The Trouble with Repeat Cesareans February 22, 2009

TIME magazine’s recently published an article called “The Trouble with Repeat Cesareans” about the increasing trend in the denial of vbac to women who have had a prior cesarean.

“Indeed, the International Cesarean Awareness Network (ICAN), a grass-roots group, recently called 2,850 hospitals that have labor and delivery wards and found that 28% of them don’t allow VBACs, up from 10% in its previous survey, in 2004. ICAN’s latest findings note that another 21% of hospitals have what it calls “de facto bans,” i.e., the hospitals have no official policies against VBAC, but no obstetricians will perform them.”

So ICAN concluded that almost half of the hospitals they surveyed, either in policy or in practice, were denying women the chance to have vbacs. But why? Because vbacs are more dangerous than repeat cesareans? No one will deny that there is more risk to a vbac than a straightforward vaginal birth, but the documented risk of uterine rupture is 0.7% And repeat cesareans are not without risk. It is major abdominal surgery, and the risk of hemmorhage, infection, and death are all higher than with a vbac.

Which brings us back to why. The author wrote the a follow-up article called “Childbirth Without Choice” where she was told in frank terms why vbacs are becoming scarce:

“Or, as one ob-gyn put it when I asked why she and other doctors no longer allow VBACs, ‘It’s a numbers thing. It is financially unsustainable for doctors, hospitals and insurers to engage in a practice when the cost of doing business way exceeds the payback. You don’t get sued for doing a C-section; you get sued for not doing a C-section.’”

So, basically, it comes down to money. It isn’t about the safety of mothers and it isn’t about the safety of babies, women are being denied the chance to have a vaginal birth after they have a cesarean because of malpractice insurance and because doctors are afraid of getting sued.

WHY DOESN’T THIS HAVE MORE PEOPLE OUTRAGED?! Women are getting cut open again and again, without frank discussions about the risks and benefits of vbac over repeat cesareans. Truly, how are we supposed to trust our doctor’s judgment when it has been made clear that they don’t necessarily have our health and safety in mind when they make decisions about our care? That they might be glossing over the risk of repeat cesareans because it isn’t in their best interest to attend a vbac? How disgusting. How unethical.

But bless that doctors out there who are still willing to attend vbacs, who are truthful with their clients, who believe women should be given choices in birth and not railroaded into repeat surgery.

Where to go from here, though? How to change this, so that we don’t go back to “Once a cesarean, always a cesarean”? So that women don’t just hear about how risky vbacs are with no discussion about the reprocussions of repeat cesareans. To turn the tide so that the health and safety of women and their babies is more important than money?

Blaming mothers for choosing early surgical birth February 2, 2009

Let’s play Operation!

This is a blogger’s look at the article on the study “Timing of Elective and Repeat Cesarean Delivery at Term and Neonatal Outcomes”. The basic conclusion of the study was that more adverse outcomes are seen in babies born by repeat elective ceserean at less than 39 weeks.

The lead researcher goes on to suggest that it is because of the demands of mothers that obstetricians are preforming surgical births at less than 39 weeks. And I have to echo the author of the above mentioned blog’s incredulity. Why does the responsibility rest with the pregnant woman? Presumably, these obstetricians know better than an average woman how important those last few weeks are, especially in regards to lung development. Doesn’t the responsiblity lay mainly with them to educate woman about these risks? Where is the informed consent?

Even days count. Better outcomes are shown at 39 wks compared to even 38 wks and 5 days. This could be the difference between a baby and it’s mother recovering together instead of the baby being separated and put into the NICU. I am willing to bet that most women would be willing to put up with another few days of end-of-pregnancy discomfort rather than go through the stress of having their baby in the NICU.

So instead of blaming mothers for choosing surgery early, I would love to see steps taken to ensure that proper informed consent is given.

And I am back… December 3, 2008

My apologies for the lack of content on this blog as of the last couple of months. I am pregnant with a bambino due in June, so much of the last couple of months have been spent feeling yucky. But I am hopeful that things are coming around as my first trimester ends. I have gotten to hear the little ones heartbeat, which is always reassuring.

In January, things will get interesting. I will be seeing a group of perinatologists for a consult about the whole blood incompatibility thing (if you have no idea what I am talking about, you can read about my pregnancies in the first couple of posts on this blog).

Dread. I have thought and thought and pondered some more about how I can get out of this. I can’t. There is no way but through. I cannot pretend that this isn’t real, because that could end up with me mourning the loss of my newborn son or daughter. And so I go on this journey, because at the end, 6+ months of stress will be worth it. And because it challenges me. It challenges my assumptions about birth, life, death, what I am willing/able to endure for a child I haven’t met yet, but is still so very real to me already.

But I still wish….

I wish that this was not a journey that I had to go on. I wish that there was no blood incompatibility… that I could gestate and birth in peace. I squelch the jealousy that threatens to rise within me when I think of all the women that can do just that.

But wishes do not reality make. And there is hope. Lots of hope, if I am willing to accept it in whatever form in comes in. Since my husband is heterozygous for the antigen, there is a 50/50 chance that our baby will have it. All three of our other children have it, so statistically, there is a better chance of this one not having it. Hope.

Hope. For whatever reason, even though my two boys had the antigen, they were not effected by it, it did not “see” them. More hope.

Hope. This is now a diagnosable condition. There are things, prenatally and after the baby is born, that can be done to help the baby in the event that the antibodies are killing the red blood cells. This is the scary path, but there is still hope.

So right now, I take it one day at a time and hope for the best.

My thoughts on why the birthing woman gets the final say in where to birth October 10, 2008

I have been sitting on this post for a while, because it is not my intention to offend. A conversation in August with a dear friend prompted me to write down my feelings on this. I feel very passionately about this and yet, I still recognize that I don’t understand the dynamics of every relationship and it is up to the parents to negotiate what works best for them.

Our discussion revolved around whether a woman should submit to her husband if she wants to have a homebirth and he is uncomfortable with it.

A Christian Perspective
I suppose we should start with a discussion of submission. If you break it down into it’s Latin roots you have sub= under and missio= sending (as on a mission, which obviously is where that word came from). “Wives should be submissive (under the mission of) to their husbands, as to the Lord”(Ephesians 5:22) Well, what is my husband’s mission? What was he sent forth to do? For the purposes of this discussion, I suppose we would say that it is a husband’s duty to protect his wife and his children. That is his mission. Shortly after that in Ephesians 5, we have the verse, “Husbands, love your wives, just as Christ also loved the Church and handed himself over for her”(Ephesians 5:25) We are called to be under his mission. He is called to sacrifice himself for us, mirroring Christ’s sacrifice for the Church.

The Reality is that Homebirth is Safe
What does this have to do with birth? Reality- homebirth is as safe or safer than hospital birth for a low-risk woman. That is a fact, backed up by study after study. Most husbands who are reluctant to “let” their wives homebirth have not researched this issue at all. They are basing their ultimatum on their fear, which stems from the myths that society has fed them about birth: Birth is dangerous. If you don’t go to the hospital, your baby/wife could died. Never mind that the reality is that the hospital creates most of the problems that it solves. Never mind that most of the practices that are hospital protocol (continuous fetal monitoring, i.v. fluids, staying in bed, nothing by mouth) are not evidence-based and have not been shown to improve outcomes. Most homebirth practices have a c-section rate of 5% or less. With as good/better outcomes than hospital birth. It is the hospital that husbands should be afraid of, that is the reality.

Why is it so dangerous to “submit” to a husband’s wish for his wife to birth in the hospital when her desire is to birth at home/in a birth center? His mission is to protect her/his unborn child. He is not fulfilling his mission by forcing her into the hospital. He is risking her bodily/mental health. It is absurd that our husbands should ask that of us! What if our husbands requested that we have a cesarean? After all, it is easier to schedule for his time off of work, your vagina will still be “perfect”. Ridiculous right? Where is the line drawn? If men demand that their wives birth at the hospital, when they prefer to be home, what is to stop them from demanding them to have a cesarean?

And that is the danger when you go to the hospital to give birth. 1 out of 3 woman that walk into the hospital to give birth walk out of the hospital with a big gash on their belly in charge of in infant and recovering from surgery, perhaps traumatized by the experience, their future children and their health at risk, and their birthing choices limited. And why? Because our husbands are uncomfortable with homebirth, which they neither have researched or understand? Because they are afraid of what people will think? Is that loving us like Christ loved the Church? Or is he wrapped up in his own fears and pride? I would never ask my husband to risk his physical and emotional health that I might be comfortable in my irrational fears and I hope that he would not ask that of me.

And that is why a woman’s comfort during birth is paramount to her husband’s/partner’s. Because it is the woman, the mother that live with the consequences. He doesn’t have to to live through the flashbacks of a traumatic birth, a woman does. He doesn’t have to suffer from ppd. Women cannot let other people’s irrational fears jeopardize their physical/emotional/spiritual health. They owe it to themselves, their babies and their marriages.

What about the Fathers? September 18, 2008

I am excited to see this addressed. I have thought much about how unnecessary routine intervention impacts mothers and babies, but have really never given much thought about how watching these things effects the partner/father. What an intriguing subject!

August 13, 2008

I am still working on my response to the video. I started it, but can’t really articulate my thoughts well, so I am mulling it over some more. Until then, however…

I found this exchange particularly interesting. ACOG responds regarding VBACs, I respond back This woman wrote ACOG (American College of Obstetrics and Gynecology) regarding their policies restricting VBAC. They wrote back, with gross misinformation and she responded back. Scroll down to read her initial letter, their response is in the middle and her rebuttal is the nearest the top.

I find ACOG’s response alarming, though not surprising. They are willing to spout facts and figures, but where they got their “facts” has yet to be seen. No research backs up their response. None. It is hard not to laugh at the ridiculousness of their assertion. Just like their opinion on homebirth, their position is not based in safe, evidence-based practice. And the majority of American woman are putting their bodies, their reproductive health, their babies in the hands of these obviously delusional individuals. Scary.

Summary of the video August 8, 2008

In the previous post, I featured videos of Michel Odent talking about the importance of gentle, unhindered birth. If you didn’t get a chance to watch them (or you got a couple of minutes into it and decided you didn’t have the patience to discern the heavy accent. lol), here is my summary.

First, he speaks of the comparable safety of cesarean section to vaginal birth today. Cesarean section is undoubtedly safer than it was even 50 years ago. Then he poses the question… so, why not offer them to woman, if they are as likely to end up with a live infant as vaginal birth? He then speaks of the Scientification of Love, meaning love studied from scientific perspective. In all mammals there is a period shortly after birth that is critical in mother/baby attachment. And it is no coincidence that the primary hormone important in birth of a baby and delivery of placenta is the “love” hormone, oxytocin. There is a complex cocktail of love hormones to birth a baby, nature’s way of ensuring we will accept our young.

Secondly, he speaks of the necessity to rediscover the basic needs of laboring women. Woman cannot properly release the hormones that facilitate childbirth if we do not meet these basic needs: to give her privacy, so as not to feel observed and to have no one but a motherly, low-profile, silent midwife present. The midwife present must be relaxed, so that the mother does not release adrenaline because adrenaline opposes the release of oxytocin.

And thirdly, he speaks of how societies have been disturbing birth and the immediate period after birth with belief and ritual for thousands of years. An example he used was the belief that colostrum is bad for the baby. The ritual that follows is that the baby is separated from the Mother shortly after birth. When the third stage is disturbed, there is a higher incidence of bleeding issues for the mother, since oxytocin causes the uterus to clamp down after birth. We must now rely on physiologists and not culture, which affirm that the safest place for baby right after birth is in the arms of the mother.

So, in summary, if we give laboring women what they need, privacy and an undisturbed third stage, the cocktail of love hormones will follow from which flow attachment and safer birth.

I’d love to give my reflection on this sometime soon!

August 6, 2008

These are some of French obstetrician, Dr. Michel Odent, thoughts on the importance of normal, unhindered birth. He has a heavy French accent, so I suggest watching this when all is quiet and you can give it full attention.

August 2, 2008

You know the digressions i talked about in this post? This is one of them.

For the last six months, I have been strongly considering and feel led to start pursuing my midwifery education. The course I have chosen is with the Ancient Art Midwifery Institute because the rumor is that it is the most comprehensive, most difficult program out there. And I figure, that if I am going to do this, I might as well do it right. The program is also committed to normal birth- to trusting birth. That is the model I want to be trained in.

So I keep coming back to the question, why now? And I find myself with no answer. It seems like a bad time- I have three little ones, and I can’t say that there won’t be more, we are starting homeschooling in the fall. But like so many times on this journey into birth work, I am caught up in a momentum that isn’t of me. Until six months ago, I felt very content to put off my midwifery education until the kids were much older. That would be the smart, practical, easiest thing to do. But for whatever reason (maybe because I am basically very lazy and the challenge would be good for me?) I am feeling that the easiest path may not be the best in this case.

I feel frustrated. I want to do the best for my kids. I don’t want to sacrifice their childhoods for my dreams. And let’s face it, midwifery doesn’t have the most predictable hours. But I also want to model perseverance and following through with something that is worthwhile and important.

And it is important. Birth is important… how it happens is important. I would like to explore that more in my next post though…. why gentle birth is important to us individually and as a species.

So I trudge ahead, hoping I am doing the best thing. Hoping I can strike the balance. I want to get most of my book education out of the way before I start an appreticeship, for several reasons: to have an increased knowledge base prior to actually getting into the work, to get more time with the littles before being on-call is a part of life, and to grow in life experience. I walk on in faith.

Vaginal Exams (Part II) July 24, 2008

We have discussed how a vaginal exam is performed and what it measures, along with the pros and cons of vaginal exams prenatally. In this post, I want to discuss vaginal exams during labor and birth and their impact on the birth process.

What is the point of a vaginal exam during labor? In a typical hospital birth, labor is “supposed to” follow a pattern, called Friedman’s Curve. Here is a chart depicting what is expected of a laboring woman’s cervix:

This typically equates to the cervix opening about 1cm an hour. And so, dilation is usually checked about every hour, to make sure a woman is following the curve. If they are not, their labor is labeled “dyfunctional” and often, pitocin is used to augment labor. If that doesn’t work after a few hours, this is where the diagnosis “failure to progress” comes in and a cesarean is performed.

The problems with this? There are many. The most glaring being that Friedman’s curve is based on averages. What do we know about averages? That they are the mean, that there are normal labors that are shorter and there are normal labors that are longer. It is ridiculous to put a time limit on a physiological process, as long as mother and baby are doing well. It is based on the idea that Birthing Woman are Machines…. if the Machine doesn’t dilate X number of cm in X amount of time, the Machine is dysfunctional and we try to “fix” it. If the Machine won’t be fixed with pitocin, it must be broken, so let’s open it up and do a baby extraction.

So many things are involved in birth, the position of the baby, the strength of the contractions, the mother’s comfort and mental readiness for birth. Because the medical establishment likes to believe that the mind and body are separate, it completely discounts that if a woman is uncomfortable in her surroundings, her labor will not progress smoothly. But we are mammals. Most mammals make their nest and need darkness, privacy and quiet to birth. If they are disturbed, labor stalls. Humans are the only mammal that make their nest and then leave it to give birth. It is no wonder labor often slows down once a woman gets to the hospital (or when the midwife arrives at the home in some cases), the mammal part of her says, “New environment, people poking me and asking me questions, not a safe place/time to birth”

The physical aspect of it is that it can be, and often is, very painful. During a time when a woman’s body is trying to open up and push down and out a baby, fingers up into the vagina are invasive and counterproductive. In addition, the more vaginal exams, they higher the incidence of infection, especially if the water is broken. If the bag of waters breaks before labor starts, one of the most harmful things a care provider can do is a vaginal exam. As long as things stay out of the vagina, the risk of infection is minimal, but as soon as anything foreign is introduced (sterile gloves included), the risk goes up.

The psychological aspect of vaginal exams during labor is that they can be extremely discouraging if things are not progressing “normally” The language used during vaginal exams is often negative… only 3, just 7, not quite 10 cm. And let’s go back to the fundamental truth about vaginal exams that we discussed last post: They only tell what the cervix is doing at that moment. There is no accurate predictor of how long the rest of labor will take. It is entirely possible to go from 4 or 5 cm to complete and pushing in a matter of minutes. In the absence of an actual problem (and a long labor is not a problem) it is a completely pointless procedure.