delivery unit, I ask students to review what the disadvantages and advantages are of laboring at home as long as possible. What, if anything, does your hospital environment offer in the way of comfort and privacy that would help you get into and maintain your labor?
#2.Walk, move around and change positions throughout labor. Once inside a labor and delivery room, I have a student volunteer to get in the bed, try out the controls, etc. I point out the fetal monitoring equipment and any other equipment that may happen to be in the room. I also point out the floor space and have a woman and her partner volunteer to try a few positions. Is there enough floor space to really move about easily in the room, or are you going to be cramped? Are all the rooms the same size? What about the hallways? Can you imagine yourself feeling free enough to walk, squat and crawl in this environment? I encourage students to talk to their care providers and let them know that they want to be able to move about freely in the hospital environment. I have them ask their care providers for suggestions to support freedom of movement. I also have them ask their labor nurse to help them use movement once they arrive in the hospital for their birth.
#3. Bring a loved one, friend or doula for continuous support. During this part of the tour, usually while we are still in the labor and delivery room, I ask the couples how comfortable they think that they will be in that room. I address the fathers and birth companions, reiterating that they will be the primary support both at home and here at the hospital. I point out any tools available to help ensure continuous support during labor, such as chairs that pull out into beds, a rocking chair, a birthing ball and other items. We review how and when to engage the labor room nurse. What kind of support can you expect from her? I also take this time to talk about doulas again as another option to provide continuous labor support.
#4. Avoid interventions that are not medically necessary. This is the time in the tour to ask the participants if they are familiar with their hospitals polices and procedures. It’s a great idea to hand the class members a list of questions that they might ask along these lines. People ask about whether or not to have birth plans, do they have to have an IV, can they change positions and who in the hospital hierarchy do they ask? This also is a good time to review key comfort measures and remind the birth companions and fathers that the laboring mother needs four ounces of water for every hour of active labor; assist her in getting up to go to the bathroom and keep her bladder empty; eating light snacks if she is hungry.
#5. Avoid giving birth on back and follow the body's urges to push. This part of the tour can be so much fun. The group is in the hospital room. It’s a great time to have them play with positioning the bed. I have someone get in the bed and try different positions. I bring a birth ball in the room and demonstrate positioning on the birth ball. The value of the tour can be in helping the couples understand how they can apply what they have learned and what has been demonstrated in class. If your teacher is not bringing these things up on the tour, ask her about them.
#6. Keep mother and baby together – it's best for mother, baby and breastfeeding. Does this hospital practice rooming in? What is the hospital’s written policy on breastfeeding? Are certified lactation consultants available, how often and when? Where and when do the hospital staff do routine procedures such as weighing the baby or giving medications? This is also a good time for you to review how to connect with and soothe your newborn in the moments, hours and days after birth.
Looking, seeing and doing on the tour will reinforce previous classroom learning and help the unfamiliar become familiar. Becoming familiar with your surroundings can help to boost your confidence when you are in labor. Anything that positively adds to your confidence is going to help you trust yourself that much more once you are in labor. Knowledge, confidence and trust in yourself, will go a long way toward making your birth experience the best one possible for you and your baby.
Carol Penn is the co-founder of Anjali: The Women's Health and Wellness Collective and director of Core of Fire, an Interfaith Women’s Dance Ensemble. A long-time volunteer with Lamaze International, she has been the recipient of the Lamaze President's Award and created the Lamaze International Community Outreach Program. Carol is a graduate of the University of Medicine and Dentistry, School of Osteopathic Medicine and is completing her residency training in Family Practice.
HEALTHY TIP
Affirmations for Pregnancy
Repeat these affirmations to yourself daily, or stick post-it notes with these affirmations around your house where you’ll read them.
- My body knows how to give birth.
- I’m strong and powerful.
- I’m surrounded by people who care about me.
- The work I’m doing is important.
- Women have been doing this work forever.
- The existence of birth technology doesn’t mean I can’t give birth safely without it.
- My baby is growing well.
- My baby and I are working together to prepare for birth.
- On the day I give birth, I will be joined in my work by many other women around the world.
- I am beautiful.
QUICK STUDY
Continuous electronic fetal monitoring is used in more than 90 percent of labors in the United States. However, decades of research show that this ubiquitous machine does not live up to its promise of safeguarding babies in labor. In fact, researchers who evaluated all of the published studies comparing continuous fetal monitoring with intermittent auscultation (a method where a provider listens to the baby’s heartbeat regularly throughout labor) found that, when the mothers are healthy and labor is uncomplicated, there were no differences in important outcomes for babies regardless of the method used. However, their research confirmed that intermittent auscultation has a major advantage—it results in far fewer cesarean surgeries.
Source: Alfirevic, Z., Devane, D., & Gyte, G. M. (2006). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, 3, CD006066.
TESTIMONIAL
“When I gave birth to Gavin, I made sure I chose a hospital that uses a Doppler to check the baby’s heartbeat, instead of constant electronic monitoring. I barely noticed when the nurse listened to the baby, and I was able to move around as much as I wanted. It was reassuring to know my baby was doing well, but nice to not have that be the focus of my care during labor.”
– Alyssa
RESOURCES
“Just as a woman’s heart knows how and when to pump, her lungs to inhale, and her hand to pull back from fire, so she knows when and how to give birth.”
– Virginia Di Orio
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