Just an Example

As one of my New Year's projects, I've decided to try to informally track the deliveries at my hospital and watch the trends over 2012. This is not a rigorous scientific study, by any means; it's really little more than anecdotal. I plan to record our deliveries daily, and to make note of method of delivery, primary vs repeat cesarean, indication for surgery, etc. This will only include babies who are admitted to the well baby nursery, so there will be a good chunk of missing information right there; we do have a Level IIIb NICU, and it will be difficult to obtain delivery notes on those infants admitted directly to them on days I'm not actually here. So, as I say, this is just a sort of exercise-- in observation, data recording, and preliminary analysis.

I started recording delivery stats on December 19; I have 21 consecutive days of data, as of today. Just for giggles, so to speak, I decided to glance over them-- to see what I had. Here's my data:

n= total deliveries= 68
v= vaginal deliveries= 39  (57.4% of total births)
x= c-sections= 29 (42.6% of total births)
r= repeat c/s= 11 (16.2% of c/s)
p= primary c/s= 18 (26.4% of c/s)

The cesareans were done for a small number of predictable reasons. I broke the indications down into four categories:

1. "failures"-- labeled as such by the OBs, including "FTP (failure to progress)," "FTD (failure to descend)," "failed induction," and the ever-popular, vague, and widely inclusive "NRFHT (non-reassuring fetal heart tones)"

2. primary elective for breech-- no one here will do vaginal breech deliveries on purpose, so for all intents and purposes, these are physician-elected c/s

3. primary elective for maternal reasons-- there were three of these, including one mom who was HSV+ with a current outbreak, one mom who had a history of spina bifida and attendant multiple back surgeries, and one mom who was urged to elect her c/s for that fabulously accurate diagnosis, "suspected macrosomia"

4. other-- only because I wasn't sure where else to put it; I didn't have enough history in the report I got or on the chart; it was presented as a primary nonelective, nonemergent cesarean due to oligohydramnios and "placental issues, nonspecific"

The majority of the primary c-sections fell into the first category: 10/18, or 34.5%. There were 4 breech sections-- three scheduled, one discovered in labor (when mom was ready to push!)-- so 13.8% of the total. The other 4 were also scheduled, for the reasons listed above. That nonelective, nonemergent one resulted in a completely normal newborn with no signs of distress . That allegedly ginormous baby weighed a whopping 8 lbs 4 oz. Oh, and most of those NRFHT sections (ie, for fetal distress) produced babies with APGAR scores of 8/9 and 9/9. Sigh.

So, in the past three weeks (covering Christmas and New Year's), we had a cesarean rate of almost 43%-- well above the national average. I'll be curious to see if this trend continues. I've long suspected that our facility's c/s rate was that high, but I've never been able to demonstrate it. If I can keep this up, at least I'll be on my way to documenting outcomes for one mid-size hospital in Middle America. That's the plan, anyway.

Redemption

On the occasion of my sweet son's SIXTH (!!!) birthday, I wanted to post the story of his birth-- and mine. I warn you: it is LONG! Interestingly enough, since it's been 6 years, the dates correspond to this year's calendar. 


This is the story of the birth (yes, BIRTH!) of Rowan, my third child, the first baby to whom I gave birth. It's the story of my long-fought-for and dearly wanted VBAC, my UBA2C. In a way, it's my own birth story-- because I felt that I died on the operating table when my second baby was extracted from my body after a failed induction, but I was born as Rowan emerged from my strong, resilient uterus.

I'm taking some of this straight from my journal-- I've long since succumbed to some mommy amnesia. Some of my labor and birth are already fuzzy... some parts, like the feel ofRowan's head as he was crowning, I will never forget. Never.

Sunday, 4 September 2005

My physical state is fine. No sign of impending labor. Let it be. [This Beatles song gave me my pregnancy and birth mantra.]

Emotionally... sigh. Bored, discouraged, depressed. Wish it'd just get going so I could stop worrying about it. DON'T want to go back to work on Tuesday, but no choice if no labor-- I can't afford to lose paid time off hours. BLECK!!

Monday, 5 September 2005 -- Labor Day. Ha!

Physical: fine, a few more ctx [contractions], some fairly intense.

Emotional: hate the world, wish everyone in it would bugger off and leave me alone! 

Tuesday, 6 Sept 2005

41 weeks, on the dot.

WHY AM I NOT IN LABOR???!?!?!

Am I really broken?

No. Can't be. Surely not.

It'll happen. Won't it?

Tami G. emailed me and said something profound: in a month, I'll be holding my baby. Hang onto that.

ICAN VBAC!!!!!!!

Wednesday, 7 September 2005  ~5 pm

Stopped to get gas-- reached down to pop the gas tank door-- felt another distinct POP! Water broke-- gushing, but clear. Baby obviously not engaged. Got back in the car and drove home-- lots more fluid with each ctx. Niagara Falls effect stopped when I got home and got upright for awhile-- Rowan's head settled deeper in pelvis?

Few light ctx, not regular. Trying to stay up, moving, etc, but leaking is a problem. Stood at computer and emailed ICAN, IM'd Lisa-Marie. Hard to concentrate.

6:30 pm-- kneeling on bed, rocking hips-- feels good. Ctx still seem light.

7 pm-- up and around a bit, lots of show. Loose stool. Light ctx every 2-3 minutes (trying to avoid the clock). Bored. Lying on side uncomfortable-- up to shower again.

9 pm-- ctx spaced out. Not timing. Can only focus on one thing at once during ctx. RELAX. More gushing-- not like earlier, though. Sleep soon?

10 pm-- KIDS ARE DRIVING ME INSANE!!!!!!!!!!!!!!!  Whining, fighting, carrying on-- wish I had someone to take them AWAY! Definite downside to DIY. Ctx more intense. More show. Going to sleep soon-- assuming kids will stay in bed! [NB: Rhiannon, my daughter, was 5 at this time; Gareth, my first son, whose story I posted on his birthday, was 3. They slept through everything.]

11 pm-- no sleep for me, can't lie down comfortably. Shower WONDERFUL!

_____

This is where my journal entries end-- I couldn't write anymore. The kids did stay in bed, and I sent their dad, John, to bed too. I told him to get some rest, and I'd call him when I needed him. I figured I had hours ahead of me, and he would need the sleep. Then, labor hit like a freight train!

I had been in the shower for maybe ten minutes when I got out to tell him that I needed the pool NOW. And I promptly went and got into it!

The pool was set up in my living room, and was about a quarter filled. John had started working on it as soon as I came home and informed him that my waters had released-- we never did get a hose or an attachment for the faucet, so he was filling it one bucket at a time. Luckily, we have a wonderful hot water heater-- it never failed me. And John, who was a trooper through the whole labor, boiled pot after pot of water (how stereotypical can you get?) to "hot up" my pool even more.

When the pool was about 2/3 full of blissfully hot water, John set up camp in the living room. He dragged in the mattress from Gareth's (unused) toddler bed, covered it with sheets and a comforter, then got in and tried to go back to sleep, while I labored in the pool.

It was about midnight-- I'd made John turn the clock away from me, because I didn't want to watch it all night. I knew I had a long slog ahead, and I didn't want to get discouraged. I'd seen that the contractions were coming roughly every 2 minutes, and I didn't want to know anymore.

The contractions... I'm not sure what to say about them. In the shower, I handled them best by letting the water spray on my back, down low (where I kept my fists jammed most of the night, the result being that my shoulders were killing me the next day) while I rocked my hips back and forth. I was chanting the Goddess Chant through each surge-- two versions, mine and 
Starhawk's. Sometimes I got them mixed up, but I doubt the Bright Lady cared!

Starhawk: Isis Astarte Diane Hecate Demeter Kali Inanna

Mine: Isis Athena Rhiannon Cerridwen Brighid Anath Arianrhod

Soon it changed to "Open" over and over, longer and more drawn out with each surge: "Oooooooopennnn. Oooooooooooooppppppennnnnnn." Four or five of those got me through a contraction.

In the pool, early on, I spent time on my knees, still rocking my pelvis. When a contraction came, I had to submerge-- get under it, literally. I went to my hands and knees, then into a push-up position. I hung onto the side of the pool, chanting "open" again and again-- my old trick of counting through each contraction, which I used throughout my labor with Gareth during that idiotic seventeen-hour induction, failed me this time. Nor was I able to escape the sensations and go elsewhere, the way I had last time. This was much faster, much more intense. 

I found I was better able to handle the contraction on my feet, so I stood up much of the time, knee-deep in warm water, fists thrust into the hollow of my back, toning. "Open" was now just "Ohhhhhh... ohhhhhhh" low and loud-- I couldn't control it, though I didn't want to wake John up. I stood there in the semi-darkness-- the living room lights were out, but the bathroom light shone through-- singing my birth song and trying to work with, rather than against, the expansions of my uterus.

Does anyone remember the study that said that even a "virtual doula" helps a woman get through labor-- that someone in her head, an imaginary doula to encourage her, is beneficial? Well, I can say that for me, at least, it was true. The real-life doula I had during my attempt at hospital VBAC was kind but ineffectual. The one in my head this time-- Kmom!-- was brilliant! She said everything I needed to hear: you're doing great. Keep breathing. don't forget to pee. You're doing this, you really are!

And so I labored. As before,  I had no concept of time. John tells me it was about 1 am when my vocalizing changed and he woke up fully (he'd only been dozing anyway). About 1:30 he remarked casually, "They're less than a minute apart now. You ARE progressing. They're lasting about 20 seconds."

Twenty seconds--?? I was crushed. I kept thinking, "longer, stronger, closer together." If these were only 20 seconds-- !!!

"I don't want to know that," I groaned. "Don't tell me that."

After a few minutes, Kmom told me to go to the bathroom again, so I did. I emptied my bladder-- John had placed a large mug of water and a huge plastic cup of crushed ice on a milk crate beside the pool, and I had been drinking and crunching plenty-- then got back into the shower. It wasn't as comforting as it had been, so I went back to my pool and asked John to add some more water. He tried to hold me, offering to do a supported squat, but I couldn't bear to be touched during a contraction. So he bailed some water out of the pool and replaced it with hot.

He was so supportive, even though he felt he didn't do enough, that he was "too hands-off." But that's exactly what I needed. He held the space and he kept my water hot. He sat quietly and watched me, but didn't interfere; he helped me focus when I really needed it. He was perfect, and for that, I will always be grateful.

A small piece of my mind wondered where I was, dilation-wise. I didn't want to psych myself into thinking it would be done soon, even though it felt VERY fast and intense to me. I was trying to prepare myself, physically and mentally, for another whole day of this-- longer, if necessary! Think of Eugenie, I told myself-- Eugenie, brave woman, who labored for 80-plus hours to birth her son. Yes, I argued with myself, but think...

There were clues, and I couldn't help but notice them: the way I was toning through contractions, the lowing, birthsong quality to them. Shorter, more intense contractions could mean I was in or near transition. I was starting to feel nauseated at the end of each surge. I never did throw up, but I told John repeatedly that I felt I might. I started dozing or "zoning out" between contractions, drifting into a strange, incoherent laborland. I could only endure contractions by standing and rocking my hips, then getting underwater and floating once I'd passed the peak.

I realized I was feeling very foggy. Random thoughts crossed my mind-- bizarre, dreamlike notions that seemed to make sense at the time, even though a part of me knew they didn't. The only one I remember was odd-- and please, don't anyone take this as offensive, it's just what wandered through my head: "I wonder why it is that white women named Irene often shorten their name to Reni, while non-white women just use 'Irene'?" [I have no idea if this is true, but I doubt it. Weird labor thoughts!] "And why is it 'Ear-ray-na" in England, but 'Eye-reen' here?" Transition, anyone? ;)

Then, abruptly, the fog lifted. Suddenly I was thinking clearly again-- the world came back into focus. And to my astonishment and chagrin, I realized that I was pushing at the end of each contraction!

This can't be right, I thought wildly. Something's wrong-- it's too soon--

But it didn't feel wrong; it felt right. Not good, but RIGHT. So I pushed.

I remember thinking, I want this over! I want it over and done. How much can a person be expected to take? This is silly! I did not have to do this!

I don't think I said any of this aloud (and Kmom chastised me, albeit gently, in my head!). I know I did whine, "I can't do this!" once or twice, and John came and looked me straight in the eyes, saying, "Yes, you can, you are, you're doing great." I reminded myself that I'd known what I was getting into, I'd made my choices and I had to accept them, and whinging about it wasn't going to help anything. I may as well be there, since I had to be-- it was like that old kids' game, "Going on a Bear Hunt" : "Can't go over it. Can't go under it. Have to go THROUGH it." At times I hated it-- my friend Gretchen is right, pushing SUCKS-- but I kept going through.

The urge to push was subtle. It wasn't "I GOTTA PUSH," the way it was when I was laboring with Gareth. It was like something had taken over my body and was pushing whether I liked it or not! I began to roar with each push, getting louder and stronger.

"You're progressing," John said with satisfaction.

"I think I'm pushing," I told him.

"Don't wear yourself out. Take it easy."

Easy to say, but the effort was impossible to resist. I was worried-- it still seemed too early (as far as I can make out, it was only about 2 am) to be pushing. I hadn't been laboring long enough. I was afraid that I was only 5 cm with a badly malpositioned baby, that I was making it worse with every surge, swelling my cervix and sealing my doom. I didn't know what to do, and I said so. Then, in a fit of desperation and doubt, I asked John to check me-- the first vaginal exam I'd had since I was 9 weeks along and worried about a possible miscarriage.

He went and scrubbed up-- offered to use bleach (!!!) but I convinced him that soap and water was sufficient, as long as he scrubbed for at least 20 seconds. (I think he did 2 solid minutes. ;) He came back, and we waited through another contraction. Then I tried to lay back and let him fumble around for a moment or two, as long as I could endure. He reported, "No, nothing."

I wanted to cry. In fact, I think I did cry, a little it. How much more could I bear? What should I do?

Another surge, like a terrier shaking a rat. Lots of show, some gushing fluid, intense pressure in my rectum. Something was moving through me-- there was no escaping it. "It feels like it's right there," I kept saying. "It" was hard to describe, but it felt foreign-- not me. It seemed to move opposite to me-- if I swung my hips left, it rotated right, or else I rotated around it while it stayed still. It didn't hurt, but it was very, very uncomfortable. There was no getting away from it. It was... inexorable.

I pushed and roared and pushed, giving up my brain's worries to let my body, my primitive self, take over. "I surrender," I told the Universe. "Whatever happens..."

It went on, and on, and on. I had no clue what time it was, or how long I'd been there. I pushed standing up in my pool until my knees shook and threatened to buckle, then I went back to kneeling. I tried to push while lying on my side-- first right, then left-- but while floating on my side and back between contractions felt good, pushing in those position did NOT!

Standing was best-- kneeling was tolerable, but only just. Sitting, lying, even floating in the push-up pose I'd used earlier-- these were all completely untenable.

"Bathroom," Kmom commanded in my head, and I managed to drag myself out. I sat on the toilet and pushed there through a few surges-- that felt pretty good, but not as effective as I'd hoped, so I went back to the pool. Surge-- push-- howl like a wolf. Repeat.

After awhile, John, who was getting more excited and nervous, asked me, "Should I check you again?"

"If you want..."

More groping, then, "It feels like it's getting harder."

"The head?"

"I don't know... but I can tell you, you're really open."

Push. Roar! Breathe. Again. And again. Have I ever worked so hard in my life?

Push. Push with all my might-- I was worried that I was doing the "purple pushing" encouraged in hospitals. Shouldn't I be trying to breathe the baby out instead?

Screw it! I thought grimly. I don't care if I tear six ways from Sunday. I want this kid OUT!

Push. ROAR! Breathe.

Over and over, more than body and soul can bear. I can't do it. I can't. Not anymore. I can't.

"Yes, you can," John insisted. "You've come this far. You're not giving up now. You've told me a hundred thousand times you can do it, and I believe you. You CAN."

I reached down, trying to see if I could feel-- something, anything. "If it helps," John was saying, "your belly [meaning the bump that was Rowan] is lower." With my last push, I had felt a stinging sensation, and the phrase "ring of fire" had danced through my mind, but I had quickly dismissed it. Still-- maybe my perineum was at least bulging a bit--

And there "it" was, just under my fingers, barely inside me: a squishy soft mound, damp and warm. I froze. O my dear good Goddess--

"There's a head there," I said, shocked.

John lit up. "Yay! You're almost there!"

Another push-- the head slipped back, but only a little, and there was a definite burn now. I didn't care-- it wasn't bad, and anyway, there was a head there! Set me on fire, I don't mind, I'm BIRTHING!

The surge ended. "Want to feel?" I asked John, and he reached into the water-- I must have been kneeling at this point. I can't describe the expression on his face. "Yeah," he whispered. "Yeah..."

PUSH! I bore down hard, remembering the old saw, "Giving birth is like passing a watermelon through a hole the size of a lemon." I pressed my fingers hard into the skin around my vagina, trying to stretch the tissues. That one stung-- but in the next moment, I had a small (!) firm head in my hand! John was holding it too-- Rowan was out to his ears, maybe, and I was screaming. It HURT-- the only part of the whole labor I could truthfully call, well, excruciating.

"What now?" John wanted to know. He was stunned.

"Wait," I gasped, "for the next contraction..."

"Come on..."

It felt like forever. I tried to push without the contraction, but the baby didn't budge. For the first time all night I was praying-- pleading-- BEGGING for another contraction!

Finally it came-- and I PUSHED--

The head came out; the shoulders and body quickly followed. (So much for my fears about shoulder dystocia!) Before my brain could register was had happened, I was holding a slippery new baby in my arms!

I sat back-- the pool, which up till now had stayed remarkably clear, was now murky with fluid, blood, mucus, and fecal material-- but mine; there was no meconium. I didn't care what I was sitting in. I had done it! I BIRTHED MY BABY!!!!

I VBAC'd!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

"Hello," I crooned to my new little bug. "Oh, hello!"

He was perfect-- well, I didn't know he was a "he" yet-- snuggled up to my shoulder. He was dusky, but his face and chest were pink. He hadn't made a sound. I rubbed him, talked to him-- he opened his eyes and looked at me, but he still didn't make a peep.

"Hi, sweetie," I said. "Oh, you're so beautiful. Look at you-- oh, hello, Rowan!" 

He finally whimpered a little when I gave into John's increasingly anxious requests and turned him over to check the sex. I laughed in surprise: "Oh my God, it's Rowan Riley!"

Rowan would have been Rowan whether he was a boy or a girl, but with different middle names depending on gender. We had been expecting a girl all along, but Rowan fooled us. We laughed and Rowan finally cried, and I held him close while John got a towel to cover us.

I couldn't stop thinking, I did it! I DID it!! I DID IT!!!!!

"What time...?" I managed.

"Congratulations!!!" John shouted. "You did it-- 4:33 am!"

4:33 am?? That's ALL??! I was in complete shock-- my water broke at 5 pm, I'd only really labored since 11 pm. Five and half hours, and most of it pushing...? Early in the evening I had joked, "Wouldn't it be great if the kids could wake up and find their new sibling? And I could call my mom and tell her to stop by on her way to work?" I never thought it would happen...

John helped me out of the pool and we headed for the bedroom, marveling over our new baby boy. I found a tape measure and tried to get some stats-- I came up with 14 1/2" head circumference (molded) and 21 1/2" body length, but Rowan wasn't very cooperative, so they were largely gross estimates. He seemed smaller than his siblings-- smaller than Gareth, certainly, who had been 10 lbs 5 oz; maybe littler than Rhiannon, who'd weighed a pound less. But who cared? I had birthed him!

I put him to the breast, and he latched on and nursed for quite some time-- twenty, thirty minutes? Can't recall. I was still have irregular, intense contractions, and around 5:15, they started gearing back up, getting stronger and closer together. I told John to get the big plastic bowl I'd bought, and I got up to deliver the placenta. Push-- but only a small, palm-size piece came out. A clot? No, definitely part of the placenta. It was followed by another, larger chunk, and in a few minutes, the largest piece-- but still only a quarter to a third of the whole. This one included the cord, which was perfectly, beautifully attached, just as it should have been-- a proper, three-vessel cord with textbook insertion.

I knew that a placenta that delivers in pieces is a bad thing, and if I had been thinking straighter I would have called for transport then. But I was high on my birth, I was exhausted, and I just wanted it to be over so I could bask in the afterglow and snuggle with my little guy. In retrospect, of course, it was a bad call.

John went and called my mom and said, as I'd instructed, "Stop by the house on your way to work-- there's someone you'll want to meet." Then he came back and took the baby, and I got up and took a shower! Such a small thing, but when one's previous "birth" experiences entailed major surgery and a long period of convalescence, the ability to step into one's own shower, unassisted, is nothing short of a miracle-- and underscores yet again (as if I needed reminding!) the vast difference between a vaginal birth and cesarean surgery. The latter is most definitely NOT "just another way to have a baby"!!

At 6:30 we woke the kids up to get ready for school. John told Rhiannon, "Come in here and see-- baby Rowan came." Rhi tore into my room, saw Rowan, and stopped short, staring in awe. Then she cooed, "Oh, he's soooo cute!" Gareth came just after, amazed to find that "the baby came out of Mama's tummy!" They were just precious, both of them.

My mom and sister arrived at 7:15 with a baker's dozen of Krispy Kreme doughnuts. They stayed with me and admired the baby while John took Rhi to school. My sister was especially amazed-- she had fully expected me to have to be taken to the hospital in a flight-for-life helicopter for emergency surgery. She'd had nightmares that Rowan and I would die-- the main reason I hadn't told her or my mom that I'd been in labor.

"I can't believe it," my sister kept saying. "You look great. I remember after Gareth was born-- even after Rhi. You looked so sick-- grey and little and sick. Now you're just... glowing!"

If pride and excitement were visible, I'd be lighting up the entire city. I've never felt so alive, so empowered, in my life. I could move mountains!

My mom went on to work, and my sister took Gareth. John and I rested, then got up and took Rowan to our pediatrician, when he was 6 hours old. The office staff was aghast and amazed when we told them about our unassisted homebirth. But the doctor pronounced Rowan "perfect!" and gave us the official stats: 21 1/2" long, 14 1/2" head, 10 lbs 8 oz!!!! Bigger-- just a little, but he had had a wet and dirty diaper since his birth-- than Gareth!!!

I was stunned-- I'd really thought Rowan was smaller, since I didn't get as big as I had with his brother, and he just seemed little. I'll admit I was slightly disappointed, thinking, Well, maybe I couldn't deliver a ten-pounder, but at least I can deliver an eight-pounder.... But the scale confirmed it: TEN-POINT-FIVE POUNDS, definitely a "big baby" by modern medical standards. That ten-pound stigma had caused my medwife to dump me last time-- she was terrified of Gareth's size. But I birthed the same size baby on my own with no problems-- no sticky shoulders, not a tear, not a skidmark, nothing! HA!!!!!!!!!! Take THAT, sOBs and Evil Medwives of the world!!!

Birth happens. I know it does. It happened right there in a blow-up pool in my living room. Birth happens as God/dess intended, without drugs or knives or sterile fields. Birth happens.

It wasn't perfect-- I still had the retained placenta to deal with. (I'll write a separate epilogue for that-- I've gone on long enough!) But in the end, it was all so beautifully simple. I went into labor. I dilated to complete, without anyone having to reach gloved fingers into my body to verify it. When it was time to push, my body did what it was supposed to (although I'm a little bitter that I didn't get my "rest and be thankful" moment!). I acted instinctively to assume the positions that were best to facilitate Rowan's descent. I supported my own perineum, and I did not tear. Rowan was born-- and so was I.

Capitalizing on Loss and Risk

My dear friend Shannon at BirthAction wrote this post that everyone should read. Go on, read it. I'll wait.

Capitalizing on Loss and Risk


It brings up so many good points... the main one being that, for women birthing in hospitals, the playing field is never level. True informed consent does not exist in our current system; without it, women "choose" interventions and procedures that damage them and their babies-- and sometimes kill. How can we increase awareness? How can we make women understand that they have choices? That labor starts and progresses without dangerous drugs-- that babies can be born without drips and wires and gleaming metal instruments? How can we convince women that they are strong and capable, and they do not have to lie down for the knife? Most of all, that birth is safe... interference is risky?

VBAC Viability

Other, better commentators (Henci Goer, Marsden Wagner, Sarah Buckley, Kmom, Rixa, Laureen Hudson, Jen of vbac.com, and many more) have written extensively about VBAC and why it's preferable to repeat cesareans for most mothers. Anyone who has done even the most casual reading on the subject knows that surgical deliveries carry with them a significantly increased risk of injury, infection, hemorrhage, and other complications for mothers and babies. Cesareans require longer hospital stays, more pain, more drugs, more risk of respiratory problems. NICU stays are more common; so are post-op transfusions, deep vein thromboses, and hysterectomies. Recovery is substantially longer-- those first few weeks of motherhood are challenging enough without adding the debilitation of major abdominal surgery to the mix! Babies are less likely to continue breastfeeding-- mothers who are exhausted and in pain, who can't lift their infants or even sit up straight, often give up and bottle feed. Consequently, cesarean-delivered babies are more likely to experience jaundice shortly after birth, and asthma, allergies, and obesity later in life. And while the initial cut is bad enough, each subsequent cesarean raises the risk of long-term complications for mama: placentation problems (placenta previa, abruptio placentae), secondary infertility, miscarriage, and ectopic pregnancy. Any of these are potentially devastating issues-- and yet mothers are told, time and again, "It's just a c-section."

"Just" a c-section? I've heard this phrase over and over, both as a mother and as a nurse. When completing a history and physical for a new family doctor, I checked the box that said "Prior surgeries" and wrote in "cesarean times two." The medical assistant who reviewed my chart commented, "So you've had surgery? Oh, no, I see-- you've just had c-sections." I had to bite my tongue to keep from screaming, "What part of major abdominal surgery aren't you getting? Have you been splayed open like a fish, your guts exposed to all and sundry, your abdominal muscles split and left to reapproximate in whatever slapdash fashion they choose? Have you dragged yourself up and down a flight of stairs, clutching the banister with one hand and your belly with the other, convinced that you're going to open up and spill your internal organs on your shoes? Sure-- just c-sections!"

Hollywood and the media are responsible in large part for the public perceptions of birth and cesareans. Everyone has seen the TV version of labor and delivery: mom rolling around in a hospital bed, screaming, cursing her husband's name, swearing "He'll never touch me again!" Comic sidekicks rush in and out while mom groans and shrieks and generally does her best Exorcist impersonation before delivering a bright-eyed three-month-old to the general adoration of all in attendance. Celebrity moms-- Victoria Beckham, Britney Spears, Madonna-- all those "too posh to push" mums, who get tummy tucks at delivery, who have personal trainers to get them back in shape fast and personal chefs to feed them and nannies to take care of their newborns and older children-- they make cesareans look like the easy, chic way to have babies. None of the fuss and muss of labor-- just show up at the hospital on the appointed day, coiffed and made up and manicured, pop into the operating room and get that oh-so-lovely epidural, and wait for your surgeon to hand you your clean, scrubbed, blanket-wrapped newborn.

Unfortunately, we don't get to see the all-too-common aftermath: a mom too drugged to hold her new infant; when the epidural comes out, in too much pain to put him to breast. The indignity of having a Foley catheter removed, only to have it reinserted when she can't urinate on her own. The agony of hobbling to the bathroom like an octogenarian, terrified of falling or opening her incision. The frustration of having to tell her toddler that she can't pick him up because of the ouchie on her tummy. The days and weeks of lingering pain, muscle weakness, helplessness.

In the years since my two cesareans (ten years ago and seven and a half, respectively), I've gained a bit of perspective. I don't rant much anymore; I don't brood often, or for long when I do. I take care of new mothers who actively choose their c-sections, and seem reasonably satisfied with the results; mostly I'm able to keep my feelings to myself. I slip referral cards into teaching packets with links to ICAN and vbacfacts.com. When families ask "is this much pain normal?" or "what can she expect when she goes home?" I tell them the unvarnished facts: Cesareans hurt, surgery is painful, recovery takes time. Occasionally I'm asked if a mother might ever reasonably expect to birth a subsequent child vaginally; on those rare occasions I offer my (heavily edited) stories and the assurance that VBAC is possible and definitely worthwhile, but it takes work. The sad fact is that most of the women I meet aren't willing to do the work-- their doctors tell them no, it's too much hassle, it's dangerous, etc., and they accept that answer as gospel. Society supports the status quo; those of us who are willing to educate ourselves, take responsiblity for our health and our births, are regarded as hippies, zealots, weirdos. Good girls don't buck the system. Good girls do what they're told, lie down and allow themselves to be sliced open for their obstetricians' convenience. Good girls put themselves and their babies at risk by choosing repeat cesareans-- or, probably more accurate, allowing repeat cesareans to be chosen for them. True informed consent is rare: as one OB famously stated, "If one went to the extreme of giving the patient the full details of mortality and morbidity related to cesarean section, most of them would get up and go out and have their baby under a tree..." (Neel, J. Medicolegal pressure, MDs' lack of patience-- cited in cesarean 'epidemic.' Ob.Gyn.)

Cesareans are forever. No matter how good one's experience, the effects remain. Scars heal, fade, but mothers ever after will experience statistically higher morbidity and mortality. I had a life-altering vaginal birth after two cesareans, but my triumph was marred by a retained placenta. Was it caused by my cesareans? I don't know for certain, but I strongly suspect so. I managed to push a baby out of my vagina, but I still had to turn to medpros for a D&C-- another uterine surgery, which in itself increases my risk of complications should I ever plan another birth-- all thanks to an OB who wanted to get home sooner than later.

I will never go into labor without that CNN-style ticker tape in my head, reminding me of the warning signs of uterine rupture; I will never welcome a baby in blissful ignorance, as so many of my patients seem to do. I envy them sometimes, the mothers who have never had a reason to question their doctors, who go to the hospital with the first twinge of labor, accept all the interventions, and still pop out their babies with very little trouble and no apparent lasting effect. Still... there is something to be said about the journey. And there's no question that my journey has been valuable-- priceless, even. That's the intangible reward of pursuing VBAC: the self-searching, the questioning, the obtaining of knowledge. I learned more about myself in the years that I struggled against depression and PTSD than I ever would have if I'd been one of the "lucky ones," the women who make it through the birth mill unharmed. I survived the inferno and emerged from the crucible, tempered and, I think, strengthened. Certainly I would not be the person I am without my fight to VBAC-- and after a good many years, I'm finally able to say that, yes, I like that person. That's worth almost as much as my children.

Barbarism, 2009

Let's play pretend. Let's say that there's an operation that everyone undergoes at age 21-- removal of the left pinky finger, for example. There's no reason for it; it's just something everybody does. There are ostensibly scientific-sounding people who point out that people with left pinkies have 100% higher risk of left pinky finger cancer than people without left pinkies. Besides, everyone does it, and most people agree that people who've had the procedure are just more attractive. It's neater, you see-- more streamlined, more aesthetically pleasing.

When you reaches your 21st birthday, you goes to your-- oh, let's say, dentist. Doesn't make a lot of sense, but you're probably getting their wisdom teeth out too, so it can all be done at once. And the longer it's put off, the worse the recovery, so-- there you are. The dentist straps your left arm down-- and your right too, for good measure. He stabs you a few times with the novacaine hypodermic, which has no time to take effect because he follows immediately with a big scalpel. He hacks off your pinky while you scream bloody murder and the assistant offers you a sip of sugar-water to calm you down. It's over in a minute or so-- the dentist holds some pressure, then checks the site to make sure it's not bleeding, then wraps some vaseline-soaked gauze around it. "Leave that there till later today. Then you can rewrap it with some more vaseline later."

You slump in your seat while the assistant removes the restraints and pats you on the shoulder. "See, it wasn't so bad... you're not even crying." You look at her dazedly; you're in shock, and couldn't produce a sob to save your life. But it's all over, and you're grateful. Your parents got through it. Your siblings, friends, coworkers... everyone manages, so surely you'll be all right. They all say you won't remember when all's said and done... and now you look just like everybody else.

Well... there is that one whack-job at work who insisted on keeping his left pinky. Weird. He says he came with ten fingers, so why forfeit one just because it's what's done? But he's in the minority and clearly insane-- no one keeps their pinkies except for certified granola-crunching flower children, after all.

Your head is swimming and your hand aches. You ask feebly for some pain medication, but the assistant, who keeps coming back to make sure your stump isn't bleeding, shakes her head. "Sorry," she says with sympathy, "I can't give you anything. You might get an infection, and anything I give you for pain could mask the symptoms. You'll be okay." Pat, pat.

You close your eyes, sick to your stomach. All you can do is pray for sleep and time to ease your pain.

Sound ridiculous? Unnecessary? Downright stupid? Of course it does. No one would volunteer to have his finger chopped off, "just because." Certainly no one would think of inflicting such a procedure on a person who could not consent, could not even understand what was happening or why. And yet... we do it every single day, to defenseless baby boys who have no choice in the matter whatsoever. And we wonder why our society is getting more violent by the day?

I am sick to death of circumcisions. There, I said it.

It's not like my position on them is vague or unspoken-- everyone who works with me knows where I stand. I despise them. I think they are barbaric, horrible, hideous, disgusting, and appalling on every level. I loathe having to assist with them in any way, and I absolutely cringe when I have to clean up the mess afterward. It infuriates me that we allow people to perpetrate this kind of violence on helpless newborns!!

This morning, one of the OBs came in to circumcise two babies. He had a 12-year-old boy with him, shadowing him for a school project. "Now, Thomas," Dr H said to the boy, "I did this to you, remember. You sure you want to see this?" Thomas insisted that he did. One of the lactation nurses was passing and commented, "That's awful, how can he subject a little boy to that?" EXCUSE ME?? How can we subject INFANT BOYS to that??!?!?!

Seriously... it's grotesque. I know people say it can be done humanely, but I humbly beg to differ. There is nothing humane in mutilating the body of an hours-old baby: strapping him down on a cold plastic board, letting him scream his lungs out, offering no comfort but sugar-water on a pacifier or a gloved finger, providing nothing for anesthesia except-- maybe, and not even usually-- inadequate injections of lidocaine or a smear of EMLA (topical lidocaine that is, by the by, not recommended for use on infants under 1 month of age), and then brutally clamping his penis in a device that looks like it was developed by sadistic Inquisitors during the Dark Ages and hacking away one-third to one-half of the skin of his most sensitive organ. Don't believe this is what happens? Don't take my word for it.

And for what? There is no medical indication for routine infant circumcision: so says the American Academy of Family Physicians, so says the American Academy of Pediatrics, and so say I. So why do we do it? Because it's "cleaner"? (It's not. And cleaning an intact penis is no more difficult, and no harder to teach someone to do, than cleaning an ear.) Because it "prevents cancer"? (It doesn't. There's no evidence that an intact man who practices even minimal hygiene will induce cancer in himself or a partner.) Because we want baby "to look like daddy"? (That's important... why?) Because "the other boys will laugh"? (Not if they're intact too. And not once they find out what they're missing without their foreskins.)

With the overwhelming evidence falling squarely on the side of not circing, why is it still such common practice? This is something I simply can't figure out. Are people so brainwashed that they're willing to sacrifice their sons' physical (and eventually sexual) wellbeing to a misguided standard of social acceptance? I don't think parents wake up sometime during pregnancy and say to each other, "I know, honey! Let's mutilate our beloved baby boy as soon as he arrives!" I think they genuinely believe they're doing what's best for-- or at least, they're not harming-- their infants. I honestly believe that if these parents were given true informed consent on circumcision, if they really knew what their little guys would endure, most would choose to leave their sons' penises intact. Maybe if they were required to watch this video, produced in informative (and graphic, so be warned) detail, the appalling statistics would change.

I wish I could convince every expectant parent to thoroughly and comprehensively educate themselves about circumcision. I've seen some of the most informed parents-- loving, caring people who would no more put their children in danger than they would club baby harbor seals for sport-- who still opt to circ, with no more convincing rationale than "that's how it's done" or "hey, his dad survived it." I've seen a disturbing trend among immigrant families, whose home cultures have never routinely circumcised their infants, choosing the procedure in order to give the impression that they're really assimilating into American society. Most new parents give it no more thought than whether they'll choose to diaper their infant (bearing in mind, by the way, that there are those who don't, but the sad fact is that circumcision is not the benign procedure it's painted to be. Mishaps happen; there are risks. Moreover, allowing a surgeon to remove the prepuce of a male newborn is circumventing that new little person's right to bodily integrity. Does anyone honestly think that a brand-new baby boy, if we could ask him, would-- if given the choice-- declare with enthusiasm, "Sure, lop it off!!"

Blogging by Proxy

I'm being lazy, but this is the best, most concise summary of the whole cesarean situation that I've seen, thanks to the wonderful and always well-informed Kmom.

Check it out!

BIB!

Babies have an impetus to be born. They have no concept of time; "due dates" and calendars mean nothing to a developing infant. They come when they're ready, in their own good time. Unforunately, most obstetricians do not respect this intrinsic wisdom, and try to fit babies into their own schedules by encouraging (insisting upon?) inductions for no readily apparent (or blatantly made-up) reasons. Babies resist these interferences; a baby who is not ready to be born will hold out against even the most aggressive induction, and their mothers' bodies will instinctually act to hold their infants in. All the pitocin in the world will fail to evict a baby who is unready to be born; the result is "failure to progress" and an unplanned, or even "emergency," cesarean.

The OBs present these elective inductions as the conscientious, convenient, and compassionate choice. "You look miserable... aren't you tired of lugging that belly around? Your blood pressure is a little elevated, too. Let me induce you-- let's just go ahead and get that baby out of there. I'll pick a day that's good for all of us. We'll just get you taken care of, and you won't have to worry about waiting for labor anymore."

Sounds delightful, yes? Appear at the hospital at the appointed time. Check in with the cheerful, unharried staff. Trade your clothes and dignity (oops, is my bias showing?) for a hospital gown, climb up on the bed and receive your IV and monitor belts. Fluid drips into your veins; you perspire prettily. The Clooney-esque OB arrives, checks you ever so gently, and announces with a flourish that you're ready to push. You strain daintily, and out pops your beautiful baby. No fuss, no muss. All done. Ready for that close-up, Mr DeMille!

If you believe that scenario, there's a bridge in Brooklyn I'd like to discuss with you. It's much more likely that you'll work like a dog all day (they call it "labor" for a reason, especially when it's chemically created and interfered with and mucked up, even with the ubiquitous epidural), the OB will materialize in the last five minutes or so, then suction the baby out with vaccuum, or drag her out with forceps, inflicting a large episiotomy on you in the process. This last indignity will be "necessary" (or unnecessarily necessary, as I usually think of it) because your epidural has been cranked up to the max and you can't feel the lower half of your body well enough to push effectively. Besides, you've been splayed in the frog-like lithotomy position and gravity is, to say the least, unkind to birthing mothers who are stranded on their backs.

If an induced birth is difficult for Mom, it's as hard-- or harder-- for baby. Too often, those conveniently scheduled inductions occur before baby is "cooked"-- in other words, ready to be born. Remember, babies can't read calendars! Sure, "term" is defined as "37-42 weeks," but it's a rare infant who's good to go at the early end of that range. The lungs are the last organs to develop; consequently, many induced babies experience respiratory distress-- hopefully, but not always, transitory. The March of Dimes has been addressing this issue lately, noting the sad and shameful fact that so many NICU patients are near- or later-preterm infants (ie, 35-38 weeks' gestation), and there are special considerations to keep in mind when caring for these babies. Iatrogenic prematurity-- babies born too early for no reason other than because the OB couldn't or wouldn't wait any longer-- is epidemic in this country, and in almost every case it's preventable.

Regardless of reason-- and there are a few legitimate reasons to induce labor-- inductions are geared to the convenience of the physician. The ideal scenario of for a pregnant mother to arrive at 6 am, get hooked up, pitted, and medicated: epidural at 10, complete at 2, pushing and delivered by 3 pm. This gives the OB a morning free for office visits and consultations, then gets him home for dinner at 5. Perfect. Moms, of course, don't always cooperate-- they may not conform to the neat labor curve that the OB expects, and thus may well end up a c-section for "fetal distress," "failure to progress," or the dreaded "CPD" (officially "cephalopelvic disproportion," more often "care provider dysfunction"). For the obstetrician, who is a trained surgeon and relishes the opportunity to wield a scalpel, this is a logical and agreeable conclusion to the day. He's not the one who has to hobble home, guarding an abdominal incision and trying to care for a newborn.

Sometimes moms go faster than the doc expects. The pitocin or cervidil or, heaven forbid, cytotec, work too well. Like yesterday: the nurse who was laboring Jane (names changed to protect the innocent), who had come in at 6:30 a.m. for a pit induction, went to check on her around 9. Jane told her that she felt "something down there." The nurse calmly checked her-- saw a fuzzy little head crowning-- and calmy proceeded to catch the 7 lb 4 oz little girl. We call this a "BIB" delivery-- "baby in bed." It went swimmingly: baby had excellent APGARs, mom's perineum was intact, the placenta delivered spontaneously and intact. Textbook. The physician, who had been paged, arrived shortly thereafter-- and chewed the nurse out for letting his patient BIB!

Now, bear in mind that when the nurse walked in, the baby was crowning. Birth was immiment-- there's no going back at this point. What was she supposed to do? Answer: stop the pit and tell mom, "DON'T PUSH!! Breathe... breathe...relax..."

Seriously. Baby is on the perineum-- hell, through the perineum-- and Jane is not meant to push??!?!??!? She's supposed to just lay there and endure the titanic forces of labor until the OB deigns to appear?

Yes.

That's the OB's feeling on the matter. The nurse should be able to control labor to the nth degree-- regulate it perfectly, so that it's fast, but not too fast. Speed up as needed-- if it gets away from her, she should manage to slow it back down to wait on the physician. And if, gods forbid, a mother actually has the gall to deliver without him, he'll make sure the nurse catches an earful.

Occasionally an OB will punish the patient as well. Not too long ago, we had a mother who BIB'd and was perfectly happy about it. The OB was furious. The nurses all got chewed out, but worse, the patient spent the next two days being harassed and even verbally abused by the physician. The OB insisted that the precipitous delivery must mean that the patient had a retained placenta, therefore she was in imminent danger of bleeding out. Dr M ordered an ultrasound to check for placental fragments, and for an indwelling catheter to be placed. The patient (smart mama) refused: she knew she'd delivered an intact placenta, that she was having scant lochia and no trouble voiding, and that the catheter only increased her risk of urinary tract infection. When informed of the patient's informed refusal, Dr M screamed down the phone at the nurse, "You MAKE her take that catheter!" The nurse reminded the doctor that patients are in fact free to refuse any medication or procedure (at least in theory) and it's illegal to force said medication or procedure on a person who has refused it. Dr M then demanded to be connected to the patient's room, and browbeat the mom, telling her she was "negligent" and clearly cared nothing for her baby, since she was likely to hemorrhage and leave her infant motherless. The patient, bless her, held out-- she never did take the catheter. Dr M retaliated by informing her that, once discharged fron the hospital, she would no longer provide care for her (the mother). No big loss, in my opinion.

I couldn't stop thinking about that particular case for a long time. Why was the physician so hostile? Why do OBs get angry when nurses catch their babies, when women give birth on their own, without the doctor to strut in and look important?

And then I realised why: when a woman BIBs, when babies are born in their own time, without assistance (interference) from the OB, it's glaring proof that the OB is not indispensable to the process. Jane didn't need her doctor. Dr M's smart, courageous patient didn't need her OB either. Obstetricians want control, they want to think they've beat nature into submission, that they can do better than women's own bodies.

The simple truth? They're wrong.

Cesarean Awareness Month: April 2009

Once again, it's April, Cesarean Awareness Month 2009. Every year the CDC announces the latest statistics; every year for the past fifteen at least, the percentage of births via cesarean has gone up.

So, what's the big deal? What difference does it make which way a baby comes out, as long as it does? Vaginal birth, cesarean birth-- it's all the same, isn't it? After all, a healthy baby is all that matters...

More than thirty percent of pregnancies in the United States now end in surgical delivery. Estimates vary, but at least half of these operations-- probably many more than half, in truth-- are of questionable necessity, and a huge number of those are outright unnecessary. When truly indicated cesarean surgery can, of course, be a lifesaving procedure for mothers and infants; however, it is clear that the majority of cesareans today are performed for nonemergent reasons.

One simple fact that cannot be argued is this: a cesarean, no matter how we dress it up and make it palatable for general consumption, is major abdominal surgery, with all its attendant risks. A mother undergoing a cesarean is four times more likely to die as a woman who delivers vaginally. Morbidities are inarguably higher: risk of infection, significant blood loss (sometimes requiring transfusion, which introduces another level of risk in and of itself), damage to bladder and bowel, blood clots, adhesions. Post-op moms face longer recovery times, lingering pain, even long-term or permanent nerve damage. Anesthesia-- even that "harmless" epidural society embraces as the savior of laboring women-- adds another tier of risk, one that is rarely addressed by physicians.

Women are almost never informed about the risks to future pregnancies, but there are many, and they are not benign. Uterine rupture, used so often by physicians to frighten mothers into scheduling repeat sections, is a potential complication-- probably the best publicized, if not the most common. Abnormal placentation, secondary infertility, stillbirth-- all are sharply increased after surgical delivery.

Cesareans, despite what apologists would have us believe, are not without risk to babies, either. Mechanical injury-- scalpel wounds, nerve and soft tissue damage from less-than-gentle extractions-- are more common than one might think. Elective sections, touted as "mother's choice" and "humane" by proponents, are often scheduled for 37-38 weeks' gestation-- technically term, at least by the obstetrician's reckoning, but babies can't read calendars, and surgeons frequently fail to account for the diversity of women's menstrual cycles and ovulation times. The lungs are the last organs to mature; when an infant is forced from her cozy womb at 7:34 a.m. (first scheduled section of the day; after all, the OB wants to be done in the operating room by 11 so he can get back to the office for more lucrative appointments) on a Tuesday, she may simply not be physically ready to part from the umbilical cord and placenta and transition to air breather. Respiratory distress is common-- disturbingly so-- in cesarean-born babies; many suffer transient tachypnea of the newborn, often referred to as "wet lungs." For many babies this translates into several days of labored breathing that resolves with time and may eventually manifest later in life as asthma. For too many others, it means a stay in the neonatal intensive care unit with assisted ventilation, IV lines, antibiotics, ultrasounds and chest x-rays, brain scans, eye exams, and unexpected complications such as NEC (necrotizing enterocolitis)-- a disease that still claims the lives of too many babies every year. This is certainly not a situation most parents envision when consulting their schedules to choose their little ones' birthdays, but it's one that is played out all too often.

The emotional cost of cesareans cannot be underestimated either. Women in late pregnancy are primed by their hormones to react, on a subconscious, emotional, or "gut" level, a certain way to labor, birth, and the early postpartum experience. This is to insure that our primal mammalian selves will receive and nurture the newborn-- simple biology at work. Often, that chemical cascade is interrupted, throwing bonding off track and making it difficult for mothers to transition fully to their new role. Cesarean mothers may be at higher risk for postpartum depression and are less likely to breastfeed their newborns. There are many reasons for this: the post-op mom is tired, hurting, hampered by an abdominal incision. She can't get around easily-- forget jumping up at her baby's first cry. Even a tiny infant starts to weigh a ton when she's resting on a fresh surgical wound. Breastfeeding is awkward and hard to manage when mom can't change positions easily and without significant pain. Let's face it: surgery is a lousy way to begin motherhood!

If asked, the majority of mothers who choose cesarean deliveries will respond that they are most concerned with providing a safe birth for their children. They cannot be faulted for this conviction: the medical establishment and the media are responsible for convincing the public that c-sections are safe and even preferable to vaginal birth. The serious potential for permanent injury-- or even death-- during and after the surgery is rarely mentioned. The cesarean is presented as an easy, convenient, scientific, controlled alternative to the inherently messy, unpredictable way designed by nature.

Convenience is a huge driving factor in the rising cesarean rate. Obstetricians prefer cesareans for many reasons, not the least of which is their ability to exercise some control over nature by making birth conform to the physicians' schedules. It is not cost-effective to attend a woman in labor; birth happens at all times of the day and night, every day of the week, heedless of holidays, vacations, special occasions, even plain exhaustion. Cesareans, on the other hand, can be timed quite specifically without creating conflict for the OB: all he has to do us appear at the appointed hour, scrub in, and be presented with the neatly draped and sterilized belly of the pregnant mother. Forty-five minutes later, the surgeon strips off gown and gloves, pauses to dictate or jot a delivery summary in the patient's chart, and is back on his way to his office, where a waiting room full of paying customers sit patiently for their fifteen-minute time
slots for check-ups or consults.

Parents like the convenience as well. Scheduling surgery means that family can be on hand at the prescribed time, employers can be informed and leave arranged-- down to the minute!-- well in advance. Mothers need not worry about how much longer their pregnancies will last, instead focusing on the matter of preparing for their new arrivals. Dad can be certain his job will accomodate his time off; grandma can be right there to scoop up her precious new grandchild; care can be arranged for siblings without any middle-of-the-night drama or panicked phone calls. All that stress eliminated-- sounds ideal. Why not schedule a cesarean? It just makes sense.

Except...

Regardless of what ACOG, a trade union dedicated to furthering and protecting the interests of its members, and the popular media insist, cesarean surgery is simply not the optimal way for a baby to be born. Vaginal birth is infinitely more complex than purple-pushing an inert lump through one's "bottom" to produce a squalling newborn. It is a complicated, carefully calculated dance, choreographed down to one's very cells, perfected over millenia to provide human infants their very best start in life. No manmade intervention, no matter how well-intentioned (for the mother or the physician), can replicate the delicate and profound forces that combine to bring a child into the world. It is sheer arrogance for surgeons to assert that they can match, much less surpass, a process millions of years in the making.

Fortunately, there are those who recognize this folly, and are fighting to be heard above the rhetoric and misinformation. There is support for mothers trying to recover from cesareans, for mothers wanting to avoid them, for women planning a birth after a cesarean-- whether that's a vaginal birth or a more empowered surgical delivery. I want to add my voice to theirs, to speak my truth: Birth is Life, and we were designed to live it.