Peachy Keen Birth Services Blog

In a time when 32.8% of babies are being born by cesarean, Cephalopelvic Disproportion (CPD) is one of the most common reasons cited for resorting to the notoriously over-performed surgery these days.

So what is cephalopelvic disproportion?
Cephalo = Head
Pelvic = Pelvis
Disproportion = Somethin’ Ain’t a-Fittin’ (This could  mean the head is too big, the pelvis is too small, or perhaps the pelvis is mis-shapen. But no matter how you break down the terms, it literally means that this baby’s head is not physically, geometrically, or in any other way capable of fitting though mom’s pelvis.)

Now let me start out by saying that CPD is not a myth. It is a true condition. I am in no way saying that it doesn’t happen or minimizing the absolute seriousness of true CPD. There is a small percentage of women whose pelvises will just not fit even an average sized baby, whether because the pelvis is just too small, or because it isn’t properly shaped (perhaps flat in the front instead of arched). So I am not making light of the fact that it can be a very real complication in which a cesarean is an absolute, life-saving blessing. But notice I said small percentage. Do you know exactly what percentage of women have a pelvis that isn’t physically capable of accommodating a baby passing through? Yeah, well, neither do I because there is no accurate research to this effect. But I can most surely tell you that it is nowhere near the ridiculous prevalence we hear about from random moms at the park who’ve “had to” have a cesarean because their “baby was too big.” Read on to find out why the majority of CPD diagnoses may just be masking the real “complication” – namely, the many fundamental problems with the way modern obstetrics treats laboring women.

There are two aspects to curbing the current insanity of everyone and their mama being diagnosed with CPD:

1. Avoid an inaccurate diagnosis of CPD in the first place.
Read on to see why this will save you a world of hurt later.

2. If you have been diagnosed with CPD in a prior pregnancy/birth, you may want to seriously evaluate whether it was accurate.
a) A CPD diagnosis might automatically exclude you from attempting a VBAC with your next baby, depending on your provider and the place you plan to give birth.
b) Even if there was a true reason your last baby really might not have fit through your pelvis, it doesn’t mean your next automatically won’t. And it doesn’t necessarily mean it was true CPD.

If you were diagnosed with CPD in a prior pregnancy and any of the following sound familiar, then you should question your diagnosis. Remember, CPD literally means that a baby is NOT PHYSICALLY CAPABLE of fitting through your pelvis. So if you have been previously diagnosed with CPD, but (fill in the blank below), it is quite possible you did not actually have CPD… and here’s why:

“I was diagnosed with CPD, but…”

1. “I wasn’t even allowed to go into labor.”
   THERE IS NO ACCURATE WAY TO DIAGNOSE CPD BEFORE PLENTY OF LABOR (AND PUSHING). Okay, scratch that. In a mom with severe rickets, an thus a severely abnormal pelvis, you may be able to diagnose CPD prenatally. But in a well-nourished modern woman with a properly shaped pelvis, there is no way to predict ahead of time if the baby will be able fit.
   a) There is no way to accurately measure the size of the pelvis and the size of the baby’s head to the degree you would need to in order to be able to determine if a baby would fit. Let’s face it, ultrasound often can’t even tell a 10lb baby from an 8lb baby. How many people do you know who’ve had a scheduled cesarean for a “big” baby that turned out to be an entire pound of two smaller than it was supposed to be? Now consider that when determining the pelvis/head ratio you’re talking about teeny tiny centimeters that can make a huge difference, and we just don’t have any way to attain that level of accuracy.
   b) Even if there was some magical way to obtain these measurements in the last weeks of pregnancy, it’s NOT, and I repeat NOT the size that the parts in question will be at the time the mom gives birth. The mom’s pelvis continues to loosen and flex due to surges of hormones and enzymes that relax connective tissue, both in pregnancy and even during labor and birth! Also, the baby’s head is made up of bony plates rather than one solid bone, allowing the baby’s head to mold to fit through the pelvis and birth canal. In short, your pelvis will get bigger and the baby’s head will get smaller. It’s really quite perfect, when you think about it.
   
2. “There was a time limit placed on my labor.”
   It’s getting more and more common to see a CPD diagnosis simply because labor has stalled for a bit. As in, “You haven’t made any progress for 2 hours.” You’d be amazed at how this can vary from provider to provider. I have worked with fabulous OBs who consider no dilation for 4 hours to be just part of the beautiful, individual process of progress and plateaus… and then there are those that consider anything less than 1 cm per hour to be a complication. First stage labor is about so much more than just dilation! It’s about softening and effacing the cervix, rotating the baby into the perfect position for your pelvis, helping the baby straighten its head into just the right angle, loosening your pelvic joints and opening your pelvis. And let’s not forget the emotions. Very often when a mom knows she only has “X” hours to dilate before a cesarean will be performed, the pressure and stress from that knowledge alone is enough to screw with the labor process. If you were not given plenty of time for your baby to position itself and for your pelvis to open, you can never know for sure what your body would have been capable of.
   
3. “My labor was induced (or augmented).”
   Chemical inductions, such as those with Pitocin or the unholy Cytotec, are notorious for causing contractions that are ridiculously long, strong, and close together. Unfortunately, this can cause the baby to literally be wedged down into the pelvis in an unfavorable position, making it difficult or impossible for the baby to fit through the pelvis. And with these unnaturally-painful induced contractions, it is much more likely that mom will want an epidural, which severely limits her range of motion and poses its own set of risks. I find it ironic that we are routinely inducing to prevent CPD because “we don’t want the baby to get too big”, when in reality the induction itself can increase the likelihood that the baby won’t be able to fit through the pelvis due to malposition, or the inability of the mom to change positions or effectively push after the epidural.
4. “I wasn’t allowed to move around during labor.”
   Again, so much of labor is about positioning the baby so that it will fit through the pelvis! But for the baby to be able to rotate into the optimal position, mom needs to be able to move, sway, walk, get on her hands and knees, or otherwise assume whatever crazy position her body is telling her to. Very few women in labor would willfully choose to lay in a bed for hours upon hours. Women instinctively move. What’s more, our bodies tell us how to move. A woman instinctively tries different positions in labor until she finds the one that feels the most comfortable at that time. The beauty and perfection in this is that the position that feels the best for the mom is almost always the one that’s getting the baby into the best position… that’s why it feels more comfortable! The relaxation aspect comes into this as well. It’s so much easier for a mom to relax when she is physically comfortable. However, if you’re told you have to lay in bed and it’s painful for you to be in that position, it’s going to be impossible to relax. If you can’t relax, it causes tension and fear and more pain, and this in itself can inhibit labor progress. So unless you had the freedom to listen to your body and move however your heart desired, it’s impossible to know how your labor and birth might have progressed.
5. “They broke my water.”
   This all comes back to the position of the baby. The baby’s descent into and through the pelvis is literally like a key fitting into a lock. The baby needs to be able to wiggle and rotate to find just the right position as labor progresses. The bag of waters helps facilitate this by creating a cushion of fluid around the baby, helping the baby to wiggle and rotate more easily. Unfortunately, many providers routinely break the water during labor to “speed things up” or “help the baby descend.” The problem with this is that it can “help the baby descend” right into a crappy position, and now it will be much harder for that engaged baby to rotate without the cushion of fluid, and this can cause the baby not to fit! Sometimes the water breaks spontaneously early in labor, which of course you have no control over. But the evidence seems to scream “If ain’t broke, don’t break it.” If your water was artificially ruptured, there is no way to know if your baby would have been able to get in a more favorable position had it had that cushion.
6. “My baby was known (or suspected) to be in a bad position.”
   Then this is not true CPD. Yes, a bad position that isn’t resolving can mean that THIS baby was not able to fit through your pelvis at that time, but it does not mean that your pelvis isn’t capable of fitting your next (hopefully more cooperative) baby through. Just because this baby’s head was asynclitic (cocked to the side, with its ear toward its shoulder) does not mean that the next baby will do the same. A bad position is just that – a bad position – not necessarily CPD that should doom you to an automatic cesarean the next time.
7. “I had an epidural.”
   An epidural can contribute to a baby not being able to pass through the pelvis in so many ways.
   a) Position – Yep, you guessed it. More on the importance of the position of the baby. It’s only logical that if mom has a very limited range of motion during first stage labor due to the epidural, the baby may not be able to rotate into an ideal position.
   b) Inability to Push – There is a varying degree of loss of muscle control with an epidural. Some women still seem to be able to push like champs. Some (like me) lose all sensation and muscle control from the abdomen down and literally just can’t make those muscles work very well when it’s time to push.
   c) More on Position – An epidural will almost always greatly limit your options when it comes to pushing positions. For a baby that doesn’t seem to be descending, trying lots of new positions is your best bet. But it’s very unlikely that you will be physically capable of getting into the more upright and active positions like squatting, standing, hands and knees, etc. when you have an epidural.
   If you had an epidural, one of the factors above could be the actual reason your baby wouldn’t “fit,” not necessarily true CPD.
8. “I had to push on my back.”
   Pushing on your back, or even the oh-so-popular semi-reclined position, is really not the greatest way to push… not by a long shot. Either of these positions will make it impossible for your pelvis to reach its full potential, so to speak. The sacrum and coccyx are compressed in this position, which literally makes the pelvis smaller. Other positions, such as squatting and hands and knees, can open up the pelvis by an amazing amount (seriously, I get gasps when I show this in the first class on my model pelvis). This is another thing that varies so greatly from provider to provider. I’ve worked with OBs who suggest different pushing positions before the words can even pass my lips… but I’ve also heard an OB tell a mom that laying on your back is the only way babies fit through pelvises (WTF?!?!). If your baby wouldn’t descend, but you were only “allowed” to push on your back, it’s possible that your baby would have descended just fine in another position. So it’s impossible to diagnose true CPD without letting mama push in every position imaginable.
9. “I was only given 2 hours to push, then told that my time was up.”
   This is literally how my first birth turned into a cesarean. I was young and clueless. After 2 hours of pushing on my back with just the nurse, in strolled the doctor (I refer to him as Dr. Douchebag now), and declared that 2 hours was way too dangerous and it was time to do a cesarean. The sucky part is that I was making progress, the baby was in no way in distress, and you could see about an inch and a half diameter of his head! But I wasn’t one to question a doctor at that point, so it never occurred to me that it was up to me to consent or decline. You can not diagnose true CPD until mom has had lots and lots of time to push. Some babies just take longer than others to rotate into the perfect position to allow descent. Remember the key-in-the-lock analogy. I have been to births where the mom pushed for 3 1/2 hours with no descent, but then BAM! Baby finds just the right position and rockets out in 30 minutes.
10. “I found out later that my OB has a 50% cesarean rate.”
    In all likelihood, you probably don’t know your OBs cesarean rate, since they aren’t a matter of public record. I was able to find out after the fact that my OB did have about a 50% cesarean rate! Now, for certain OBs that specialize in high-risk patients (perinatologists), this statistic might not be unreasonable. But if your run-of-the-mill OB had an unusually high cesarean rate, it shows that they may have a tendency to find problems where problems don’t exist. As I said in the opening of this post, the national cesarean rate is 32.8%, which is ridiculous in and of itself. So how much more ridiculous is it to let an OB with a 50% cesarean rate tell you that your body doesn’t work? This is a case where you have to consider the source. I would be much more likely to believe a CPD diagnosis given by an OB with an unusually low cesarean rate.

Yes, CPD is real. Yes, when it comes to true CPD a cesarean is the only way to a healthy mom and baby, and is an absolute Godsend! However true CPD is a lot rarer than today’s abundance of diagnoses would lead you to believe. Very often it seems to be an inaccurate diagnosis, masking the true complications caused by modern obstetrics’s constant interference with normal, physiological birth. Depressing as it may be, this fact also carries with it hope. The hope of using your knowledge to avoid a CPD diagnosis in the first place, and the hope of overcoming a previous CPD diagnosis.

I was told by Dr. Douchebag as he finished up the cesarean that a baby would never fit through my pelvis anyway, so we would schedule cesareans for future babies. After becoming educated, I went on to have my 2nd baby completely naturally in a different hospital, with only about 15 minutes of pushing. And that baby was a pound and a half bigger than the first baby who was taken by cesarean. CPD, my ass!