Avoiding the C-section

Nationally the average mother has about a 20% chance of getting a C-section during each pregnancy if she has never had a section (primary C-section).  Historically the odds were only about 5% of pregnancies would end up as a primary c-section.  To understand this change we have to ask ourselves why do we, doctors, recommend C-sections.  There are only about 7 reasons c-sections happen. 

1. Failure to dilate or descend: No progress in labor.

2. Maternal fatigue: Mom gets to tired and can no longer push effectively

3. Drops in heart beat or non-reassuring patterns on baby heart tracings

4. Malpresentation: Breech or butt down babies

5. Medical reasons where vaginal delivery is not the best option

6. Multiples: Twins in certain circumstances, triplets and above.

7. Elective primary C-section: the mother wants to avoid a vaginal delivery for a nonmedical reason.

So how can we limit the need for a c-section from each of these causes

1.Failure to progress:  This is the one factor that is most controllable by the mom and doctor.  With a team approach most C-sections can still be avoided. 

So what can the pregnant mom do?

-The right answer is be healthy.  Unhealthy weight gain and diet habits can lead to big babies.  Big babies don't fit as well as normally sized ones. Poorly controlled diabetes, maternal obesity and large pregnancy weight gain are all things you can control to increase the odds of baby fitting. 

So what can a doctor do here? 

-At the first visit we can advise you on your ideal weight gain.  We can watch baby's weight closely help can decide on the best timing to deliver. Sometimes induction of labor at 39 weeks is the best option before baby grows any bigger.  During labor Pitocin can be your best friend and worse enemy. It's important to have contractions that are strong enough for labor but if you push too hard you are likely to end up as a c section for reason number 3, drops in the baby heart rate. There is a delegate balance of only using interventions like Pitocin when needed. 

But most of all a doctor needs to be patient.  Traditionally most OBs would move to C section if there was no significant change in cervical dilation for two hours.  New studies suggest waiting longer.  Waiting 4 to 6 hours from the last change and not calling active labor until 6 cm dilation will greatly decrease the need for C-sections. 

2. Maternal fatigue:  Overall fitness is super important.  Pushing a baby out, especially on your first, is often more like a marathon than a sprint.  I recommend at least 15 mins of exercise every day.  This will get your heart and lungs ready for the workout delivery will be.  If you do get worn out we can also help avoid the C-section with an operative delivery.  Using a vacuum can get baby out faster and avoid the c section most of the time when the limiting factor is fatigue.  But you can likely avoid this by staying fit.  Using IV fluid with D5 may also assist in fatigue.

3. Nonreassuring fetal heart tracing (NRFHT) or drops in the baby heart beat:  ​Some of these drops are super normal as the baby gets squished down toward delivery.  Others are a true medical emergency.  I have found several ways to limit the number of C-section for this indication.  As the placenta ages, the risk of babies being delivered for NRFHT go up.  My preference is to deliver between 30 and 40 weeks of gestation for this reason.  As noted above, Pitocin can be your enemy here.  When Pitocin is used during normally progressing labor, the baby can be squeezed too hard and the heart rate can drop. Therefore knowing when to increase and when to back off the Pitocin is another key.

4. Malpresentation: Breech vaginal deliveries have fallen out of favor in the US for many years.  There are very few providers that will do a vaginal breech delivery because of the risk of entrapment of the fetal head.  But instead of delivering vaginally breech we can turn the baby more than 50% of the time with a procedure called external cephalic version.