Awareness

It's April again... it seems to come faster and faster every year. And I'm back-- I know, I said I was done, but... well, in birth advocacy, it seems there's no "done" until every baby and every mother has the best birth possible under their respective circumstances. Of course this year was special: it was an ICAN conference year, and the conference was wonderful, as always. It went too fast (as usual) and I didn't get nearly as much accomplished as I'd hoped, but I wouldn't trade that four days for anything. We are truly "gentle angry women," and I am honoured and proud to join my sisters in what has become a sacred pilgrimage every two years.

Now... Awareness. It seems like a simple concept: being in the moment, experiencing life as it comes. In practice, awareness is exquisitely difficult, at least for me-- in terms of the cesarean epidemic, it's excruciating. Let me illustrate.

The CDC numbers are out for 2009 (the most recent statistics); the United States currently boasts a 32.9% cesarean rate. That number has risen every year for the last thirteen-- and it's more than double the highest rate recommended by the World Health Organization. Effectively one-third of all women giving birth in this country are having their babies surgically removed, exposing them and their infants to risks that include haemorrhage, infection, injury to bowel and bladder, respiratory difficulty, and, yes, death... now, or in later pregnancies. C-sections are no laughing matter; they are most assuredly not "just another way to have a baby. That said, many of these surgeries are undoubtedly necessary, and certainly when they are everyone involved is glad that there are skilled surgeons available to intervene. But in the majority of cases, surgical delivery is not warranted, and too often, mother or baby suffers because of it. Baby has transient tachypnea of the newborn that devolves into neonatal respiratory distress syndrome, leading to a stressful (and costly) stay in the NICU. Mom develops a wound infection and has to be re-hospitalized. Breastfeeding relationships are compromised. In a future pregnancy, mom is diagnosed with placenta accreta or another problematic placental issue that can lead to uterine rupture (yes, even without attempting that controversial VBAC thing), placental abruption. The end result can be utter devastation.

And this has what, exactly, to do with awareness? Well, I'm getting to that. Firstly, being aware means understanding that all of the above goes on every single day. True, most cesareans come off without a hitch-- "mother and baby are doing well," as many an excited new father has announced proudly to his friends and family. But... not always. And we should never lose sight of the fact that terrible things happen: while one mother is recovering without incident and enjoying her new baby, another is... not. I refer you, for example, to  the heartbreaking story of Liz Logelin, which now graces the New York Times bestseller list, thanks to one remarkable father and his determination to turn his personal tragedy into inspiration and support for others.

I work in maternal-infant health. It's a rare day on my unit that we don't get a c-section up from L&D. Some are scheduled, elective surgeries that are usually (but not always) repeats. Others are non-elective-- rarely true emergencies, most are what I would term unnecesareans, which Jill discusses much better than I can. Usually these are the "failed inductions"-- moms are brought in and given drugs (pitocin, cytotec) to force them into labor. Too frequently, they don't work-- well, of course not, since any sensible pregnant body will fight against such a thing to protect itself and its offspring-- and then it's off to the OR. "Time to get this baby out," the OB will say, when in reality he's probably thinking, I really don't want to be up all night, clinic will be a bear tomorrow, and I'm tired of listening to the wife nag when I'm late again for dinner, so let's get this over with right now. Mom is exhausted, confused, frightened; she readily agrees when the experts tell her that her baby is in distress and if they wait much longer he could die. When it's all over, the OB comes out covered in glory-- he saved the baby, after all!-- and mom is just grateful that all's well that ends well.

I see this scenario over and over. So often, in fact, that I and all my coworkers consider it routine. Another c/s coming to room 3. Get an IV pole and a pump for the SCDs. CBC for in the morning. Clear liquids now, regular diet in the morning. Foley catheter out and dressing off in 24 hours. Epidural stays in till post-op day 2; expect discharge on POD 3. No big deal; it's just another delivery.

But it's not. And that is so hard to keep sight of, day in and day out. I don't know what my hospital's cesarean rate is (they are not required to release those numbers to the public, just to the health department, and the stats are lumped in with those from the county's other hospitals), but based on what I see, I would expect it to be higher than the national average-- probably at least 35%, maybe closer to 40%. On some days it's much higher-- there was a string of Fridays back in January and February where we were doing 5 or 6 sections each day, which was 75-100% of the total deliveries on those days. Coincidentally (!), our NICU admissions soared during that period as well...

Commonplace. Routine. So normal, in fact, that a day without a surgical delivery is remarked upon by nurses, doctors, even housekeepers. How does one maintain awareness, then, in such an environment?

I tell myself every work day that, even though for me it's just another day at the grindstone, for my patients, it's the beginning of the rest of their lives. They will remember what I will not. It helps... but not enough.

So. It's April again. Almost May, now. I renew my promise, every year, to cultivate awareness in my life, to be fully present for these new mothers and families, for the babies who are welcomed earthside in what believe to be less than optimal circumstances. I bear witness. It's all I can offer.