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When might a cesarean not be necessary?
Individual obstetricians can vary widely in cesarean rates. Some of these reasons involve judgment calls, where the number of cesareans could be safely reduced. There is no evidence that doing large numbers of cesareans produces better outcomes in babies or mothers. All but about 15 percent of cesareans are performed for one of the following indications (17):
One or more prior cesareans: Based on 30 studies of vaginal birth after cesarean (VBAC) totaling 56,300 women, VBAC is no more risky for the baby than planned cesarean and a planned cesarean is riskier for the mother (20,41). Recently, the American College of Obstetricians and Gynecologists retreated from its 1995 position that VBAC and planned repeat cesarean both have risks and that in the absence of a new indication for cesarean, VBAC should be the norm (3). This move was prompted not by new data but to protect against malpractice suits (2, 38).
Slow progress: Failure to progress, labor dystocia (difficult labor) and cephalopelvic disproportion (baby’s head too big to fit through the mother’s pelvis) are all ways of saying the baby didn’t come out within someone’s idea of a reasonable time. In all too many cases the real problem is such things as: failure to use simple strategies that promote labor progress, failure to give Pitocin (a hormone given intravenously that stimulates stronger contractions) , an adequate trial (45), the indiscriminate use of labor induction (4, 14, 31, 40, 52, 57, 59) and most important, failure to wait (18).
Breech baby (buttocks, feet, or knees down): The changeover from mostly vaginal birth for breech babies to nearly all breech babies being delivered by cesarean section has not improved outcomes (1, 13, 22, 51). This is because the main reasons breech babies have problems: prematurity, physical or neuromuscular abnormalities, growth retardation, have nothing to do with birth route. The problem leads to the breech, not vice versa. Also, the same types of birth injuries that occur during vaginal breech birth can occur when maneuvering a breech baby through a cesarean incision. That being said, researchers have now published a trial that randomly assigned 1,000 women carrying breech babies to planned vaginal birth or planned cesarean delivery (26). They reported that 1 in 257 babies in the planned cesarean group experienced serious complications versus 1 in 20 in the planned vaginal birth group. Rumor has it, though, that most of the birth injuries occurred at one or two centers, which suggests that management, not vaginal breech birth, may be at fault. If the rumor is true, the jury is still out on the safety of vaginal breech birth.