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Cesarean Section - The Ultimate Intervention

In considering which intervention to discuss, it was suggested to me in light of the new ICAN statistics to cover the ultimate of interventions, Cesarean Sections. I think this is a very important intervention, especially since it is all too often the ultimate. Currently in the United States, Mississippi has the highest cesarean rate in the country, weighing in at a hefty 31.1%. The average rate for the Jackson area alone is around 47%.

In 1970, only 1 in 20 US women had cesareans. This number rose significantly over the next few years and by 1987, 1 in 4 women in the US were having cesareans. Since ICAN began urging the elimination of routine repeat cesareans, this number has remained about the same and today the national average is 25% of the women in the United States having cesareans.

The term “Cesarean Section” is said to have derived from the legend of Caesar being cut from his mother’s womb. This is a much-debated legend since his mother was known to live into Caesar’s adulthood and yet during his day babies were only cut from their mother’s womb if she were dying. Those opposed to this legend insist that the term derived from the Latin term caesura, meaning a cutting. Jacob Nufer, a Swiss pig-gelder in the year 1500, performed the first known cesarean operation through which the mother lived. He performed the surgery on his wife using his only gelding tools after the doctors had given up on her. She not only lived, but also went on to have four more normal vaginal deliveries with healthy children. Puts a new spin on “Once a Cesarean, Always a Cesarean!”

Most of the common indications cited for a cesarean are debatable. One of the most common is the notorious repeat cesarean. Often women who are interested in seeking a VBAC are adamantly discouraged against even attempting one. They are told they could attempt a trial of labor, but it wouldn’t be recommended. All too often, highly respected doctors are quick to tell their patients how risky a VBAC would be for their baby and ‘you do want what’s safest for your baby right?’ In reality, most of these women would be safe and successful in their VBAC attempts with support and encouragement.

Another common indication for Cesareans in our country is a breech or transverse lie. There are very few physicians in Mississippi who will even attempt to turn a baby with an external version. It is even rare to hear of a doctor recommending things the mom can do to help her baby turn. I haven’t heard to date of any local doctor who will actually deliver a baby in a breech lie and it is impossible to deliver a baby in a transverse lie vaginally. It is important to remember though that often the position of the baby correlates with the position of the placenta. The placenta for a baby in a transverse lie may be on the top of the uterus, attached beneath the fundus. Likewise a breech baby may be in this lie because his or her placenta is over the cervix. (This also applies to posterior babies whose placenta is often attached to the anterior wall of the uterus.)

A few of the other debatable reasons for cesareans are a baby who is too large, a baby who is assumed to be unable to tolerate labor, an infection such as herpes and HIV, presumed fetal compromise (during labor, determined by the use of electronic fetal monitoring), Cephalopelvic Disproportion (CPD), Failure to Progress, and Shoulder Dystocia. A baby who is too large and Cephalopelvic Disproportion go hand in hand. I have a tendency to disagree with both of these reasons based solely on philosophy. I believe wholly in birth and a woman’s ability to birth. In turn, I must also believe in her ability to grow her baby well. I believe that God in His infinite wisdom doesn’t create a baby who can’t fit through his mother in a way that God intended for babies to enter this world. That is to say a mistake has been made and I can’t accept that. Having a baby who cannot tolerate labor is a very rare occurrence. The baby would have to have a major defect that would make it too fragile to endure the stress of labor. If your clients run into this reason, urge them to investigate it fully and not to just accept the doctor’s words at face value. In regards to an active herpes or HIV infection, this is not always a good reason to schedule a cesarean. Mothers with herpes who were infected before becoming pregnant are probably not putting their babies at risk. Herpes most commonly affects the inside of the vagina during its initial outbreak and after that is usually external and thereby having no effect on the baby coming through the birth canal.

The last three most common and most debatable reasons for cesareans once labor has begun are often times just plain untrue. Presumed fetal compromise detected by EFM is often incorrect. When fetal compromise has truly arisen, sadly in most cases it could have been prevented. Doctors are very malpractice-conscious and quick to rush mothers into ‘emergency’ cesareans only to cut a perfectly healthy baby from his or her mother. When the baby has been compromised, the source can often be traced to an earlier intervention during labor, like immobility, constant EFM, pitocin, etc.

Failure to progress is a term coined from the idea that women should have their babies within a certain timeline, according to an ideal of normal (surely a man didn’t come up with this!) This is possibly the most damaging of all the indications as it leaves moms feeling broken, that their bodies aren’t capable of giving birth. Sadly it is usually the result of a failed induction that neither mom nor baby should have been subjected to.

Shoulder Dystocia in its true form is rare. Usually, a baby who isn’t getting a good fit through the pelvis can easily be remedied with frequent position changes. For the average woman, this means upright and opening, such as squatting, lunges, etc. In a true case of shoulder dystocia when all other options have been tried, an experienced midwife will carefully slip the baby’s shoulder past its block. A doctor though will be likely to call a cesarean when the mother has been pushing in the lithotomy position for two or more hours with no baby and diagnose her with shoulder dystocia.

On the other side of the many reasons for Cesarean we may disagree with and continually try to save women from becoming the next victim of a doctor who is knife-happy are the few reasons that are truly an emergency. These reasons include Prolapsed Cord, Placenta Previa and Placenta Abruptio. In the event of a prolapsed cord, the baby enters the birth canal behind the umbilical cord, compressing the cord and depriving the baby of essential life giving oxygen. Placenta Previa occurs when the placenta covers the cervix. In this situation, should mom begin to push the baby out, the placenta will come first also depriving the baby of his or her oxygen. Placenta Abruptio refers to the placenta completely separating from the wall of the mother’s uterus. In this situation there are only a few minutes to spare the baby’s life.

These emergencies are the cases where obstetricians are valuable. Sadly though, far too many women have their babies cut from their bodies each day needlessly. Besides leaving a life-long physical scar, there are many other negative effects of a cesarean. Moms recovering from this surgery will have a longer hospital stay than their vaginal birth counterparts and pay $4,000 –5,000 more. Beyond the hospital stay, their recovery period in itself will last much longer. Most women report that their full energy level doesn’t return until at least three months postpartum. There is a significant increase in the risk of hemorrhage and infection in mom. Many mothers report having difficulty breastfeeding because of the discomfort of their incision. Also, since 95% of postpartum depression is related to birth-experience there is a much higher incidence of postpartum depression after cesarean births. Possibly one of the most dangerous effects of cesarean is the possibility of placental abnormalities in subsequent pregnancies. A mother with just one previous cesarean has a 50% higher chance for experiencing Placenta Accretia (abnormally strong adhesion of the placenta).

Our job as labor assistants is to make sure women are educated. It is our calling, our reason for seeking this field. At least, it should be. I have heard moms who have had cesareans say ‘My body didn’t work’ and ‘I guess I’m just not capable of giving birth’. Those of us who have had our bodies cut in anyway during birth know just how deep that pain goes. Even so, I am very thankful I survived my daughter’s birth without having her cut from my abdomen. Because the fact is that quite possibly, the very next woman who gave birth did not survive such a cut. We must accept that we cannot change every outcome of our client’s births. We will serve women who will have unnecessary cesareans. We will hurt for them, we will probably cry for them. But hopefully we will be able to know that because of education and support, we were able to have a small part in saving one woman from being needlessly cut.


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