Special thanks to Birth Sense: A Common-Sense Guide to Normal Birth for giving us permission to re-post this article. Read more of their great content at www.TheMidwifeNextDoor.com.
In recognition of International Cesarean Awareness Month, sponsored by the International Cesarean Awareness Network (ICAN), I wanted to discuss a problem I feel contributes significantly to the high rate of primary c-sections in the United States. It is critical that we look at what can be done to decrease the primary c-section rate (the first cesarean for a woman), because once the first c-section is done, it becomes increasingly difficult for many women to find support for a subsequent vaginal birth.
I’ve spoken before of birth apathy, a problem that is quite prevalent among American women. Many seem to have the mindset that “it won’t happen to me,” and willingly accept or even request interventions or procedures known to increase the risk of that first cesarean.
I recently had the experience of talking at length with a client who was near her due date and desperate to be induced. Her reason? She was tired of being pregnant, and her mother was scheduled to be at her brother’s baseball games the following week. She wanted her mother with her during labor. I explained the reasons that I don’t due elective inductions. I explained the risks, and stressed the fact that since she was having her first baby and her cervix was not “ripe” for labor at that time, she had a 50% chance of ending up with a c-section. I emphasized that an induction would likely take two days, because her cervix was so unready for labor. I guess my words did not make much of an impression because she talked one of my colleagues into inducing her. After more than 24 hours of labor, she went for a c-section for failure to progress (this in spite of hours of documented adequate contractions with an internal monitor). The baby had poor apgar scores and had to be in NICU for several days. My client and her mother both missed the brother’s games. How might the ending have been different had she been willing to wait for labor to start on its own?
Many women ask questions of their providers, trying to identify someone they can trust to avoid c-section unless it is truly necessary and lifesaving. I think that the questions women are advised to ask are often misleading. For example, if you asked my obstetrician backup what his c-section rate is, it might be higher than the books tell you to accept, because he provides backup for several midwives. He only sees the patients who are having complications and problems severe enough that the midwives can no longer provide care for them. Yet I know he is very patient with the process of labor, and has never argued with me about allowing a woman more time to labor if both she and baby were tolerating labor well.
So, here is my list of essential questions to ask. I recommend asking these questions at the first prenatal visit. It becomes increasingly difficult to consider a transfer to another provider as the pregnancy progresses, and the tendency is to rationalize that everything will be OK, it won’t happen to me, or my husband (or doula) will advocate for me. Right–just keep telling yourself that!
1. When labor and birth are progressing without complications noted, what routine procedures do you perform? I suggest avoiding the word “interventions” because many practioners do not consider IVs, breaking the water, continual monitoring, etc., to be interventions. Some truly believe these things must occur in most labors in order for birth to happen in a normal, timely way. Some, sadly, have never seen a birth without interventions.
2. How do you prefer to monitor the baby in a labor that has no complications? I recommend the term “labor without complications” rather than “normal labor,” because many providers consider any labor that ends in a vaginal delivery to be normal labor. The optimal answer to this question would be a preference for intermittent monitoring without requiring the woman to be attached to a fetal monitor, in order to allow for optimal movement during labor. Avoid practitioners who believe that continual fetal monitoring in an uncomplicated labor is optimal. In a low-risk labor without complications, the standard practice of twenty minutes continual monitoring every hour has not been shown to have any benefit. I recommend asking the practitioner open-ended questions, rather than yes or no questions, such as “can I have intermittent monitoring,” because it gives you a better feel for the practioner’s personal philosophy. Although your practitioner may agree with everything you request, if it is contrary to their personal philosophy of practice, things are likely to change when you are actually in labor. Once you are in the midst of having a baby, you are not in a good position to debate the merits of procedures your provider is recommending. What’s more, if your provider is telling you that your baby is in distress, you are likely to agree with whatever is recommended to you, simply because you care about your baby. That’s why it’s so critical to lay the groundwork to find a supportive practitioner early in the pregnancy.
3. What position do you prefer your patients to use for giving birth? The correct answer here is, “Whatever position she chooses.” If the provider starts telling you why semi-sitting or reclining on one’s back is the ideal birth position, RUN! If the provider tells you that you can choose any position you like, ask him or her to share with you what position the women in their last several deliveries have used. If it’s reclining on the back, you can be sure that even if this practitioner is willing to deliver babies in other positions, s/he is not encouraging women to move about freely and find the best birth position for them.
4. How would you handle it if we had a difference of opinion about a procedure you were recommending to me during labor? The answer to this question should give you a clear idea of the provider’s need to be in control. While we all recognize there are rare occasions when an emergency does not allow time for much discussion, this is not the norm. It’s important to know how your provider will respond if you don’t want a procedure s/he is recommending to you in a non-emergent situation.
5. What were the reasons for the last few non-scheduled c-sections you’ve done? This should give you a pretty clear picture of normal practice for the provider you are interviewing. If the last several c-sections they have done were all for “failure to progress,” “failed induction,” “failure to descend,” etc., you would do well to consider another provider. There should be few c-sections done for any reason involving “failure.” Most cases of failure to progress are actually “failure to exercise patience” on the part of the provider. The majority of non-scheduled c-sections done by a practitioner who support non-interventive birth should be for reasons that are truly emergent, such as placental abruption, a pathologic fetal heart rate pattern, etc. You might also consider asking for details about c-sections done for stuck babies. How long was the woman allowed to push or to “labor down” with an epidural? Was she held to the outdated Friedman’s curve, or was she given every opportunity to give birth on her own? While it can be difficult to judge the provider’s actions when you were not there, you are trying to get a picture of the provider’s philosophy of practice.
By asking these questions, and dialoguing with your provider, your chances of establishing a relationship with a provider who supports normal birth are enhanced. Avoiding that first c-section is a major key to resolving the cesarean epidemic affecting America today.