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.
Showing posts with label cesarean. Show all posts
Showing posts with label cesarean. Show all posts
Sunday, January 8, 2012
Sunday, March 7, 2010
How to Have a Hospital VBAMC
It's difficult-- nearly impossible, in some parts of the country-- to find an obstetrician who will agree to "let" a mother attempt to use her vagina for its biologically mandated purpose once she has had a cesarean. As access to hospital VBAC gets more and more rare, many moms opt to stay home, choosing to labor and birth with a midwife or on their own. Others, though, still want to have their babies in the hospital, but refuse to submit to a repeat cesarean. These mothers may plan to stay home as long as possible in labor, waiting until the last moment to notify their OB and go to Labor & Delivery. Sometimes this works-- "showing up pushing" can mean that even a VBAC-wary doctor won't have time to object, when they walk into the room and the baby is already crowning. Other times, though, the ploy fails: there are many horrible stories (see Jennifer Block's Pushed for details) of mothers arriving in the emergency room in hard labor, and being forced instead to undergo a stat section. One dear friend experienced just that: as she neared the end of a perfectly normal labor, she was wheeled into the OR, screaming, "I do not consent!" No one listened; she was cut against her wishes. Another brave mom I know had her crowning baby shoved back up the birth canal and then removed surgically-- again, without my friend's consent.
If having a hospital VBAC is difficult, finding someone to attend a VBAMC (vaginal birth after multiple cesareans) is that much harder. Even though ACOG itself admits that two c-sections are not an absolute contraindication to VBAC, it's a rare OB who will agree to attend a trial of labor for a VBA2C, and only then if the mother has had a previous vaginal birth (not necessarily a VBAC). Higher-order VBACs(those occurring after three, four, and even more cesareans, as documented here) by Kmom in hospitals are nearly unheard of; the majority of OBs, and even many midwives, consider the risks unacceptable. In fact, there are few studies that look at VBAMC, and a recent study even suggests that VBA3C moms face risks comparable to any other VBAC mother. Of those risks, the most loudly trumpeted is uterine rupture-- something a mom who wants to labor after multiple cesareans is likely to be told is nearly inevitable in her case, even though this assertion is not supported by the evidence. Faced with this fearmongering tactic (referred to by birth advocates as the "dead baby card"), most would-be VBAMC mamas back down, defer to the "expert" obstetrician, and schedule a repeat cesarean-- which will be coded as "elective"-- and honestly, who can blame them? Aren't doctors supposed to know best-- aren't they there to protect our interests as patients, to keep us safe? To do no harm?
It is well to keep in mind that physicians are human, and humans, no matter their ideals or sense of altruism, are ultimately most concerned with their own best interests-- precisely why every pregnant woman, regardless of circumstance or desired birthplace, must educate herself and become her own number-one advocate. ACOG is, first and foremost, a trade union, and it does what such organizations do best: it protects its members. Obstetricians, because they deal intimately with such a life-changing (life-beginning!) process, are targets of litigation- because in our society, if something goes wrong with a delivery, if a family is presented with a so-called "bad baby," they naturally look for someone to blame. It's common wisdom among OBs that "the only c-section you get sued for is the one you don't do"-- in other words, if a baby sustains injury or lasting damage during a vaginal birth, the first question a lawyer seeking reparations will ask the OB is, "Why didn't you do a c-section?" (Or, in this day and age, even "Why didn't you do a c-section sooner?")
Fear of litigation drives medical care in this country, especially where mothers and babies are concerned. Obstetricians pay some of the highest malpractice insurance premiums in the business. So perhaps it's understandable that they panic in the fact of what they see-- what they are conditioned to see-- as unacceptable risk, such as VBAMC.
Dr Wells (note: all names and a few details have been changed, in compliance with HIPAA laws) must have experienced a chill when he got the call from the medical exchange Wednesday night: his 25-year-old patient, Anne, was in labor. Anne has three older children: five, three, and eighteen months. Anne has had three c-sections.
At just 37 weeks' gestation, Anne hadn't expected to go into labor. Her (arbitrarily and probably unwisely) scheduled fourth c-section was still a week away. When she realized that she was having regular contractions only a minute or so apart, it dawned on her that she might behaving this baby sooner than later. She went to the nearest emergency room-- at a small local hospital with no L&D and no maternity services. She was triaged, and the ER nurse quickly determined that she was definitely in labor: Anne was completely dilated, with a bulging amniotic sac. Dr Wells was paged and implored to come, stat!
Dr Wells hit the road running. As soon as he arrived at the emergency department and checked Anne, he called for her to be taken to the nearest OR at once. The staff balked; they did not have the necessary equipment on hand for a cesarean, much less to care for a late preterm infant. Dr Wells-- who, it must be said, is well known for his colorful vocabulary-- cursed and called the nearest large hospital with a level III neonatal intensive care unit, demanding that they send a team at once. The NICU staff demurred, stating-- quite reasonably-- that they would be unable to provide a comprehensive neonatal resuscitation team, with all the requisite personnel and equipment, in time. The physician argued, insisting that a nurse and respiratory therapist must jump into an ambulance at once and drive at full speed to attend a stat section fifteen miles away. Again, the NICU declined, at which point the nurse manager was treated to an unexpurgated rant by the OB.
And Anne? She was still in labor, and within twenty minutes of the irate doctor's arrival, she delivered a healthy seven-pound baby girl-- vaginally, without complications of any kind, right there in the ER. Mother and daughter were transported to the larger hospital, to our mother-baby floor, where I was privileged to care for them until they went home yesterday. When I asked her how her recovery was going, she laughed and said, "It's a world away from a c-section!"
When her OB rounded, he spent less than a minute in his patient's room-- and nearly half an hour with her chart. Dr Wells's main concern, it seemed to me, was to fully document the incident-- concerned, as always, that a lawsuit of some kind might be in the offing. He wasn't interested in the implications: Anne had escaped major surgery-- a surgery he had mandated-- and had instead had an uncomplicated VBAC. She and her baby were happy and healthy-- isn't that all that matters?
Not to this obstetrician. He had lost control of the situation. Instead of a calm, routine cesarean, he was forced to race across town in a mad dash to catch a baby in a hurry. Apparently, non-bankers'-hours obstetrics are not his cup of tea. Will he encourage VBACs for future patients? I doubt it. Will he permit Anne to labor again, if she becomes pregnant in another year or so? Unlikely... he will probably scare her to death with what-if tales of horror, and insist that she submit to a cesarean at 36 weeks. What's one more preemie, if he can continue to circumvent birth?
I'm at a bit of loss, myself, as far as how to feel about this story. I'm thrilled for Anne, who had a quiet everyday miracle of her own in a rural emergency department. But I'm honestly not sure she understands what she accomplished-- or how she did it. I don't know for certain that she's ever even heard the term VBAC-- I'm positive, given that Dr Wells has delivered all her children, that she has never been offered the opportunity to even go into labor, much less have a vaginal birth. If she gets pregnant again, will she go back to Dr Wells, knowing what she does now? Will she demand a VBAC, or will she schedule another section?
If having a hospital VBAC is difficult, finding someone to attend a VBAMC (vaginal birth after multiple cesareans) is that much harder. Even though ACOG itself admits that two c-sections are not an absolute contraindication to VBAC, it's a rare OB who will agree to attend a trial of labor for a VBA2C, and only then if the mother has had a previous vaginal birth (not necessarily a VBAC). Higher-order VBACs(those occurring after three, four, and even more cesareans, as documented here) by Kmom in hospitals are nearly unheard of; the majority of OBs, and even many midwives, consider the risks unacceptable. In fact, there are few studies that look at VBAMC, and a recent study even suggests that VBA3C moms face risks comparable to any other VBAC mother. Of those risks, the most loudly trumpeted is uterine rupture-- something a mom who wants to labor after multiple cesareans is likely to be told is nearly inevitable in her case, even though this assertion is not supported by the evidence. Faced with this fearmongering tactic (referred to by birth advocates as the "dead baby card"), most would-be VBAMC mamas back down, defer to the "expert" obstetrician, and schedule a repeat cesarean-- which will be coded as "elective"-- and honestly, who can blame them? Aren't doctors supposed to know best-- aren't they there to protect our interests as patients, to keep us safe? To do no harm?
It is well to keep in mind that physicians are human, and humans, no matter their ideals or sense of altruism, are ultimately most concerned with their own best interests-- precisely why every pregnant woman, regardless of circumstance or desired birthplace, must educate herself and become her own number-one advocate. ACOG is, first and foremost, a trade union, and it does what such organizations do best: it protects its members. Obstetricians, because they deal intimately with such a life-changing (life-beginning!) process, are targets of litigation- because in our society, if something goes wrong with a delivery, if a family is presented with a so-called "bad baby," they naturally look for someone to blame. It's common wisdom among OBs that "the only c-section you get sued for is the one you don't do"-- in other words, if a baby sustains injury or lasting damage during a vaginal birth, the first question a lawyer seeking reparations will ask the OB is, "Why didn't you do a c-section?" (Or, in this day and age, even "Why didn't you do a c-section sooner?")
Fear of litigation drives medical care in this country, especially where mothers and babies are concerned. Obstetricians pay some of the highest malpractice insurance premiums in the business. So perhaps it's understandable that they panic in the fact of what they see-- what they are conditioned to see-- as unacceptable risk, such as VBAMC.
Dr Wells (note: all names and a few details have been changed, in compliance with HIPAA laws) must have experienced a chill when he got the call from the medical exchange Wednesday night: his 25-year-old patient, Anne, was in labor. Anne has three older children: five, three, and eighteen months. Anne has had three c-sections.
At just 37 weeks' gestation, Anne hadn't expected to go into labor. Her (arbitrarily and probably unwisely) scheduled fourth c-section was still a week away. When she realized that she was having regular contractions only a minute or so apart, it dawned on her that she might behaving this baby sooner than later. She went to the nearest emergency room-- at a small local hospital with no L&D and no maternity services. She was triaged, and the ER nurse quickly determined that she was definitely in labor: Anne was completely dilated, with a bulging amniotic sac. Dr Wells was paged and implored to come, stat!
Dr Wells hit the road running. As soon as he arrived at the emergency department and checked Anne, he called for her to be taken to the nearest OR at once. The staff balked; they did not have the necessary equipment on hand for a cesarean, much less to care for a late preterm infant. Dr Wells-- who, it must be said, is well known for his colorful vocabulary-- cursed and called the nearest large hospital with a level III neonatal intensive care unit, demanding that they send a team at once. The NICU staff demurred, stating-- quite reasonably-- that they would be unable to provide a comprehensive neonatal resuscitation team, with all the requisite personnel and equipment, in time. The physician argued, insisting that a nurse and respiratory therapist must jump into an ambulance at once and drive at full speed to attend a stat section fifteen miles away. Again, the NICU declined, at which point the nurse manager was treated to an unexpurgated rant by the OB.
And Anne? She was still in labor, and within twenty minutes of the irate doctor's arrival, she delivered a healthy seven-pound baby girl-- vaginally, without complications of any kind, right there in the ER. Mother and daughter were transported to the larger hospital, to our mother-baby floor, where I was privileged to care for them until they went home yesterday. When I asked her how her recovery was going, she laughed and said, "It's a world away from a c-section!"
When her OB rounded, he spent less than a minute in his patient's room-- and nearly half an hour with her chart. Dr Wells's main concern, it seemed to me, was to fully document the incident-- concerned, as always, that a lawsuit of some kind might be in the offing. He wasn't interested in the implications: Anne had escaped major surgery-- a surgery he had mandated-- and had instead had an uncomplicated VBAC. She and her baby were happy and healthy-- isn't that all that matters?
Not to this obstetrician. He had lost control of the situation. Instead of a calm, routine cesarean, he was forced to race across town in a mad dash to catch a baby in a hurry. Apparently, non-bankers'-hours obstetrics are not his cup of tea. Will he encourage VBACs for future patients? I doubt it. Will he permit Anne to labor again, if she becomes pregnant in another year or so? Unlikely... he will probably scare her to death with what-if tales of horror, and insist that she submit to a cesarean at 36 weeks. What's one more preemie, if he can continue to circumvent birth?
I'm at a bit of loss, myself, as far as how to feel about this story. I'm thrilled for Anne, who had a quiet everyday miracle of her own in a rural emergency department. But I'm honestly not sure she understands what she accomplished-- or how she did it. I don't know for certain that she's ever even heard the term VBAC-- I'm positive, given that Dr Wells has delivered all her children, that she has never been offered the opportunity to even go into labor, much less have a vaginal birth. If she gets pregnant again, will she go back to Dr Wells, knowing what she does now? Will she demand a VBAC, or will she schedule another section?
Friday, February 26, 2010
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.
"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.
Tuesday, May 26, 2009
Brilliance That Cannot Be Improved Upon
Check it out here. There's no possible way I could add to this or make it any better. I wish every VBACing mama-- every pregnant woman-- every single person who's concerned with her rights to bodily integrity and selfhood would print this out and take it to her OB.
Giselle, I applaud you. Brilliant!!!
Giselle, I applaud you. Brilliant!!!
Saturday, April 18, 2009
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.
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