Part 3: Policies and Practices that Avoid an Avoidable Cesarean

by | Jan 5, 2021 | Cesarean Surgery

Previously, we documented that first and repeat cesarean rates are much higher than they should be and focused on how to choose a care provider who would best promote avoiding a first cesarean and who would best promote avoiding a repeat cesarean.

Now we turn to policies and practices that decrease your odds of cesarean. All but one are noncontroversial and are backed by authoritative sources, but none are common obstetric practice, which means that implementing them may be up to you.

Practices and Policies to Avoid an Avoidable Cesarean

Before we begin, I must point out one hitch: some of these practices and policies require that your care provider know how to perform a procedure or can bring in a doctor who does, and others depend on your care provider’s or hospital staff’s cooperation. You will need to discuss them with your doctor or midwife. To assist with that, I’ve given you the sources of the recommendations. The numbers are keyed to a list at the end of the post.   

Hire a doula.

Continuous one-on-one care from a person trained in labor support, A.K.A., a doula, who is not a hospital staff member decreases the likelihood of cesarean (Bohren 2017).

Source of recommendation: 1, 7, 8

Try strategies to turn a breech baby.

External cephalic version (ECV), turning the baby via a hands-to-belly technique done by a doctor, increases the number of babies who are head down at birth (Hofmeyr 2015), which reduces the number of cesarean deliveries since in the U.S., at least, breeches are routinely delivered by cesarean. While ECV at 37 weeks or beyond is recommended for babies who haven’t turned on their own (ACOG 2016), we have good evidence that ECV at 34 to 35 weeks results in more head down babies at birth compared with waiting until later probably because the baby is less likely to have dropped below the pelvic brim and because there is more amniotic fluid (Hutton 2015). A few more babies will be delivered before term—2 more per 100 with early ECV—but no differences are seen in adverse outcomes. Prior cesarean delivery, by the way, is not a reason for disallowing a version (Homafar 2020).

Alternative techniques such as applying the heat of a burning herb (moxibustion) or acupuncture at a particular point or the Webster technique, a chiropractic technique that involves manipulating the pelvic bones, are also used to turn breeches. While I couldn’t find any formal studies of the Webster technique, studies of moxibustion and moxibustion in combination with acupuncture suggest that moxibustion may be effective in turning breeches, and the two in combination may do even better (Coyle 2012). Since these techniques appear to do no harm and may possibly do some good, you might try these beginning in your 8th month even though most babies who are breech this early will turn by themselves.  

Source of recommendation: 2, 5, 7

Unless there is reason to do otherwise, plan vaginal birth with twins.

While many obstetricians deliver all twin pregnancies by cesarean, this doesn’t improve outcomes compared with a more selective policy (Hofmeyr 2015). The American College of Obstetricians & Gynecologists (ACOG) recommends planning vaginal birth provided the twins are not in a single amniotic sac and the twin coming first isn’t breech, both circumstances that increase the potential for complications with vaginal birth (ACOG 2016a).

Source of recommendation: 3, 5

Decline a planned cesarean if the baby is estimated to weigh less than 11 lbs (5000 g).

The American College of Obstetricians & Gynecologists and The Society for Maternal-Fetal Medicine (ACOG/SMFM) arrived at the 11 lb threshold based on weighing the risks of shoulder dystocia, a complication where the head is born but the shoulders hang up behind the pubic bone, and brachial plexus injury, an injury to a complex of nerves serving the shoulder and arm, versus the risks of non-medically indicated cesarean surgery (ACOG/SMFM 2014). This threshold had the advantages of both accounting for the likelihood of overestimating fetal weight and, because few babies are estimated to weigh in this range, of being a threshold few women will cross.  

Source of recommendation: 4, 5

Decline induction based on the baby being estimated to weigh more than 8 lb 13 oz (4000 g), the usual definition of macrosomia (big body).

ACOG’s guidelines for suspected macrosomia do not recommend routine induction for babies estimated to weigh in this range because it has not been shown to improve outcomes (ACOG 2016b). 

Source of recommendation: 4, 5

Decline elective (no medical reason) induction if your cervix isn’t ready for labor.

Likelihood of cesarean with induced labor increases with decreasing Bishop score, a measurement of readiness for labor, regardless of the use of cervical ripening agents (Laughon 2012; Teixeira 2012).

Source of recommendation: 7

When being induced, make sure you are given enough time for it to work.

ACOG/SMFM guidelines recommend 24 hours or longer in early labor and 12-18 hours of I.V. oxytocin (Pitocin or Syntocinon) administration before diagnosing a failed induction.

Source of recommendation: 5

Delay hospital admission until active labor.

The problem with hospital admission in early labor is that care providers often apply standards for labor progress that should only be applied to women in active labor, thereby starting a downward spiral that ends in the operating room. Unless there are reasons for hospital admission early in labor, ask to be checked before going through the admission procedures. If you’re not at least 4-6 cm dilated, you may wish to hang out for a while and get checked again, but if you’re still in first gear, go home.

Source of recommendation: 1, 6, 7

Decline routine continuous fetal monitoring in favor of intermittent listening to the fetal heart rate.

Continuous fetal monitoring, A.K.A. cardiotocography, was supposed to reduce deaths during labor and serious neurologic injury such as cerebral palsy compared with listening to the baby’s heart rate at periodic intervals. It does neither, and it increases cesareans (Alfirevic 2017).

Source of recommendation: 1, 6, 7, 8

Decline routine rupture of membranes (amniotomy).

The theory is that breaking the bag of waters will speed up labor thereby reducing cesareans. It doesn’t, and, in fact, it probably increases them (Smyth 2013). In any case, if you want to reduce cesareans, simply having less impatient care providers will accomplish that goal.

Source of recommendation: 1, 6, 8

Decline a cesarean for slow progress in early labor.

It is normal for dilation to proceed at a leisurely pace until around 6 cm dilation. Often, other processes must complete before labor kicks into a higher gear, such as the cervix softening, moving forward to line up with the baby’s head, and thinning (effacement), and the baby’s head moving lower and helping to press open the cervix. Slow progress in early labor doesn’t mean a woman won’t be able to birth her baby. ACOG/SMFM guidelines state that with a first baby, even 20 hours without moving into active labor is not a reason for a cesarean (ACOG/SMFM 2014).

Source of recommendation: 5, 7

Controversial: Make an epidural Plan B instead of Plan A.

Majority obstetric opinion holds that research has shown that epidurals don’t increase the likelihood of cesarean surgery. I think equally compelling studies conclude that they do, and there are weaknesses in the studies concluding that they don’t. Many strategies that women themselves rate as effective can help you cope with labor pain without need for an epidural (Declercq 2006).

Source of recommendation: N/A

Keep active during the dilation stage of labor.

Staying active and changing positions during the dilation phase reduces likelihood of cesarean probably because gravity helps bring the baby down if you’re upright, and moving and changing positions can help shift the baby into a favorable position for birth (Lawrence 2013).

Source of recommendation: 1, 7, 8

Decline a cesarean based solely on exceeding a preset time limit.

Adhering to preset time limits for progress increases the cesarean rate without improving outcomes. Some women just need extra time to birth vaginally, including women with a prior cesarean, women being induced, high BMI women, women older than 35 having a first baby, women with epidurals, women with a bigger baby, and women with a baby facing its mother’s belly instead of her back (occiput posterior).

Source of recommendation: 5, 7

If oxytocin (Pitocin, “Pit,” Syntocinon) is needed to strengthen contractions, give it time to work.

You may be allowed as little as 2 hours receiving I.V. oxytocin before moving to cesarean if progress doesn’t resume or speed up, but studies show that many women will progress to vaginal birth if given more time (Rouse 1999; Rouse 2001). ACOG/SMFM 2014 guidelines cite studies in which women were given 8 hours in total, which resulted in substantially more vaginal births without harm to their babies (ACOG/SMFM 2014).

Source of recommendation: 5

Have manual rotation of a baby who is still facing your belly instead of your back (persistent occiput posterior) by the time you are ready to push.

Babies who are facing their mother’s belly don’t fit easily through the pelvis, and once full dilation is reached, few will swivel to the more favorable position on their own. With manual rotation, once the woman is fully dilated, the doctor uses a hand or fingers during a vaginal exam to turn the baby’s head, and the baby’s body follows, a procedure that has been shown to be safe and to reduce cesareans (Bertholdt 2019; Le Ray 2007; Reichman 2008).

Source of recommendation: 5

Sources of Recommendations

  1. ACOG. Committee Opinion No. 766: Approaches to Limit Intervention During Labor and Birth. Obstet Gynecol 2019;133(2):e164-e73.
  2. ACOG. Practice Bulletin No. 161: External Cephalic Version. Obstet Gynecol 2016;127(2):e54-61.
  3. ACOG. Practice Bulletin No. 169: Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies. Obstet Gynecol 2016a;128(4):e131-46.
  4. ACOG. Practice Bulletin No. 173: Fetal Macrosomia. Obstet Gynecol 2016b;128(5):e195-e209.
  5. American College of Obstetricians & Gynecologists, Society for Maternal-Fetal Medicine, Caughey AB, et al. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014;210(3):179-93.
  6. National Institute for Health & Care Excellence (NICE). Intrapartum care. Care of healthy women and their babies during childbirth; 2014.
  7. Smith H, Peterson N, Lagrew D, et al. Toolkit to Support Vaginal Birth and Reduce Primary Cesareans: A Quality Improvement Toolkit. Stanford, CA: California Maternal Quality Care Collaborative; 2016.
  8. World Health Organization. WHO Recommendations. Intrapartum Care for a Positive Childbirth Experience. Geneva: World Health Organization; 2018.

Other References

Alfirevic Z, Devane D, Gyte GM, et al. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev 2017;2:CD006066.

Bertholdt C, Gauchotte E, Dap M, et al. Predictors of successful manual rotation for occiput posterior positions. Int J Gynaecol Obstet 2019;144(2):210-5.

Bohren MA, Hofmeyr GJ, Sakala C, et al. Continuous support for women during childbirth. Cochrane Database Syst Rev 2017;7:CD003766.

Coyle ME, Smith CA, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev 2012(5):CD003928.

Declercq E, Sakala C, Corry MP, et al. Listening to Mothers II:  Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection; 2006.

Hofmeyr GJ, Barrett JF, Crowther CA. Planned caesarean section for women with a twin pregnancy. Cochrane Database Syst Rev 2015(12):CD006553.

Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database Syst Rev 2015(4):CD000083.

Homafar M, Gerard J, Turrentine M. Vaginal Delivery After External Cephalic Version in Patients With a Previous Cesarean Delivery: A Systematic Review and Meta-analysis. Obstet Gynecol 2020;136(5):965-71.

Hutton EK, Hofmeyr GJ, Dowswell T. External cephalic version for breech presentation before term. Cochrane Database Syst Rev 2015(7):CD000084.

Laughon SK, Zhang J, Grewal J, et al. Induction of labor in a contemporary obstetric cohort. Am J Obstet Gynecol 2012;206(6):486 e1-9.

Lawrence A, Lewis L, Hofmeyr GJ, et al. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev 2013;10:CD003934.

Le Ray C, Serres P, Schmitz T, et al. Manual rotation in occiput posterior or transverse positions: risk factors and consequences on the cesarean delivery rate. Obstet Gynecol 2007;110(4):873-9.

Reichman O, Gdansky E, Latinsky B, et al. Digital rotation from occipito-posterior to occipito-anterior decreases the need for cesarean section. Eur J Obstet Gynecol Reprod Biol 2008;136(1):25-8.

Rouse DJ, Owen J, Hauth JC. Active-phase labor arrest: oxytocin augmentation for at least 4 hours. Obstet Gynecol 1999;93(3):323-8.

Rouse DJ, Owen J, Savage KG, et al. Active phase labor arrest: revisiting the 2-hour minimum. Obstet Gynecol 2001;98(4):550-4.

Smyth RM, Markham C, Dowswell T. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev 2013;6:CD006167.

Teixeira C, Lunet N, Rodrigues T, et al. The Bishop Score as a determinant of labour induction success: a systematic review and meta-analysis. Arch Gynecol Obstet 2012;286(3):739-53.

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