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Excerpt from

Seven Steps Toward Cesarean Prevention

What Mothers and Midwives Should Know

by Judy Edrnunds

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 with 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, (because of a footling breech with borderline oligohydramnios). Three other women who transferred late into my care required primary cesareans for malpresentations or 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 ever turn anyone away. I attend women from all walks of life, ethnic origins, socio-economic situations, ages and parity. Some of these women 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 skillful 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, even lifesaving. 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 to 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 bona-fide 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 to affect some improvement, maybe a few, or gradually many more, surgeries may 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. I noted 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 that prove difficult to push out. Conversely, other babies 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 HPV, and the residual scar tissue dramatically interferes with dilation. Many babies begin labor in posterior or other sub-optimal presentations, which 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 post-date 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 repeat surgeries, 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 baby 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 decision-making 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 a mother’s motivation to explore objectively and thoroughly the alternatives to surgery in order 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 women will have had a cesarean. If a woman voices regret or raises questions about the necessity of her surgery, the event 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 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, or 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, or they’re small and sickly, 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 1.” 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

Pregnant women should know the dangers of cesarean surgery. But these risks are often downplayed or sugarcoated, so where’s the motivation to avoid something that doesn’t seem all that bad’? To encourage 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 4 to 8 times higher than in vaginal births. Postpartum hemorrhage, gallbladder disease, genitourinary problems and appendicitis are commonly associated complications. Pelvic injuries are twice as common compared to vaginal births. Uterine infection is twice as likely, (1 out of every 4 or 5). 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. Two to 6 percent of babies will also be accidentally cut during the surgery. More cesarean babies than babies delivered vaginally require diagnostic work-ups (including a lumbar puncture/spinal tap).

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. Then consider that the mother is incapacitated for some time following the surgery, and 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 complication, like infection or hemorrhage, or the uncommon complications, like 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 U.S. 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 dangers, cost and aftermath, they are obligated to find ways to communicate this information to their 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

Midwives can promote and mothers can encourage reasonably sized babies by limiting excessive intake of processed foods, dairy products and sweets. Don’t be passive about prolonged gestations. Be thorough in determining accurate “due dates” early on and pro-active about facilitating labor past the due date. Inadequate diets must be identified early so counseling and follow-up can be employed to correct deficiencies or bad habits.

Smoking should, of course, be discouraged, but it will take more than just lip service or education handouts. If quitting immediately seems out of reach for an expectant mom, she should work with her care provider toward at least reducing harm by delaying and decreasing the response to smoking urges.

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 multi-disciplinary approach, the more likely it will be 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 are 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 multiplies the chances of ascending infection exponentially 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 the care provider have to perform lengthy manual seduction 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 medical 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, attention to mother’s 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. Ultrasounds are rarely necessary. While determining position can be tricky, it’s worth the effort, as correction is usually possible with an early enough start. 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, and visualization or via external cephalic version. Or at least mother and care provider can work to optimize the conditions for a vaginal breech delivery. When the going gets tough and the labor is long, everyone thinking they just can’t take it anymore, a cesarean may seem like the easy way out. Women and midwives should weigh their choices carefully. 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 mom is OK (even if she’s really, really tired) the labor is probably OK, too. Take a break, walk outside, change position, music, temperature or lighting. Mom should be encouraged to nap between contractions. Midwives should consider calling in fresh attendants, offering refreshment, redirecting efforts. Pray fervently for wisdom and help. And know this: Pushing for more than 2 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, but it’s worth it!

Step 7. Provide Leadership

Some cesareans may be prevented by simply refusing to go along with the popular consensus, that which promotes surgical deliveries of multiple gestations and breeches, as well as routine inductions, including epidurals, supine positioning, restricted movement, electronic fetal monitoring and NPO (no food or drink) policies. Just as protesters chain themselves to old growth trees to prevent their being cut down, midwives must attach themselves to birthing women to prevent their 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 will all boldly educate and inform.

When one really comprehends the full seriousness of major abdominal surgery, she will be more inclined to preserve it as a genuine last resort. Cesarean surgery is a procedure for when mom’s or baby’s life or health is in dire jeopardy; not for when she is tired, fed up and feeling helpless. Prior to labor, the mom must have built up her health and endurance; she should have 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 let 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 and licensed massage practitioner.

Issue #7 Autumn 2002
Having a Baby Today

Birthing Life’s 10 Steps for Cesarean Prevention and Gentle Birth
  1. Eat well (protein, water, and a “gallon of greens”) and exercise regularly while pregnant.
  2. Ask lots of questions, educate yourself and have birth wishes clearly though out and documented.
  3. Avoid lounging and lying on back in the last trimester of pregnancy. Then be active in birthing and drink and pee a lot.
  4. Have your baby at home or at a birth center if possible.
  5. Make sure your provider believes in the non-interventive midwifery model of care and is comfortable and accepting of normal natural childbirth (see www.motherfriendly.org).
  6. If you are going to a hospital to have your baby, don’t go too soon; wait until you are very actively birthing (i.e. when Mom is so tuned into her bithing that she can no longer carry conversation between surges).
  7. Be patient, but move a lot during birth if your baby needs help descending.
  8. Have minimal or no vaginal exams, both during late pregnancy and especially during birthing; no amniotomy
  9. Avoid medicating your body and the feelings of birthing with drugs.
  10. Have complete trust in your body, your baby, and your birth process. Relax in knowing that both your body and your baby know exactly what they're doing!

For more information on cesarean prevention, you may wish to visit the following links:

Did You Know?
Home births have been shown to be safer than hospital birth for healthy moms???
Read more!

We have a secret in our culture, and it's not that birth is painful... it's that women are strong.
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