ACOG Prevention of Primary C-sections Part 3: For the Patient

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AGOC has new recommendations for managing labor to help decrease c-section rates. Parts 1 and 2 look at the article your doctor should be reading. Part 3 will discuss what you should expect them to recommend based on the research and what this means for you.

When 1 in 3 births end in a c-section, that is a problem not with the laboring mothers, but with the management of their labors. ACOG, the organization that many OB providers in the US look to for guidance, has not always been supportive of laboring women. C-section rates have skyrocketed, birth outcomes have not improved, and unintended complications from those c-sections are being realized. ACOG is finally recognizing that some of these surgeries could have been avoided by changing labor management practices. While c-sections are sometimes necessary, and even life saving, they have become all too common and in some places, where the c-section rates are closer to 50%, routine.

Any new recommendations, even those that are research proven, can take years to become the new “standard of care”. For example, research (and common sense) says that if you induce labor too early, the baby might not be ready and has an increased chance of having breathing and feeding difficulties. This has been known for years, and hospitals are only just recently putting policies in place to make it more difficult to schedule inductions before 39 weeks, and sometimes even before 41 weeks, without a medical indication.

The ACOG recommendations to decrease the primary c-section rate were released in 2014, and many providers have not begun following them yet. For example, one of the biggest changes was redefining “active labor” as not beginning until 6cm of dilation, where it was previously thought of in the hospital setting as 4cm, or even worse, at the earliest cervical change with regular contractions. Laboring women had the “clock” started in some cases as early as 2cm! The fear is that if labor is not progressing correctly, also known as “failure to progress”, there is an increased risk of complications like infection, having the baby get stuck during delivery (shoulder dystocia), postpartum hemorrhage, etc. While this can be true, research is showing that these risks do not increase until much later than previously thought. ACOG calls for providers to be more patient and realize that as long as mom and baby are both doing well during labor, that labor can progress much, much more slowly than what was expected in the past and still be completely normal and healthy.

While there can certainly be indications for a c-section prior to active labor, if your provider recommends a c-section due to “failure to progress” before 6cm AND your water is not broken, you should absolutely ask for more explanation behind their decision. If you are at least 6cm and in active labor with your water ruptured, the decision to proceed with a c-section for failure to progress should be questioned if you have not been given 6 hours to make cervical change (or 4 hours if an internal monitor is in place and you have had contractions reaching a certain strength).

This change also requires you, as the laboring person, to be patient with progress. It is easy to become exhausted and frustrated when early labor does not progress quickly. However, this slow progression, with some false alarms included, is normal. It is best to try to stay home (if you are planning an out of home birth) and rest through this part. Realize that you won’t be pregnant forever, and don’t try to rush the process. Until 6cm, try not to think of yourself as “in labor”. Sometimes the early part can take hours, or days, and it can be physically and emotionally draining to act the way you would while in active labor (being up moving around, changing positions, not resting, anticipating the birth any minute) for that long. It can be disheartening to be 1cm dilated and contracting, attempt to “get things going” by walking all night and contract for 12 hours, only to find yourself 2cm in the morning, then go on to have contractions space back out and be pregnant for another week. Realize that this is COMPLETELY NORMAL. Don’t try to rush the process and tire yourself out.

If baby and mom are both doing well, recommended pushing times have also been increased. If it is your first baby, you can typically push for 3 hours, and if it is not your first, then for 2, before the risk of complication increases. If you have an epidural, add an hour. Even if you hit this time, it does not automatically mean a c-section if you are making progress. Before your doctor recommends a c-section for prolonged second stage (the time between complete cervical dilation and the delivery of the baby), you should request to be evaluated for a vacuum or forceps assisted birth (assuming this is something you are interested in attempting. If YOU decide you would like a c-section instead, that is your decision).

If your labor is induced, you should find out if your cervix is “favorable”. There something called a Bishop Score that predicts the likelihood of success of induction. It measures things like how dilated and thinned out your cervix is, the position of the baby, and the position and consistency of your cervix. The higher your score, the better chance you have of the induction being successful. If your score is low (your cervix is “unfavorable”), your provider should use a “ripener” prior to starting the induction to help get your body ready.

A BIG BABY IS NOT AN INDICATION FOR CESAREAN. The fear is that a big baby could get stuck during delivery (shoulder dystocia). Most dystocias are minor and corrected with a few maneuvers, but they can occasionally be devastating. However, half of all shoulder dystocias happen in small or normal sized babies. Ultrasounds are also notoriously inaccurate in the late third trimester, and are terrible at predicting fetal size. For this reason, c-section SHOULD NOT be offered for “big baby” unless the baby is expected to be over 11lbs in a normal pregnancy, or 9.9 lbs in a diabetic pregnancy (babies of diabetic mothers can have broader shoulders, making them slightly more likely to get stuck). Even if it is offered, it is not mandatory, and a trial of labor is acceptable.

If your baby is breech, your provider should offer you an “external version” to try to turn the baby, before resorting to c-section. If you do decide to have a breech baby vaginally, you should realize that this can have an increased complication rate and find a provider experienced in these deliveries. If you have twins and the first baby is head down, you should be offered a vaginal delivery, regardless of the position of the second baby; it SHOULD NOT be an automatic c-section.

ACOG also recognizes that continuous labor support, especially with a trained doula, is “ONE OF THE MOST EFFECTIVE TOOLS TO IMPROVE LABOR AND DELIVERY OUTCOMES”. It is fantastic that they are realizing that doulas can be incredibly beneficial, and their use should be encouraged. It was mentioned as a small paragraph, at the end, but it is a start! In the past, relationships between doulas and doctors have sometimes been strained, even hostile, but hopefully this will change as the birth culture changes.

Many of these changes are things you can ask your doctor their opinion on early in pregnancy to see if they are up to date and will be a good fit. Things like, “When do you think active labor begins? What is your opinion on big babies in a normal pregnancy? If my baby is breech, do you offer a version? How long are you comfortable with me pushing for? What is your opinion on doulas?” etc, can all be discussed before labor has begun. The earlier in the pregnancy, the better, as it’s not ideal to find out that your doctor does not offer versions for breech babies at 37 weeks while she’s scheduling your c-section. If your provider thinks active labor starts at 3 cm, talks to you about a c-section for an 8lb baby, or won’t “let” you have a doula, then they aren’t practicing evidence based medicine You should provide the evidence and see if it changes their opinion, or find one who does.

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