Cesareans not safe or effective for preventing pelvic problems:

          Having identified that the ‘prophylactic’ use of Cesarean is unable to prevent cerebral palsy in babies, elective C-section is often promoted as a prophylactic procedure whose value lies in reducing pelvic floor problems later in the woman’s life. However, reputable research also does not support the use of elective Cesarean surgery as either a safe or a reliable method to achieve this goal.

          In an article entitled “Elective Cesarean Section: An Acceptable Alternative to Vaginal Delivery?”, Dr Peter Bernstein, MD, MPH, Associate Professor of Clinical Obstetrics & Gynecology and Women's Health at the Albert Einstein College of Medicine, reported on the failure of the obstetrical profession to practice evidence-based medicine as it applies to this topic.  Addressing the popular notion that pelvic floor damage and incontinence were the inevitable result of normal birth (to which cesarean surgery was the proposed remedy), Dr Bernstein observed:

“...these adverse side effects may be more the result of how current obstetrics manages the second [pushing] stage of labor. Use of episiotomy and forceps has been demonstrated to be associated with incontinence in numerous studies. Perhaps also vaginal delivery in the dorsal lithotomy position [lying flat on the back] with encouragement from birth attendants to shorten the second stage with the Valsalva maneuver [prolonged breath-holding], as is commonly practiced in developed countries, contributes significantly to the problem.”

         A guest editorial published in Ob.Gyn.News; August 1, 2002 by Dr. Elaine Waetjen debunked the idea that elective cesareans were safe or could reliably prevent the need for pelvic surgery later in life.

“Cesarean surgery causes more maternal morbidity and mortality than vaginal birth. In the short term, C-Section doubles or triples the risk of maternal death, triples the risk for infection, hemorrhage and hysterectomy, increases the risk of serious blood clots 2 to 5 times and causes surgical injury in about 1% of operations.”

In the long term, cesarean section increases the mother’s risk of a placenta previa, accreta or percreta, uterine rupture, surgical injury, spontaneous abortions and ectopic pregnancies while decreasing fecundity. Babies delivered by cesarean have a higher risk of lung disorders and operative lacerations.” 

Dr Waetjen stated that a: “[physicians] would have to do 23 C-sections to prevent one such surgery.” She ends by commenting that: “… instead of offering elective cesarean in an attempt to prevent future prolaspe or incontinence, we should be examining what we can do in our management of vaginal deliveries to protect pelvic floor function”.

Non-physiological pushing styles and positions are risky for mother and baby both -- “purple pushing” during 2nd stage labor damaging to the soft tissue of the birth canal; study confirms that traditional upright positions provide the most room for baby to be born normally:

         Another report in published in Ob.Gyn.News, March 15, 2003, councils against “purple pushing”. This describes a common practice in medicalized birth when the mother is directed to hold her breath and push so long that she temporarily uses up all her oxygen and gets purple in the face. Prolonged pushing of this type can cause tiny blood vessels [capillaries] in the mother’s face to break and sometimes surface blood vessels in her eyes will rupture, leaving a telltale bright red spot, similar to the damage that accompanies a black eye. Purple pushing is result of using the Valsalva maneuver, a combination of prolonged breath-holding and “closed-glottis” pushing.

         The Ob.Gyn.News article is a synopsis of research done by Lisa Miller, CNM, JD, a former labor and delivery nurse, a nurse-midwife and also an attorney. She identified the general idea of ‘directed’ pushing as an undesirable practice that interferes with normal physiology. Directed pushing usually means the mother is being coached by the labor room nurse or doctor to hold her breath to a count of ten and push as long and hard as possible. This is the familiar scene in the movies that show the mother lying in bed on her back, while her husband helps to hold her legs up in the air. With every uterine contraction, the hospital staff exhorts the laboring women to push “harder, harder, harder, hold it, hold it, now come on, give it all you’ve got, one more push, come on, just a little longer, we can see a little bit of the baby’s head, don’t waste your contraction” etc, etc, etc until the mother is out of breath and purple in the face. This style of ‘shout it out’ pushing is biologically unnecessary and counterproductive for several reasons.

         The hospital’s coaching policy assumes the mother’s natural biological urge to push is somehow inadequate or that she wouldn’t know how and therefore labor attendants must instruct the mother to hold her breath to a count of ten three times for each pushing contraction. Purple pushing is uncomfortable, undignified, and, when contrasted with the ‘right use of gravity’, usually counterproductive. It is not recommended by evidence-based studies because it disturbs the oxygen-carbon dioxide balance and causes a dangerous rise in the mother’s blood pressure.

         Most regrettably, this form of coached, ‘shout it out’ pushing is perceived by laboring women as an unspoken criticism, that somehow she isn’t doing it quite right or isn’t trying quite hard enough. Even more disturbing is the anxiety it introduces, which gives everybody in the room the idea that either childbirth is a race with a big prize at the end for the fastest birth or the baby is in deep do-do and the staff is tying to get it out before they have do a crash C-section. Neither is true for 99.99% of healthy women.

Ms. Miller states that:

“Long Valsalva's maneuvers -- or “purple pushing”--- and standard supine [i.e. lying on one's back] positioning should be reconsidered. ….

Long Valsalva pushing can adversely affect maternal hemodynamics, which in turn adversely affects fetal oxygenation

Purple pushing--or closed-glottis pushing--during which the patient holds her breath for 10 seconds while pushing is safe in the approximately 80% of low-risk pregnancies. But that doesn't mean it works best … in high-risk cases, the baby can't tolerate that kind of pushing

....near-infrared spectroscopy used to evaluate fetal effects revealed that closed glottis and coached pushing efforts led to decreased mean cerebral 02 saturation and increased mean cerebral blood volume. All Apgar scores were below 7 at one minute and below nine at five minutes. [i.e. sub-optimal Apgar scores indicating a transient stress for the newborn]

Open-glottis pushing, on the other hand, allows the patient to exhale while bearing down and leads to minimal increase in maternal blood pressure and intra-thoracic pressure, maintained blood flow, and decreased fetal hypoxia.”

Right and wrong use of gravity: At a meeting of the Radiological Society of North America, two radiologists from the University Hospital, Zurich, Switzerland described a pelvimetry study using magnetic resonance imaging (MR) to determine which maternal positions provided the most room for the baby to be born.

 The study contrasted the conventional supine position (mother lying flat on her back) to positions in which the mother was squatting or on all-fours, in a ‘hands and knees’ position. A report on their presentation, aptly entitled “Upright Positions Offer Most Room for Delivery”, was published in Ob.Gyn.News [2002;Volume 37 • No 3]. They measured the space available for the baby to pass through at the three critical landmarks of the childbearing pelvis –intertuberous diameter, interspinous diameters, and the sagittal outlet. They discovered that upright positions provided an average of slightly more than a centimeter at each of these junctions.

“Upright birthing positions provide significantly more room for delivery in terms of pelvic dimensions, compared with lying supine [on her back], Dr. Thomas Keller said. He and his colleagues …who performed MR pelvimetry on 35 non-pregnant women to compare pelvic bony dimensions in the supine, hand-to-knee, and squatting positions.


These differences are statistically significant and confirm the advantages of birthing positions long practiced in other cultures, the study's coauthor Dr. Rahel Kubik-Huch noted during an interview. [emphasis added]


… the theoretical ideal would thus be to adopt the hands and knees position to help the presenting part through the interspinous diameter, and to squat rather than remain supine as the it [the head] traverses the sagittal outlet, said Dr. Kubik-Huch.”


This silly little centimeter of extra space between lying down and standing up can easily be the difference between a spontaneous vaginal birth with a healthy baby and a difficult one that requires unusually long and hard pushing, the use of forceps or vacuum to extract the baby or even a Cesarean section that may leave both mother and baby in need of prolonged hospitalization or specialized care after the birth. It turns out that the ‘right use of gravity’ during the 1st and 2nd stage of labor is the best way facilitate a normal birth. By avoiding the use of obstetrical forceps or vacuum extraction, the soft-tissue of the mother’s pelvis and the unborn baby’s brain are protected from the damage associated with either prolonged pushing or instrumental deliveries. 

faith gibson -- all rights reserved June 2008