For many expectant moms entering the third trimester, your baby’s impending due date can yield so many mixed emotions. You’re anticipating meeting your baby yet having some trepidation about all the changes that come with a newborn.
There’s also a key element that weighs on every expectant mom’s mind towards the end of her pregnancy: the labor and delivery. Will you have a vaginal birth or caesarean section (C-section)? Medicated or unmedicated? Induction or natural? Of course, there are strong debates about which approaches are best for mom and baby. From your best friend and mom to your next-door neighbor and the stranger at the grocery store, everyone has an opinion.
We asked our own Amy Loreen, MD, a SLUCare OB/GYN who practices at SSM Health St. Mary’s Hospital – St. Louis, to discuss some key labor and delivery elements, specifically vaginal versus C-section; how she handles cases of breech babies; and the use of epidurals for pain management during labor.
Vaginal Birth Versus C-section
Q. What are the benefits of a vaginal birth versus a C-section?
A. Women’s bodies are designed to deliver babies vaginally. It’s also considered the safest in most cases. There are several benefits with delivering your baby vaginally, including:
- A shorter hospital stay (two days or fewer)
- Faster recovery
- Higher rate of successful breastfeeding
- Avoid risks associated with major surgery such as infections and blood clotting issues
- Less potential for complications with future pregnancies and births
- Lower risk of developing postpartum depression
- Better prepares a baby’s lungs to breathe
- Exposure to healthy bacteria that boosts a newborn’s immune system
Although a C-section can be an essential, lifesaving surgery, it can also put women and babies at unnecessary risk of short- and long-term health problems if performed when it’s not medically necessary. We’ve come to learn that those medically necessary situations are less common than we previously believed.
Unfortunately, according to new research from the World Health Organization (WHO), the C-section rate continues to rise, accounting for more than one in five (21 percent) of all childbirths worldwide. This number is set to continue increasing over the coming decade, with nearly a third (29 percent) of all births likely to take place by caesarean section by 2030. We can do better.
At SSM Health St. Mary’s Hospital – St. Louis, we take pride in having one of the lowest C-section rates – between 15 and 17 percent – in the region and nationwide. This is attributed to our dedicated, skilled practitioners, excellent nursing staff, and the support of an academic teaching institution. We work with each patient to understand her birth plan wishes, while also providing guidance and encouragement with the shared goal of a healthy baby and mom.
Q. Does medically inducing labor increase your risk of needing a C-section?
A. In some cases, as expectant moms get closer to their due dates, they may want to discuss being medically induced instead of waiting to go into labor on their own. Once they reach 39 weeks gestation, I offer labor induction as an option for my patients. I also recommend an induction once a patient reaches 41 weeks gestation, although going past 41 weeks can be safe with certain testing. Most women will have gone into labor by 42 weeks, but if not, I recommend induction due to the increasing risk of stillbirth.
Contrary to popular belief, being induced does NOT increase your risk for a C-section. A 2019 study (ARRIVE) examined labor inductions versus expectant management in more than 6,000 patients and found that inductions were associated with a lower C-section rate compared to going into labor naturally. These inductions involved administering oxytocin to women between 39 weeks, 0 days and 39 weeks, 4 days. Of the 3,059 patients who were induced, 18.6 percent had a C-section compared to 22.2 percent of the 3,037 patients who went into labor naturally.
Q. What are the most common reasons women end up needing a C-section?
A. There are a few scenarios where a C-section may be medically necessary, including:
- Fetal distress
- Cord prolapse
- Placenta issues such as placenta previa or placental abruption
- Chronic health condition or infection such as HIV or genital herpes which can be transferred to baby through vaginal delivery
- Known birth defects such a congenital heart defect or excess fluid on the baby’s brain
Additionally, in cases of labor arrest when the cervix stops dilating, patients often end up undergoing a C-section. Patients can easily get discouraged if their labor stalls. However, this can often be avoided by giving the mom more time and more oxytocin to make sure her contractions are strong enough. I give my patients at least six hours to work through labor arrest.
Traditionally, we’ve used the baby’s heart rate as a guide to reassure ourselves that things are progressing normally and safely. However, it shouldn’t be the sole indication that there’s a problem. The rise in C-sections really started when we introduced heart rate monitoring. We know it can be normal and common to see changes in the baby’s heart rate during labor. We must remind ourselves of this before we quickly resort to a C-section. The labor process is not just mom working hard – the babies must work, too.
Q. Why do some patients elect to undergo a C-section even if it’s not considered medically necessary?
A. There are also certain scenarios where patients may elect to schedule a C-section, because they believe it’s their only option. For example, some women assume that because their first baby was born via C-section that all future children will have to be born this way.
Many women also worry that the scars from a previous C-section will open with a subsequent pregnancy; however, this risk is less than one percent. In fact, approximately 90 percent of women who previously had a C-section are candidates for a vaginal birth after caesarean section (VBAC). Deciding to try for a VBAC is an individual decision women should discuss with their physician.
So many women don’t even realize that a VBAC is a viable option. I recently had a new patient who was new to the area and pregnant with her third baby. She had two prior C-sections, so I asked her if she had considered a VBAC with this third delivery. She was floored to learn that this was even a possibility.
Breech babies are another scenario where an expectant mom might consider a C-section. Traditionally, in a case where the baby is breech (with feet or butt positioned above the birth canal), a C-section is often recommended. See the next answer for other options.
Breech Positioning
Q. How common are breech babies?
A. Most babies move and flip around throughout the course of the pregnancy. As your due date approaches, most babies flip into the proper birthing position – head down. Only three to four percent of babies are in the breech position when labor begins.
Q. If a baby is still breech towards the end of the pregnancy, what are an expectant mom’s options?
A. Again, most babies will flip into position by the time labor begins. As I mentioned above, a vaginal delivery may still be possible with a baby in the breech position. However, we frequently first offer to try what we call ‘flipping’ or ‘spinning’ the baby. This is a proven, safe method that’s performed in the hospital around 37 weeks with an epidural. Your OB/GYN or medical practitioner externally maneuvers the baby to get him/her to flip into the head down position. This can put some stress on the baby, affecting the heart rate temporarily. It yields a 50 to 70 percent success rate.
If that’s not successful, then there are certain cases where we can safely deliver babies vaginally in breech position. We have several providers in our group (myself included), who offer breech vaginal deliveries. Not every mom or baby may be a candidate, so discuss with your OB/GYN for more information. Otherwise, this is a common reason for a cesarean birth.
Epidurals for Pain Management
Q. What are the key benefits of getting an epidural during labor?
A. An epidural is one of the most effective methods for pain relief during delivery and childbirth. Approximately 80 percent of my patients elect to get an epidural during their labor. It’s one of the safest, most effective pain management option with minimal side effects for both mom and baby. Here are some of the key benefits:
- It works quickly and can begin to relieve pain within 10 to 20 minutes.
- It allows you to rest, which is helpful especially if you have a long labor.
- It can help you stay alert so that you can take an active part in the birthing experience.
- If you need to deliver by C-section, an epidural allows you to stay awake during the procedure and provides pain relief during your recovery.
- You can get an epidural practically anytime during labor, even if it wasn’t originally part of your birth plan.
Q. What are the risks or side effects associated with an epidural?
A. Epidurals are very safe to use for pain management during labor. That said, there can be some risks or side effects to note, including:
- It limits your ability to move around, so keep that in mind if you’re wanting to labor outside of the hospital bed.
- It can cause low blood pressure, which may require oxygen, fluids, and/or medication.
- It can cause shivering, fever, or itchiness.
- After the removal of the epidural, you may feel nauseous or dizzy, and have back pain and soreness where the needle was inserted.
- Though very rare, permanent nerve damage is possible if the spinal cord is damaged by the needle or catheter, or by bleeding or infection in the epidural area. Anesthesiologists undergo extensive training, so the risk of permanent damage is extremely rare.
- It may make pushing more difficult; however, we can adjust the dosage to allow you to feel some pressure to aid with pushing.
Q. When is an epidural typically administered in the labor process?
A. Patients often ask me how long they should wait to get the epidural. I always say listen to your body; if you’re in pain and ready for it, that’s the right time. Regardless of when it’s administered, epidurals don’t seem to affect labor progress.
When it comes to your labor and delivery, you are your best advocate. Let your doctor know what your birth wishes are with the understanding that things can and may need to change. I approach each of my patients during one of the prenatal appointments to discuss her ideal birth experience. It’s a personal, individualized decision, but I’m there to help guide you and determine what will work best to safely bring your baby into the world.
For more information about labor and delivery, breech positioning, epidurals and what to expect with your delivery, visit https://www.ssmhealth.com/maternity/expecting-a-baby.
Amy Loreen, MD, is a board-certified obstetrician/gynecologist, who practices with the SLUCare Physician Group at SSM Health St. Mary’s Hospital – St. Louis. She provides general obstetric and gynecologic care, including well woman care, family planning services, prenatal care, and consultation for gynecologic issues. She also offers substance abuse treatment for pregnant women through the WISH Center at SSM Health St. Mary's Hospital - St. Louis. Dr. Loreen is an assistant professor in the Department of Obstetrics, Gynecology, and Women’s Health, Division of General Obstetrics and Gynecology, at Saint Louis University School of Medicine. She is a member of the American College of Obstetrics and Gynecology and Alpha Omega Alpha Honor Medical Society. To make an appointment with Dr. Loreen, call (314) 977-7455.
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