Friday, May 7, 2010

Avoiding The First C-Section

This entry was posted by The Midwife on Monday, 12 April, 2010

In honor of Cesarean Awareness Month, featured in the Courtroom Mama blog, I am continuing the topic of avoiding the first c-section. Why is it so important to avoid the first one?

  • It’s major abdominal surgery, and carries increased risks for mother and baby
  • It often puts the mother in the position of having repeat c-sections, because she cannot find support for vaginal delivery after a cesarean
  • It increases the risk of abnormal implantation of the placenta, which can lead to hemorrhaging or need for hysterectomy
  • It increases the risk of unexplained stillbirth in a subsequent child.
No one will argue that c-sections can be lifesaving under certain circumstances. Placental separation, placenta previa, cord prolapse, and certain abnormal presentations of the baby might cause injury or death to mother and child if it were not for the ability to deliver a baby by cesarean. I am thankful we have the ability to perform this surgery in a very safe manner. However, the majority of c-sections are not done for emergent, life-saving reasons. It’s those c-sections I want to focus on preventing.

Since most women having a primary (first-time) c-section are also having their first baby, I have five simple precautions that have been invaluable in my practice in helping women to avoid a c-section. I am writing from the perspective of hospital birth, knowing that the majority of women will not choose home birth, although I believe this is the number one way to avoid a c-section:

1. Stay at home in labor as long as possible, and consider giving birth at home. Why?
  • Consider an animal in labor. If you’ve ever observed a cat or dog preparing to give birth, you may have noticed that they seek solitude. If they are disturbed during labor, they ahve a natural “fight or flight” reflex that slows or halts labor, allowing them to move to a safer location. While we as human women can intellectually understand the reasons for moving to another location (the hospital) to give birth, our bodies may still respond with a slowing of the labor process.
  • It is understood that pain relieving medications can have a slowing effect on the process of labor. Epidurals are associated with a higher rate of vacuum, forceps and cesarean births in some studies. Yet it is difficult for a woman in hard labor to resist the offering of total relief of her pain. When you are at home, you know the pain medication is not available, and so the mind does not focus on it. It is easier to work with the contractions when you aren’t constantly thinking of the epidural available to you in only minutes.
  • Staying home in the earlier stages of labor helps you to avoid the urge that hospital staff will feel to “speed things along” if your first part of labor takes many hours. It is common for dilation from zero to four or five centimeters to take many hours, and sometimes more than one day. If you are in the hospital and you are not yet dilated to four centimeters and having contractions three or four minutes apart, you are not in active labor. This part of labor is best spent at home.
2. Hire a doula if you can possibly afford it. If not, seek out an older woman who has had several children naturally herself, or has been present at several natural births, to be with you at home until you decide to go to the hospital.
  • A woman who is familiar with the process of a normal birth will be invaluable to you in helping you know when it is time to got to the hospital. She can reassure you that what you are feeling is normal, that you can do it, and that you are stronger than you think.
  • Many women are afraid to stay home in labor. A doula or experienced woman will be aware of the normal process of labor and be able to help you feel calm about laboring at home.
3. Find a practitioner who does not put arbitrary time limits on how long you can be in labor. If you are feeling strong, the baby is doing well, and you want to keep going, there should be nor reason to rush to a c-section simply because the labor is taking longer than average.

4. Carry on your usual activities as long as possible. Far too many first-timers make the mistake of doing everything they can to speed labor along. All too often, their efforts succeed at nothing but making them miserable and exhausted. Allow labor to unfold in its own time. Ignore the contractions until you are physically incapable of doing anything else during a contraction as well as in between contractions. This is where many women take their labor too seriously. They think because they have to breathe with a contraction, they are in hard labor. The actions of the mother between contractions are more indicative of the stage of labor. During the latter stages of dilation, the woman is usually quiet, tired, and may even fall asleep between contractions. She does not feel like talking much, or doing anything but resting before the next contraction. If your labor starts in the day, do what you normally would have been doing if you’d not started labor. If your labor starts at night, stay in bed and try to sleep, at least between contractions. If you cannot sleep, at least rest until your normal getting-up time.

5. Stay off the fetal monitor! The American Congress of Obstetricians and Gynecologists has published guidelines for intermittent auscultation of the baby, stating that it is just as safe for low-risk pregnancies as continual monitoring. It has the added benefit of having a lower c-section rate. This suggests that many c-sections are done for “fetal distress” seen on the monitor tracing, when the baby is actually fine. Once you allow someone to connect you to the continual monitor, you most likely won’t be off of it for the rest of your labor. What is intermittent auscultation? It is not being connected tot he monitor for 20 minutes out of every hour, as many hospitals’ protocols require. Rather, it is listening to the baby’s heart rate with a hand-held doppler before, during, and after a couple of contractions every 15-30 minutes during the first stage of labor. A skilled practitioner can determine if the criteria indicating fetal well-being are present, even with a hand-held doppler.

There you have it–my top five precautions to avoid the first c-section. I’d love to hear your ideas for other ways to avoid an unnecessary cesarean.

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