This year marks the end of the second “Healthy People” decade. Healthy People is a program that puts together an extensive set of 10-year health goals for our nation with the intention of promoting health for America. Various government agencies, along with outside organizations, have worked together to come up with goals that are of the highest priority for our nations’ health.
Being in the field that I am in, I am always eager to see the goals they set for maternal and infant health, along with how we do in meeting those goals. Of specific concern to me is how they view the rate of cesarean sections.
In the Healthy People 2000 set of goals, a target of a 15% total cesarean rate was set for our nation, with a 12% rate for first time, low risk (full-term, singleton, vertex presentation) moms, and 65% target for repeat cesareans. The actual numbers were an improvement from what they had started at, down to 21.8% for total, 15.7% for first time moms and 66.4% for repeats, but did not meet the intended goals.
For Healthy People 2010, you may notice that the target rate went up. The goal for first time cesarean section was set at 15%, and target repeat cesarean was for 63%. A few points difference, but when you take into account how many thousands of women those points account for, that’s a lot of cesareans. We do not have any comprehensive data on these statistics any more current than 2007, but if we are continuing along the trend we see from that year’s rates, we are far, far, FAR from our goal! Last I heard, our overall cesarean section rate was around 31.8 %.
That’s more than twice the intended rate.
So, what’s going on here? Our health agencies and organizations believe that reducing the rate of cesarean sections is imperative for improving the health of our nation, but we are moving away from our goals in this area.
Why is a low cesarean rate an indication of a healthier nation? Isn’t cesarean a life-saving technique? Yes, it is. Having access to technology that can be used in emergencies is an indication that our country is advanced, but the use of these procedures does not mean that we are healthier because of our advancements. My belief is that we are too quick to use our advanced techniques when low-tech approaches could work just as well, if not better. If our high cesarean rates are a reflection of the number of emergency births that take place, there is something seriously wrong happening. Our women are becoming very unhealthy if one-third are unable to birth their babies. Our babies are becoming very unhealthy if one-third are too distressed to be birthed. Not only is our high cesarean section rate an indication of poor health prior to birth, but it increases health risks following birth, creating a new epidemic of young women with fertility problems, uterine problems and needing hysterectomies. If it is true that one-third of our nation’s births are emergency situations, we need to back WAY up and figure out how we can help women become healthy prior to, and throughout their pregnancies. We need to figure out how to grow healthy babies and promote that.
My question for Healthy People is how they intend for these goals to materialize into action? It’s one thing to set a goal, it’s quite another to make a plan of action and follow it. What is the point in setting these rates when there is no plan also set in place in how to achieve them?
Healthy People states that they are “grounded in the notion that establishing objectives and providing benchmarks to track and monitor progress over time can motivate, guide and focus action” but this is clearly not the case in obstetrical care. Though the “Mother-Friendly” and “Baby-Friendly” stamps of approval were established as an incentive to practice evidence-based, goal-meeting, care in hospitals, in the 14 years that these guidelines have been established, I can only find 86 hospitals in the entire United States that can claim being Baby-Friendly, and have yet to find one Mother-Friendly award.
Do we just not care? On the one hand, we see it important enough to list in our health priorities, but on the other hand, the shows we watch, the organizations that are respected, and the numbers themselves all show us that we really don’t care enough to do anything about it. Instead of it being seen as a medical emergency, cesareans are beginning to be seen as the norm.
Setting a goal without a plan of action is like saying you want to lose ten pounds and then continuing your life as you always have. If you want to lose weight, you need to make an effort and have a plan of what you are and are not going to do. The same goes with the Healthy People goals. Just setting a goal is not inspiring enough to the obstetricians in our nation. They need steps to guide them.
So, let’s look into the cesarean epidemic. Why are our rates so high? Why do they continue to climb when our goal is set for something much lower?
The first thing we need to do is address the top reasons for medically necessary cesarean sections.
1. A Previous Cesarean
Well, the easiest way to avoid this is to avoid the first cesarean! But, since that’s not always an option, we need to look into the reasons why a primary cesarean necessitates a repeat cesarean. Research shows that the risks of a vaginal birth after cesarean are much less than the risks of having another cesarean section.
A previous cesarean should not automatically place a woman in need for a repeat cesarean. The opportunity for women to have a vaginal birth after cesarean (VBAC) needs to be supported and encouraged.
2. The Baby is Too Big
This is a commonly given reason for a truly rare problem. American women, with their access to plenty of nutrition, should not be suffering from debilitating bone growth conditions, such as rickets, which would inhibit their ability to birth a baby. American women, in general, have pelvises that are perfectly suitable for passing a baby.
The problem lies in a misunderstanding of a pregnant woman’s anatomy, physiology, hormone production, and the baby’s role in his exiting.
A woman’s production of relaxin and hyaluronidase during the last part of
pregnancy and throughout labor loosens up the ligaments of the pelvis, enabling it to stretch and move a lot more than a typical non-pregnant pelvis. As a side note, dehydration can decrease hormone production, so do not restrict access to fluids.
A woman needs to be able to move in labor in order to allow the baby to navigate its way through the twists and turns of the pelvis. This is best done if a woman is upright and has the use of her legs.
Squatting during pushing can open the outlet of the pelvis by more than 10% to allow more room for a descending baby.
Physiological pushing ensures that mom is not wasting energy and only pushing when she and baby are truly ready.
A well-toned pelvic floor can encourage a proper head flexion of the baby to allow for the smallest diameter of the head to lead the way out.
Allowing enough time in labor and encouraging movement with the mom will help baby get into a good exit position, rather than rushing a baby down into a more difficult position.
Not rushing a labor, and letting it progress on its own time will help with the baby’s head molding into a shape that fits through a mother’s pelvis.
3. Breech Baby
Delivering breech babies vaginally has been taboo for so long now, that it has come to the point where there are very, very few doctors who even know how to deliver a breech baby. Preventing breech babies should be the first consideration, followed by more attempts at delivering breech babies vaginally. The best ways to discourage a breech presentation are through the following:
Have an extensive knowledge of optimal fetal positioning, and practice it throughout the end of pregnancy and in labor.
Make time for body work such as chiropractic adjustments, craniosacral therapies, myofascial release, massage therapy, acupressure, acupuncture, and physical therapy.
Have a practitioner who is good at palpating to have an understanding of how the baby lies, or do it yourself through belly mapping.
If baby is not moving through home techniques and body work, try an external version.
Allow mom to go into labor and utilize the wide range of movements to allow for baby to turn in labor.
4. Transverse Baby
A transverse baby is a problem indeed. A baby truly cannot come out of his mother shoulder-first. To reduce the likelihood of this position, the guidelines for preventing a breech presentation apply to transverse presentation as well.
5. Placental Problems
We cannot prevent all, but a healthy lifestyle and good nutrition prior to conception and throughout pregnancy, will greatly reduce these issues. Mothers with previous cesareans are at greater risk for placental problems due to the scar tissue acquired from the cesarean.
6. Slow or Arrested Labor
Failure to progress is one of the most common reasons for cesarean sections. The reasons why labors slow down or stop are so various it’s hard to address the issue unless you know all the little details surrounding each woman’s circumstances. But here are some basic things to consider.
Starting a labor with artificial means increases the chance of a labor stalling out, because sometimes, a body just isn’t ready! Letting moms go into labor on their own will increase the chances of labors happening at a time when both mom and baby are ready.
Women in labor are incredibly sensitive to what’s going on in their surroundings. Privacy is vital in order for a woman’s body to follow the natural course of labor. If she does not feel safe or respected, her body will shut down the labor process. Being respectful, quiet, and calm around a laboring woman will help to support her through the process.
Encouraging movement and walking throughout labor can help a labor along. Studies show that it can shorten the length of labor by 25 %. Walking opens the inlet of the pelvis, allowing room for the baby to descend and move into a good position.
Epidurals are known to slow down labors when given too early, or just as a reaction in some women. Using natural pain coping techniques can be effective in managing labor pain, as well as helping labor progress at a steady rate.
A body that is well nourished and has the strength and stamina to endure hours of labor will be less likely to wear out and give up. Encouraging good nutrition and exercise throughout pregnancy can give women a better chance of a healthy labor.
The presence of a supportive birth partner has been shown to shorten labors by 25%. Encourage participation by husbands, partners, and the use of doulas.
If a woman is not in good active labor, she should not be wasting her time in the hospital! Being admitted at an early stage of labor can cause boredom, stress, excessive use of medication and fear, all of which can slow and stall a labor.
In about 1/3 of labors there is a phenomenon that occurs called the Natural Alignment Plateau. During this time, contractions may continue but dilation does not happen, or contractions may stop all together. While dilation is not occurring, progress may still be occurring. Muscle revitalization, hormone production, a baby changing position, head molding, the release of fears, colostrum production – these are all ways in which progress can be made while dilation is not occurring. Staying patient while this occurs can lead to a labor which ends in rapid dilation (once all of the unseens are taken care of, things tend to move quickly). To force a labor forward that is experiencing a natural alignment plateau may be interfering with processes that are vital to the mom, baby, or both.
7. Umbilical Cord Prolapse
A cord prolapse is a true emergency situation. The umbilical cord is the baby’s lifeline while it is in utero. If the cord slips down past the baby’s head and gets pinched or compressed, the baby’s oxygen source is cut off.
> One of the ways to avoid a cord prolapse is to not artificially rupture membranes, especially early on in labor. Early ruptures are at a higher risk of cord prolapse because the baby tends to still be high in the mother’s pelvis, allowing more room for the umbilical cord to slip past.
> Avoiding internal exams during pregnancy and excessive exams during labor can help prevent early rupture of membranes. Each time an exam is done, bacteria from the birth canal is pushed up toward the bag of waters. This bacterium can eat away at the membranes and increase the likelihood of an early rupture.
> Healthy diet throughout pregnancy helps to create a strong membrane that is less likely to rupture early on.
8. HIV or Genital Herpes
In this instance, preventing the diseases prior to pregnancy is a must. Continued education on abstinence and safe sex practices needs to be encouraged. Women with genital herpes may still be able to have a vaginal birth if they are able to suppress a herpes outbreak at the time of birth.
9. Multiple Births
Multiple births seem to be on the rise now that infertility treatments have become so readily available. In order to grow healthy multiples, a healthy diet and lifestyle is absolutely necessary. Just because there’s more than one baby growing in the uterus this should not automatically put mom in the cesarean category. Vaginal birth of multiples is possible and should be attempted. Because of the increased likelihood of a breech presentation with multiples, vaginal breech deliveries need to be revived and doctors should relearn this practice.
10. Fetal Distress
The majority of cesarean sections I know of are a result of fetal distress. This is a scary situation. Why are so many babies unable to handle the rigors of labor? If this was the intended way for babies to come out, shouldn’t they be able to endure contractions and birth? While contractions and exiting through the vagina is the way that our bodies and babies are intended to work together, the rest of the labor story tends to stray from the intended course.
While distress can occur even during a completely natural and hands-off labor, it is important to note that any time you interfere with the natural process of labor, you are inviting repercussions. That’s why every single intervention should be weighed in a risks vs. benefits analysis.
One of the most noted side effects of pitocin is fetal distress. Pitocin, which causes unnatural contraction patterns, affect babies differently than normal contractions. Because they are stronger and last longer, they are adding stress to the baby in utero.
Add the epidural. Again, one of the most noted side effects of an epidural is a drop in mother’s blood pressure and decelerated heart rates in babies. And when an epidural is used in conjunction with pitocin, the pitocin is much more likely to be abused. If the mother cannot feel the intensity of the contractions, the medication can be administered in higher doses, without thinking that the baby still is feeling the intensity.
So, to counter the cesarean due to fetal distress, we need to:
Lower the induction rates! Starting a labor chemically can stress out a baby who isn’t ready for labor, and it can cause stress to a baby due to the intensity of the pitocin-powered contractions.
Utilize movement in labor! Movement in labor helps a labor to progress, which means less likelihood of having it augmented by pitocin or artificial rupture of membranes. Rupturing the membranes can also increase stress on a baby, as the cushion of water is no longer present and the strength of the uterus squeezing directly on the baby’s head can become harmful after time. Movement also helps to move baby into good positions. Many times women are asked to lie down on the bed and not move in order for the baby’s heart rate to be picked up on the fetal monitor (to ensure that baby is not in distress). The funny thing is, laying down and being still can put baby in a compromising position and cause distress in and of itself! Fetal heart tones can be picked up on a woman upright and moving by holding the monitor to the belly in conjunction to where the baby is during that time.
Avoid pitocin. Avoid it for induction, avoid it for augmentation. It’s just better to stay away from the stuff.
Avoid epidural. Having an epidural can slow down contractions which can then lead to augmentation with pitocin. Epidurals in and of themselves can cause fetal heart rate deceleration. Epidurals also prevent a mom from being able to move and when mom lays in one position, babies can get stuck in compromising positions.
If fetal distress is suspected, fetal scalp sampling can be done to test for true distress in a baby.
11. Maternal Medical Conditions
There are many different medical conditions that cause concern for mothers who are carrying a baby. Some are truly incompatible with labor, some can handle labor if mom is
If there’s a chance for a mom with a medical condition to give birth vaginally, it’s important to keep these in mind:
healthy eating and a healthy lifestyle prior to conception can make a huge difference in your options once you are pregnant.
Controlling your medical condition through nutrition, exercise and medications throughout pregnancy can help increase your chances of a normal labor and birth.
Try labor. See how the mom’s body reacts. Don’t just rule out labor.
12. Baby’s Birth Defects
Some birth defects are incompatible with labor, so cesarean is the best option for these babies. But often times, labor is beneficial for the health and well-being of a baby who has problems, so this is something that a parent needs to really research.
The March of Dimes has gone through a huge effort to help prevent birth defects through education. Good nutrition and a healthy lifestyle prior to conception and throughout pregnancy cuts down on the chances of birth defects, as well as a mother taking the right supplements (i.e. folic acid).
Now that we’ve addressed the top reasons for medically necessary cesareans, we need to figure out the steps to take prior to the cesarean becoming necessary.
1. Nutrition and lifestyle counseling. This should not start *in* pregnancy, this needs to start in infancy! This is a lifelong goal, and not one that should be brought to action only after a woman is pregnant. If a woman is unhealthy when she enters a state of pregnancy, encouraging good health and nutrition still can make a difference, and should occur, but the earlier, the better.
2. Utilize midwifery care. We are seriously lacking in balancing out the specialized practice of obstetrics with practice of caring for normal pregnancy with midwives. The midwifery model of care goes a long way in preventing many of the reasons for cesarean sections, and our nation needs to look seriously at this.
3. Utilize doulas. Because doctors and nurses are kept so busy, doulas are wonderful additions to the labor room. They provide continuous labor support for the mother, father and family. They help the mom with the emotional side of labor and help her through finding her own way. They drastically cut down the medicalized part of labors and help moms get up and moving. Insurance companies would be very, very wise to reimburse families who use doulas. They can greatly reduce the cost of a hospital stay.
4. Train nurses in taking care of laboring women. Because of the high percentage of medicalized births, many nurses do not know the needs of a naturally laboring woman. If cesarean rates are to go down, those who work with laboring mothers need to know how to help them in ways that protect, rather than interfere, with the natural process.