The earliest type of c-section was anything but a life saving procedure.
Today, there is no doubt c-sections can and do save the lives of mothers and babies around the world.
In the past, this surgery was rare, and was only performed when the life of mother or baby hung in the balance, and it was deemed necessary to take the risk.
Not so today.
The rate of c-sections has increased worldwide over the past two decades, and it is now one of the most common surgical procedures performed.
C-sections are often the end result of a cascade of interventions.
When a woman has her first baby by c-section, it also increases the chances all future babies will also be born via c-section.
This further increases the risks of adverse outcomes for mothers and babies, when compared with vaginal births.
Despite all this, many first time mamas aren’t aware there are many ways to avoid having a c-section.
The increasing rate of c-sections is of great concern, and health organisations are now responding, by making recommendations to reduce the number of primary (first) c-sections.
In 2014 The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) issued a joint Obstetric Care Consensus statement that looked at how safe ways to prevent primary c-section.
The guidelines represent a positive step forward. They demonstrate how maternity care should be provided to women and the ways in which care providers and hospitals can reduce the number of women having a primary c-section.
The ACOG statement addresses a basic fact: vaginal birth is best for most babies and mothers:
Childbirth by its very nature carries potential risks for the woman and her baby, regardless of the route of delivery. The National Institutes of Health has commissioned evidence-based reports over recent years to examine the risks and benefits of cesarean and vaginal delivery. For certain clinical conditions – such as placenta previa or uterine rupture – cesarean delivery is firmly established as the safest route of delivery. However, for most pregnancies, which are low-risk, cesarean delivery appears to pose greater risk of maternal morbidity and mortality than vaginal delivery.
Based on the ACOG recommendations, here are 12 ways women can avoid having a primary or first c-section:
1#: Slow Early Labour Is Normal
Early or latent labour is the time when the cervix begins to soften, thin and dilate.
An archaic study, performed in the 1950s by Dr Emanuel Friedman, concluded if a baby wasn’t born after 20 hours of contractions then labour was considered prolonged and abnormal.
More updated research shows the latent phase can last from six hours to 2-3 days; some women might experience even longer latent phases.
The ACOG guidelines state a prolonged latent phase (longer than 20 hours for first time mothers and more than 14 hours for subsequent births) is not an indication for c-section.
BellyBelly Tip: If you want to cruise through early labour, check out Early Labour – 8 Tips For A Low Stress Early Labour At Home.
#2: Slow And Progressive Labour Is Normal
In standard maternity care, it was expected a woman would dilate 1cm per hour during the first stage of labour, starting at 4cm.
More current research has debunked the basis of this expectation – Friedman’s Curve – and instead shows women can dilate more slowly. The rate of dilation begins to increase when the cervix is about 6cm dilated, rather than 4cm. Slow and steadily progressing labour in the first stage (after 6cm) is normal and is not an indication for c-section.
The ACOG guidelines advise labour that is slow but progressive in the first stage is not an indication for c-section.
BellyBelly Tip: If everything is fine with you and your baby, tell your care provider you would like more time.
If the problem is failure to wait, 8 Natural & Effective Tips For a Slow Or Stalled Labour might help.
#3: Active Labour Starts Later
As mentioned above, prevailing practice has been to consider active labour as starting at 4cm. On arrival in hospital, a woman is usually assessed as to how dilated she is.
If dilation is determined to be at least 4cm, then she’s considered to be in active labour and the clock begins ticking from that point (see #2 above).
ACOG recommends cervical dilation of 6cm be considered the beginning of the active phase of labour for most women, and standards of care for active labour should only apply after this.
BellyBelly Tip: The cervix can only tell you what’s happening in that moment; it can’t predict the future.
To understand cervical dilation, check out this article.
#4: Ruptured Membranes
In an estimated 8-10% of births the amniotic sac ruptures before labour begins; this is known as prelabour rupture of membranes (PROM). Labour is usually expected to begin 24 hours after the waters break, after which an induction or c-section becomes necessary.
This idea stems from the 1950s, when the death rate of babies was very high after PROM. In those days women were generally not advised to go to hospital if PROM occurred; neither were they routinely given antibiotics.
However we now know 60% of women whose waters rupture before labour will go into labour within 24 hours, and 75-95% of women will go into labour within 48 hours of their waters breaking. Very few will go beyond 96 hours.
BellyBelly Tip: If your waters break before labour starts, and if all is well with you and your baby, you can request to wait 24-48 hours before action is taken.
Check out this article for the real risk of infection after waters break.
This article will help you to understand whether or not meconium in your waters is dangerous.
#5: Instrumental Birth Reduces Need For C-Section
Forceps and vacuum tools have been used for difficult births for a very long time.
These tools can be beneficial when used appropriately, but there’s an increased risk of birth injuries to babies and complications for women following instrumental birth.
The ACOG guidelines note the rate of instrumental birth (forceps or vacuum) has significantly decreased in the last 15 years. At the same time, the c-section rate has been increasing.
The number of care providers trained in safely performing instrumental births has declined, and many obstetricians report they don’t feel confident using forceps for birth.
Research shows less than 3% of women who have had an attempted instrumental birth will go on to need a c-section.
BellyBelly Tip: Before birth, check whether your care provider is skilled up with instrumental birth techniques, in case this is likely to make the difference between having a vaginal birth and a c-section.
#6: Second Stage Can Take Longer
Since the late 1800s, it’s been standard for the second or pushing stage of labour to be considered ‘arrested’ if it takes longer than two hours, or three with an epidural in place.
Once this diagnosis of arrested labour has been made, the woman is whisked off for a c-section, often regardless of how she and her baby are coping.
The ACOG guidelines advise supporting women to push for longer durations in the second stage, based on their individual status. This takes into consideration whether or not they’ve had an epidural, whether mother and baby are coping well, and whether there is some fetal malpositioning. If there is progress, second stage labour should not be considered stalled after two hours.
BellyBelly Tip: There are many reasons why the second stage can take longer for some women. You might be interested to learn about the fetal ejection reflex.
#7: Avoid Unnecessary Inductions
Induction of labour is becoming increasingly common and, unfortunately, it often occurs for non medical reasons, such as women going past estimated due dates. An induction increases the risk of c-section so, for your first birth, it’s important to be well informed about the risks of induction as well as knowing when one would become necessary.
ACOG doesn’t recommend induction before 41 weeks (unless medically necessary) and cervical ripening first can help to reduce the chance of a c-section. Women should be given 24 hours following artificial oxytocin and ruptured membranes before considering induction a failure.
If you do need an induction ask for 24 hours to give you plenty of time to get things going before having a c-section.
#8: Big Baby Isn’t An Indication For C-Section
Macrosomia, or big baby, is a very common reason given for performing a c-section. About 30% of women are told their babies are ‘too big’ but only 10% of those women actually give birth to babies weighing more than 4kg.
Late pregnancy ultrasounds are linked to a higher likelihood of a c-section, with no evidence of improved outcome for babies, despite research showing ultrasounds are inaccurate for weight estimations.
The ACOG recommends c-section should be used rarely with a suspected big baby, and only when the baby is estimated to weigh at least 5kg, in non-diabetic women, and over 4.5kgs in diabetic women. The ACOG also notes birth weights over 5kg are extremely rare.
BellyBelly Tip: Unless there is a medical need, avoid late pregnancy ultrasounds. If your baby is suspected to be over 4.5kg, discuss with your care providers the risks and benefits of vaginal birth and their ability to deal with possible shoulder dystocia.
#9: Fetal Heart Rate
A common cause of primary c-section is an abnormal or changeable fetal heart tracing. There is a wide range of opinion among care providers as to what is considered normal and abnormal.
It’s frightening to be told there is a possible problem with your baby’s heart rate. It’s also important to know there are potential solutions to resolve it before opting for a c-section.
BellyBelly Tip: Know what is normal and what’s not for a baby’s heart rate during labour and avoid having continuous fetal monitoring (CFM) unless you are high risk. CFM increases the c-section rates without improving outcomes for mothers and babies.
C-section does not improve outcomes for twin pregnancies, especially when the first twin is head down. ACOG recommends mothers who are pregnant with twins should be advised about vaginal birth.
BellyBelly Tip: In most countries it is recommended women carrying twins have a planned birth by induction or elective c-section. There is an increased risk of premature birth with both these options, so it is a good idea to know when is the best time for your twins to be born.
#11: Breech Before 37 Weeks
In less than 4% of pregnancies babies are persistently breech (bottom down) beyond 37 weeks. In 85% of these cases, women have their babies by c-section.
An external cephalic version (ECV) is a procedure which turns the baby from bottom to head down. A recent study showed this was attempted in less than 50% of cases. ACOG believes ECV is not being offered or utilised enough for breech presentation and recommends mothers should be offered the choice of having ECV performed.
BellyBelly Tip: Get the low down on the safety of breech vaginal birth and know your options, so you are not left thinking a c-section is your only choice.
#12: Continuous Labour Support
One of the most effective ways to reduce primary c-section rates is to offer continuous labour support, which is provided by a known midwife or birth doula. ACOG notes this resource is probably underused, even though for many women it is likely to be very accessible, especially as birth doulas increase in popularity.
BellyBelly Tip: If you not in a position to hire an independent midwife or access a midwifery led model of care, hire a birth doula.
Your partner and other support persons can be valuable, as long as they are well informed and educated about normal birth and prepared to help you advocate for your choices.