The early weeks of pregnancy are fragile—and confusing. Here, the answers to your questions.
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These days, doctors are also much more likely than in the past to turn to C-section for breech babies, twins and cases of lengthy labors. The trend, Thorp suggests, is partly due to a profession- wide “loss of skill and confidence.” When doctors aren’t accustomed to delivering vaginally in all but the easiest situations, the C-section cycle perpetuates itself. As even Declercq, a vaginal-birth advocate, points out: If your doctor isn’t confident and experienced with vaginal births, “you don’t want this person delivering your baby vaginally.”
Also contributing to the high C-section rate is the near-universal use of electronic fetal monitoring. Monitors measure the fetal heart rate during labor to detect signs of distress, but they have a high false-positive rate. Says Fink: “Until there is some better way, it’s our only tool to assess the baby’s safety, but it ultimately results in a lot more C-sections than are probably necessary.” Declercq considers the commonplace use of fetal monitoring “part of our general affection for technology” and says there’s “no evidence that fetal monitoring as a universal practice saves lives.”
A secondary factor in the rising C-section rate is the sharp decline in VBACs, from 28 percent in 1996 to about 9 percent now. In roughly 1 percent of attempted VBACs, the woman’s uterine scar ruptures, and in rare cases, the rupture results in severe blood loss in the mother and/or brain damage or death of the baby. “Not every hospital or health-care system can offer the anesthesia and operatingroom availability that VBAC requires,” North Carolina’s Thorp says. The overall VBAC success rate is about 70 percent, but in many parts of the U.S., there are no hospitals that allow VBACs or doctors willing to attempt them.
No accurate formula exists to predict whose uterus will rupture, but there are numerous established criteria for which women make the best VBAC candidates. For example, your success rate may be as high as 85 percent if you have had a previous vaginal birth, if your uterine scar (not the visible scar on your belly) is from a “low transverse” incision, if you’re younger than 40 and not overweight, if your C-section was more than two years earlier, and if you arrive at the hospital during labor rather than being induced. “It’s rare to see these women now,” says Wise, who performs VBACs. “But when we do, it works beautifully.
Some obstetricians predict the pendulum will soon start swinging back in favor of vaginal births. “Everything in my specialty is driven by fad and consumerism,” says Thorp. “I imagine there will be a backlash and that families will start valuing vaginal delivery and seek out the doctors who likewise value it.”
Circumstances beyond your control may cause you to deliver by Cesarean, but you can take these steps to increase your odds of delivering vaginally.
1. Seek out a care provider who’s inclined toward vaginal births. A family-practice physician or midwife is a good bet. If you chose an OB, ask for your doctor’s first-time C-section rate as well as that for his or her medical practice, because your baby may end up being delivered by the doctor who’s on call.
2. Compare the C-section rates for hospitals in your area. Only Massachusetts and New York hospitals are legally required to publish this information, but many advocacy organizations have gathered their own statistics, so do a Google search for your state. Or call local hospitals.
3. Avoid being induced. Jump-starting labor before the cervix is ready can sometimes lead to unproductive labor, which, in turn, can prompt a C-section. An early epidural may also increase your odds of Cesarean. Ask your doctor for details.
4. Labor at home as long as possible. You’ll minimize your odds of being hooked up to an electronic fetal monitor and experiencing other interventions that can impair your mobility, increase your discomfort and lead to a Cesarean.
5. Hire a birth doula. In a study of 420 women randomly assigned to deliver with a birth doula or without one, the doula group had a 13 percent C-section rate, compared with 25 percent for the control group.
Cesarean section rates vary dramatically across the U.S. and even among hospitals and medical practices in the same city. The C-section rate in New Jersey is about 38 percent; in Utah, it’s 22 percent—only slightly higher than that of Sweden, one of the industrialized world’s lowest. (Because Utah’s birth rate is the nation’s highest, doctors there have great incentive to keep the primary C-section rate low in order to prevent repeat C-sections.) Rates in California hospitals average 31 percent.