At what point should I choose to have a c-section?

Question

There is a good history of obstructed births in my family; something to do with pelvises apparently. My grandmother had problems, my mother wasn't able to have any of us 4 without c-sections after labor (which nearly killed my younger sister) and a 1st cousin recently needed an emergency c-section for the same reason.

I don't know if I'm affected by the same genetic condition, and won't know until the day.

Interestingly I've talked to the midwife about this twice and she doesn't seems to think it's a big deal. I don't even think there's a note in my file.

The pros and cons of c-sections are immaterial here, obviously I would prefer to have the child naturally if possible, but I'm realistic. I'd assumed it would be OK to try naturally, and if things start to go at all difficult to opt for a c-section.

I recently heard that it is less stressful on both mother and baby (with faster recovery time) to just choose a c-section rather than to have an emergency c-section.

My question is:

how do I respectfully handle this with the midwife and the hospital? How do I tactfully make them fully aware that I'm not paranoid, this is a genuine risk?

Am I better just requesting a c-section (though I'd rather not for health and hormones)?

Worst case scenario, at what point on the day would I "pull the pin" and seriously ask for a c-section?

On the other hand should I just have blind faith in my health care professionals? I want to, I absolutely trust in the profession and believe in them -- but the health of my unborn child is paramount to me and I want to do everything I can.

Despite my pregnancy being ideal so far, after listening to the family horror-stories, I honestly believe there's a good chance I'll be end up on the chopping board. Either way I just want what is healthiest for us and to know what my options and rights are, while having utmost respect for the hardworking professionals involved.

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For those curious to the outcome: the baby chose. After 29-hours of labor (having we believe both "Passenger" and "Passage" complications). She became distressed and it was a painless decision between me, my team and the professionals involved to have the caesarian as soon as possible. After the necessary epidural anaesthetic it all happened like a machine. Overall it was a stressful day, but it usually is. Note that we chose a major public hospital that performed C-sections. The (purportedly "nicer") insurance preferred choice wasn't able to and we would have required a (likely unpleasant) transfer. Having chosen to be at a place to perform the operation limited our options, but fortunately the public hospital completely exceeded expectations, with freshly renovated maternity ward with all the mod-cons and many (free) days in hospital to ensure everyone was fine. Everyone is thriving in the end.

Answer 1

My question is: how do I respectfully handle this with the midwife and the hospital? How do I tactfully make them fully aware that I'm not paranoid, this is a genuine risk?

Your midwife has done many deliveries, and if you're satisfied with her care so far, since there is no way to predict your need for a C-Section (even pelvimetry Xrays most likely won't help), you can trust her to have your best interests at heart.

However, whenever a health-care provider isn't hearing you, repeat your concern until it is adequately addressed in your mind. Your concern might be satisfied by an explanation of her own approach, or it may mean you ask her to check with an Obstetrician she works with to get a more definitive answer and get back to you. It's not paranoia to ask for answers to questions which worry you.

You are the person with the most to lose here, and - sadly - you need to be your own advocate.

In terms of elective CS, don't even wonder - no one can predict whether you'll need one; only the most patient-pleasing doctor would do an elective CS on a primiparous (first pregnancy) patient because the known risks outweigh the unknown benefits.

Yes, it's harder on you if you have a CS after a significant time in labor. But a trial of labor for primiparous patients is by far the norm.

What you can and should discuss is how far you're willing to go before the decision to have a CS is made. Discuss with your midwife the stages of labor and what happens in each stage. With your family history, I think for you to be "stuck" fully dilated at zero-station for 14 hours of labor plus 9 more hours of pitocin is unreasonable.

This may sound scarey, but it's not intended to scare. It's intended to start a dialogue with your midwife so that you feel comfortable throughout your pregnancy and labor that someone is thinking of the situation and has a plan.

That is your right as a patient.

Answer 2

First, not every section that happens after labour begins is an emergency C section. In an emergency section, the cut is vertical and large, and everyone is in kind of a panic. You might get a general if you don't have an epidural already in place. These things have a bigger impact on you. In a "normal" section, the cut is low, horizontal, and relatively small. This means less muscles are affected. You can have an epidural which means the dangers of a general are not in play, and you don't need to be intubated either. You will have more pain and damage from an emergency C section, but that doesn't mean your section needs to be scheduled. Normally, if labour is not going anywhere, the decision to do a section is pretty low key and they can take their time. This is probably why your midwife is not too worried. You don't need to schedule a section to avoid an emergency section.

Second, this "genetically we have small pelvises" theory is probably not really true. But the way to find out is to go into labour. Maybe you won't dilate ("failure to progress") and your labour won't become productive, in which case regardless of pelvis size, you'll get a section. Maybe you'll dilate but the baby won't descend, in which case you'll get a section. It's a decision that can be made once labour is well underway. The baby will be monitored the whole time, so stories in old books about babies being damaged by 24 hours of unproductive labour, oxygen deprivation etc are not really relevant: the very first signs of distress are what will cause people to come to you suggesting it's time for a section.

You may just dilate, push, and have a baby. That would be the easiest, since you won't have to recover from surgery. Your midwife doubtless wants that outcome for you. You can ask her why she doesn't think your family history is a big deal - my guess is that there's not much correlation between family history of c sections and having one yourself - but it's important you two understand each other. If you are confident that you will get good advice while in labour and switch to a section should things not progress, you can relax and give your attention to labouring. If you don't have that confidence in the person or people who are there to help you through it, your number one priority now is to get it - by talking to them and explaining your worries, and hearing why they dismissed those worries, or by replacing them.

Answer 3

If you feel you aren't being heard by your birth team, and there's time, I would strongly recommend seeking out a second opinion or an advocate to help you BE heard. Do you have the option of finding a doula? Having a doula helped me tremendously in my first pregnancy, as I was bucking the medical establishment in my birth plan.

If you do not feel you have enough time until the impending birth to find an advocate, maybe it's time to drop the 'respectfully' part of your request and let them know this is a genuine concern and you would like it addressed ASAP. If you can, maybe bring along someone who is familiar with the birth history of your family (mother, family doctor, etc.) who can help you stress the urgency of this issue.

_{I had a c-section for my second child (placenta previa); it was planned out with the OBs prior to my son's scheduling his delivery. At times I did have to go back to them and stress things that were of concern to me about my son's health and my recovery, and I found that a direct approach was more productive than trying to worry about anyone's feelings.}

Answer 4

There's not a lot of ways to know if you'll need a c-section or not before delivery. If your baby is breech, or if the placenta is too low, or other conditions then a c-section is basically required for a safe delivery, but apart from obvious indications, there's not a way to know for sure.

I have two cousins who had c-sections, they had no idea they were going to need them. One had a failed induction and was two weeks past her due date. Her body just was refusing to go into labor. There was no way of predicting that. My other cousin had a failure to progress, which turned out to be because the cord was wrapped around the baby's neck a couple times, so the baby literally couldn't descend without strangling himself. Again, no way to predict that. Ultrasounds are only so sensitive and babies move around causing things to change.

If your midwife is affiliated with an OB you should ask for a referral ASAP, as you want to make sure you like the doctor and learn more about what a c-section would entail and how/when it would be good to request one (particularly in light of the risk of whatever particular condition is common in your family). They are likely to have much more experience in seeing difficult births than midwives.

It's not good if your providers think your concerns are paranoia, you deserve to have your concerns taken seriously. No provider should ever discourage you from asking questions or voicing concerns. Saying "family history" should be enough to make any decent health care provider listen as it's one of the best indicators of future health concerns there is.

Answer 5

Giving birth naturally puts a huge strain on your body and is exhausting, and having an operation also puts a huge strain on your body and is exhausting. Having both one after the other is a significant strain and takes a lot longer to recover from. This is why many women who have a high potential for a c-section will opt for an elective rather than try to push and then need one anyway.

I think unless there are x-rays of your pelvis that can be measured you won't know how much space there is for your baby to get out, and health care professionals are very reluctant to x-ray an expecting mother. So it's unlikely they'd do this for you. If you have had previous x-rays of your pelvis then you could ask for them to be evaluated.

As for how to proceed without that information I'd say it's your personal choice. The doctors and midwives really have no idea on this one; in this case you have more information than them and are in a better position to decide whether to have an elective or not. Stick to your guns on it.

If you decide to go for a natural birth there isn't really a time-frame to say "now I want a c-section", the doctors and midwives will monitor your situation and have lots of experience of when it is time to move it to the operating table. What you would want to do is tell the medical staff when you go in that your family history is full of emergency c-sections because of pelvis size and they will keep it in mind.