Picture this: you’re 34 weeks pregnant and your OB confirms via ultrasound that your baby has yet to settle into the head down birthing position. They start talking to you about ways to get baby to move and tell you that if your little one is not locked and loaded by 36 or 37 weeks, they will need to schedule a cesarean to “get you on the books.” If your plan is for a vaginal birth, you begin to panic a little, since you have not planned for a cesarean birth in any way whatsoever.
This was me. At 34 weeks, my daughter was what they call transverse-lie. The moment the c-word was uttered, I started to black-out a little bit. I had spent six weeks attending a Hypnobabies course with my husband, practicing almost every day since completing the classes at 26 weeks, so in my mind, vaginal birth was the only option. I’ve gone my entire life without needing surgery, so the idea of having a cesarean utterly terrified me. To add to my increasing anxiety, I was advised that if my water broke at any time, I needed to rush to the hospital since a transverse lie baby with a broken bag of waters could lead to cord prolapse (when the cord comes out before the baby), which is an obviously dangerous situation. As action items, my midwife offered suggestions on how to get my babe to go head down: acupuncture, chiropractic care, and spinningbabies.com. My appointment was at 9am, and by 12pm, I had scheduled my first visits with a Webster-certified chiropractic doctor and an acupuncturist who specializes in women’s health. I was also scouring the internet for advice from other mommies who had once been in my shoes, hoping someone would have the magic concoction on how to get my baby girl to turn.
My husband and best friends were the reason I didn’t totally go off the deep-end (I can be a bit of a head-case). They assured me that Avery was entering this world in a matter of weeks, and our main concern should be not how she would get here, but the safety of both her and I. I spent the next few weeks doing everything I felt was in my control (see my last post regarding my lists about control) to get her to move, and by 37 weeks, she was head down. Are the techniques I utilized the reason she decided to venture south? We’ll never know for sure. I know moms who applied similar tactics and their babies stayed breech, and I know moms whose babies flipped on their own, without much assistance or effort. I think at the end of the day one thing can be certain – these babes do whatever they damn well please, both inside and out of your uterus.
But this post isn’t about breech babies; it is about cesareans. Whether you respond with fear after hearing you need to have one, or you’re relieved since a vaginal birth was not something you wanted to experience (like Alex with her first), you are not alone. There’s a lot to know about why they happen, how they happen, and what it means for your postpartum experience, and although I had to have conversations about potentially needing one, I don’t have my own experience to pull from, so I enlisted the help of the incredible Dr. Jeffrey Illeck, MD, who was kind enough to answer some of my questions in our effort to recognize April as cesarean awareness month.
Q: What are the main reasons a woman would need a cesarean?
A: There is an increasing need to address the high cesarean delivery rate across our nation. The biggest emphasis now is on the NTSV rate: Nulliparous(first time mom), Term(full term), Singleton(not multiples) and Vertex(head down). The idea is if we can make every effort to have first time moms have a vaginal delivery, odds are, all her subsequent deliveries will be vaginal. If she has a cesarean, odds are, her subsequent pregnancies will be repeat cesareans. Currently, there is a push to get hospitals to be under a 23.9% NTSV rate. This number comes from medical societies. The most common reason for a first-time mom to have a cesarean is for arrest disorders (ie: she doesn’t get to 10 cm which is called arrest of dilatation, or she is unable to push the baby out which is called arrest of descent). At Hoag, here in Newport Beach, the variation between doctor’s cesarean rates range from 15% to about 50%. There are some doctors that year after year have a 50% cesarean rate for first time mothers. Some of these doctors are some of the busiest in the community, so you can imagine the negative effect this has on Hoag’s cesarean delivery rate.
The second most common reason for a first-time mom to have a cesarean is abnormal fetal heart rate tracing or fetal intolerance to labor. This is also extremely variable, as some doctors are much more tolerant of fetal heart rate tracings compared to others who get nervous very quickly and decide to intervene.
Q: What categorizes a cesarean as “emergency” vs “routine”?
A: There are a lot of reasons to call for a cesarean, but emergent cesareans are typically due to what was mentioned in the previous answer: abnormal fetal heart rate tracing or fetal intolerance to labor. When an emergent cesarean is called, we usually try and get the baby out as soon as possible. There is not an exact time frame, but ACOG guidelines suggest getting the baby out within a half hour. However, if it is truly an emergency, being at a hospital that can do a cesarean quickly is important. With real fetal distress, most of us can get the baby out in less than a minute once mom has adequate anesthesia.
Q: Can a mom have immediate skin-to-skin contact with baby after a cesarean?
A: At Hoag, we try to establish skin-to-skin ASAP, usually within a few minutes, at the parent’s request. At delivery, we bring the baby over to the isolate to do a quick assessment and if parents want skin-to-skin, the nurses will take the baby right over.
Q: For moms who wanted a vaginal birth but ended up with a cesarean, what factors contribute to being able to have a VBAC (Vaginal Birth After Cesarian) with the next baby?
A: For a patient to have a VBAC, the incision in the uterus from the prior cesarean should be a low transverse incision. There are very few reasons that a person would not have this type of incision. ACOG has made the statement that essentially all women should be offered the possibility of a VBAC if their hospital has the capability to do it. There are several factors that suggest the possibility of success for a VBAC. These can change as the pregnancy progresses (ie: the size of the baby, the patient’s cervical exam at term, spontaneous labor vs induced labor). There are also several physicians who say they encourage VBAC but at the end of pregnancy, discourage the patient. Patients should ask their doctor how many VBACs they do a year and what criteria make them want to proceed with a repeat cesarean delivery instead of allowing the patient to have a trial of labor. At Hoag, we do a fair amount of VBACs, but they are usually with the same doctors. In the last 2 years, I have probably done about 30 VBACs but there are some doctors who have done zero. Others have done 1 or 2. There are nationwide guidelines for recommended VBAC rates. At Hoag, we have a low VBAC rate because some doctors are not really committed.
Q: What are the biggest misconceptions about cesareans?
A: The biggest misconception about cesareans is that they are no big deal. Because it is the most common surgery performed in the United States, and about 1 in 3 births are a cesarean, there is an idea that it is not risky. Complications are rare, but it is still a major surgery. Women who have cesareans have greater risk of infection, hemorrhage, damage to internal organs, and death. And with subsequent cesareans, the risks go up. That is why the safest thing for a mom is to have a VBAC as opposed to a repeat cesarean. We have been seeing a big increase in placenta complications related to so many cesareans. That being said, cesareans are also a necessary surgery for many reasons. For the moms who have a cesarean, they should not feel like they failed. Couples put so much time and effort preparing for the delivery they envision, but they should not feel like they failed if they need a cesarean. A healthy baby and maternal safety are the most important outcome and NO mom is a failure if she and her baby are safe.
Q: If you could share advice regarding postpartum recovery to a woman who is scheduled for, or experienced a cesarean, what would it be?
A: The important things for mom’s who have cesareans is to acknowledge that they had surgery and to take it easy. All the layers of the abdomen have been cut through and need to heal. Asking for help is important. Using pain medication, if necessary, is not a problem. Taking stool softener and medication to combat constipation is important. There is usually a fair amount of blood loss so taking iron or iron rich foods is helpful. Taking care of a newborn is overwhelming as it is but having to recover from major surgery makes it harder.
And he’s absolutely right, ladies. Caring for a baby after childbirth is overwhelming and difficult, so listening to your body and asking for help is imperative. While I have firsthand experience with a vaginal birth recovery and can talk about that for hours (which may mean there’s a post about that coming up), I want to touch on postpartum care as it pertains to cesareans. The attention we get during pregnancy, in labor and delivery, and in the hospital from providers like Dr. Illeck is second to none; but then you are sent home with stitches in your shrinking stomach, and typically get only two postpartum check-ups: one to check how the incision is healing and another to, ultimately, confirm that your uterus has gone back to it’s rightful place. Let’s think about that for a second. Your lower abdomen was sliced open through your uterus and a baby was removed, but you receive only a couple post-op appointments. Dr. Illeck is correct when he says this is major surgery and it isn’t something to shrug your shoulders at; but there is more that should be done. Just like any other major surgery, physical therapy should be a mandatory prescription for every mom. Thankfully, there are wonderful professionals in the field who focus on women’s health, such as Dr. Whitney Sippl DPT, WCS, CPT. Not only is she a trusted advisor and partner of The New Mom School and very involved with the newborn class series, she also has her own practice where she offers in home care (hello, convenience and privacy)! To quote her website, “There are many conditions related to pregnancy and the postnatal periods that are often considered “normal” here in the US; however, although symptoms like incontinence, pelvic pressure, scar pain, or painful intercourse are common, they are NOT normal and there is hope and healing available.”
I’m a true believer in the saying, “it takes a village,” so put your health and recovery in the forefront and utilize the incredible network of women who walked before you as resources, or those who offer invaluable services like Dr. Sippl.
In health, happiness, and hunger (currently eating my fourth lactation cookie),
Professional resources mentioned in the article:
Webster-certified chiropractic care (North Orange County): Dr. Aimee Bautista at Momma’s Chiro in Huntington Beach, CA
Prenatal/postnatal chiropractic care (South Orange County): Dr. Valerie Farino at South Coast Midwifery in Irvine, CA
Acupuncture: Joyce Wellness Group in Costa Mesa, CA
OB/GYN: Dr. Jeffrey Illeck, MD
Physical Therapy & Wellness: Dr. Whitney Sippl, DPT, WCS, CPT