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How To Avoid The Avoidable Cesarean

16 Jul

If you are expecting and planning to labor and give birth in a hospital, you may want to find out about outdated care practices that are likely to increase your odds for a cesarean. Knowing about them and discussing them with your caregiver during your pregnancy will help you to avoid unnecessary complications that can lead to the need for a cesarean that could have been avoided.

Maternity care experts found that, “ Current obstetric care in the United States remains distinctly different from the rest of the world, applying a high-risk model to all women and overusing costly procedures that increase risk.” That includes the overuse of cesareans for low-risk mothers-mothers that should have had a normal birth.

In addition to looking for a hospital with low-cesarean rates with midwives as well as physicians on staff,  knowing about these evidence-based practices will give you the best chance of having a vaginal birth.

Portrait of stressed young woman in bathtub

Your labor is more likely to progress normally if you are admitted to the hospital with regular painful contractions. When your cervix is effaced 80% or more and dilated 4 to 5 centimeters. If you are admitted to the labor and delivery unit too early (at 3 to 4 centimeters dilation) you are likely to have more interventions, twice as likely to be given oxytocin to speed up your labor, and more likely to have a cesarean. Find out more from Lamaze International about what to expect in early labor and how to make yourself comfortable until it’s time to head to the hospital.

Intermittent auscultation, checking your baby’s heartbeat at certain times during labor and birth, is the preferred method of monitoring labor for low-risk women. If you have had a healthy pregnancy and go into labor at term, continuous electronic fetal monitoring (EFM) can increase your risk for a cesarean. Although many hospitals routinely use continuous EFM, this intervention offers no benefit to your unborn baby nor does it improve your health. In addition, EFM restricts your movements. It denies you the ability to walk, change positions, take a shower, or use a tub for pain relief. Women who have freedom of movement during labor, are upright and walk during labor have fewer cesareans. Labor can be monitored intermittently with a hand-held device such as a fetal Doppler. Intermittent monitoring is usually a better choice.

Avoid a routine early amniotomy (breaking the bag of waters) before 5 cm. Many caregivers break the bag of waters during labor. Doing so removes the cushion of the forewaters that can help the baby rotate during labor to a favorable position for birth. Breaking the bag of waters may result in non-reassuring FHR patterns (fetal distress) that can lead to a cesarean.

New guidelines now consider that women are in active labor at 6cm dilation, not 4 cm as previously thought. That is the phase of labor when the fastest rate of dilation begins. Evidence shows that to progress from 4cm to 6cm takes longer than we previously assumed. It may take more than 6 hours to progress from 4 to 5cm, and more than 3 hours to progress from 5 to 6cm. If you are laboring for the first time it may take up to 20 hours to reach 6cm dilation and up to 14 hours if you have labored before. That means that your caregiver should not recommend a cesarean for “failure to progress” before 6cm.

Caregivers often call for a cesarean too early in labor. If a cesarean is recommended for labor that is “too slow” or for “ arrested labor,” you should be at 6cm dilation, with a broken bag of waters, and have labored for 4 hours with adequate contractions without any cervical change. All three conditions must be present before a cesarean can be considered for “failure to progress.” If you were given oxytocin, at least 6 hours should have passed without cervical change before a cesarean is recommended. If you have an epidural during labor, change positions every 20 minutes to help the baby rotate to a favorable position for birth.

Allow for passive decent of the baby. Many mothers don’t feel the urge to push at 10cm dilation. The strong urge to push may come as long as two hours after full dilation. Mothers who wait for the urge to push tend to have a shorter pushing time and greater chance of a spontaneous birth.

Caregivers often call for a cesarean too early during the second stage (pushing phase) of labor. Before your caregiver recommends a cesarean for second stage arrest you should have tried to push for at least 3 hours if this is your first labor and for 2 hours if you are a mother who has labored before. If you continue to have an epidural during the pushing stage, you can push for up to 4 hours if this is your first labor and for up to 3 hours if you are an experienced mother as long as vital signs are normal for you and your baby. If you ask for the lowest dose of epidural analgesia, you are less likely to need an assisted birth with a vacuum or forceps and more likely to have a shorter pushing phase.

Although these evidence-based practices will give you the best chance to avoid the avoidable cesarean, many caregivers and hospitals have not yet made these changes in their practice guidelines. Take the time to talk to your care provider about them during your pregnancy and during your labor to help you have a normal birth.

 

ACOG Reaffirms the Need to Respect Women’s Choices

1 Jun

The American College of Obstetricians and Gynecologist Committee on Ethics just published Refusal of Medically Recommended Treatment During Pregnancy. The update to the 2005 Committee Opinion Number 321 reaffirms in no uncertain terms that a woman has the right to refuse any recommended treatment or intervention despite the fact that it may create an ethical dilemma for her obstetrician–gynecologist.

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With regard to pregnancy and childbirth, a physician may feel strongly that not following through with his or her recommendation may put the expectant mother or her baby at risk but, ACOG emphasizes that it is the caregiver’s ethical obligation to “safeguard the pregnant woman’s autonomy.”

A U.S. national survey of healthy, low-risk pregnant women with a prior cesarean reported that almost 9 out of 10 physicians strongly recommended a routine repeat cesarean to their patients rather than laboring for a VBAC.  Many women felt they had no choice but to comply.  Healthy pregnant women’s informed decisions to refuse routine hospital policies such as continuous fetal monitoring  and restricting a woman’s movement to the hospital bed have often been denied.

Evidence in the California Maternal Quality Care Collaborative  Toolkit to Support Vaginal Birth and Reduce Primary Cesareans indicates that when used routinely, without evidence of improved outcomes, both labor and delivery policies can increase the risk of an avoidable cesarean.

The following are highlights of the Committee on Ethics recommendations:

Informed refusal is the corollary of the doctrine of informed consent; it is an ongoing process of mutual communication between the patient and the physician and enables a patient to make an informed and voluntary decision about accepting or declining medical care.

Pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected.

Obstetrician–gynecologist’s actions should be guided by the ethical principle that adult patients who are capable decision makers have the right to refuse recommended medical treatment.

Forced compliance—the alternative to respecting a patient’s refusal of treatment—raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality.

Obstetrician–gynecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision.

Intervention on behalf of the fetus must be undertaken through the pregnant woman’s body. Thus, questions of how to care for the fetus cannot be viewed as a simple ratio of maternal and fetal risks but should account for the need to respect fundamental values, such as the pregnant woman’s autonomy and control over her body.

(The) patient should be reassured that her wishes will be respected when treatment recommendations are refused.

ACOG’s document also outlines various recommendations to improve physician/patient relationship, develop patient trust and communicate effectively. Refusal of Medically Recommended Treatment During Pregnancy reinforces existing national and international policies and human rights protections to include all patients in the decision-making process and respect their individual values and cultural beliefs.

The concepts of respectful maternity care, and childbirth rights specifically are two of the most prominent issues that expectant women and birth advocates are currently talking about.

Resources

MedlinePlus 

Human Rights in Childbirth

Improving Birth

Birthrights

World Health Organization 

The White Ribbon Alliance

 

Professional Midwives Provide Excellent Care for Mothers and Babies

5 May

In honor of the International Day of the Midwife 2016, let’s celebrate the excellent and compassionate care they provide to mothers and babies.

Compared with physicians caring for similar healthy women, professional midwives offer women more prenatal visits and spend more time counseling and educating expectant mothers about pregnancy nutrition, childbirth and sexuality. Their patients are less likely to develop prenatal or intrapartum hypertension and are less likely to be hospitalized for prenatal complications.

Midwives recommend fewer inductions of labor. During childbirth, midwives  socialmedia-English-IDM2016-skyscraperencourage and support freedom of movement, walking during labor and upright positions for birth. Mothers are free to eat and drink.

Midwives are less likely to use medical interventions during childbirth. To augment contractions with pitocin, break the bag of waters, use intravenous fluids in labor, continuous fetal monitoring and pain medication. Their approach to childbirth therefore results in fewer complications for mothers. Less need for an episiotomy, instrumental birth (use of vacuum or forceps), and 3rd or 4th degree lacerations.

With the midwifery model of care, women have fewer cesareans and more VBACs.

Perinatal outcomes are excellent with midwives. Compared with physicians caring for similar healthy women, mothers have fewer or comparable numbers of preterm births and low-birthweight babies. During childbirth, fewer babies experience fetal distress, birth trauma and require admission to a neonatal intensive care unit (NICU). At birth babies are more likely to have skin-to-skin contact, more likely not be separated from their mothers and to be exclusively breastfeeding after birth and at 2-4 months later.

Expectant mothers who choose midwives as their primary care provider really value the continuity of care, participation in making decisions and the empathy and the close relationship they develop during pregnancy and birth. They feel confident, respected and supported. Mothers also appreciate the lower cost of midwifery care.

Resources

Normal Healthy Childbirth for Women & Families: What You Need to Know

Choosing a Caregiver

Midwives Model of Care

The Mama Sherpas (video)

 

Reducing the Complications of Cesareans Is Finally Getting the Attention It Deserves

25 Apr

In 2014 the U.S. national cesarean rate was 32.2%, 1.3 million U.S. women gave birth by cesarean.  According to the World Health Organization, “cesarean section rates up to 10-15% at the population level are associated with decreases in maternal, neonatal and infant mortality. Above this level, increasing the rate of cesarean section is no longer associated with reduced mortality.” Medical, business, insurance and hospital associations are finally beginning to take this issue seriously.

Happy Young Attractive Mixed Race Family with Newborn Baby.

One of the scheduled sessions at this year’s annual American College of Obstetricians and Gynecologists meeting in Chicago will address the “cesarean epidemic.” A popular OB/GYN online newsletter is questioning the necessity of 1 in 3 surgical births and is recommending more patience by physicians before calling a cesarean for failure to progress.

A study of severe obstetric complications in the United States from 1998 to 2005, found an increase in renal failure, maternal respiratory distress syndrome, shock, the need for ventilation, pulmonary embolism, and blood transfusions. The study concluded that the increase in complications paralleled the increase in cesarean sections during those years.

According to the California Maternal Quality Care Collaborative (CMQCC), cesareans in the U.S. have risen by over 50% in the last 15 years without any benefit for mothers or babies. The rates for cerebral palsy and neonatal seizures have not changed since 1980. However, maternal and neonatal complications from the surgery have increased. žOver the last 15 years OB hemorrhage increased by 50% žand blood transfusions during birth increased by 270%. ž The CMQCC found that both complications correlate with the rise in cesarean sections.

The National Institutes of Health has set a goal of reducing first cesareans for low-risk women to 23.9% by the year 2020. California’s health insurance exchange, Covered California, has set a policy of excluding approved provider networks with a cesarean rate higher than 23.9% beginning in 2019. The state wants to reduce the number of medically avoidable cesarean births to reduce complications and costs.

Research shows us that repeat cesareans may do more harm than good for low-risk mothers who can labor for a VBAC. Mothers and babies experience these harms both in the short- and long-term. Cesareans put mothers’ next pregnancy and fetus at risk for complications. Downstream complications include difficulty becoming pregnant again, an embryo that implants in the cesarean scar (ectopic pregnancy), and an increased risk for preterm birth and low birth-weight.

Since almost 90% of women in the U.S. with a prior cesarean will have a repeat operation (most of them as a routine procedure), the CMQCC is set to publish guidelines in April to prevent low-risk first cesareans and support vaginal birth. The CMQCC Toolkit to Support Vaginal Birth and Reduce Primary Cesareans, a collaborative project, includes the contributions of multi-stake-holders such as ACOG, ACNM, AWHONN, AAFP, Blue Shield of California, California Hospital Association, California Department of Public Health, Pacific Business Group on Health, Kaiser Permanent, various university health systems, birth centers and birth professional groups including Lamaze International, Coalition for Improving Maternity Services and Doulas of North America.

Although national consumer advocacy and maternity care quality improvement organizations have brought attention to the risks of cesareans, the addition of the recent release of Safe Prevention of the Primary Cesarean and  increasing interest in lowering  maternal and infant complications of avoidable cesareans may finally move the country towards reducing cesareans in a significant way.

Resources

VBAC Education Project, Module 3: A Closer Look at Repeat Cesareans: Benefits & Risks

VBAC Education Project,  Module 5: Four Main Reasons for a First Cesarean: What You Can Do Differently This Time

Coalition for Improving Maternity Services, CIMS Fact Sheet: The Risks of Cesarean Section & Expectant Mother’s Checklist