C-sections gone wild?

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Cesarean section refers to delivery of a baby through an abdominal incision. A cesarean section (often called a "c-section") can be a life-saving surgical intervention-- for moms and babies.  Sometimes it is absolutely necessary. In fact, studies in very poor countries show that increased maternal and child mortality directly correlates with poor access to urgent cesarean section.

However, here in the US, we have the very opposite problem:  rising c-section rates are associated with increasing maternal and neonatal mortality. And no one knows just how to stop cutting.

In 1988, US cesarean rates peaked (we thought) at 24.6% of all births. That's 1 in 4 babies! By 1996, largely thanks to public policy work and change in medical culture, the rate had dropped to 19.7%. The US government's  Healthy Families 2010 goal was to get that c-section rate down even further-- to 15.5%.  At the time, this seemed an attainable and health-wise goal. 

Unfortunately, c-section rates started increasing again, and despite policy work, by 2010 we came far short of our goal; the rate was up to 26% and rising. Today, our national cesarean rate is 33.1%. In Sonoma County, our cesarean section rate for hospital births is currently 26.3%, better than the national average, but still pretty darned high.

Did you catch that? Today 1 in 3 women in the US are birthing via c-section. There is a range across states, but it's not terribly wide (Utah has the lowest c-section rate  in the country, at 22%, Kentucky and New Jersey the highest at 38%). Perhaps most telling, our government's 2020 Healthy Families goal of 23.9% seems to be moving in the wrong direction!

The main indications in this country for cesarean section are:
1) Labor isn't progressing (i.e. woman isn't dilating as quickly as we would expect, hope, or imagine)

2) Abnormal fetal heart tracing (i.e. some concern that the baby might be in distress)

3) Fetal malpresentation (this includes breech babies, as well as babies who are occiput posterior in my land sometimes called, "sunny side up")

4) Multiple gestation (twin primary c-section rates have skyrocketed from 53% in 1995 to 75% in 2008, despite the fact that a study published in a super esteemed journal in 2013 reported no improved outcomes in c-section vs. vaginal birth for twins. Huh.)

5) Suspected macrosomia (i.e. big babies)




It's hard to determine exactly what the "correct" c-section rate should be-- WHO (the World Health Organization) has long advocated a maximum c-section rate  of 15%. A 2011 study confirmed that once a cesarean section rates tops somewhere between 10-15%, the benefit for women and babies wanes.
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Source: Dieva Larissa Tattoo

One thing that most of us can agree on is that 33% is too high--- risks of c-sections including wound infections, blood clots, and other post-operative complications are on the rise. Here are ways that both birth professionals and birthing women should be advocating to change the way decisions are being made regarding c-sections

1) Be more patient: just this year, ACOG (the professional organization representing obstetricians and gynecologists) released recommendations offering women MORE time, and also not labeling a woman as being "in active labor" until she is 6cm dilated. That means a woman can be in labor for over 24 hours before we even start considering that "labor isn't progressing" and that gives women more time to have their own labor curve before we start counting.

2) Reconsider what abnormal fetal tracing is: this is super tricky, as the fetal tracing is what literally tells us "how the baby is doing"-- studies show that continuous monitoring has no better outcomes than intermittent monitoring (i.e. having that thing strapped on all the time while you are in labor vs. for 60 seconds every 15-30 minute) and yet, even in places that "say" they believe in intermittent monitoring, most laboring women are strapped up for large chunks of their labor

3) Make sure we are offering versions for women: a version is a procedure in which a physician literally pushes on a woman's belly in order to turn that baby from bum down to head down. It's usually done around 36 weeks, and though it isn't comfortable, success rates range from 1 in 3 to 1 in 2. That means a good number of women could be saved a section. There is also some interesting data on "moxubustion", an acupuncture/traditional Chinese medicine technique shown to help turn babies around. We should be doing everything we can do to get babies head down, including letting mom's rest!

4) Offer vaginal birth trial for women who have multiple gestation with Twin A in cephalic presentation (that's "baby closest to the vagina being head down", in doctor speak). It's unconscionable that 75% of those women are getting cut without being offered the possibility of a vaginal birth.

5) Be careful about the ultrasounds we order to evaluate neonatal weights. Remember, ultrasound in the end of pregnancy is pretty horrible at predicting weight-- plus or minus 2 pounds. Which basically means you could be having an 8 pound baby OR a 10 pound baby OR a 6 pound baby, on the same ultrasound report. We should be judicious about deciding we need to "check" on a baby's size unless we have some other really good indicators (like, for example, the woman has had two 11-pounders in the past). Sometimes it's tempting, but we shouldn't be tempted without good reason.

6) Lastly, we NEED to stop the FIRST c-section because we know that once a woman had a c-section her risk of having another one goes up. . .This is because an unhelpful combination of fear, hospital policies, and convenience.

Remember, doctors and families, talk about this stuff. It's important.

Also remember that c-section is an important and valuable tool in certain circumstances. Make sure you have a trusting relationship with your healthcare provider so that those decisions that are so important are done in the most shared-decision model way you can imagine.



Additional resources
http://www.ncbi.nlm.nih.gov/pubmed/24720614
http://www.huffingtonpost.com/2013/10/02/twin-birth-c-section_n_4030971.html
https://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Prevention_of_Early-Onset_Group_B_Streptococcal_Disease_in_Newborns