HOW TO AVOID UNNECESSARY CAESAREAN SECTIONS

1.                  Carry out a Pelvic examination before getting pregnant. Ovarian tumours and/or uterine fibroids previously unknown to the woman can be discovered. An ovarian tumour that is a solid tumour that can block the descent of the baby into the pelvis during labour can be removed surgically.

This is to avoid repeated caesarean sections that can follow if this not done.

2.                  A submucous fibroid (one lying just below the inner living of the womb) can be the reason for recurrent miscarriages and excessive bleeding of the woman during menses. This can deplete her blood leading to severe anaemia (lack of blood) and the need for repeated blood transfusions. This is a major reason for reproductive failure (inability to have a child in spite of many pregnancies).

Fibroids located in the lower segment of the uterus may not necessarily prevent conception but will definitely in most cases prevent vaginal delivery as they block the descent of the baby into the pelvis. An operation done to remove such a fibroid will prevent the woman from undergoing repeated caesarean sections if such fibroid was not removed. A bimanual pelvis palpation can be done and a pelvis ultrasound should also be done.  

 

3.                  A woman who wants to avoid unnecessary caesarean section, should

register for antenatal care on time in a centre where tests can be done and where the attendants are safe motherhood compliant. Urine testing done especially in the first three months of pregnancy can reveal the reason why some women will end up with caesarean section later. If there is sugar in the urine and it is later confirmed that the person has diabetes mellitus she can be advised to go on non-sugar food like unripe plantain, beans and bean products like moi-moi, akara, leafy vegetables, etc. She will be told to minimize taking sugar -containing drinks, alcohol, carbohydrate foods like rice, yam, garri,  akamu etc.  These will help to keep her blood sugar level at normal range. If that does not happen she can be given insulin injections.

If no tests are done especially in early pregnancy, the baby can grow very big and may be unable to pass her pelvis thereby leading to caesarean section to save her life and that of the baby. The baby can also die suddenly before delivery. If vaginal delivery taken place she and the baby can sustain a lot of injuries.

 Haemoglobin estimation (level or quality of blood) done in early pregnancy can help care givers detect women with anaemia (lack of blood) such woman will be encouraged to eat food that can improve the quality of their blood like crayfish, oysters, vegetables, fruits, bone marrow liver, milk. They will be given blood building drugs such as folic acid, fersolate, vitamin C, B complex tablets, multivites. If the anaemia is severe, iron dextran infection can be given to improve the haemoglobin level. If the level of the haemoglobin is very low before the labour stars blood can be transfused. No woman should go into labour with haemoglobin less than 10g% (70%). Those with haemoglobin level of 6g% (42%) or less should be transfused.

Anaemia causes weakness. The cervix may fail to dilate completely with anaemia in place. The woman in labour with anaemia will be unable to push her baby out and can even go into heart failure in the later part of labour and die. Such woman may end up having a caesarean section. If a vacuum extractor is available such women are better off delivered by vacuum extraction can assisted vaginal delivery.  During caesarean section they can bleed excessively due to the paucity of platelets and clotting factors responsible for clotting of blood

A urine test done in early pregnancy can also reveal that protein is in the urine. This may be a pointer to infection of the urinary system (presence of poisonous germs).

Another test known as urine microscopy, culture and sensitivity need to be done to find out what type of germs are prevent and the antibiotics that can clear them off.

Antibiotics that are safe in pregnancy should be used. If the infection is not discovered and treated, it can lead to pyelonephritis (an infection of the kidneys) which causes high fever and pain in the loin of the woman. This infection causes prolong labour and weakness of the woman and may make her care givers opt for caesarean section to deliver her.

Blood pressure should be checked at every antenatal visit. When blood pressure is high it can be reduced using anti hypertensive agents and anxiolytics (drugs that reduce anxiety).

Uncontrolled high blood pressure can make doctors opt for caesarean section to deliver the woman to avoid fits and death of the baby and the woman.

Early registration for antenatal care and adherence to instructions by skilled care givers can reduce the in accidence of unnecessary caesarean sections.

Women who go to Safe Motherhood compliant care givers have the benefit of being to assume for babies not staying well to stay well. When babies persist in abnormal positions and presentations, caesarean section may be the only way to ensure safe delivery.

Women who registered for antenatal care in centres knowledgeable about this can benefit from instructions on how to stay for the babies to turn to normal positions and presentation. The babies can only turn to normal postions, however, if there are no mechanical reasons such as fibroids ovarian tumours and low-lying placentas or cord accidents responsible for the abnormal positions. Babies may also not turn if the woman has drained liquor (loss most of the fluid around the baby). 

The woman will also have the benefit of buying and reading books like "Coping with labour" where such information are available.

Sitting upright most of the time with knees at a lower position then wash enhance good positioning of the baby.  The  best position for a baby to assume to 

be delivered vaginally is to bend its head completely on the neck (well flexed) and for the back of the head to face the mother’s front directly. The back of the head is known as occpito     

Picture here of well flexed baby and pictures of abnormal positions and presentations that do not favour vaginal delivery.

Manoeuvres that assist a baby stay in the right position can be resisted by these aforementioned reasons. Cord accidents, fibroids and other tumours can make it difficult for babies to stay permanently in a normal position even when attempts are made to have the babies turn to the normal positions.

Babies in abnormal positions can turn to the correct position if the woman stays in all fours on the floor. This happens most often if there are no mechanical reasons as has been mentioned that can hamper this manoeuvre.  The baby also may not turn if the water around it is insufficient to permit it such as can happen with premature drainage of liquor (breaking of bag of waters).

Picture of all fours

How do we know a baby in an abnormal position?

1. The pregnant abdomen does not look rounded. It has a depression at the  centre around the umbilicus.

  

Abdomen showing baby                     abdomen showing a 

                         in normal position.                            mal positioned baby.

2.                  The limbs or small parts of the baby are palpated felt at the front side of the abdomen. Such parts usually shift in position when touched unlike the back that is smooth and consistent.

3.                  The fetal heart sounds are heard best towards the back of the women, not in the front below the umbilicus. 

4.                  Relatively flat suprapubic area (area above the pubic hair).

5.                  Baby can be born face to pubic (baby is delivered facing the mother’s pubic hair).

Normally positioned babies are born backing their mother’s pubic hair.

Normal positioning of a baby is very crucial for vaginal delivery especially when the woman’s pelvis is sizeable enough to allow the baby pass. Even a woman with a borderline pelvis (hip neither large enough or too small) can have a safe vaginal delivery if the baby’s head is well positioned. Most caesarean sections are performed to deliver babies who got stuck in their mothers’ waists as a result of persistent abnormal positions like the direct occipito posterior position ( direct Opp).  Many families in our sub-region detest caesarean sections. Therefore all stake holders in the delivery business such as pregnant women, their spouses, midwives, doctors, Pastors, women and community leaders should take seriously the simple manoeuvres a pregnant woman can perform to keep her baby in a normal position. This will reduce the number of caesarean sections. It will also reduce number of women and babies dying from complications of prolonged obstructed labour.

These simple manoeuvres of pregnant women being in the upright position most of her working  moments and being in the all-four position during labour can save countless numbers of lives and reduce the cost of pregnancy and delivery. They are also learnt by all that attend the Safe Motherhood pregnant women’s health seminars and those that read "Coping with labour".

Knowledge of methods to reduce caesarean section rate as imbibed by pregnant women, their husbands and advisers will help to engender confidence in orthodox health care settings where such knowledge are got. People will feel their best interests are considered since caesarean sections are not done indiscriminately. Those that actually need caesarean section will accept it happily since they are aware that everything has been considered before such a decision was made.

Treating dehydration and infection to avert caesarean section

 It has been noted that dehydration, hypoglycaemia (low sugar level) due to prolonged period of abstinence from food and fluids can stall cervical dilatation and progress of labour. Some childbirth attendants withhold food and fluids from the labouring women and so inadvertently stop labour. Urinalysis done on such labouring women can show the presence of acetone. This is a pointer to starvation. This has led to a number of caesarean sections done on account of prolonged labour. Giving parenteral fluids to the women like Dextrose/saline infusion can solve the problem. Labour can continue until delivery. Moderate or severe chorioamnionitis (infection of the amniotic fluid and membranes) can also stall labour. Many women have undergone unnecessary caesarean sections because of that. Examining labouring women who have drained liquor especially with bare hands or unsterile hand gloves can lead to this. Prolonged drainage of liquor or frequent vaginal examinations can also lead to this. Treatment with parenteral antibiotics can kill the germs and recommence labour and vaginal birth can take place

Ceftriaxone, gentamicin and metronidazole injections are usually given.