How to know you might be heading for an unnecessary Caesarean Section & steps to avoid it.

By Anchen Verster – Registered nurse, midwife, SA Certified Perinatal Educator – SACPE, wife, mother to 4 children including a set of twins

As a childbirth educator I’m often asked by expectant moms how they will know if their doctor is recommending a caesarean that is not necessary. Short answer is that you won’t necessarily know but here are some tips to help you self-assess your ‘risk’ for an unnecessary caesarean.

Step 1: Know what you’re looking for. What kind of service are you purchasing? Like buying any item, you choose to shop where you’re most likely to find that item at the price you want it for. Choosing medical care in the private sector in South Africa is much the same. Don’t go looking for natural birth at a hospital with a very high caesarean rate.

Attending childbirth education classes with a childbirth educator who is well qualified and certified should help you make a decision based on current evidence. Most women and their partners have a rough idea what they want (ie vaginal birth or caesarean section) when they go for their first antenatal visit, but this can be ‘fine-tuned’ as you learn more about the birth and baby journey and the research that should govern good practice. If you want a vaginal birth, your best chance is with your first birth. It’s much more difficult to have a vaginal birth after a previous caesarean section so shop in the right place the first time round so that you have the best chance possible!

Step 2: Look for common courtesy. I have been amazed at how many couples have told me that their caregiver makes no effort to greet or interact with the dad/partner during consultations. A small amount of courtesy goes a long way and basic etiquette can give you some insight into the personality and perhaps even the ethics of the person you’re seeking medical advice from. Most moms feel more comfortable with a discussional-style where they are given information and then have an opportunity to discuss the information and share in the decision-making. Some research shows that doctors who have a good relationship with their clients and take time to answer their questions have a lower incidence of litigation. You shouldn’t feel like you are on a sausage machine when you’re going for your antenatal visits.

Step 3: Ask questions. There is significant variability in caesarean section rates across private and state hospitals in South Africa. In general the state hospitals win out with lower caesarean section rates but vary significantly from between 19-50% whereas some private hospitals ‘boast’ a 60-90% C-section rate. When you go on your labour ward visit, ask what the hospital’s C-section rate is and ask your obstetrician what his/her C-section rate is. Be concerned if they don’t want to tell you. An expectant mom recently told me that she was shocked on the hospital tour to hear the hospital had a 95% caesarean section rate. If she was looking for her best chance at a normal birth, that hospital would not be the place to ‘purchase’ it.

The World Health Organization recommends a rate around 10-15%. When the rate hovers around these percentages it has a positive effect on mother and baby outcomes. That means it’s the right amount of intervention to save lives but not too much intervention that it exposes women to unnecessary risk. As soon as it rises above these ‘markers’ there is either no improvement in outcome or an increase in maternal and neonatal morbidity (health condition or complication) and mortality (death).

Other questions to ask your Obstetrician / midwife:

“Will you be happy to deliver the baby if I am squatting or on ‘all fours’? In other words a position other than semi-recumbent?”

A friend recently asked her gynaecologist this and he told her there was no chance he was going to crawl around on all fours on the floor after her. Needless to say she went elsewhere for her care, but ‘hats off’ to him for being honest!

How far over 40 weeks do you usually allow moms to go before performing an induction?”

Keep in mind in most countries a baby not born by 42 weeks is considered ‘post date’ whereas in South Africa many inductions are done before 40 weeks

“Do you allow a mom to go into labour first and see how the labour progresses before deciding that the baby is too large?”

“If I have a medical indication for a caesarean, would you be happy for me to go into labour first before the caesarean is performed?” 

Step 4: Get a 2nd opinion. Don’t be scared to get another opinion. If you are unsure of the planned intervention or feel uncomfortable, ask another doctor for another opinion. I once told a doctor I wanted another opinion prior to major back surgery. His response to me was that I was making a “dumb decision”, that he could do the surgery and he didn’t need my money. That was an absolute confirmation to me that I not only needed another opinion, I needed another doctor! One of the negatives of another opinion is that you have to pay for another consultation, however it might save the cost of a C-section.

Step 5: Don’t rush to hospital as soon as you go into labour. While ensuring that your caregiver is happy for you to labour a few hours at home, this will decrease the chance of unnecessary intervention and being diagnosed incorrectly with a labour that’s ‘not going fast enough’. The International Childbirth Education Association recommends staying at home until you reach the 5-1-1 mark. This means your contractions are 5 minutes apart, lasting for at least 1 minute, for a period of 1 hour.

The 4 walls of a labour room can be very boring. Home is much more relaxing and offers more variety in distraction. Your hormones may also be able to do their job better because you’re more relaxed at home thus enabling your labour to progress better.

Step 6: ‘Test the waters’. Nosipho really wanted a vaginal delivery but her doctor wanted to do an induction at 39 weeks because the baby wasn’t growing. She was concerned that the induction might end in a caesarean. She asked her doctor if he would be happy for her to come back in 2 days for a check-up. He said he didn’t think it would be safe to wait longer and that the induction needed to be started that night. She ended up delivering her baby normally after an induction. She tried to delay the delivery but felt sure her doctor was genuinely concerned about her baby’s well-being.

Mareli was told she needed an induction because the amniotic fluid levels were too low. She also wanted to try and avoid the induction and asked her doctor if she could come back the next day for a check-up. He said he was happy to check day-by-day. The next day the baby’s heart rate was perfect and the fluid volumes hadn’t changed. Three days later the fluid levels were normal and she went into labour spontaneously and delivered her baby naturally. Both moms ‘tested the waters’ to see if there was an alternative to the suggested intervention and to see if their doctor thought the situation was serious enough for immediate intervention. The answer was different for each but both trusted their doctor’s judgment and also had their birth of choice.

I’ve noticed some trends that should trigger warning bells…

  • Your caregiver does not want to talk about your desired type of birth or birth plan or is putting off the discussion for subsequent antenatal visits.

(I do that with my children when they ask for something I don’t want to say yes to. Instead of disappointing them immediately I say “we’ll see” or “let’s talk about it later”. What I actually mean is “no”.)

  • At your last few antenatal visits your caregiver alludes to the size of the baby’s head as being “very big”. You immediately assume that the size of your baby’s head is bigger than average and you start to lose confidence in your body’s ability to facilitate the passage of the “unusually large head”. Did you know that an ultrasound scan to determine the size of the baby in the 3rd trimester is much less accurate than in the 1st trimester! Ask Tina who was talked into a caesarean section because her baby was “very big” and the doctor told her she would never forgive herself if the baby got stuck during a vaginal delivery! Her baby was born at a healthy average weight of 3 500grams. Yes that’s a true story!

The average size of a baby is between 2 500 grams and 3 500grams.

  • Your caregiver wants to do an induction prior to 40 weeks for no other reason than it’s close to your due-date (or he’s going on holiday next week). The greater proportion of first time labours’ start after 40 weeks. Inductions fail or end in caesarean sections in at least 50% of cases.
  • Your small frame, ‘narrow pelvis’ or shoe size are alluded to as reasons for planning a caesarean.
  • Your doctor is going on leave/holiday around your due date. (In which case, by the way, many mothers opt for an induction or a caesarean so that their doctor can still deliver the baby and not a locum doctor they don’t know). Ask about holiday plans early on in your antenatal visits.
  • Too little amniotic fluid. Although this may be a reason to start labour earlier (not a reason for a caesarean unless there are other indications), it is worth having the fluid volumes (pockets) measured again in a day or two as the measurement may not always be 100% accurate.
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