Cesarean Decision-Making & 10 Tips To Avoid Cesarean Birth

prenatal visit

It’s important to discuss your birth preferences with your doctor or midwife during your prenatal visits.

There are lots of reasons for having a Cesarean birth. Some C-sections are due to circumstances that are discovered during labor such as failure for labor to progress, disproportionate sizing between the baby’s head and the pelvis, and abnormal fetal heart rate. Others are planned or scheduled due to conditions that were exposed during pregnancy including breech position, multiple pregnancy (e.g. twins), and placenta previa. In very rare instances, Cesareans are performed because of emergency situations such as cord prolapse or placental abruption. Occasionally, women opt for a Cesarean delivery for personal reasons even when there is no medical indication for having one. The question that remains, however, is what proportion of the 30% Cesarean rate is influenced by perceived “benefits” to the physician such as shortening the length of labor and financial incentives?

The unplanned Cesareans that occur because of issues that arise during labor allow for more subjective assessment than those in the planned, emergency and elective categories. In a recent report, Physicians Treating Physicians: Information and Incentives in Childbirth, economists Erin Johnson and M. Marit Rehavi presented findings potentially related to such subjectivity: patients that were physicians were 10% less likely to receive a Cesarean compared to non-physician patients. Because obstetricians in many hospital settings are paid more for Cesareans, there appears to be an interaction between financial incentive and patient knowledge as factors in the obstetrician’s decision-making.  As described in NPR’s report on Johnson’s and Rehavi’s paper, money may be subconsciously or consciously motivating some obstetricians to perform Cesareans on patients that have lesser understanding of the indications for surgical intervention during labor. They also found that patients that were physicians had better health outcomes, “suggesting overuse of C-sections adversely impacts patient health.”

So, as a patient, what can you do to decrease your chances of having a Cesarean?

Below are 10 Tips to help you achieve that goal:

During Pregnancy

  • Eat healthy food and exercise routinely – stretching and strengthening exercises such as prenatal yoga are especially helpful in preparing your body for the positions of labor.
  • Take an evidence-based childbirth education class to learn about your options including indications, risks and benefits related to Cesarean birth.
  • Discuss your birth preferences with your doctor or midwife during your prenatal visits.
  • Avoid electing to have an induction or Cesarean for non-medical reasons.
  • Consider interviewing and hiring a doula for labor support.

During Labor

  • Stay at home during early labor.
  • Have ample support from your birth partner, support person(s) or doula while laboring and pushing.
  • Change positions every 20 – 30 minutes when possible and use gravity to your advantage with upright and forward leaning positions during labor and pushing.
  • Delay the use of an epidural so you have the option to engage in all positions, including out of bed options.
  • If your doctor or midwife recommends a medical procedure, including Cesarean delivery, ask about risks, benefits, possible alternatives and any other questions you may have. Find out if the situation is urgent or if there is opportunity to allow more time before deciding.

Cesarean birth is sometimes medically necessary and always a reassuring option when a situation requires such intervention; however, Cesarean rates have increased over time without leading to improvement in outcomes. It is time to reassess this increase and the best place to start is to augment your own knowledge so you feel confident in contributing to the decisions involved with your pregnancy, labor and birth.


Chris Just, RN, MSN, CNM


About Chris Just CNM MSN

Chris is responsible for overseeing the clinical component of the prenatal education programs at Isis and is actively involved with our hospital partnerships and community outreach. She is a certified nurse-midwife with over 20 years of maternity care experience in educational and clinical roles. Chris is co-creator of Mind Body Birth by Isis and a board member of MA Healthy Mothers and Healthy Babies. She is also a member of the MA Special Legislative Commission on PPD Public Education sub-committee and a member of the MA Perinatal Quality Collaborative Educational/Communication sub-committee. Her focus is on increasing access to relevant, evidenced-based education through on-site and online education, scholarships, community classes and social media. A former Peace Corps Honduras volunteer, Chris is also dedicated to coordinating educational services for underserved populations. Chris received a MSN from Yale University and a BA from Middlebury College. She enjoys time with her husband, Jim, and they are proud parents of a young daughter and son.

One Response to Cesarean Decision-Making & 10 Tips To Avoid Cesarean Birth
  1. Kristin
    October 6, 2013 | 3:30 am

    Thank you for this balanced article. I am an L&D nurse (I deliver high risk as well as midwife patients) and I can’t tell you how upsetting it is to see all of this information out there that makes MDs and RNs the enemy before you even walk in the door, and telling women to outright refuse interventions. I’ve seen many women and babies very badly hurt – or have died – because women who thought they were being empowered or progressive refused a life-saving intervention. This article encourages women to do exactly what they should: don’t blindly trust the MD but defend your right to know exactly what is going on with your care; ask to be explained the risks, benefits, and potential complications in accepting AND refusing the intervention. ASK FOR EVIDENCE. If in the course of your prenatal care and labor you don’t get respectful, conscientious replies from your MD, switch and tell him or her why you are. Lastly, please remember that the job of a L&D RN is to be your labor support. We are so quick to jump right to doulas, but an RN is a doula with medical knowledge. And again, if your RN isn’t supporting you, giving you conscientious and evidence-based rationale in answer to your questions, say you want to switch! That’s your right!

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