In recent years, we’ve seen a sharp increase in C-sections.
What is the reason for this? Is it because we are delivering babies at an older age? Or do hospitals fear being sued? Or something else entirely?
According to a recent study from August 2016, the US C-section rate in 1965 was 4.5 percent. However, the national C-section rate peaked in 2009 at 32.9 percent, and has since dropped slightly to 32.2 percent by 2014. Now, about 1 in 3 women give birth via C-section.
First, it is important to know the 3 stages of labor:
- Stage 1: Starts when you begin having contractions which causes the cervix to fully dilate (open) and efface (thin out).
- Early Labor: cervix gradually effaces and dilates
- Active labor: cervix begins to dilate more rapidly and contractions are longer, stronger, closer together.
- Stage 2: Begins when you are fully dilated (10 cm) until you deliver. This is called the pushing stage of labor.
- Stage 3: Kicks off right after birth and ends with delivery of the placenta.
There are several theories about the recent rise in C-section rate.
Some assert that more women are asking for C-sections without medical rationale, or perhaps number of women who genuinely need a C-section is increasing. There are also some who say that liability pressure on health care providers is driving up rates.
Below are some fact-based reasons for the high C-section rate, from a recent study from Childbirth Connection:
- Low priority of enhancing women’s own ability to give birth. Many models that use midwives, doulas, and other methods to allow a baby to move from breech (feet first) to head down are not commonly used or encouraged by doctors. Several C-sections are also carried out when fetus size is determined to be too large, which is being determined due to newer techniques of fetal monitoring.
- Labor interventions that are now commonly used, seem to slow down labor. Inducing women when the cervix is not ready to open, may slow down labor as the body was not ready to go into spontaneous labor. Continuous electronic fetal monitoring has also been shown to increase C-section rate, as the woman must stay in bed and this in and of itself will slow down labor. It is noted that continuous electronic fetal monitoring was developed in the 1950’s, but became more popular in the 1960’s. The other option for monitoring fetal heartrate is by auscultation with a stethoscope and/or Doppler. This is performed frequently however not continuous. Also receiving an epidural without a high does of Ptocin will also increase with likelihood of C-section. Once the woman receives an epidural, she is usually in bed, and this will also slow down the progression of delivery unless Ptocin (will increase contractions) is administered.
- Refusal to offer the informed choice of vaginal birth. A recent survey found that women that have had C-sections, are not offered the option of a vaginal birth after C-section (VBAC). 9 in 10 women that have had C-sections, will end up having a second C-section.
So, why would someone need a C-section?
Here are some valid medical reasons provided by the March of Dimes:
- If you have had a C-section or other surgeries on your uterus
- Problems with the placenta, so if this ruptures it can cause dangerous bleeding during vaginal birth: placenta previa.
- An infection, like HIV or genital herpes
- If you are having multiples (twins, triplets, or more)
- A chronic health condition like diabetes or high blood pressure. Ie. GDM or preeclampsia
- Baby is too big to pass safely through vagina
- Baby is in breech position (bottom and feet facing down)
- Labor is too slow or stops
- Umbilical cord slips into the vagina where it could be squeezed or flattened during vaginal birth. This would limit the food and oxygen that is delivered from the placenta to the baby.
- Fetal distress, ie. the baby’s heart beat slows down.
- Baby has a birth defect
What are some of the potential outcomes of C-sections?
Findings of recent studies suggest that C-section babies could have a higher risk of adult obesity, type 1 diabetes and asthma, however researchers note that there is not sufficient evidence to link C-sections as the direct cause – nor is there enough to conclude that C-sections babies may seem to have more sensory deficits as they did not have sufficient time to accommodate to their new environment outside of the womb. Lung development may not be sufficient and therefore more babies may end up in the special care nursery. Since mothers receive sedation, this delays skin to skin contact, and may delay or limit ability to breastfeed.
The mother is also at higher risk for infection after undergoing surgery. Healing time is much longer and lifting restrictions will be placed on the mother generally for 6-8 weeks until the surgery site heals.
In 2014, ACOG released new C-section guidelines due to the increasing rate across the US.
The guidelines basically say that doctors should allow otherwise healthy women more time to deliver their babies vaginally before assuming that labor has stalled. A study from 2012 at the NIH, found that one stage of labor takes up to 2.5 hours longer than previously thought. This can be attributed to older age of mothers, as well as an increase in the use of epidurals, which can slow labor.
Other recommendations targeted towards physicians: Avoid ordering a C-section if first stage of labor is prolonged. This is considered the latent phase and this is when contractions are mild and far apart and cervix is barely dilated.
Active labor is now thought to begin when the cervix is dilated at 6 centimeters (previously thought to be 4 cm). At 6 cm, contractions become stronger and more rapid. Other recommendations include allowing women to push for at least 2 hours if it is their second baby, and three hours for a first baby. Forceps can also offer a safe alternative to certain cesareans if used by an experienced, well-trained physician.
So, what are some ways you can you avoid a C-section?
- Pick a doctor with a low C-section rate. Be sure to check the entire practice, as you never know who will be on call when you go into labor
- Choose a midwife instead. Midwives’ C-section rates tend to hover around 3-4%
- Hire a doula. The presence of a doula can lower the C-section rate by 40 percent. A doula is a birth coach that can help with positioning and being an advocate for a mother.
- Don’t get induced. Induction increases the odds of a C-section by 40 percent. The cervix is usually not ready, so trying to force it will not help. Try to hold off until 41 weeks. At this point the health of the baby can be compromised, and after 42 weeks the placenta stops working well enough to keep your baby healthy.
- Labor at home for as long as possible; hospitals will admit women when they are 4 cm dilated, but you should try to wait until 6 cm to come into the hospital. The moment you step into the hospital, you are exposed to many different medical interventions which will all slow down labor. Even just being hooked up to an IV can slow your mobility, and therefore slow down labor.
- Expect that labor will go slower than usual. The old methods predict a faster labor, which has been shown to be outdated.
If your doctor recommends a C-section, ask these key questions first.
1. Is my baby okay, is there any danger at this point?
2. Am I okay?
3. Can we please wait? If the answer is yes, then continue to labor.
After delving into all of these articles and studies, it’s still not clear to me exactly why the C-section rate has been steadily increasing, but at least now I know more about the general trends and potential explanations. For expecting mothers, it might be best to ask the right questions before going into labor.