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Relative Reasons For Cesarean Birth
Often the first thing a woman thinks after a C-section is…was it necessary. There are four straightforward situations in which surgical delivery is absolutely necessary for the survival of the mother or baby or both. These are placenta previa, transverse presentation, true cephalopelvic disproportion, and cord prolapse in the first stage of labor. But beyond those four scenarios, there’s a gray area where cesarean delivery may be in the best interests of both mother and baby. These conditions should be fully discussed with your doctor. You might even want to get a second opinion to make sure you’re happy with your options. Or you may just trust your doctor to want what’s best for you and your baby. These conditions are much more common and are the reason for most cesarean deliveries.
Disproportionate head-to-pelvis ratio: Unlike true CPD, where you can never deliver vaginally, relative CPD means that you cannot deliver vaginally. In most cases, CPD in relatives is diagnosed some time after you have given birth and your doctor has given your body the opportunity to deliver vaginally.
There are several possible reasons for this. First, maybe the baby is too big for your pelvis. My first C-section was for this reason; my son weighed nearly ten pounds. I spent five years angry at my doctor and feeling like I had failed. But in my second VBAC his brother who was a pound smaller than me got stuck in the shoulder (shoulder dystocia) which was a very serious emergency. In that moment, I was endowed with the gift of hindsight that few women have, knowing that my C-section was absolutely necessary. I’ve successfully delivered an 8 lb baby, but my pelvis isn’t big enough to accommodate a 9 or 10 lb baby easily. Some clues that you may have relative CPD are 1) Your baby’s head never drops into your pelvis. You may hear your doctor or midwife discuss your baby’s negative status. 2) Ultrasounds are also sometimes used to estimate the baby’s size. Note that this is not always accurate. It’s a relative problem; I have a friend who has 11 babies with ease while my sons have trouble passing through my pelvis.
The second reason for relative CPD is described in more detail below.
dislocation: In order for your baby’s head to pass through your pelvis, the smallest diameter of its head must line up with the largest diameter of your pelvis. The best position is with the chin tucked in to the chest. But sometimes babies throw their head back as if looking up (called eyebrow display). This makes it more difficult for the head to pass through the narrow opening in the pelvis.
Likewise, the best position for premature birth is with the baby’s face toward your buttocks. This is because the face is softer and easier to squeeze through the pelvis. However, if the hard part of the back of your baby’s head is pressing against your spine, called the posterior occipital (OP), you may experience a very painful and slow back birth. This sharp pain is caused by two hard surfaces rubbing against each other. Labor may be slower because in relative CPD, the baby’s head is not in direct contact with your cervix, which means the head is not putting pressure on the cervix to open it.
Remember, malposition is not an absolute indicator of cesarean delivery. Sometimes your baby’s position changes during labor, and sometimes you or your healthcare provider can use technology to change your baby’s position. But again, sometimes none of this works. My second C-section was the result of surgery. I have wonderful and supportive midwives. I tried all the usual options for pain relief and faster labor (showers, walks, back massages) and nothing worked. I never doubted that this C-section was necessary because I knew I had reached my limit.
Breech presentation: Closely related to malposition, when the baby turns, the breech is present rather than the head. If the head is larger than the base, the risk of the baby getting stuck in the birth canal increases. For this reason, many doctors believe that surgical delivery is safer. A few things to consider are that the baby may change positions before or during labor. Sometimes it is even possible to encourage the baby to move through a process called external release, but it is important that this is only done under close monitoring by trained medical personnel. Natural breech delivery is possible even if the baby does not change position. But this should be a joint decision with your healthcare team. You may even need to seek out a caregiver who is more experienced in breech delivery.
Maternal exhaustion: Reaching your limit is another relative indicator of a cesarean delivery. Sometimes we just can’t go on. Are we failing somehow? No, we did our best, and then we used the help available to do what was best for us and our children. Every woman and every birth has different limitations. It is common for all women to reach this point during childbirth. Usually this indicates that her cervix is almost fully dilated and her baby is about to be born. However, if you have reached this point and you may still be hours away from labor, discuss your options with your midwife or doctor.
Failure to make progress: Known as a dystocia, the term carries some strong emotional associations…failure to make progress. What it actually means is that, for some reason, your body is not giving birth in the way your doctor or midwife thinks is normal. This alone is probably the weakest indicator of a cesarean delivery. But dystocia is often combined with maternal exhaustion or fetal distress (which we discuss next). These then become key indicators.
Fetal distress: Fetal distress is one of the most common reasons for cesarean delivery. Most of the time, a change in the baby’s heartbeat on the monitor indicates fetal distress. The use of monitoring devices during labor has increased dramatically over the past twenty-five years, and cesarean delivery rates have risen with it. Common changes that may indicate pain are beating that is too fast (tachycardia) or too slow (bradycardia). Another common pattern is called late deceleration. It’s common for your baby’s heart rate to slow down during contractions, but to resume once the contractions are over. In late deceleration, the heart rate rises slowly or not at all. The thing to remember about fetal distress is that sometimes babies diagnosed with fetal distress are born without any problems. But as a parent, you need to weigh the risks of continuing the labor against the risks to your baby in all but the most dire of circumstances.
Stage 2 cord prolapse: Like the previously discussed cord prolapse, this is a serious and life-threatening condition for your baby. However, if you’re fully dilated and already pushing, sometimes your doctor may decide it’s best to perform an episiotomy (a cut between the vagina and anus) and use forceps or vacuum suction. It’s often a question of what the doctor thinks will get your baby out of the hospital the quickest in this critical situation.
Past Obstetric History (Past C-Section): In 1986, when I had my first C-section, I was told that my baby would always have to be delivered by C-section. Today, though, there is a wealth of research showing that vaginal birth after cesarean (VBAC) is not only safe, but often better for both mother and baby. As the saying goes, a C-section ends up being a C-section because of the fear that the previous scars will separate during childbirth. But studies have shown that this is extremely rare. As a result, many doctors now encourage their clients to deliver subsequent babies vaginally. Many women who have a cesarean section usually also wish to have a vaginal delivery in future pregnancies. If this is the case, the first step is to carefully select a doctor or midwife experienced in VBAC and a VBAC-friendly place of birth.
Birth options: More and more women are opting for an elective C-section, either after the trauma of first childbirth or because of deep-seated concerns about the safety of their babies. While it is your healthcare provider’s responsibility to provide you with all information and obtain your full informed consent, remember that this is still your birth and ultimately the choice is yours. This is a very personal decision that you should make with your doctor.
If you find yourself facing any of these situations during or before labor, a good question to ask is…do we have time to talk? This question will give you an idea of how serious the doctor thinks the situation has become. If the answer is yes, a good follow-up question is… what happens if we do nothing at this point? Maybe your doctor will be willing to change your posture and see if it improves. But this is your child, and maybe you feel the best course of action is to follow your doctor’s advice right away.
But as I said at the beginning of this article, these situations are all relative. They’re about pros and cons, weighing options, and deciding what’s best for you and your baby based on your unique situation. While your medical team can and should provide expert guidance, ultimately you are in the best position to decide what is best for you and your child. But also remember that you are always personally responsible for the choices you make. This is just the first of many difficult, sometimes life-and-death decisions that you will have to make on behalf of your child in the years to come.
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