PLEASE NOTE PORTIONS OF THIS SECTION HAS BEEN UPDATED AS OF SEPTEMBER 2024- IF YOU HAVE AN OLDER MANUAL IT MAY NOT QUITE LINE UP. THANK YOU FOR YOUR UNDERESTANDING AS WE CONTINUE TO STRIVE TO MAKE SURE YOU HAVE THE MOST UPDATED INFORMATION.

Four Main Reasons for Cesarean and How to Safely Avoid Them

There are four common reasons as to why women have initial Cesareans. Just because they are common, does not mean they are always unnecessary; however, sometimes they are. There are also many other reasons that a woman may need a C-section that are not included here. The best way for someone to determine what the C-section was for is to contact the medical records office at the hospital where they birthed and make a request for the operative report. As doulas we suggest all of our VBAC clients obtain their OP reports as soon as they can so they can have a deeper understanding as to why the provider said they had a Cesarean. It is not uncommon for the reason noted in the report to be different than what they were told. Knowing what is in the operative report can help them better prepare with the information listed here:

Malpresentation (Baby in Wrong Position or Breech)

There are many things that can be done to ensure baby is in a good position prior to labor starting and to get baby in a good position during labor. Things like getting on their hands and knees, squatting, not laboring on the back, and being mobile help significantly. If you have a rebozo you can teach your clients how to use this and also work magic on a baby’s position when you are supporting them in labor. In 2018, ACOG released Committee Opinion 745 on breech presentation (attached below) and it states:

“There is a trend in the United States to perform Cesarean delivery for term singleton fetuses in a breech presentation. The number of practitioners with the skills and experience to perform vaginal breech delivery has decreased. The decision regarding the mode of delivery should consider patient wishes and the experience of the healthcare provider. Obstetrician-gynecologists and other obstetric care providers should offer external cephalic version as an alternative to planned Cesarean for a woman who has a term singleton breech fetus, desires a planned vaginal delivery of a vertex-presenting fetus, and has no contraindications. External cephalic version should be attempted only in settings in which Cesarean delivery services are readily available. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for eligibility and labor management. If a vaginal breech delivery is planned, a detailed informed consent should be documented—including risks that perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a Cesarean delivery is planned.” (ACOG, 2018)

Failure to Progress

Historically, evidence has shown that many care providers do not give women the chance to progress in the first stage of labor (dilated to 10cm) or enough time to push the baby out when they do get there. In 2011, ACOG and SMFM (the Society for Maternal-Fetal Medicine) put out an updated definition on time limits for the first and second stages (the pushing stage) of labor. The new guideline says that a woman is not considered to be in active labor until six centimeters and cannot be termed as “failure to progress” until she is at least six centimeters dilated, her waters have ruptured, and no cervical change has been made in six hours of labor.

For the second stage of labor, there is no time limit for pushing the baby out and pushing can continue for up to three or four hours, as long as the mom and baby are stable. Many women certainly had their primary Cesareans because their care provider did not give them enough time to labor or push (ACOG, SMFM, 2014).

Labor progress is not just about cervical dilation either. Labor progresses through these six stages:

• The cervix moves from posterior to anterior position
• The cervix ripens and softens
• The cervix effaces
• The cervix dilates
• The baby’s head rotates, flexes, and molds
• The baby descends, rotates further, and is born

A mother’s emotional state and ability to cope with physical discomforts also plays into the body’s ability to labor effectively.

Macrosomia (Big Baby) or CPD (Small Pelvis)

A ‘big baby’ is defined as a baby who is more than nine pounds, 15 ounces. Macrosomia, literally meaning “big body,” is when a baby is born weighing 11 pounds or more. 16% of indications and 9% of C-sections are due to suspected big babies, when, only 1.7% of babies are born bigger than nine pounds, 15 ounces. According to the 2010 National Vital Statistics, the average weight of suspected big babies was seven pounds, 13 ounces (Declerg, Cheng, & Sakala, 2018).

But don’t take our word for it. We LOVE the article Dr. Mazumdar, M.D. (2016) wrote defining everything in layman’s terms and spelling out what the truth is about small pelvises and big babies. He states:

“Diagnosis of CPD is very difficult. This is because it is difficult to estimate exactly how much the mother’s ligaments and joints will ‘give’ or relax before labor starts. The fetal head also has a great capacity to mould - the skull bones can overlap to some extent and decrease the diameter of the head. So, a baby who appears to be too big to pass through its mother’s birth passage before labor, may do so without much problem when active uterine contractions start. A ‘trial of labour’ should always be given to all women with average sized pelvis and an average sized fetus even if the pelvis appears apparently too small for the baby.”

When a provider is saying a pelvis is too small, they are referring to CPD, which stands for Cephalopelvic Disproportion. Actual CPD is incredibly rare and very hard to diagnose; it is very discouraging for women, and often, leads to a woman having repeat C-sections for her subsequent pregnancies. The pelvis and baby's head is able to mold during labor and, when laboring on positions other than the back, can expand by up to 30%.

If your client has EVER been told their pelvis is too small to birth a baby, or that they make babies too big for a vaginal birth, we highly suggest giving them this article to read, https://gynaeonline.com/cpd.htm, and encourage your client to have an educated conversation with their provider. A slight exception to this would be if the client has diabetes, type I or II, or, gestational diabetes. If either of these apply to them, we recommend they talk to their provider to find a birth plan conducive to their specific circumstances. BUT even then we know many moms who have had diabetes or GD and have gone on to give birth vaginally.

CPD is quite rare. According to the American College of Nurse-Midwives (ACNM), CPD occurs in 1 out of 250 pregnancies. They even go further in saying that If you have been told that you have CPD it doesn't mean that you will for sure have problems with other births.

It may be shocking to know that providers out there today will pre-diagnose people with CPD before the baby is even born. If your client's provider is suggesting that their baby is "too large" or implying that their pelvis may be too small it is a RED FLAG and something you may want to educate them more on. We also know that providers can start doubting the baby's ability to exit the pelvis in the second stage of labor. See the full PDF of The second stage of labor Wayne R. Cohen, MD; Emanuel A. Friedman, MD, Med ScD (2024) . You can also read more on The Journey of Obstetrics Gynecology.

Fetal Heart Problems

In a hospital setting, continuous fetal monitoring is usually a requirement for VBAC women, and in about 70% of rupture cases, EFM (external fetal monitoring) has picked up an abnormal heart rate pattern that can suggest separation of the scar (ACOG, 2017). However, it is also normal for the heart rate to fluctuate outside of normal readings. A heart rate dropping several times or one that drops and doesn’t recover may be resolved by simply changing positions to adjust baby’s position in relation to the cord.