Birthing Room / Why She May Need A C-Section

Why She May Need A C-Section

The rate of cesarean births in the United States has skyrocketed from 5 percent in the 1960s to nearly 25 percent since the 1980s. Many factors have contributed to this increase, including the frequency of repeat cesarean delivery, the use of electronic fetal monitoring, the declining use of vaginal breech and forceps deliveries, and the drift toward surgical intervention for “failure to progress” in labor.
While cesarean delivery is certainly safer today than during the 1960s and obviously indicated in extremely high-risk situations or emergencies, it still causes a higher rate of maternal injuries than vaginal delivery.
Cesarean delivery is often accepted as the inevitable outcome to a complication arising during labor. Based on the experience of the past two decades, however, most experts agree that surgical intervention is not always in the best interests of the woman or baby. In order to make an informed decision, it's important to understand some of the common complications that can occur during labor.
Premature Rupture
Most women begin labor spontaneously when their membranes rupture and their pregnancies have reached full term. When labor does not begin within 12 to 24 hours, the situation is described as “premature rupture of the membranes” (PROM). Because PROM certainly plays a role in high cesarean rates, more doctors are proceeding with a quick induction of labor after a PROM at full-term.
Although the “wait-and-see” approach has been associated with fewer cesarean deliveries than the use of oxytocin to stimulate contractions, one large study has concluded that induction of labor using vaginal suppositories containing prostaglandin E2 is a viable option for handling PROM—especially in women experiencing a first labor. In the study, the rate of cesarean section in the women who received prostaglandin was half that of those who either received oxytocin or waited for the onset of labor.
Failure to Progress
Physicians generally agree that once active labor has begun, a woman's cervix should dilate 1.2 cm to 1.5 cm per hour. Sometimes dilation falters during the active phase despite regular contractions. This condition is known as “failure to progress.”
Because labor can be interrupted for a variety of reasons, the immediate cause is not always clear to the woman or her physician. Should this occur, the doctor will perform a pelvic exam, check vital signs, and monitor the baby for a short period of time. If all appears well he or she can take a hands-off approach or consider the possibility of “actively managing” your labor.
A number of procedures are effective in reestablishing labor. If the amniotic sac has not yet broken, the doctor may suggest breaking it manually, a procedure known as amniotomy. Because rupturing the membranes commits a woman to delivery, this can be a risky strategy during the latent phase, when false labor is always a possibility.
Several research studies have concluded, however, that amniotomy performed during active labor actually shortens its duration by up to 2 hours. Moreover, the rate of vaginal delivery increases, and there is no added risk of injury to the woman or baby.
Physicians disagree on how to handle the 10 percent of pregnancies that extend beyond 40 weeks. The main goal is to avoid injury or death to the baby due to lack of oxygen or intake of meconium in the lungs—established risks in post-term pregnancies. Some doctors advocate inducing labor at 41 to 42 weeks, while others recommend fetal monitoring until labor begins spontaneously.
In one large study of women with post-term but otherwise uncomplicated pregnancies, the induction of labor resulted in a lower rate of cesarean delivery, mainly because there was less fetal distress. In any event, few clinicians allow a pregnancy to continue past 42 weeks. In these rare instances, labor is often induced with prostaglandin gel or oxytocin.
Pelvic Size
Certain variations in a woman's anatomy also can lead to complications during labor. During vaginal delivery, the baby must be propelled through the pelvic area by the contractions of the uterus and “bearing down.”
In general, a woman's pelvis is large enough and shaped properly to allow for the baby's passage. In fact, unless she has a history of pelvic fracture or bone or neuromuscular disease, the physician should not discourage her from trying a natural delivery strictly on the basis of pelvic dimensions. Even if her pelvic area is smaller than average, it may still be big enough for the baby if the rest of labor progresses normally.
Nevertheless, in some cases, the size of the baby's head does exceed the dimensions of the birth canal. If this happens, labor will almost certainly fail to progress during the second stage; and the first stage of labor may be irregular as well. If the size of the baby is the cause of a woman's “failure to progress,” she will need a cesarean.
Position of the Baby
In more than 95 percent of full-term labors, the baby's head is “presenting” —pointed toward— the cervix. Typically, the baby's head is tucked against its chest, with the crown of the head facing the birth canal in preparation for delivery.
In some unusual situations, a baby's face, forehead, or top of the head is presenting. If the baby remains in either of the latter two positions throughout labor, a cesarean delivery may be necessary since the broadest part of the baby's head may be too wide to clear your pelvis.
A full-face presentation is very rare. Unless she’s already had several children, the physician will almost certainly insist on cesarean delivery should this occur. Vaginal delivery increases the risk of injury to the baby's neck or spinal cord.
The position—or attitude—of the baby is another consideration in determining the safest method of birth. More than 99 percent of the time, a full-term baby lies vertically in the uterus. In the remaining cases, known as a transverse lie, the baby's back faces the birth canal. A baby in this position when labor begins almost always must be delivered by cesarean.
Cesarean sections are surgery, so special procedures must be taken as opposed to a vaginal delivery. You can still be present for the birth, but you should know what to expect.

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