Safe prevention of cesarean section (C-section)

By MICHAEL BURKS M.D., F.A.C.O.G., Central Missouri Physicians for Women, Special to the Tribune
Wednesday, June 10, 2015 at 10:00 am
In 2013, 32.7 percent of women in the United States were delivered by cesarean delivery. For certain medical conditions, cesarean birth can be life-saving for the fetus, the mother or both, and is the safest way of delivery (for example, placenta previa – where the placenta partially or totally covers the opening in the mother’s cervix – which can cause severe bleeding before or during delivery).

The World Health Organization recommends the cesarean section rate should not be higher than 10-15 percent. The biggest factor in preventing cesarean delivery begins with avoiding the first, or primary, cesarean.

The most common indications for primary cesarean section delivery include, in order of frequency: labor dystocia (difficult or abnormally slow progress of labor), abnormal or indeterminate fetal heart rate tracing, fetal malpresentation (an abnormal position of the fetus in the birth canal), multiple gestation and suspected fetal macrosomia (a baby who is significantly larger than average).

In March 2014, both the American College of Obstetrics and Gynecologist and Society for Maternal Fetal Medicine developed recommendations entitled “Safe Prevention of the Primary Cesarean Delivery.” The following are a few, of many, ways of decreasing the likelihood of having your first cesarean:

1. Decrease elective inductions. Before 41 0/7 weeks of gestation, induction of labor generally should be performed based on maternal and fetal medical indications – not electively. Don’t ask to be induced!

2. Cesarean delivery to avoid potential birth trauma should be limited to an estimated fetal weight of at least 5,000 g (approximately 11 lbs.) in women without diabetes and at least 4,500 g (approximately 10 lbs.) in women with diabetes. Patients should be counseled estimates of fetal weight, particularly late in pregnancy, are imprecise.

3. Women should avoid excessive weight gain during pregnancy using the IOM maternal weight guidelines (25-35 lbs. for women of normal weight, 15-25 lbs. for overweight women and 11-20 lbs. for obese women).

4. Perinatal outcome of a twin pregnancy in which the first twin is head down does not improve with a cesarean delivery. Women should be counseled to attempt vaginal delivery.

5. Continuous labor and delivery support. I often recommend choosing one or two people to come to the prenatal visits and discuss ways of providing emotional and physical support before, during and after your birth.

There are many other recommendations your healthcare provider can follow, including allowing more time for labor and pushing, fetal heart rate monitoring and breech babies. Choose your healthcare provider carefully – someone who advocates for your birth choices. Only you and your healthcare provider can discuss personal risks and options.

I look forward to meeting you – have a safe, uncomplicated and memorable birthing experience.

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Decreasing the Cesarean Rate

Cesarean delivery is the most commonly performed surgical procedure in the United States. In 1970, 1 of 20 deliveries was by Cesarean; by last year, that number changed to more than 1 of 3.
Approximately 60% of all cesarean births are first-time mothers. The World Health Organization estimates Cesarean deliveries are needed in only about 10% to 15% of deliveries. Although cesarean deliveries have increased, childbirth hasn’t become markedly safer for babies or mothers.
Cesarean sections are clearly the safest option for certain circumstances, and can be lifesaving for the baby and/or the mother where delivery in cases of labor complications and health conditions require early or immediate delivery.
More than 90% of all women who have had a cesarean delivery will have a cesarean delivery with subsequent pregnancies. New clinical guidelines from the American College of Obstetrics and Gynecology and the Society for Maternal Fetal Medicine, published in the March 2014 issue of the Journal of Obstetrics and Gynecology, were released to prevent women from having cesareans with her first birth and to decrease the national cesarean rate.
Women with low risk pregnancies should be allowed to spend more time in labor. Standards most obstetricians use to define a slow or stalled labor are based on studies from Emanuel Friedman in the 1950’s. He studied 500 women, and, of those, he said there were 200 women who had idealized labors. For the last 50 years, labor has been managed based on 200 women. Studies over the past 5 years suggest the range of time for a normal labor is much broader than previously thought. Women should be allowed to push for at least 2 hours if they have had a delivery before, 3 hours if it’s their first delivery, and even longer in some situations, for example, when an epidural is used for pain relief.
Avoiding excessive weight gain during pregnancy can help. Other options include “turning the baby” when the baby is breech, which can help avoid a C-section in more than half of cases. Women are less likely to have Cesareans if they receive support during labor, such as from a Doula, a birth attendant who provides continuous physical and emotional support throughout labor and birth, but does not assist in delivery.
According to ACOG, between 16-80% of women attempting a VBAC will deliver successfully.
Cesarean section rates also depend on your choice of obstetrician. In 2013, the Cesarean rate at Boone hospital was 37.8 %. However, there was a variation between the 15 obstetricians on staff which ranged from 22.9-50.8%.
I encourage you to choose your provider carefully and discuss your options to decrease your personal risk of a cesarean delivery. Weighing the risks and benefits for each individual patient is important.

Michael Burks, M.D.,FACOG – Obstetrician / Gynecologist, Columbia, MO