Choose Wisely: Studies Show Increased Risk of Cesarean Linked to Choice of Doctor

By Jacqueline Levine

The cesarean rate in the United States has leveled off, as reported last year by the Center for Disease Control and Prevention (CDC). The information came from the National Center for Health Statistics, and it says, in sum: “After 12 years of consecutive increases [1998 to 2009], the preliminary cesarean delivery rate among singleton births was unchanged from 2009 to 2011”;  the report cites the current rate as 31.3%.  That the rate has stopped rising is good news. And that the rate is too high is not in dispute. The World Health Organization and other organizations that promote and support optimal maternity care have been making that case for a long time.

Most recently, the American Congress of Obstetricians and Gynecologists (ACOG) has come out with a report entitled “Safe Prevention of the Primary Cesarean Delivery,” with guidelines meant to prevent a first-time c-section. The study calls for revisiting the list of the common indications for cesarean. The various rationales for cesarean have held sway in maternity care for years.  These new guidelines can be seen as an admission that the rate of surgical birth is indeed far too high, and that current practices do not promote the ideal health of women and babies.

Added to this news are two studies that reveal additional factors that can affect a woman’s chance of having a cesarean. News from the American College of Obstetricians and Gynecologists’ (ACOG) 57th Annual Clinical Meeting, as reported in Medscape Today (Medscape Medical News, May 12, 2009), discussed an article entitled “Liability Fears May Be Linked to Rise in Cesarean Rates.”  The following is a direct quote (bold emphasis is mine):

“It has been suggested that medical-legal pressures are a factor in the high number of cesarean deliveries. A number of studies have borne this out.  Localio and colleagues (JAMA. 1993; 269:366-673) found a positive association between medical malpractice claims risk and the rate of cesarean delivery.   Murthy and colleagues (Obstetrics & Gynecology 2007; 110:1264-1269) found an association between professional liability premiums and rate of cesarean delivery — for every $10,000 increase in insurance premium there was a 15% increase in the rate of cesarean(s) delivery.  Dr. Barnhart said “First of all, I applaud the abstract, in that it quantifies a perceived problem,” ”We all anticipated that defensive medicine might be a reaction to litigation, and this paper demonstrates that that is indeed the case,”  ”So don’t just blame the doctor for doing a C-section, recognize that there’s probably a reason that [he or she is] doing it. And that fear of litigation is the reason,” Dr. Barnhart concluded.”

The study implies that what’s being done in the way of care might indeed be for the welfare of obstetricians who practice defensive medicine, and may not be for the best welfare of the woman in his care. The results of this study are not addressed in the recently released ACOG guidelines to eliminate the overuse of c-section, but it’s helpful to acknowledge the possible affect of malpractice insurance on women’s birth options.

We assume that the most fundamental tenet of care is that what a doctor does is for our benefit, and not for her or his well-being, convenience or safety. A doctor who picks up a scalpel and performs surgery for defensive reasons is behaving in a way that is the antithesis of ethical behavior, a betrayal of our trust in the doctor-patient relationship.

The other study addresses how an obstetrician’s personality affects your risk of having a cesarean. The article, “Women’s Risk of Having C-section May Depend on Her Obstetrician’s Personality,” discusses a study published in the Journal of Obstetrics and Gynecology in 2008. (Allcock, C., Griffiths, A., & Penketh, R., The effects of the attending obstetrician’s anxiety trait and the corresponding obstetric intervention rates. Journal of Obstetrics and Gynecology, 28(4), 390-393. [Abstract]). “Trait anxiety” is an integral and unchanging part of the human personality and is very different from “‘state anxiety’” which happens in response to a particular situation.

The results of the study are very concise (emphasis mine):

“Obstetricians were asked to complete a validated survey that measures ‘trait anxiety’ which is stable and enduring… The obstetricians with the least anxiety had the lowest emergency cesarean rates.  The obstetricians with the most anxiety had the highest rates.”

Statistical analysis revealed that the doctor’s trait anxiety levels were highly correlated with cesarean rates. 

These studies document just two of the many factors that affect a birthing mother’s chances of having a cesarean — factors that have nothing  to do with a mother’s or baby’s actual health status. The more we know about what influences doctors in the decisions they make about our care, the better our ability to recognize and request best-evidence care for ourselves and our babies. And so the question becomes, how can a birthing woman understand and avoid the influence of lesser-known factors on her chances of avoiding cesarean?

As our own best advocates, we must seek out the ethical caregivers who do not rely on routine interventions and who use surgery only to save the lives or health of babies and mothers. Before deciding  on a caregiver , it’s of critical importance to become familiar with best-evidence, optimal maternity care, so that you’re able to
question her/him about all the health care practices that will affect labor and birth. Knowing the facts about normal, healthy birth and conservative reasons for c-section based on our genuine health status help you make informed choices about your care.

Recommendations for OBs, hospitals and midwifery care from women across the United States can be found at the non-profit, all volunteer website Question your prospective OB or midwife about his/her c-section rate, induction rate, episiotomy rate, and other routine and common practices that may not confer best-evidence care. If you perceive a defensive posture about his stats, or an air of reluctance to tell you what you want to know, consider it a red flag warning and seek a new caregiver for optimal care.


Looking for more information and resources surrounding cesarean and VBAC? Check out this list of online resources and test-your-knowledge quiz from Science & Sensibility.


About the Author

Jacqueline Levine, BA, LCCE, FACCE, CD(DONA), CLC has been a DONA doula and  lactation counselor  for 10 years, a Lamaze educator for twelve years, and a WIC educator.  She teaches Lamaze childbirth education at Planned Parenthood of Nassau County, where she volunteers birth doula services to the clients of Planned Parenthood, an underserved population.  She won the Lamaze Community Outreach Award for these services to the community, and she has taught and supported pregnant teens in local high schools.

She’s been a contributor to Science and Sensibility, the Lamaze research blog, since 2009, and writes for BreastfeedingUSA, the online peer-to-peer breastfeeding site as well.  Some of her articles for breastfeeding teens have been on the US Breastfeeding Committee site, and she is a guest lecturer in the Sociology Department of CW Post College of LIU, teaching a class in the History of Childbirth in the United States, as well as breastfeeding classes for DONA doula certification that stresses best-evidence care for mothers and newborns.

She is mother of three and grandmother of five, and came to the world of birth after she retired from a career as artist and designer in the Garment Center in NYC.

April is Cesarean Awareness Month

April is Cesarean Awareness Month — a time to learn about and share important information about how to avoid a first-time cesarean, discover your options for VBAC, and find resources for support in healing from a cesarean. Where to start? ICAN - the International Cesarean Awareness Network — is an excellent place to find several resources related to cesarean, including educational white papers, ways to get involved with advocacy, and links to your nearest ICAN chapter where you can find local resources and information about hospitals and caregivers in your area, as well as connect with other women living near you who have experienced cesarean and VBAC.

What are your favorite resources for cesarean? Please share them in the comments!

What’s the [Big] Deal with Cesareans?

Want to know more about cesareans? Want to know why our current rate of cesareans is alarming? Want to know how you can reduce your risk of a cesarean? Check out this infographic, created by Lamaze, to find quick, simple, evidence-based answers. For more detailed information on cesarean surgery, visit the Lamaze website.


Cesarean Awareness Month: Evidence-based, Practical Cesarean Resources

April is Cesarean Awareness Month. While it can be a life-saving procedure for mom and baby, a cesarean is often prescribed when vaginal birth is a safe and sound option. Be aware that you have options, that you have a right to ask questions, and a right to know your risks. Educating yourself about birth is your best and first defense against an unnecessary cesarean. 

Throughout the month, Giving Birth with Confidence will be posting cesarean resources for moms. We encourage you to comment with your experience as well as any questions. For more information be sure to check out the International Cesarean Awareness Network Blog.

Knowing what happens before, during, and after a cesarean birth is helpful for moms who are scheduled to have a cesarean, but also for any mom approaching birth. It’s common not to want to learn about something you so desperately want to avoid, but educating yourself about a cesarean — even just a little — will help prepare you for all possibilities in birth, which could help ease your fears about the process should you need one.

There are several resources on cesarean around the web., however, seems to have the most complete, succinct, and practical resources. The author of’s pregnancy resources is Robin Weiss, a Lamaze Certified Childbirth Educator, a doula and doula trainer (DONA), a childbirth educator trainer, author of several maternal/child care books, and mom to eight children.

Moms who plan to have a vaginal birth, but want to know more about a cesarean, may want to read:


Moms who have a scheduled cesarean may want to read:


All expectant moms can benefit from reading the following:

Cesarean Awareness Month: Avoiding a First-Time Cesarean

April is Cesarean Awareness Month. While it can be a life-saving procedure for mom and baby, a cesarean is often prescribed when vaginal birth is a safe and sound option. Be aware that you have options, that you have a right to ask questions, and a right to know your risks. Educating yourself about birth is your best and first defense against an unnecessary cesarean. 

Throughout the month, Giving Birth with Confidence will be posting cesarean resources for moms. We encourage you to comment with your experience as well as any questions. For more information be sure to check out the International Cesarean Awareness Network Blog.

10 Tips for Avoiding a First-Time Cesarean

By Jessica English, CD(DONA), LCCE

More and more women in the United States (and around the world) are having cesarean births. A recent study from the Yale University of Medicine showed two main reasons for the rise: more c-sections in first-time moms and lower rates of VBAC (vaginal birth after cesarean).

For your first baby, what can you do to reduce your chances of an unnecessary cesarean birth? We’ve identified 10 areas where you can be proactive and stack the deck in your favor.

1) Hire your provider wisely. This point is number one for a reason – it’s critical. In most practices, you could have any one of several doctors or midwives. You get whoever is on call when you go into labor. It’s helpful to know your practice’s cesarean rates. The labels “obstetrician,” “family doctor” and “midwife” don’t necessarily tell you what you need to know about your provider’s philosophy. Some doctors practice more like midwives, and some midwives practice more like a stereotypical doctor. Will they have a toolbox of natural techniques or only medical tool to help you if your labor is complex? If you’re not sure which doctor or midwife to choose, ask a doula. Doulas see all kinds of births with many different practices, and they will be happy to make a recommendation of a provider with a low cesarean rate and good bedside manner.  If you find out that your provider is not supportive, it is never too late to switch, even if you are just a few weeks or even days before your due date.

2) Hire a doula. Simply put, doulas make birth better, and there’s research to prove it. A meta-analysis of studies shows that women who use a doula are 26 percent less likely to have a cesarean birth, among other dramatic benefits. Having continuous support from a friend of family member can be helpful too, but the best results come when women hire an outside doula, according to a recent Cochrane Review. What exactly is the doula magic? The research hasn’t pinpointed the magic, but I think the unique combination of physical, emotional and informational support, plus gentle advocacy makes a huge difference. Doulas help women feel safe and comfortable so the hormones of labor can work at optimal levels, positioning ideas and tricks can help babies work their way out, and evidence-based information and help communicating with the medical staff can help women have their best chance inside a system that doesn’t really promote natural birth.

3) Take an independent natural childbirth class. It’s not so much that you need to know a lot about giving birth, but many women (and men) need to undo what society has taught us about birth. Independent classes are usually longer and more in-depth, with more interaction and less lecture. A good instructor can help increase your confidence in your body and help you trust in the normal birth process. An independent Lamaze-certified instructor will base her class on the six Lamaze Healthy Birth Practices, a wonderful resource that lays the groundwork for the best possible birth. Another benefit of an independent class is that your teacher works for you. She can teach you how to advocate for yourself within the system, without having to worry about what doctors, administrators or anyone else might think.

4) Avoid induction unless there’s a serious medical problem. As a first-time mom, some studies show that simply walking in the door for an induction of labor doubles your risk of a cesarean. Doubles it. That’s huge! Avoiding induction is never more important than with a first baby. But if you must be induced for a medical reason, call on your natural childbirth instructor and your doula (remember them?) to help you with tips to keep it as normal and natural an experience as possible, even with the unexpected circumstances. If mom and baby are not in immediate danger, low-and-slow inductions can result in a better chance of a vaginal birth, but you’ll need great support on the journey.

5) If having your baby in the hospital, stay home at least until strong, active labor. Your independent childbirth instructor will teach you how to recognize active labor. If you follow the common hospital recommendation to “come in when contractions are five minutes apart, at least a minute long, for at least an hour,” most women having their first baby will be very early in labor. The intensity of contractions is a much better guide than the timing. The more hours you are at the hospital before your baby is born, the higher your risk of intervention (including a cesarean). In her book “Pushed: The Painful Truth About Childbirth and Modern Maternity Care,” Jennifer Block tells the story of a hospital in Florida that lost power after a major hurricane. A generator kept the essentials running, but there was not enough power for air conditioning. They wanted to save resources and keep laboring women cool, so for a full week they turned away any woman who was not in full-blown, active labor. Their emergency cesarean rates during that week dropped dramatically.

6) Avoid an epidural, at least in early labor. Research is a bit mixed, and not all studies have been high quality. But still, the best evidence available does seem to show that epidurals, especially when women get them early in labor, do increase the cesarean rate in first-time mothers. Childbirth Connection is a great resource for information on the benefits and risks of epidurals. There are rare times, of course, when getting an epidural can actually help a woman have a vaginal birth, if she simply doesn’t have the strength to go on. Every labor is different. But an epidural also makes it harder for a baby in a bad position to move into a better one, it limits your ability to move, and it requires a lot of other interventions (IV, continuous monitoring, bladder catheter, etc.). Your doula and your independent childbirth class may give you enough natural tools so that you won’t even need the drugs. Most women don’t.

7) Read only the best childbirth books. Get these books, and read them cover-to-cover. Seriously, throw away “What to Expect When You’re Expecting,” and dive into these wonderful books instead.

And while you’re at it, buy the DVDs “The Business of Being Born” and “Orgasmic Birth” – they’re even on Netflix. That’s right, I’m recommending “Orgasmic Birth.” Stretch yourself a little!

8) Get your partner on board. It’s hard to do this alone, you need support! Even with the best doula, your partner is still an integral part of your birth journey. Penny Simkin’s book “The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas and All Other Labor Companions” is a great place to start. Be sure your partner attends that independent childbirth class with you – sometimes partners benefit even more than moms from that information and support.

9) Consider an out-of-hospital birth. It’s possible, with the right support, to have a great first birth in the hospital – even a vaginal birth without pain medication. As a doula I see them fairly often, and you should definitely choose the hospital if that’s where you feel safest and most comfortable. But the best research is pretty clear that your odds of a vaginal birth are better outside of the hospital: at home or in a birth center. In 2005 the British Medical Journal published a large study that looked at home births in the United States attended by Certified Professional Midwives. The women who gave birth at home had similar outcomes to low-risk women who had hospital births in terms of safety for moms and babies. But just 3.7 percent of the women who had their babies at home transferred to the hospital for a cesarean, while 19 percent of the low-risk women who had their babies in the hospital ended up with c-sections. The current cesarean rate in the United States is 32.9 percent, according to the Centers for Disease Control. Many studies have shown similar results, which makes out-of-hospital birth at least worth considering.

10) Believe in your body! The cesarean rate for women who birth at The Farm in Tennessee is less than 2 percent. Many industrialized countries around the world have cesarean rates of 15 percent or less. Women have been doing this for millions of years! Your body works. Birth works, in all its complex and wonderful variations. Surround yourself with knowledgeable support, of course, in case you encounter any rare and unexpected complications. But truly… trust your body. Trust birth.


Jessica English, CD(DONA), LCCE, is the owner of Birth Kalamazoo, which offers birth and postpartum doula services, natural childbirth and breastfeeding classes, and in-home lactation consults. A DONA-certified birth doula and Lamaze-certified childbirth educator, she teaches an 8-week series of classes called “The Best of Natural Birth.” She is the editor of DONA International’s eDoula newsletter. A longtime writer and business woman, she also works as a consultant for organizations and birth professionals.

Finding a Voice for Homebirth Cesarean

The following is an interview with Courtney Jarecki, co-author of the Homebirth Cesarean project. Courtney also runs a homebirth cesarean support group in Portland, Oregan.


Tell us about how Homebirth Cesarean  was born.

The term Homebirth Cesarean (HBC) originated as a way for me to distinguish my birth from the options on doctor’s intake forms. My ego wouldn’t allow me to select the cesarean checkbox and my shame at a failed homebirth kept me away from the homebirth selection. I spent nine months preparing for a homebirth and even though I had a cesarean, the spirit and philosophies of the natural childbirth movement still applied to my experience. So, to make myself feel better, I wrote homebirth over the cesarean option on an intake form and I started calling myself a Homebirth Cesarean mama.

The Homebirth Cesarean book began as a conversation between me and my midwives, eight months after my birth. I reached out to provide feedback about their care and we were able to process the birth together. This topic sparked an interest in Laurie, one of my midwives, and she wanted to write an article on homebirth transfers that end in cesarean. I wanted to write a book about my experience, but knew it needed to be bigger than just me. I asked her to partner with me on a book that shares both the mom’s and midwife’s perspective of homebirth cesareans. From that conversation, this project was born.

A few months later I created the Homebirth Cesarean Facebook page and invited every birth worker and HBC mom I knew. I wasn’t sure what my purpose with the group was, but knew it needed to be out there. An hour later there were 50 new members and now, a year later, there are over 800. It quickly became clear that the intention of the Facebook group is to bring both HBC moms and birth professionals together so practitioners can listen, observe, ask questions and learn how to better support HBC mothers. This group has helped so many moms in their healing process and changed the way midwives, doulas an childbirth educators talk to their homebirth clients about cesarean.


What have been the key components to your moving through this experience?

For years prior to becoming pregnant I was studying to become a homebirth midwife. I had completed a year of apprenticeship at a birth center and had my own doula and childbirth education business ( My entire identity and career was based on the idea that low risk women can birth at home.

The cesarean experience left me devastated, isolated and feeling like a failure. My shame and hatred of myself was deepened when, no matter what I tried, I wasn’t able to make breast milk. It felt I couldn’t do anything right and like I was an outcast from the homebirth and natural birth community. I was ashamed of my birth, my body and my lack of ability to feed my daughter.

I started talk therapy at 6 weeks, which saved me. Over the course of two years I have sought many healing modalities for my body, scar and spirit. Of course, this book has been the biggest component of my healing.

Laurie calls HBC the homebirth community’s dark secret. And it’s true! Other homebirth moms don’t want to hear about our births, midwives don’t post our birth stories on their websites and friends and family members tell us that we should just be grateful for a healthy baby.

Our homebirth cesarean work is focused on providing a platform to discuss these births so that mothers and midwives can regain the power and confidence that can be lost in the process.

For mothers, we seek to hold space so they can tell their sacred birth stories. For midwives, we seek to provide new opportunities for them to talk to, for, and on behalf of these mothers.


Is there any evidence yet as to rates of homebirth transfers resulting in C-sections?

We are still awaiting data from MANA, an organization that is conducting a large homebirth study in the US. However, many midwives we’ve spoken with estimate that of homebirth transfers that occur in labor, about 50% result in cesarean.

Individually, homebirth midwives have a very low cesarean rate.  For example, a typical midwife in the Portland, Oregon area transports about 10 out of every 100 clients to the hospital – some prior to labor, some in labor, and some just after birth.  Of those 10, if half have cesareans, the midwife will have an overall 5% cesarean rate.  For a midwife seeing 50 clients per year, that means she will have at least 2 or 3 clients who will have a cesarean every year.

Stats aside, if a homebirth cesarean happens to a mom, it doesn’t matter if her midwife had a 0% cesarean rate, for this mom it is 100%.


What are some ways women considering home births could prepare for the occurrence of an unexpected hospital transfer and C-section?

Every midwife needs to be talking to their clients about the realistic possibility of transport AND cesarean throughout their care, not just in the initial interview or at 36 weeks.

A lot of homebirth women never even consider that a cesarean could actually be their story, and they don’t know what the experience would be like if it did happen for them. When women have a realistic sense that they could have a homebirth cesarean, they are more willing to plan for what that birth would look like. In turn, if women can clarify their hopes and options for a hospital stay and cesarean birth, they will be more satisfied with the outcome, despite it not being their first choice.

Therefore, many moms report feeling blindsided and unprepared for a cesarean. The moms who had a midwife that suggested a hospital tour or had frank discussions about all interventions, including cesarean, had an easier time integrating their birth experience.


How do you see partners involved in the discussion, preparation, education, etc.?

Partners play a big role in our book. We plan on sharing birth stories from the partner perspective as well as highlighting partner’s intuition during the birth and those critical minutes when the partner is away from mama as she’s being prepped for surgery.

In 100% of our interviews with partners they, at some point, felt helpless in the birth or caregiving process. They also never thought of self-care for themselves in those early postpartum weeks. Helping midwives bring a bit more attention to the partner during the birth and postpartum can go a long way for mom’s own healing.


How would you advise women to approach concerns about HBC with a homebirth care provider?

Ask lots of questions and really feel how your care provider is responding to your questions. If you tell your midwife you’re worried about being able to push a big baby out and her response is that she’s helped many women do that very thing, does that feel helpful for you? If it does, great. If you tell her your worst fear is cesarean and her reply is that it probably won’t happen to you, that certainly isn’t helpful.

Sometimes it can be hard to get really clear on what your deep fears are around birth. If you feel like a fear is hanging around or you feel like something just isn’t right, talk about it. Conversation around what’s bothering you will bring it out to the light and, hopefully, transform the fear into conversation to plan for all possible outcomes.

Women and their providers need to be open when planning for birth and not be bound to a specific place of birth. Approaching birth as a journey into parenting, which is all about flexibility, resilience and open-mindedness is a great place to being.


What have been some of the surprises in this project?

A big ah-ha moment is how close to death, either physical or spiritual, so many HBC moms feel during transport or the cesarean. Even if moms aren’t physically close to dying, they may feel like they are. When women experience HBC, they are faced with the daunting physical recovery from labor, then major surgery, then the emotional fallout from the birth, all the while providing for the intense needs of a newborn! This makes it hard to process the fear and trauma they experienced during the birth and it plays into their postpartum recovery and coping skills as a new mom.


Co-authors Courtney & Laurie.


Co-authors Courtney Jarecki and Laurie Perron Mednick have been interviewing HBC moms, midwives, birth professionals and care providers since 2012. They are done with the majority of the interviews and we will have interviewed more than 150 people when the project is complete. Their goal is to find a publisher this year and have this book available to the public in the next couple of years.


New Resource: What Every Pregnant Woman Needs to Know About Cesarean Section

Childbirth Connection has published a new mother and family-friendly resource that speaks in detail about cesarean section. The free resource guide talks about the current statistics, the possible benefits and harms, how to make informed decisions, how to help prevent a cesarean, and provides realistic information on what it’s like to have a c-section, including the particulars during birth and postpartum recovery.

If you are pregnant, I encourage you to read through this informative, easy-to-read, and helpful guide. Many pregnant women do not want to think about the possibility of having a c-section, but it’s important for everyone to know about and understand the procedure.


Cesarean Awareness Month: Cesarean Resources

Today is the last day of Cesarean Awareness Month. Throughout the month, Giving Birth with Confidence posted a variety of information and resources on cesarean birth. As the month comes to a close, we would like to leave you with a list of helpful resources for cesarean information. (The description for the resources below has been taken from each respective website.)

ICAN (International Cesarean Awareness Network) -

The International Cesarean Awareness Network, Inc. (ICAN) is a nonprofit organization that was founded by Esther Booth Zorn and many other motivated women in 1982.  ICAN has now grown to over 130 chapters throughout the United States and worldwide.

The Unnecesarean -

Blog and site author Jill Arnold is a consumer advocate who founded The Unnecesarean in August 2008 as a collection of big baby birth stories, as well as women’s accounts of their cesareans and VBACs (vaginal births after cesarean).  After refusing a planned cesarean for suspected macrosomia based on a 38 week ultrasound estimate of fetal weight, she gave birth vaginally to a healthy baby and later found that the midwives model of care better met her needs as a pregnant woman.

Childbirth Connection -

Childbirth Connection is a national not-for-profit organization founded in 1918 as Maternity Center Association. Their mission is to improve the quality and value of maternity care through consumer engagement and health system transformation. Childbirth Connection promotes safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families.

VBAC Facts -

After her daughter’s birth in 2004, site author Jennifer Kamel spent the next couple years wading through the research on vaginal birth after cesarean and became frustrated. Over the years, she slowly and meticulously collected information. And after her son’s victorious birth in 2007, a home VBAC, she created in order to make the studies she had compiled, and the analyses she performed, easily accessible to others.

Cesarean Rates - is a snapshot of online cesarean rate reporting in the United States as of January 2012. The site compiles the most current hospital-level data accessible to the public online, whether reported directly by a state’s department of health or gathered from state hospital association web sites via pull-down menus.

Special Scars – Special Women -

A “special scar” is one resulting from a Classical, Inverted T, J, Low Vertical, Upright T or any other cesarean incision other than the most often used Low Transverse. The Special Scars website was born from the need to get more accurate information to women with these scars. It is a collection of information — articles, studies, & our own stories — regarding the possibility of VBAC after an these special incisions.

A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations

group of maternity care experts and VBAC advocates came together to create A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations, a free online resource guide that addresses the most common and pressing questions women may have about their birth choices in what could be called the “post-NIH-Consensus-Recommendations Era.” The guide gives you the tools you need to empower yourself to advocate for you, your baby, and your birth choices!


Do you have a cesarean resource to add? Let us know below in the comments. 

Cesarean Awareness Month: Postpartum Recovery Tips for Cesarean Birth

April is Cesarean Awareness Month. What should you be aware of? Be aware that a cesarean, while it can be a life-saving procedure for mom and baby, is often prescribed when vaginal birth is a safe and sound option. Be aware that you have options, that you have a right to ask questions, and a right to know your risks. Educating yourself about birth is your best and first defense against an unnecessary cesarean. 

Throughout the month, Giving Birth with Confidence will be posting cesarean resources for moms. We encourage you to add comments with your experience as well as any questions — we will tag cesarean questions and answer them in a subsequent post. For more information and stories this month, check out the International Cesarean Awareness Network Blog.

Postpartum Recovery Tips for Cesarean Birth



Giving birth, whether vaginally or by cesarean, is a major physical event. A mother’s body goes through immense physical changes in the minutes, hours and first days after birth.  Recovering from major abdominal surgery while making the transition to not being pregnant and caring for a newborn can be extra challenging.  Here are some tips for the very first days after you have had a cesarean, and some of this information is just good info for the first days after birth, no matter how your baby arrived.

1. Discuss with the anesthesiologist about the possibility of having them administer Duramorph for immediate post-op pain.  This medication is placed through the spinal needle or epidural catheter during the surgery, and usually provides effective regional pain relief for 18-24 hours.  After that, you can switch over to oral medications as prescribed by your doctor or midwife.

2. Stay on top of your oral pain medication.  This is not the time to be a hero!  Make sure you are taking the right dosage of meds at the right time, even if the pain has not returned fully yet.  It is really hard to play “catch-up,” so taking your medication in a timely manner allows you to feel your best, be more open to moving and functioning, and gently participating in baby care. You may even want to set your smart phone to “alarm” a few minutes before each dose is due, to help you track and remember what is needed and when. Give yourself some time before you try and reduce the amount of oral pain meds you need. The more you move and do some gentle, easy walking, the faster your recovery may be. Adequate pain medication will help in this process.

3. Think about your recovery set up at home?  Where is your bedroom?  Is your bed very low to the ground?  Where are your baby changing stations?  If you have a lot of stairs, consider relocating your sleeping area to one that is more accessible, close to a bathroom and the kitchen/place to eat.  It will only be a temporary move, but may make things easier for taking naps and resting.  If your bed is very low, consider placing it temporarily on cement or wooden blocks to make it higher.  It will be easier on your abdominal muscles to get up and down from a higher bed.  You can set up a portable changing area for the baby close by or in the same room as where you will be spending most of your time.

4. Use a pillow to “brace” your abdomen when getting up from a chair, couch or bed.  Sometimes, when you are laughing, sneezing or coughing, that can be helpful too.  If your couch or favorite chair is too low, think about adding some extra pillows for the additional height that you need in the early days.

5. Consider using a TENS (Transcutaneous Electrical Nerve Stimulation) unit to help with post-surgery discomfort.  Several studies show that women who used a TENS unit around the incision area needed less narcotic pain medication during their cesarean  recovery. (TENS units can be purchased online or may be acquired from your care provider.)

6. You may want to consider using a gentle belly binder or even a rebozo to “hold things together” for the first days or even weeks post cesarean.  Some women find that the gentle support offered by these products helps them to feel less sore and more supported.  Just be sure that whatever you use does not irritate the incision. (Some care providers offer belly binders automatically during your hospital stay. If not, you can ask for one.)

7. Work at becoming an expert in the side-lying breastfeeding position, which I consider the hardest to master for the mother-baby dyad, but the most useful once you do.  This way, you can rest as much as possible, and even doze for a few minutes during those extended feedings.  The key to doing this successfully is lots and lots of pillows!  A couple for your head, one between your legs, one behind your back at a minimum.  In general, your milk may come in a little slower after surgery than after a vaginal birth, so frequent nursing sessions, and lots of skin-to-skin time with your baby will help this to happen sooner.

8. Be sure to use stool softeners, stay very hydrated and eat food with lots of fiber. Oatmeal is a galactogogue (food that helps increase milk production) and is high in fiber at the same time.  Narcotic pain medication can cause constipation, and post surgery, the thought of having to strain to have a bowel movement can be emotionally challenging.  Most women find the fear is worse then the reality, but it is good to do what you can to keep things “moving,” so to speak.  Also, your bladder and urethra may be a bit irritated from the foley catheter that was placed to drain urine during surgery and the first hours of recovery. You may want to take cranberry pills or drink cranberry juice to help with bladder health and prevent a urinary tract infection.  Also, you will have received IV antibiotics before or during the surgery to prevent infection, and some women are more prone to getting yeast infections after receiving antibiotics.  A  yeast infection on your nipples (Thrush) is no fun either, and can be shared between you and the baby. You may want to use some probiotics (found over the counter in a pharmacy) or eat yogurt with live cultures, to help restore the balance of good bacteria normally found in your digestive tract.

9. Create a “nursing bag” full of all the things you need during a nursing session.  Cell phone, snacks, filled water bottle you can operate with one hand, something to read, burp cloth, breast care products, etc. can all be put in a bag or basket, and moved around with you, so that you have everything you need when you sit down to nurse.

10. Ask your friends and family to do some of the more physical household tasks and contribute meals during your recovery.  Use a website like or for scheduling assistance and for letting people know how and when they can help.

11. Recognize that you will have lifting restrictions that limit the weight you can carry to just the baby for at least a couple of weeks or even more!  It is recommended that you not lift the carseat with the baby in it until you have done some healing.  You also may not be driving for several weeks, (and certainly not while on narcotic pain meds) and your partner may have returned to work already, leaving you feeling a bit isolated.  It would be nice to have someone stop be every day to help, visit, or take you out for a short trip if you are up for it.  You may want a baby carrier (sling, Moby Wrap etc.) to help you hold/carry your newborn while your physical recovery moves forward and your mobility returns.

12. Working with a massage therapist who specializes in postpartum recovery can also help with postpartum pain and minimize the development of internal adhesions and promote healing.  Get a recommendation for someone skilled in this type of scar work and see if they make house calls!  Some massage therapists will come to the house in the first days of your postpartum period.

13. Connect with your local International Cesarean Awareness Network chapter, ( to find one near you) and consider joining their online group or attending a meeting when you are ready.  This peer-to-peer support is invaluable as you process your birth and recover from a cesarean.


Go easy on yourself after you have had a cesarean birth.  It is hard to recover from surgery and ease into parenting a newborn at the same time.  Ask for help, make little changes around the house to support your recovery, and take it easy to give your body a chance to heal.  Laying low and resting will give you plenty of time to connect and snuggle with your new little one while you get your strength back.


Sharon Muza, CD(DONA), BDT(DONA), LCCE, FACCE, is a birth doula, doula trainer and Lamaze Certified Childbirth Educator in Seattle, WA.  Sharon is also the co-leader of the Seattle chapter of the International Cesarean Awareness Network, (ICAN.)  Sharon can be reached through her website,, if you would like more information. 

Cesarean Awareness Month: Making Your Cesarean Mother-Baby Friendly

April is Cesarean Awareness Month. What should you be aware of? Be aware that a cesarean, while it can be a life-saving procedure for mom and baby, is often prescribed when vaginal birth is a safe and sound option. Be aware that you have options, that you have a right to ask questions, and a right to know your risks. Educating yourself about birth is your best and first defense against an unnecessary cesarean. 

Throughout the month, Giving Birth with Confidence will be posting cesarean resources for moms. We encourage you to add comments with your experience as well as any questions — we will tag cesarean questions and answer them in a subsequent post. For more information and stories this month, check out the International Cesarean Awareness Network Blog.

Making Your Cesarean Mother-Baby Friendly


You may find yourself headed for a cesarean birth, even when that was not what you planned.  A cesarean might have been in the cards all along for a variety of reasons, or  this change in plans might occur before labor begins, or during labor, when you, your partner and health care providers feel that a cesarean is now the best option.

As a long time birth doula and Lamaze certified CBE, I always encourage my clients and students to plan for a potential cesarean, even though many mothers feel like that outcome is unlikely.  Current cesarean rates in theUnited States tell us that more than 1 in 3 women will give birth by cesarean this year.  Having a simple plan with some wishes that continue to honor the birth of your baby, can go a long way toward making the experience a positive one.

Here are my top tips to make your cesarean birth as mother-baby friendly as possible. Discuss these items in advance with your health care provider to see what is possible in your situation and in your place of birth.

1. If you know you are going to have a cesarean, without an opportunity to labor, discuss with your provider if there is any risk in letting the baby pick his/her birth date and you heading to the hospital when your water breaks or gentle contractions start.  There are many benefits to your body, your baby and future labors if you allow your baby to initiate labor.  There are certain situations that may preclude this from being an option available to you, like placenta previa, where the placenta covers the cervical opening.

2. When the decision is made to have a cesarean, and if time allows, take a moment to talk to your baby.  Let him or her know what will be happening, that you have confidence in your team and your baby and that you will soon be holding him or her in your arms.

3. Walk into the operating room if possible.  It is very empowering to move to the OR under your own steam, if you and the baby are stable.  If you have been laboring without an epidural or the cesarean is planned, anesthesia is usually done in the OR, so you should be able to walk there on your own.

4. Ask for two support people in the operating room with you.  Your partner can be one, of course, and then your doula, family or friend may also be included.  Having two people in the OR means that your partner can go over to greet your baby at the warmer, and you can still have support with you right by your head. If your baby needs immediate transfer to a special care nursery, your partner can go with the baby, without worrying about leaving you alone.

5. Bring in music of your choice that can be played during the birth.  A CD or even an mp3 or smartphone placed on the pillow near your head playing softly can help you remain relaxed and positive.

6. Ask that everyone in the room take a moment to introduce themselves before the surgery begins.  There are several more people than you might expect in the OR during a cesarean birth, and everyone may look the same, all gowned and masked.  It can feel a little more personal to hear the staff introduce themselves and state their job…”I am Mary and I am the baby nurse…” can help you to feel like it is not such an impersonal procedure.

7. If you were waiting to discover the sex of the baby at birth, you can still do that.  The staff and surgeons do not need to announce “boy or girl” but leave that to be discovered by you and your partner.

8. Ask if it is possible to delay cord clamping for even a very short amount of time, if baby is stable.  Even 30 seconds of continued pulsing can provide benefit to your baby.

9. Sometimes, women may feel a bit nauseous during the surgery.  It may be a result of the procedure, or nerves, or unfamiliar sights, sounds and smells.  Consider bringing a little cotton ball or gauze pad with some peppermint oil dabbed on it, in a Ziploc bag.  Peppermint oil can reduced the nauseous feeling and help you to not vomit.  There is medication that can be given to you during the operation, but it may also make you sleepy, so if you can avoid it, that is great.

10. Talk to your baby after s/he has been born.  Ask your partner to tell you what is going on, and what your baby looks like; “Oh, honey, he has the same long fingers as you do…” Talk or sing to your baby, so that your little one can hear your voice as it makes the transition to the outside world.  When your baby is brought over to you, you and your partner can sing happy birthday or a special song that you may have been singing to your baby during pregnancy.

11. Ask that all possible newborn procedures be delayed until after you have returned to your room with your baby and had a chance to breastfeed.  Unless it is critical to have the weight of the baby immediately, this measurement and other procedures, (Vitamin K, eye antibiotic medication, dressing, etc.) may be able to wait until you and your baby have had a good snuggle and a breastfeeding session back in your room.

12. Ask if it is possible to get skin to skin with your baby in the OR, while your incision is being closed.  Prepare for this in advance by having removed or unsnapped your gown, and having just a warm blanket on top of you, ready for the baby.  While the baby may not be able to breastfeed in the OR, while you are on the table, you can certainly have the closeness and skin-to-skin snuggles.  You will always need some support during this time, so make sure that partner knows to keep their hands on the baby for safety.  If you are unable or prefer not to have skin-to-skin in the OR, consider letting your partner have some skin-to-skin time with the baby while sitting next to you.  Wearing a shirt that opens in the front, or even a t-shirt that has been cut a little down the neck will make it easier to slip your naked little one inside their OR gown or scrubs.

13. Ask that your uterus not be exteriorized during the procedure.  Exteriorizing your uterus is when the surgeon moves the uterus out of your body and onto the sterile field for examination and repair.  Studies show that postpartum pain after the surgery is greater when this has occurred and offers no benefits over doing the repair “in situ” (in position).

14. Ask that your uterus be double-layer sutured.  While current research is not clear that this provides any advantage over single-layer suturing, should you wish to attempt a vaginal birth after a cesarean with a subsequent pregnancy, some physicians are more comfortable and supportive of this VBAC attempt if there has been double layer suturing during the repair.

15. When you return to your room and get a chance to spend those first minutes really holding your baby and initiating breastfeeding, try and keep visitors and guests away for just a little bit, so you and your baby can get a chance to get acquainted on the outside.  This time is precious and the fewer distractions the better, to help you and your baby connect and bond.

A cesarean birth, whether expected or unplanned, offers unique challenges and circumstances for you and your baby.  It is helpful to recognize that a cesarean birth is still a birth, and you can prepare in advance by including plans for a birth on your terms, even when it occurs in the operating room.


Sharon Muza, CD(DONA), BDT(DONA), LCCE, FACCE is a birth doula, doula trainer and Lamaze certified childbirth educator in Seattle, WA.  Sharon is also the co-leader of the Seattle chapter of the International Cesarean Awareness Network, (ICAN.)  Sharon can be reached through her website,, if you would like more information or need some support in planning your birth.